CARDIOVASCULAR

NCLEX REVIEW
PART THREE
3- CARE OF THE CLIENT UNDERGOING
CARDIAC SURGERY
 CARE OF THE CLIENT UNDERGOING CARDIAC
SURGERY WITH CARDIOPULMONARY BYPASS

 Monitor hemodynamics for  Provide comfort measures

lower cardiac output or  Limit fluid intake as ordered
excess fluid
 Weigh client daily
 Measure fluid intake and
output  Monitor for signs of cardiac
tamponade
 Monitor specific gravity of
urine  Administer blood and blood
products as ordered
 Monitor ECG (EKG) rate and
rhythm  Provide emotional support
 Monitor peripheral perfusion  Observe incision sites for
signs of infection
 Monitor neurological status
 Care of the client with chest
 Administer IV fluids as tubes
ordered
 Monitor arterial blood gases
 Administer oxygen as as ordered
ordered
 Care of the client on a
ventilator
 Administer medications as
ordered
 Nursing interventions

 Nursing interventions avoid 

  activities known to cause angina
assist client with ADL (activities of daily living)
 maintain partial bed rest as prescribed  physical activities for two hours after
 meals
assist with turning, coughing and deep breathing
exercises  very cold and very hot weather or
 relieve chest pain by oxygen and medication as
environments
ordered
 alcohol and caffeine drinks
 during angina attacks, monitor BP, heart rate,
 diet pills, nasal decongestants, or any
pain, meds, findings; get electrocardiogram .
 remedy that can raise heart rate or
have fresh nitroglycerin available for immediate
use blood pressure
  use of
reinforce client and family teaching regarding:
 nitroglycerin tablets; carry at all
 risks
 review the risk factors for CAD (coronary
times in pocket, not purse
 prevent from being in heat or
artery disease)
sunlight
 encourage client to lose weight; review
 if necessary, use nitroglycerin
low-fat, low-cholesterol diet
patch
 review actions for smoking cessation
 replace opened NTG meds every
 review expected side effects of drugs for three to six months
CAD  report
 reinforce stress reduction techniques to  how to access EMS
be used daily  angina changes
 angina > 15 minutes with meds
or rest, call EMS or have
someone take to hospital
 Shock

 Definition - tissue or cellular hypoxia; body cells need more oxygen

than blood is supplying. Cells and then organs fail. Shock has many
different causes. It is a medical emergency.
 Etiology: five types of shock - cardiogenic, hypovolemic,
anaphylactic, septic, neurogenic
 
 Findings: progression of shock
 initial stage:
 decreased cardiac output and perfusion

 cellular function interrupted

 anaerobic metabolism increases

 no clinical symptoms at this stage

continue findings
 continue findings
 Chemical compensation: decreased pulmonary blood  findings of decompensation
flow causes hypoxemia; hypoxemia is sensed by  consciousness - L.O.C. severely
chemoreceptors that increase rate and depth of depressed, drowsy, lethargic,
respirations, which results in respiratory alkalosis semi-comatose
 Findings of compensatory stage of shock  lungs - hypoventilation, moist
 altered level of consciousness (L.O.C): anxiety, crackles
restlessness  cardiovascular - decreased BP:
 tachypnea systolic below 90 mm Hg,
 tachycardia
narrowing pulse pressure,
tachycardia, irregular pulse,
 skin cool and clammy peripheral pulses weak,
 diaphoresis thready, may be absent
 elimination - urine volume
 thirst
below 20 cc/hour, urine
 pupils dilated osmolality dilute, absent bowel
 weak peripheral pulses sounds with paralytic ileus
 refractory stage: shock
 decreased urine output
irreversible: death from multi-
 concentrated urine system organ failure is evident
 decreased bowel sounds    findings
  decompensate stage of shock - compensatory  cardiac failure
mechanisms can no longer maintain perfusion  respiratory failure
 severe hypoperfusion  renal shutdown
 massive cell death  liver dysfunction or failure
 organs begin to fail  loss of consciousness -
comatose
 
Angina
 Angina

 surgical treatments
 intra-aortic balloon counterpulsation

 left and right ventricular assist pumping

 heart transplant

 hypovolemic shock: rapid fluid replacement therapy to replace lost volume

 crystalloids such as 0.9% normal saline provide quick but temporary
volume expansion
 colloids such as Hetastarch (Hespan) give longer-lasting volume
expansion
 blood products such as packed red blood cells expand volume and
improve oxygen carrying capacity of the circulation
 anaphylactic shock:
 epinephrine (Adrenalin)

 antihistamines

 aminophylline (Truphylline)

 neurogenic
 treat according to cause

 minimize spinal cord trauma with stabilization of the vertebral column

 septic shock
 antiinfective agents based on culture results

 fluid replacement

 improve cardiac output with positive inotropes and vasopressors

 Angina

 Nursing interventions for shock: The Cardio-Care Six except

 do not elevate head: maintain complete bed rest in flat position

with or without legs elevated - called modified Trendelenberg
 do not move client; no bedside commode
 keep client warm
 administer / monitor parenteral therapy, drugs, and O2 as
ordered
 monitor hemodynamic indicators as ordered
 monitor blood plasma expanders or packed cells, if ordered
 maintain communication with family members regarding client
progress
Dysrhythmias and Lesser Vascular Disorders
Dysrhythmias

Dysrhythmias
 Definition: disturbance in heart rate or
rhythm
 Types of dysrhythmia
 supraventricular: sinus, atrial, and
junctional
 sinus tachycardia
 sinus bradycardia
 sinus arrhythmia
 premature atrial complexes
 atrial tachycardia
 atrial flutter
 atrial fibrillation
 premature junctional complex
 junctional tachycardia
 ventricular

 premature ventricular contraction

 ventricular tachycardia*
 ventricular fibrillation*

 ventricular fibrillation*
 asystole*
 atrioventricular block
 first degree A-V block
 second degree A-V block
 third degree A-V block
 * dysrhythmias associated with death
Nursing interventions
 PHARMACOLOGIC INTERVENTIONS
FOR DYSRHYTHMIAS
 A. Adenosine Narrow complex paroxysmal supravenntricular tachycardia; Wolff-
Parkinson-White Syndrome
 B. Amiodarone hydrochloride Ventricular & supraventricular tachycardia; atrial
fibrillation & flutter
 C. Atropine sulfate Symptomatic bradycardia (hypotension, ventricular ectopy,
chest pain, change in mentation)
 D. Beta-Adrenergic blocking agent Wolff-Parkinson-White and digitalis toxic
rhythms; Ventricular rhythms refractory to other drugs
 E. Bretylium tosylate Ventricular fibrillation resistant to defibrillation and
Lidocaine; ventricular tachycardia resistant to lidocaine and procainamide
(Pronestyl)
 F. Digoxin Congestive heart failure; Atrial flutter or fibrillation; supraventricular
tachycardias
 G. Diltiazem Atrial fibrillation or flutter with rapid ventricular response; Narrow-
complex PSVT refractory to other medications
 H. Disopyramide Premature ventricular contractions; ventricular tachycardia not
requiring cardioversion; Atrial fibrillation or flutter
 PHARMACOLOGIC INTERVENTIONS
FOR DYSRHYTHMIAS
 I. Epinephrine Ventricular fibrillation; pulseless ventricular
tachycardia; Asystole
 J. Lidocaine hydrochloride Frequent, multifocal, paired, or R-
on-T premature ventricular contractions; Ventricular tachycardia;
Ventricular fibrillation
 K. Magnesium sulfate Torsade de pointes; Refractory
ventricular fibrillation; Cardiac arrest or ventricular dysrhythmias
due to digitalis toxicity, tricyclic overdose, or hypomagnesemia
 L. Procainamide hydrochloride Symptomatic ventricular
ectopy when lidocaine is ineffective or contraindicated; in
ventricular fibrillation/pulseless VT when lidocaine and bretylium
are ineffective
 M. Quinidine Atrial fibrillation and flutter; PSVT
 N. Tocainide Symptomatic ventricular dysrhythmias when
lidocaine not effective
 O. Verapamil Supraventricular tachyarrhythmias with heart rate
>120
 EKG MEASURES ELECTRICAL ACTIVITY
OF HEART
 Electrocardiogram = (ECG) = (EKG)
Do not confuse with Echocardiogram (Echo)
 An EKG is a graphic recording of the electrical currents of the heart. It may be a one-lead,
which is used for continuous monitoring, or a 12-lead, which is used for diagnostic
purposes.
 The EKG records two basic events - depolarization and repolarization as a series of waves:
P-wave: associate with atrial contraction
P-R Interval
QRS complex: associate with ventricular contraction
T wave
S- T interval
U wave
PVCs: premature ventricular contractions
 An EKG can show these conditions:
 Sinus tachycardia
Ventricular tachycardia*
Sinus bradycardia
Atrial fibrillation
Ventricular fibrillation*
Asystole*
 *death producing
 EKG MEASURES ELECTRICAL ACTIVITY
OF HEART
 monitor hemodynamic indicators as
ordered
 administer oxygen as ordered
 provide a restful environment
 prepare the client for cardioversion, as
indicated
 initiate cardiopulmonary resuscitation as
indicated
 provide emotional support to client/family
 reinforce client teaching regarding
 medications and side effects
 importance of dysrhythmia identification
jewelry
 atrio-ventricular (AV) conduction
disturbances
 asymptomatic: no nursing interventions
indicated
 symptomatic
 administer medications as ordered
 PACEMAKERS

 A battery-powered device that provides electric stimulation for:

 Atrial pacing
 Ventricular pacing
 Atrioventricular sequential and physiologic pacing
 Pacemakers can be set to:
 Sense the client's intrinsic rhythm and pace only if intrinsic rate
declines below rate set on pacemaker
 Pace at a preset rate, regardless of client's rhythm (asynchronous)
 Overdrive and suppress the underlying rhythm in tachyarrhythmia
 Provide increased rate in bradycardias
 Indications for pacing
 Symptomatic bradyarrhythmia
 Symptomatic tachyarrhythmia
 Asystole
 Prophylaxis in clients with high-risk bradycardia
 Diagnosis of dysrhythmias during electrophysiologic testing
 PACEMAKERS
 Types of pacemakers
 Temporary pacemaker
 Endocardial ( transvenous ) pacemakers
 Transcutaneous (external) pacemakers
 Epicardial (applied during cardiac surgery)
 Permanent pacemakers
 Complications of pacemakers
 Infection
 Perforation
 Pneumothorax
 Hemothorax
 Dysrhythmias
 Thrombosis
 Reinforce client teaching regarding:
 need to take pulse for one full minute in morning before arising; if it is lower than the
lowest set pacemaker rate, client is to notify health care provider
 avoidance of contact sports / hobbies
 incision care
 type and expectations of pacemaker
 findings of pacemaker malfunction to report when they occur - dizziness, syncope, fatigue,
sudden shortness of breath
 Aneurysms

 Definition - dilation of an artery due to a weakness in the arterial

wall
 Etiology - atherosclerosis
 
 Four types of aneurysms
 saccular: outpouching of one wall in a circumscribed area
 fusiform: involves complete circumference of artery
 dissecting: accumulation of blood separating the layers of the
arterial wall
 pseudoaneurysm: tear of the full thickness of the arterial wall,
leading to a collection of blood contained in the connective
tissue
Aneurysms
 Arterial occlusive disease

 Definition: insufficient blood supply

in the arteries; usually in legs - may
be acute or chronic
 Etiology
 embolism, thrombosis, and
trauma (illustration 1 )
 femoral artery most often
affected
 Findings
 pain in affected limb, especially
with activity or walking
 cyanosis in affected limb
 paresthesia in affected limb
 if untreated, gangrene
 Diagnostics - arteriography, doppler
studies
 Management
 pharmacology  : anticoagulants
 GUIDELINES FOR CLIENTS TAKING
ORAL ANTICOAGULANTS
 Take medication at the same time every day - often in the afternoon around 4:00 PM
 Wear medical identification jewelry: "wearer takes oral anticoagulants"
 Use a soft toothbrush; report any bleeding gums
 Use an electric razor, not a straight razor
 Use minimal alcoholic beverages, as directed by care provider
 Report any signs of bleeding, red or black bowel movements, headaches, rashes, red or
pink-tinged urine, sputum, persistent sore throat
 Avoid activities with risk of trauma or contact sports
 Have INR serum levels of the anticoagulant effects every four to eight hours
 Check over-the-counter medications for aspirin; take only after care provider
consultation
 Avoid drastic changes in diet for green leafy vegetables
 a significant increase in these will decrease the effectiveness of oral anticoagulant
 a significant decrease in these will decrease the effectiveness of anticoagulant
 Know that serum tests for effectiveness are the International Normalized Ratio (INR) or
prothrombin time (PT)
 Be aware the effects of drugs will last three to seven days after drug is stopped
surgical treatment

 surgical treatment
 embolectomy
 bypass of affected artery (
illustration )

 amputation of limb
 percutaneous transluminal
coronary angioplasty
 Chronic Arterial Occlusive Disease

 Etiology
 arteriosclerosis obliterans, aneurysms, hypercoagulability states, tobacco use
 slow, progressive arteriosclerotic changes give collateral circulation a chance
to form
 collateral circulation cannot give tissues enough oxygen; result is
hypoperfusion
 hypoperfusion leads to ischemia
 usually affects legs

 Findings
 intermittent claudication indicates mild to moderate obstruction
 pain at rest indicates severe obstruction
 affected limb will show
 edema

 paresthesia

 weak or absent pulses

 skin: waxy, hairless, cool, pale, cyanotic

 in men, impotence

 Diagnostics - arteriography
 Medical management
 pharmacologic
Both Acute and Chronic Arterial
Occlusive Disease
 Nursing interventions
 administer medications as ordered
 monitor peripheral pulses and blanch test for capillary refill <
five seconds
 provide comfort measures such as placing legs in dependent
position can improve blood flow and reduce pain
 help client develop an exercise program
 provide care for the client undergoing surgery
 provide regular foot care
 reinforce for client to
 change positions frequently

 avoid crossing legs

 avoid any constrictive clothing on legs

 avoid trauma to lower extremities

 avoid cold temperature extremes

 have regular foot care

 place legs in dependent position to increase blood flow

 Raynaud's phenomenon
(arteriospastic disease)

 Definition: episodic vasospasm of the

small cutaneous arteries that results in
intermittent pallor or cyanosis of the skin
- usually affects the fingers bilaterally,
but occasionally affects the toes, nose,
or tongue that result in intermittent
pallor or cyanosis of the skin
 Etiology
 unknown
 more frequently occurs in women
 may be triggered by stress, cold or
products that cause vasoconstriction
such as tobacco, caffeine, and
chocolate
 SIGNS OF ARTERIAL INSUFFICIENCY IN
THE EXTREMITIES

 Pale color on elevation, dusky red color when lowered

 Skin cool to touch
 Decreased or absent peripheral pulses
 Little or no edema of lower leg, ankles, feet
 Thin, shiny skin and decreased growth of hair
 Thickened nails on toes
 Pain unrelieved by rest and/or activity
 Chronic pain may be either steady or intermittent
 Claudication pain (pain with walking) as tight feeling, burning, fatigue,
ache or cramping
 Raynaud's phenomenon
(arteriospastic disease)
 Diagnostics
 clinical pattern
 digital plethysmography
 peripheral arteriography
 Management
 pharmacologic agents
 Nursing interventions
 antihypertensive agents:
reserpine (Serpasil)
 alpha-adrenergic blocking
agents:
phenoxybenzamine
(Dibenzyline), tolazoline
(Piscoline)
 Vasodilators
 surgery
 sympathectomy in advanced
stages
 amputation of fingers showing
gangrene
 modification of lifesytle behaviors
and the environment
 administer medications as
ordered
 provide care of the client
undergoing surgery
 reinforce client teaching
regarding:
 managment of stress
 avoidance of tobacco products,
caffeine, and chocolate
 avoidance of temperature extremes
 Protection from extreme cold and
heat
Varicose veins

 Definition: dilation of superficial

veins of the legs and feet
 Etiology
 usually found in greater
saphenous vein (leg)
 incompetent valves
(incompetence, vavular) in
the superficial veins
 increased pressure in veins
causing them to distend
 risk factors: standing for
long periods, pregnancy
 Findings
 pain after period of standing
 foot and ankle swelling at
end of day
 distended leg veins
 Varicose veins

 Diagnostics - venography
 Management
 goal is to reduce pain and halt underlying condition
 medical: sclerotherapy (injection of sclerosing agent that causes
vein thrombosis)
 surgical: vein ligation (vein stripping)

 Nursing interventions
 provide care to the client undergoing surgery
 post-operative care includes:
 application of elastic stocking or bandages

 elevation of legs

 reinforce client teaching regarding

 not crossing legs

 elevation of legs as much as possible

 avoidance of prolonged sitting or standing

 Thrombophlebitis

 Definition: a thrombus (clot) accompanied by the inflammation of

the wall of a superficial blood vessel. It differs from
phlebothrombosis, which is a clot (thrombus) with minimal
inflammation of the vessel
 Etiology
 trauma
 intravenous catheters
 prolonged immobility
 IV drug use

 Findings - in an extremity over inflamed site

 redness
 swelling
 tenderness
 warmth
 complication: thromboembolism - dislodgement and migration
of a thrombus
 Thrombophlebitis

 Diagnostics
 history and physical
 ultrasonography
 plethysmography
 Management
 bed rest with elastic stockings
 elevation of affected extremity
 anticoagulants - to prevent clot formation
 analgesics - to control discomfort
 Nursing interventions
 keep affected extremity elevated
 monitor
 for signs of pulmonary embolism (sudden pain, cyanosis, hemoptysis,
shock)
 vital signs, including bilateral peripheral pulses

 for signs of vascular impairment (pallor, cyanosis, coolness)

 administer analgesics as ordered

 reinforce client teaching regarding:
 avoidance of tight or constricting clothing

 need to stop cigarette smoking and caffeine use

 avoidance of maintaining one position for long periods

 Deep venous thrombosis

 Definition: clotting in a deep vein

 Etiology and risk
 immobilization
 sepsis
 hematological and clotting disorders
 malignancies
 heart failure
 myocardial infarction
 pregnancy
 venipuncture
 surgeries: orthopedic, neurologic, urologic and gynecologic
 risk of pulmonary embolus
 Findings: unilateral edema of an entire extremity
 Diagnostics - venography
 Management
 goal is to eliminate the clot and prevent complications
 bed rest
 anticoagulant therapy - to prevent new clots
 thrombolytic therapy - to dissolve thrombus
 compression stockings
 surgery - thrombectomy
 Deep venous thrombosis

 Nursing interventions
 maintain bed rest
 follow guidelines for anticoagulation
 monitor coagulation lab studies (APTT for heparin, PT/INR

for warfarin)
 observe for evidences of bleeding (bruises, nosebleeds,

bleeding gums, blood in urine or stool

 advise the client to use electric razors and soft-bristled

toothbrushes

 administer medications as ordered

 Venous stasis ulcers

 Definition: chronic skin and subcutaneous ulcers usually found on

legs, ankles or feet.
 Etiology
 chronic venous insufficiency
 incompetent valves (vavular, incompetence) in perforating veins
or deep veins cause venous stasis
 pressure of blood pooling causes capillaries to leak
 ulcer begins as small, inflamed, tender area
 any trauma causes tissue to break or it may break
spontaneously
 most common sites: pretibial and medial supramalleolar areas
of ankle
 Findings
 open skin lesion with irregular border
 skin around ulcer usually brown and leathery
 pain in affected area
 Venous stasis ulcers

 Diagnostics - history and physical exam of site

 Management
 goal is to correct venous hypertension and both prevent and
correct ulceration
 local wound care
 antibiotics and analgesics as indicated
 surgery
 debridement

 skin grafting

 removal of veins with incompetent valves

 Nursing interventions
 keep client's legs elevated, with feet above level of heart as
much as possible
 apply elastic bandages as ordered, usually bilateral
 cleanse and dress ulcer as ordered
 administer drugs as ordered
 reinforce client teaching regarding: