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Information

  1. HYPERTENSION: sustained, elevated, systemic arterial blood pressure; diastolic elevation more serious, reflecting pressure on arterial wall during resting phase of cardiac cycle(Table 6.17. Imbalances in Blood Pressure: Comparative Assessment of Hypotension and Hypertension).
    1. Pathophysiology: increased peripheral resistance leading to thickened arterial walls and left ventricular hypertrophy.
    2. Risk factors:
      1. Black race (2:1).
      2. Use of birth control pills.
      3. Overweight.
      4. Smoking.
      5. Stress.
      6. Excessive sodium intake or saturated fat.
      7. Lack of activity.
      8. Genetics, heredity.
    3. Classifications:
      1. Essential (primary or idiopathic): occurs in 90% to 95% of clients; etiology unknown; diastolic pressure is ≥90 mm Hg, and other causes of hypertension are absent. Benign hypertension (diastolic pressure ≤120 mm Hg) considered controllable; asymptomatic until complications develop.
      2. Secondary: occurs in remaining 5% to 10%; usually renal, endocrine, neurogenic, or cardiac in origin.
      3. Malignant hypertension(diastolic >140 to 150 mm Hg); uncontrollable. May arise from both types.
      4. Labile (prehypertensive): a fluctuating blood pressure; increases during stress, otherwise normal or near normal.
    4. Assessment:
      1. Subjective data:
        1. Early-morning headache, usually occipital.
        2. Light-headedness, tinnitus.
        3. Palpitations.
        4. Fatigue, insomnia.
        5. Forgetfulness, irritability.
        6. Altered vision: white spots, blurring, or loss.
      2. Objective data:
        1. Epistaxis (nosebleeds).
        2. Elevated blood pressure: systolic greater than 120 mm Hg, diastolic greater than 90 mm Hg; narrowed pulse pressure. Rise in diastolic from sitting to standing with essential; fall in BP from sitting to standing with secondary.
        3. Retinal changes; papilledema.
        4. Shortness of breath on slight exertion.
        5. Cardiac, cerebral, and renal changes.
        6. Laboratory data: urinalysis, ECG, chest x-ray to rule out complications of hypertension.
    5. Analysis/nursing diagnosis:
      1. Knowledge deficit (learning need) regarding condition, treatment plan, and self-care and discharge needs.
      2. Risk for decreased cardiac output related to ventricular hypertrophy, vasoconstriction, or myocardial ischemia.
      3. Risk for injury related to complications of hypertension.
      4. Impaired adjustment related to required lifestyle changes.
      5. Activity intolerance related to weakness, fatigue.
    6. Nursing care plan/implementation:
      1. Goal: provide for physical and emotional rest.
        1. Rest periods before/after eating, visiting hours; avoid upsetting situations.
        2. pillImageGive tranquilizers, sedatives, as ordered.
      2. Goal: provide for special safety needs.
        1. Monitor blood pressure: both arms; standing, sitting, lying positions.
        2. Limit/prevent activities that increase pressure (anxiety, anger, frustration, upsetting visitors, fatigue).
        3. Assist with ambulation; change position gradually to prevent dizziness and lightheadedness (postural hypotension).
        4. Monitor for electrolyte imbalance when on low-sodium diet, diuretic therapy; I&O to prevent fluid depletion and arrhythmias from potassium loss.
        5. Observe for signs of hemorrhage, shock, stroke, which may occur following surgery.
      3. Goal: health teaching (client and family).
        1. Procedures to decrease anxiety; relaxation techniques, stress management.
        2. pillImageSide effects of hypotensive drugs: initial therapy includes diuretics and beta blockers; if response inadequate may use angiotensinconverting enzyme (ACE) inhibitors, adrenergic blockers, vasodilators, calcium channel blockers (faintness, nausea, vomiting, hypotension, sexual dysfunction) (see Chapter 8. Physiological Integrityfor specific pharmacological actions).
        3. foodImageWeight control to reduce arterial pressure.
        4. Restrictions: stimulants (tea, coffee, tobacco), sodium, calories, fat.
        5. Lifestyle adjustments: daily exercise needed; reduce occupational and environmental stress; importance of rest.
        6. Blood pressure measurement: daily, same conditions, both arms, position preference of physician; use of self-monitoring cuff; check at least twice per week.
        7. Signs, symptoms, complications of disease (headache, confusion, visual changes, nausea/vomiting, convulsions).
        8. Causes of intermittent hypotension: alcohol, hot weather, exercise, febrile illness, hot bath.
    7. Evaluation/outcome criteria:
      1. Blood pressure within normal range for age (diastolic less than 90 mm Hg)—stable.
      2. Minimal or no pathophysiological or therapeutic complications (e.g., visual changes, stroke, drug side effects).
      3. Reduces weight to reasonable level for height, bone structure.
      4. Takes prescribed medications regularly, even after symptoms have resolved.
      5. Complies with restrictions: no smoking; restricted sodium, fat.
      6. Exercises regularly—program compatible with personal and health-care goals.
  2. CARDIAC ARRHYTHMIAS (DYSRHYTHMIAS): any variations in normal rate, rhythm, or configuration of waves on ECG (Figure. 6.4. Interpretation of Normal Cardiac Cycle).
    1. Pathophysiology:
      1. Dysfunction of sinoatrial (SA) node, atria, atrioventricular (AV) node, or ventricular conduction.
      2. Primary heart problem or secondary systemic problem.
    2. Risk factors:
      1. Myocardial infarction.
      2. Drug toxicity.
      3. Stress.
      4. Cardiac surgery.
      5. Hypoxia.
      6. Congenital.
    3. Assessment: see Table 6-18. Comparison of Selected Cardiac Dysrhythmias for specific dysrhythmias.
    4. Analysis/nursing diagnosis:
      1. Decreased cardiac output related to abnormal ventricular function.
      2. Altered tissue perfusion related to inadequate cardiac functioning.
      3. Knowledge deficit (learning need) regarding cause/treatment of condition, self-care, and discharge needs.
      4. Anxiety related to dependence, fear of death.
    5. Nursing care plan/implementation:
      1. Goal: provide for emotional and safety needs.
        1. Document ECG tracing for presence of life-threatening arrhythmia.
        2. Encourage discussion of fears, feelings (client and significant other).
        3. Bedrest: restricted activities; quiet environment; limit visitors.
        4. Oxygen, if ordered.
        5. Check vital signs frequently for shock, heart failure (HF), drug toxicity.
        6. Prepare for cardiac emergency: CPR.
        7. Give cardiac medications; check laboratory tests for digitalis and potassium levels, to prevent drug toxicity.
      2. Goal: prevent thromboemboli.
        1. Apply antiembolic stockings (TED hose); segmental compression device.
        2. pillImageGive anticoagulantsas ordered. (Check for bleeding—gums, urine; monitor laboratory tests—Lee-White clotting time and activated partial thromboplastin time with heparin; prothrombin time or international normalized ratio [INR] with warfarin [Coumadin].)
        3. Encourage flexion and extension of feet.
      3. Goal: prepare for cardioversion with atrial fibrillation if indicated (usually if pulse greater than 140 beats/min, symptomatic, or no conversion after 3 days of drug therapy and anticoagulated).
        1. pillImageGive Cardizem or amiodarone as ordered at least 24 hours before.
        2. NPO 8 hours before.
        3. Hold digoxin morning of cardioversion per order.
        4. pillImageGive conscious sedation medications as ordered.
      4. Goal: provide for physical and emotional needs with pacemaker insertion.
        1. General concerns:
          1. Report excessive bleeding/infection at insertion site—hematoma may contribute to wound infection.
          2. Encourage verbalization of feelings.
          3. Report prolonged hiccups, which may indicate pacemaker failure.
          4. Know pacing mode: fixed-rate or demand (most common); type of insertion (temporary or permanent), sensitivity.
        2. Temporary pacemaker:
          1. Limit excessive activity of extremity if antecubital insertion, to prevent displacement; subclavian insertion increases catheter stability.
          2. Secure wires to chest to prevent tension on catheter.
          3. Do not defibrillate over insertion site, to avoid electrical hazards.
          4. Electrical safety (grounding; disconnect electric beds/call lights; use battery-operated equipment).
          5. Check settings.
        3. Permanent pacemaker:
          1. Limit activity of shoulder for 48 to 72 hours after insertion of transvenous catheter to prevent dislodgement; avoid extending arms over head for 8 weeks.
          2. Postinsertion ROM (passive) at least once per shift after 48 hours to prevent frozen shoulder.
          3. If defibrillation is required, place paddles at least 4 inches from pulse generator.
          4. Check site.
        4. Health teaching following permanent pacemaker:
          1. Explain procedure: duration, equipment, purpose, type of pacemaker.
          2. Medic Alert bracelet; pacemaker information card.
          3. Daily pulse taking on arising (report variation of ± 5 beats).
          4. Signs, symptoms of malfunction (vertigo, syncope, dyspnea, slowed speech, confusion, fluid retention); infection (fever, heat, pain, skin breakdown at insertion site).
          5. Restrictions: limit vigorous arm and shoulder motion for 6 to 8 weeks; contact sports; electromagnetic interferences (few)—TV/radio transmitters, improperly functioning microwave oven (maintain distance of 3 feet), certain cautery machines; may trigger airport metal-detector alarm.
    6. Evaluation/outcome criteria:
      1. Regular cardiac rhythm, monitors own radial pulse.
      2. No complications (e.g., pacemaker malfunction).
      3. Returns for regular follow-up of pacemaker function.
      4. Tolerates physical or sexual activity.
      5. Wears identification bracelet; carries pacemaker identification card.
      6. Reports anxiety is reduced to manageable level.
  3. CARDIAC ARREST: sudden unexpected cessation of heartbeat and effective circulation leading to inadequate perfusion and sudden death.
    1. Risk factors:
      1. Myocardial infarction.
      2. Multiple traumas.
      3. Respiratory arrest.
      4. Drowning.
      5. Electrical shock.
      6. Drug reactions.
      7. Multisystem failure.
    2. Assessment—objective data:
      1. Unresponsive to stimuli (i.e., verbal, painful).
      2. Absence of breathing, carotid pulse.
      3. Pale or bluish: lips, fingernails, skin.
      4. Pupils: dilated.
    3. Analysis/nursing diagnosis:
      1. Decreased cardiac output related to heart failure.
      2. Impaired gas exchange related to breathlessness.
      3. Altered tissue perfusion related to pulselessness.
    4. Nursing care plan/implementation:
      1. Goal: prevent irreversible cerebral anoxic damage: initiate CPR within 4 to 6 minutes; continue until relieved; document assessment factors, effectiveness of actions; presence or absence of pulse at 1 minute and every 4 to 5 minutes.
      2. Goal: establish effective circulation, respiration (see Cardiovascular Emergencies, Table 6.44. Nursing Care of the Adult in Medical and Surgical Emergencies, for complete protocols).
    5. Evaluation/outcome criteria:
      1. Carotid pulse present; check after 1 minute and every few minutes thereafter.
      2. Responds to verbal stimuli.
      3. Pupils constrict in response to light.
      4. Return of spontaneous respiration; adequate ventilation.
  4. ARTERIOSCLEROSIS: loss of elasticity, thickening, hardening of arterial walls; symptoms depend on organ system involved; common type—atherosclerosis. Atherosclerosis (coronary heart disease [CHD]) precedes angina pectoris and myocardial infarction.
    1. Pathophysiology:
      1. Atherosclerotic plaque, discrete lumpy thickening of arterial wall; cholesterol-lipid-calcium deposits in lining.
      2. Narrows lumen, can occlude vessel.
    2. Risk factors:
      1. Increased serum cholesterol (low-density lipids ≥160 mg/dL).
      2. Hypertension.
      3. Cigarette smoking.
      4. Diabetes mellitus.
      5. Family history of premature CHD.
        See following sections V. ANGINA PECTORIS and VI. MYOCARDIAL INFARCTION for nursing implications.
  5. ANGINA PECTORIS: transient paroxysmal episodes of substernal or precordial pain. Types: stable (follows an event, same severity); unstable (at rest or minimal exertion, recent onset, increasing severity); Prinzmetal's variant (at rest, caused by coronary spasms).
    1. Pathophysiology:
      1. Insufficient blood flow through coronary arteries. Oxygen demand exceeds supply.
      2. Temporary myocardial ischemia.
    2. Risk factors:
      1. Cardiovascular:
        1. Atherosclerosis.
        2. Thromboangiitis obliterans.
        3. Aortic regurgitation.
        4. Hypertension.
      2. Hormonal:
        1. Hypothyroidism.
        2. Diabetes mellitus.
      3. Blood disorders:
        1. Anemia.
        2. Polycythemia vera.
      4. Lifestyle choices:
        1. Smoking.
        2. Obesity.
        3. Cocaine use.
        4. Inactivity.
    3. Assessment:
      1. Subjective data:
        1. Pain—typical (Table 6.19. Comparison of Physical Causes of Chest Pain).
          1. Type: squeezing, pressing, burning.
          2. Location: retrosternal, substernal, left of sternum, radiates to left arm (Figure. 6.5. Angina Pectoris).
          3. Duration: short, usually 3 to 5 minutes, less than 30 minutes.
          4. Cause: emotional stress, overeating, physical exertion, exposure to cold; may occur at rest.
          5. pillImageRelief: rest, nitroglycerin.
        2. Note: Atypical complaints by women include jaw and upper back pain and persistent gastric upset.
        3. Dyspnea.
        4. Palpitations.
        5. Dizziness; faintness.
        6. Epigastric distress; indigestion; belching.
      2. Objective data:
        1. Tachycardia.
        2. Pallor.
        3. Diaphoresis.
        4. ECG changes during attack.
    4. Analysis/nursing diagnosis:
      1. Altered cardiopulmonary tissue perfusion related to insufficient blood flow.
      2. Pain related to myocardial ischemia.
      3. Activity intolerance related to onset of pain.
    5. Nursing care plan/implementation:
      1. Goal: provide relief from pain.
        1. Rest until pain subsides.
        2. pillImageNitroglycerin or amyl nitrite, beta-adrenergic blockers, as ordered.
        3. Identify precipitating factors: large meals, heavy exercise, stimulants (coffee, smoking), sex when fatigued, cold air.
        4. Vital signs: hypotension.
        5. Assist with ambulation; dizziness, flushing occurs with nitroglycerin.
      2. Goal: provide emotional support.
        1. Encourage verbalization of feelings, fears.
        2. Reassurance; positive self-concept.
        3. Acceptance of limitations.
      3. Goal: health teaching.
        1. Pain: alleviation, differentiation of angina from myocardial infarction, precipitating factors (see Table 6-19. Comparison of Physical Causes of Chest Pain ).
        2. pillImageMedication: frequency, expected effects (headache, flushing); carry fresh nitroglycerin; loses potency after 6 months ("stings" under tongue when potent); may use nitroglycerin paste—instruct how to apply.
        3. foodImageDiet: restricted calories if weight loss indicated; restricted fat, cholesterol, gas-producing foods; small, frequent meals.
        4. Diagnostic tests if ordered (e.g., thallium stress test, cardiac catheterization; interventional [stents]; see Physiological Integrityand Chapter 11. Reduction of Risk Potential, Reduction of Risk Potential).
        5. Exercise: regular, graded, to promote coronary circulation.
        6. Prepare for coronary artery bypass graft (CABG) surgery, if necessary.
        7. Behavior modification to assist with lifestyle changes (e.g., stress reduction, stop smoking).
    6. Evaluation/outcome criteria:
      1. Relief from pain.
      2. Fewer attacks.
      3. No myocardial infarction.
      4. Alters lifestyle; stress management; complies with limitations.
      5. No smoking.
  6. MYOCARDIAL INFARCTION (MI, HEART ATTACK): localized area of necrotic tissue in myocardium from cessation of blood flow; leading cause of death in North America.
    1. Pathophysiology:
      1. Coronary occlusion due to thrombosis, embolism, or hemorrhage adjacent to atherosclerotic plaque.
      2. Insufficient blood flow from cardiac hypertrophy, hemorrhage, shock, or severe dehydration.
    2. Risk factors:
      1. Age (35 to 70 years).
      2. Men more than women until menopause.
      3. Lifestyle: obesity, smoking, sedentary, amphetamine or cocaine use.
      4. Stress or type A personality.
      5. High levels of low-density lipoproteins, and high serum triglyceride levels.
      6. Chronic illness (diabetes, hypertension).
    3. Assessment:
      1. Subjective data:
        1. Pain (see Table 6-19. Comparison of Physical Causes of Chest Pain ).
          1. Type: sudden, severe, crushing, heavy tightness. May be absent in elderly or those who have diabetes.
          2. Location: substernal; radiates to one or both arms, jaw, neck. May be confused with indigestion.
          3. Duration: greater than 30 minutes.
          4. Cause: unrelated to exercise; frequently occurs when sleeping (rapid-eye-movement [REM] stage).
          5. pillImageRelief: oxygen, narcotics; not relieved by rest or nitroglycerin.
        2. Nausea.
        3. Shortness of breath.
        4. Apprehension, fear of impending death.
        5. History of cardiac disease (family); occupational stress.
      2. Objective data:
        1. Vital signs: shock; rapid (>100), thready pulse; fall in blood pressure; S3 gallop; tachypnea, shallow respirations; elevated temperature within 24 hours (100° to 103°F).
        2. Skin: ashen or clammy; diaphoretic.
        3. Emotional: restless.
        4. Laboratory data: increased—WBC count (12,000 to 15,000/microL), troponin T and I levels, serum enzymes (creatine kinase-MB [CK-MB]; lactate dehydrogenase (LDH):LDH1 > LDH2—"flipped LDH"); changes—ECG ( elevated ST segment, inverted T wave, arrhythmia).
    4. Analysis/nursing diagnosis:
      1. Decreased cardiac output related to myocardial damage.
      2. Impaired gas exchange related to poor perfusion, shock.
      3. Pain related to myocardial ischemia.
      4. Activity intolerance related to pain or inadequate oxygenation.
      5. Fear related to possibility of death.
    5. Nursing care plan/implementation:
      1. Goal: reduce pain, discomfort .
        1. pillImageNarcotics—morphine; note response. Avoid IM.
        2. Humidified oxygen 2 to 4 L/min; mouth care—oxygen is drying.
        3. infoImagePosition: semi-Fowler's to improve ventilation.
      2. Goal: maintain adequate circulation, stabilize heart rhythm.
        1. Monitor vital signs and urine output; observe for cardiogenic shock.
        2. pillImageMonitor ECG for arrhythmias.
        3. Give medications as ordered: antiarrhythmics—lidocaine HCl, amiodarone, atropine, beta blockers, procainamide (Pronestyl), bretylium (Bretylol); propranolol (Inderal); verapamil; anticoagulants—heparin sodium, bishydroxycoumarin or dicoumarin; thrombolytic agents—streptokinase (tPA), APSAC/anistreplase (Eminase), reteplase followed by IV heparin or a glycoprotein IIB/IIIA inhibitor (Integrilin).
        4. Diagnostic tests—echocardiogram, prepare for cardiac catheterization, possible interventional cardiology (stents), possible CABG surgery.
        5. Recognize heart failure: edema, cyanosis, dyspnea, cough, crackles.
        6. Check laboratory data—normal; troponin; serum enzymes (CK 20 to 220 IU/L depending on gender; CK-MB 0 to 12 IU/L; LDH <115 IU/L; LDH1 < LDH2); blood gases (pH 7.35 to 7.45; PCO2 35 to 45 mEq/L; PO2 80 to 100 mm Hg; HCO3 22 to 26); electrolytes (K+ 3.5 to 5.0 mEq/L; Mg++ 1.3 to 2.1 mg/dL); clotting time (aPTT 25 to 41 seconds; prothrombin time [PT] 11 to 15 seconds).
        7. CVP—zero level at right atrium; fluctuates with respiration; normal range 5 to 15 cm H2O; note trend; increases with heart failure.
        8. ROM of lower extremities; TED hose/antiembolic stockings.
      3. Goal: decrease oxygen demand/promote oxygenation, reduce cardiac workload.
        1. O2 as ordered.
        2. Activity: bedrest (24 to 48 hours) with bedside commode; planned rest periods; control visitors.
        3. infoImagePosition: semi-Fowler's to facilitate lung expansion and decrease venous return.
        4. Anticipate needs of client: call light, water.
        5. Assist with feeding, turning.
        6. Environment: quiet, comfortable.
        7. pillImageReassurance; stay with client who is anxious.
        8. Give medications as ordered: cardiotonics, calcium channel blockers, vasodilators, vasopressors.
      4. Goal: maintain fluid, electrolyte, nutritional status.
        1. IV (keep vein open); CVP; vital signs.
        2. Urine output—30 mL/hr.
        3. Laboratory data within normal limits (Na+ 135 to 145 mEq/L; K+ 3.5 to 5.0 mEq/L; Mg++ 1.3 to 2.1 mg/dL).
        4. Monitor ECG—hyperkalemia: peaked T wave; hypokalemia: depressed T wave.
        5. foodImageDiet: progressive low calorie, low sodium, low cholesterol, low fat, without caffeine.
      5. pillImageGoal: facilitate fecal elimination.
        1. Medications: stool softeners to prevent Valsalva maneuver (straining); mouth breathing during bowel movement; recognize complications of Valsalva maneuver—chest pain, cyanosis, diaphoresis, arrhythmias.
        2. Bedside commode if possible.
      6. Goal: provide emotional support.
        1. Recognize fear of dying: denial, anger, withdrawal.
        2. Encourage expression of feelings, fears, concerns.
        3. Discuss rehabilitation, lifestyle changes: prevent cardiac invalid syndrome by promoting self-care activities, independence.
      7. Goal: promote sexual functioning.
        1. Encourage discussion of concerns regarding activity, inadequacy, limitations, expectations, use of drugs for erectile dysfunction—include partner (usually resume activity 5 to 8 weeks after uncomplicated MI or when client can climb two flights of stairs).
        2. Identify need for referral for sexual counseling.
      8. Goal: health teaching.
        1. Diagnosis and treatment regimen.
        2. Caution about when to avoid sexual activity: after heavy meal, alcohol ingestion; when fatigued, tense, under stress; with unfamiliar partners; in extreme temperatures.
        3. Information about sexual activity: less fatiguing positions (side to side; noncardiac partner on top); vasodilators, if ordered, before intercourse; select comfortable, familiar environment.
        4. Referral to available community resources for information, support groups (e.g., American Heart Association, Stop Smoking Clinics).
        5. Medications: administration, importance, untoward effects, pulse taking.
        6. Control risk factors: rest, diet, exercise, no smoking, weight control, stress-reduction techniques.
        7. Need for follow-up care for regulation of medications, evaluating risk factors.
        8. Prepare for angioplasty or coronary bypass if planned.
    6. Evaluation/outcome criteria:
      1. No complications: stable vital signs; relief of pain.
      2. Adheres to prescribed medication regimen, demonstrates knowledge about medications.
      3. Activity tolerance is increased, participates in program of progressive activity.
      4. Reduction or modification of risk factors. Plans to alter lifestyle (e.g., loses weight, quits smoking).
  7. CARDIAC VALVULAR DEFECTS: alteration in the structure of a valve; impede flow of blood or permit regurgitation.
    1. Pathophysiology:
      1. Stenosis—narrowing of valvular opening due to adherence, thickening, and rigidity of valve cusp from fibrosis, scarring, and calcification.
      2. Insufficiency (incompetence)—incomplete closure of valve due to contraction of chordae tendineae, papillary muscles; or to calcification, scarring of leaflets. Results in regurgitation.
      3. Mitral stenosis:
        1. Most common residual cardiac lesion of rheumatic fever.
        2. Affects women younger than 45 years more often than men.
        3. Narrowing of mitral valve.
        4. Interferes with filling of left ventricle.
        5. Produces pulmonary hypertension, right ventricular failure.
      4. Mitral insufficiency(incompetence):
        1. Leaking/regurgitation of blood back into left atrium.
        2. Results from rheumatic fever, bacterial endocarditis; less common.
        3. Affects men more often.
        4. Produces pulmonary congestion, right ventricular failure.
      5. Aortic stenosis:
        1. Fusion of valve flaps between left ventricle and aorta.
        2. Congenital or acquired from atherosclerosis or from rheumatic fever and bacterial endocarditis; seen in men more often; pulmonary circulation congested, cardiac output decreased.
      6. Aortic insufficiency:
        1. Incomplete closure of valve between left ventricle and aorta (regurgitation).
        2. Left ventricular failure leading to right ventricular heart failure.
    2. Risk factors:
      1. Congenital abnormality.
      2. History of rheumatic fever.
      3. Atherosclerosis.
    3. Assessment: see Table 6-20. Comparison of Symptomatology for Valvular Defects .
    4. Analysis/nursing diagnosis:
      1. Decreased cardiac output related to inadequate ventricular filling.
      2. Fluid volume excess related to compensatory response to decreased cardiac output.
      3. Impaired gas exchange related to pulmonary congestion.
      4. Activity intolerance related to impaired cardiac function.
      5. Fatigue related to poor oxygenation.
    5. Nursing care plan/implementation:
      1. Goal: reduce cardiac workload.
      2. Goal: promote physical comfort and psychological support.
      3. Goal: prevent complications.
      4. Goal: prepare for surgery (commissurotomy, valvuloplasty [valvotomy], or valvular replacement, depending on defect and severity of condition).
      5. See section X. CARDIAC SURGERY, Physiological Integrity, for specific nursing actions.
    6. Evaluation/outcome criteria:
      1. Relief of symptoms.
      2. Increase in activity level.
      3. No complications following surgery.
  8. CARDIAC CATHETERIZATION: a diagnostic procedure to evaluate cardiac status. Introduces a catheter into the heart, blood vessels; analyzes blood samples for oxygen content, ejection fraction, cardiac output, pulmonary artery blood flow; done before heart surgery; frequently combined with angiography to visualize coronary arteries; also provides access for specialized cardiac techniques (e.g., internal pacing and percutaneous transluminal coronary angioplasty [PTCA]).
    1. Approaches
      1. Right-heart catheterization—venous approach (antecubital or femoral) → right atrium → right ventricle → pulmonary artery.
      2. Left-heart catheterization—retrograde approach: right brachial artery or percutaneous puncture of femoral artery → ascending aorta → left ventricle.
        1. Transseptal: femoral vein → right atrium → septum → left atrium → left ventricle.
        2. Angiography/arteriography: done during leftheart catheterization.
    2. Precatheterization
      1. Assessment:
        1. Subjective data:
          1. Allergies: iodine, seafood.
          2. Anxiety.
          3. Comfort.
        2. Objective data:
          1. Vital signs: baseline data.
          2. Distal pulses: mark for reference after catheterization.
      2. Analysis/nursing diagnosis:
        1. Anxiety related to fear of unknown.
        2. Knowledge deficit (learning need) related to limited exposure to information or sudden need for procedure.
      3. Nursing care plan/implementation:
        1. Goal: provide for safety, comfort.
          1. Signed informed consent.
          2. NPO (except for medications 6 to 8 hours before).
          3. pillImageHave client urinate before going to lab.
          4. Give sedatives, as ordered, 30 minutes before procedure (e.g., midazolam HCl [Versed] IV, diazepam [Valium] PO).
          5. Possible shaving of insertion site.
        2. Goal: health teaching.
          1. Procedure: length (1 to 3 hours).
          2. Expectations (strapped to table for safety, must lie still, awake but mildly sedated).
          3. Sensations (hot, flushed feeling in head with dye injection; thudding in chest from premature beats during catheter manipulation; desire to cough, particularly with right-heart angiography and contrastmedium injection).
          4. Alert physician to unusual sensations (coolness, numbness, paresthesia).
    3. Postcatheterization
      1. Assessment (potential complications):
        1. Subjective data:
          1. Puncture site: increasing pain, tenderness.
          2. Palpitations, chest pain.
          3. Affected extremity: tingling, numbness, pain from hematoma or nerve damage.
        2. Objective data:
          1. Vital signs: shock, respiratory distress (related to pulmonary emboli, allergic reaction).
          2. Puncture site: bleeding (hematoma).
          3. ECG: arrhythmias, signs of MI.
          4. Affected extremity: color, temperature, peripheral pulses.
      2. Analysis/nursing diagnosis:
        1. Decreased cardiac output related to arrhythmias or MI.
        2. Altered tissue perfusion related to bleeding following procedure.
        3. Pain related to puncture site tenderness.
      3. Nursing care plan/implementation:
        1. Goal: prevent complications.
          1. Bedrest: depends on size of catheter and closure procedure—Perclose dissolvable suture, 30 minutes; Angioseal (collagen plug), 2 hours; compression pump or 15-minute manual compression followed by sandbag, 4 to 5 hours; 12 to 24 hours with sheath or antiplatelet drip (abciximab [ReoPro]).
          2. Vital signs: record q15 min for 1 hour, q30 min for 3 hours or until stable; check BP on opposite extremity.
          3. Puncture site: observe for bleeding, swelling, or tenderness; check pulse distal to insertion site to determine patency of artery; report complaints of coolness, numbness, or paresthesia in extremity.
          4. pillImageECG: monitor, document rhythm.
          5. Give medications as ordered: sedatives; mild narcotics; antiarrhythmics; antiplatelet (Plavix, aspirin) or low-molecular-weight heparin (enoxaparin [Lovenox]) with stent insertion.
        2. Goal: provide emotional support.
          1. Explanations: brief, accurate; client anxious to learn results of test.
          2. Counseling: refer as indicated.
        3. Goal: health teaching.
          1. Late complications: infection.
          2. Prepare for surgery if indicated.
          3. Follow-up medical care.
          4. Limitations following PTCA procedure (see section IX below): no lifting greater than 10 lb and no vigorous exertion for 1 to 2 weeks; return to normal work and sexual activity in 2 to 3 days.
      4. Evaluation/outcome criteria: no complications (e.g., cardiac arrest, hematoma at insertion site).
  9. pillImagePERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA): A balloontipped catheter is threaded to site of coronary occlusion and inflated repeatedly until blood flow increases distal to the obstruction. It is a nonsurgical alternative to bypass surgery for coronary artery occlusion (Figure. 6.6. Arterial Balloon Angioplasty); recommended for clients with poorly controlled angina, mild or no symptoms, multiple-or single-vessel disease with a noncalcified, discrete, and proximal lesion that can be reached by the catheter; costs less and requires shorter hospitalization and rehabilitation period; successful in 90% of clients; approximately 30% restenose by 3 months (see VIII. CARDIAC CATHETERIZATION, Physiological Integrity, for nursing process). Rotational atherectomymay also be done; a high-speed drill pulverizes plaque into small particles. An intravascular stent, steel mesh or coiled spring, may be placed in the coronary artery; the stent acts as a mechanical scaffold to reopen the blocked artery. The client receives low-molecular-weight heparin and/or platelet therapy following the procedure and after discharge.
  10. CARDIAC SURGERY: done to alter the structure of the heart or vessels when congenital or acquired disorders interfere with cardiac functioning: septal defects; transposition of great vessels; tetralogy of Fallot; pulmonary/aortic stenosis; coronary artery bypass; valve replacement.
    Cardiopulmonary bypass (open-heart surgery): blood from cardiac chambers and great vessels is diverted into a pump oxygenator; allows full visualization of heart during surgery; maintains perfusion and body functioning.
    1. Preoperative
      1. Assessment: see specific conditions for preoperative signs and symptoms (i.e., valvular defects, angina, MI); (see also THE PERIOPERATIVE EXPERIENCE, The Perioperative Experience).

        2. Establish complete baseline: daily weight; vital signs—integrity of all pulses, BP both arms; CVP or pulmonary artery pressures; neurological status; emotional status; nutritional and elimination patterns; laboratory values (urine, electrolytes, enzymes, coagulation studies, cholesterol); pulmonary function studies; echocardiogram, chest x-ray.

      2. Analysis/nursing diagnosis (see also VI. MYOCARDIAL INFARCTION, Physiological Integrity):
        1. Decreased cardiac output related to myocardial damage.
        2. Activity intolerance related to poor cardiac function.
        3. Knowledge deficit (learning need) related to insufficient time for teaching.
        4. Anxiety related to fear of unknown.
        5. Fear related to possible death.
        6. Risk for spiritual distress related to possible death.
      3. Nursing care plan/implementation:
        1. Goal: provide emotional and spiritual support.
          1. Arrange for religious consultation if desired.
          2. Provide opportunity for family visit morning of surgery.
          3. Encourage verbalization/questions: fear, depression, despair frequently occur.
          4. Involve family during explanations.
        2. Goal: health teaching.
          1. Diagnostic procedures, treatments, specifics for surgery (i.e., internal mammarian artery or leg incision with use of saphenous vein in coronary artery bypass graft surgery) (Figure. 6.7. Bypass).
          2. Postoperative regimen: turn, cough, deep breathe, ROM, equipment used, medication for pain.
          3. Tour ICU; meet personnel.
          4. Alternative method of communication while intubated.
      4. Evaluation/outcome criteria:
        1. Displays moderate anxiety level.
        2. Verbalizes/demonstrates postoperative expectations.
        3. Quits smoking before surgery.
    2. Postoperative
      1. Assessment:
        1. Subjective data:
          1. Pain.
          2. Fatigue—sleep deprivation.
        2. Objective data:
          1. Neurological: level of consciousness; pupillary reactions; movement of limbs (purposeful, spontaneous).
          2. Respiratory: rate changes (increases occur with obstruction, pain; decreases occur with CO2 retention); depth (shallow with pain, atelectasis); symmetry; skin color; patency/drainage from chest tubes, sputum (amount, color); endotracheal tube placement (bilateral breath sounds); arterial blood gases, O2 saturation.
          3. Cardiovascular:
            1. BP—hypotension may indicate: heart failure, tamponade, hemorrhage, arrhythmias, or thrombosis; hypertension may indicate: anxiety, hypervolemia.
            2. Pulse: radial, apical, pedal; rate (>100 may indicate: shock, fever, hypoxia, arrhythmias); rhythm, quality. Check pacing wires.
            3. CVP and PA catheter ( elevated in cardiac failure); temperature (normal postoperative: 98.6° to 101.6°F oral).
          4. GI: nausea, vomiting, distention.
          5. Renal: urine—minimum output (30 mL/hr); color Specific gravity (<1.010 occurs with overhydration, renal tubular damage; >1.020 present with dehydration, oliguria, blood in urine).
      2. Analysis/nursing diagnosis:
        1. Decreased cardiac output related to decreased myocardial contractility or postoperative hypothermia.
        2. Pain (acute) related to incision.
        3. Ineffective airway clearance related to effects of general anesthesia.
        4. Altered tissue perfusion related to postoperative bleeding or thromboemboli.
        5. Fluid volume deficit related to blood loss.
        6. Risk for infection related to wound contamination.
        7. Altered thought processes related to anesthesia or stress.
        8. Altered role performance related to uncertainty about future.
      3. Nursing care plan/implementation:
        1. Goal: provide constant monitoring to prevent complications.
          1. Respiratory:
            1. Observe for respiratory distress: restlessness, nasal flaring, Cheyne-Stokes respiration, dusky/cyanotic skin; assisted or controlled ventilation via endotracheal tube common 6 to 24 hours; supplemental O2 after extubation.
            2. infoImageSuctioning; cough, deep breathe.
            3. Elevate head of bed at least 30 degrees.
            4. Position chest tube to facilitate drainage; suction maintains patency—do not "milk" chest tube. (See also Chest tube section in Table 11-5. Review of the Use of Common Tubes .)
          2. Cardiovascular:
            1. Vital signs: BP greater than 80 to 90 mm Hg systolic; CVP: range 5 to 15 cm H2O unless otherwise ordered; pulmonary artery line (PA catheter): mean pressure 4 to 12 mm Hg; I&O: report less than 30 mL/hr of urine from indwelling urinary catheter.
            2. ECG; premature ventricular contractions (PVCs) occur most frequently following aortic valve replacement and bypass surgery.
            3. Peripheral pulses if leg veins used for grafting.
            4. Activity: turn q2h; ROM; progressive, early ambulation.
          3. pillImageInspect dressing for bleeding.
          4. Medications according to therapeutic directives—cardiotonics (digoxin); coronary vasodilators (nitrates); antibiotics (penicillin); analgesics; anticoagulants (with valve replacements); antiarrhythmics (amiodarone, procainamide HCl [Pronestyl]); dobutamine [Dobutrex].
        2. Goal: promote comfort, pain relief.
          1. pillImageMedicate: morphine sulfate—severe pain lasts 2 to 3 days.
          2. Splint incision when moving or coughing.
          3. Mouth care: frequent, especially if intubated; keep lips moist.
          4. infoImagePosition: use pillows to prevent tension on chest tubes, incision.
        3. Goal: maintain fluid, electrolyte, nutritional balance.
          1. I&O; urine specific gravity.
          2. Measure chest drainage—should not exceed 200 mL/hr for first 4 to 6 hours.
          3. Give fluids as ordered; maintain IV patency, central line care.
          4. foodImageDiet: clear fluids → solid food if no nausea, GI distention; sodium intake restricted, low fat; give H2 blocker as ordered.
        4. Goal: promote emotional adjustment.
          1. Anticipate behavior disturbances (depression, disorientation often occur 3 days postoperatively) related to medications, fear, sleep deprivation.
          2. Calm, oriented, supportive environment, as personalized as possible.
          3. Encourage verbalization of feelings (family and client).
          4. Encourage independence to avoid "cardiac cripple" role.
        5. Goal: promote early mobilization.
          1. Out of bed within 24 hours postoperative to prevent deep vein thrombosis (DVT).
          2. In chair three times daily by postoperative day 2.
        6. Goal: health teaching.
          1. Alterations in lifestyle; activity, diet, work; resumption of sexual activity usually when client can climb two flights of stairs.
          2. Refer to available community resources for cardiac rehabilitation (e.g., American Heart Association, Mended Hearts).
          3. Drug regimen: purpose, side effects.
          4. Potential complications: dyspnea, pain, palpitations common postoperatively.
      4. Evaluation/outcome criteria:
        1. No complications; incision heals; no dysrhythmias; pacing wires discontinued.
        2. Activity level increases—no signs of overexertion (e.g., fatigue, dyspnea, pain).
        3. Relief of symptoms.
        4. Returns for follow-up medical care.
        5. Takes prescribed medications; knows purposes and side effects.
  11. MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS (MIDCAB): a variation of CABG for clients for whom sternotomy and cardiopulmonary bypass is contraindicated or unnecessary. The left internal mammary artery is anastomosed to the left anterior descending coronary artery through a thoracic incision without bypass. Small incision and minimal recovery time.
  12. HEART FAILURE (HF): inability of the heart to meet the peripheral circulatory demands of the body; cardiac decompensation; combined right and left ventricular heart failure.
    1. Pathophysiology: increased cardiac workload or decreased effective myocardial contractility → decreased cardiac output (forward effects). Left ventricular failure → pulmonary congestion; right atrial and right ventricular failure → systemic congestion → peripheral edema (backward effects). Compensatory mechanisms in HF include tachycardia, ventricular dilation, and hypertrophy of the myocardium; develops in 50% to 60% of clients with heart disease.
    2. Risk factors:
      1. Decreased myocardial contractility:
        1. Myocarditis.
        2. MI.
        3. Tachyarrhythmias.
        4. Bacterial endocarditis.
        5. Acute rheumatic fever.
      2. Increased cardiac workload:
        1. Elevated temperature.
        2. Physical/emotional stress.
        3. Anemia.
        4. Hyperthyroidism (thyrotoxicosis).
        5. Valvular defects.
        6. Uncontrolled hypertension.
    3. Assessment:
      1. Subjective data:
        1. Shortness of breath.
          1. Orthopnea (sleeps on two or more pillows).
          2. Paroxysmal nocturnal dyspnea (sudden breathlessness during sleep).
          3. Dyspnea on exertion (climbing stairs).
        2. Apprehension; anxiety; irritability.
        3. Fatigue; weakness.
        4. Reported weight gain; feeling of puffiness.
      2. Objective data (Table 6.21. Left Ventricular Compared with Right Ventricular Heart Failure):
        1. Vital signs:
          1. BP: decreasing systolic; narrowing pulse pressure.
          2. Pulse: pulsus alternans (alternating strong-weak-strong cardiac contraction), increased.
          3. Respirations: crackles, Cheyne-Stokes.
        2. Edema: dependent, pitting (1+ to 4+ mm).
        3. Liver: enlarged, tender.
        4. Neck veins: distended.
        5. Chest x-ray:
          1. Cardiac enlargement.
          2. Dilated pulmonary vessels.
          3. Diffuse interstitial lung edema.
    4. Analysis/nursing diagnosis:
      1. Decreased cardiac output related to decreased myocardial contractility.
      2. Activity intolerance related to generalized weakness and inadequate oxygenation.
      3. Fatigue related to edema and poor oxygenation.
      4. Altered tissue perfusion related to peripheral edema and inadequate blood flow.
      5. Fluid volume excess related to compensatory mechanisms.
      6. Impaired gas exchange related to pulmonary congestion.
      7. Anxiety related to shortness of breath.
      8. Sleep pattern disturbance related to paroxysmal nocturnal dyspnea.
    5. Nursing care plan/implementation:
      1. Goal: provide physical rest/reduce emotional stimuli.
        1. infoImagePosition: sitting or semi-Fowler's until tachycardia, dyspnea, edema resolved; change position frequently; pillows for support.
        2. Rest: planned periods; limit visitors, activity, noise. Chair and commode privileges.
        3. pillImageSupport: stay with client who is anxious; have family member who is supportive present; administer sedatives/tranquilizers as ordered.
        4. Warm fluids if appropriate.
      2. Goal: provide for relief of respiratory distress; reduce cardiac workload.
        1. Oxygen: low flow rate; encourage deep breathing (5 to 10 minutes q2h); auscultate breath sounds for congestion, pulmonary edema.
        2. infoImagePosition: elevating head of bed 20 to 25 cm (8 to 10 inches) alleviates pulmonary congestion.
        3. pillImageMedications as ordered:
          1. Digitalis preparations.
          2. ACE inhibitors—captopril, enalapril.
          3. Inotropic agent—dobutamine, dopamine.
          4. Diuretics—thiazides, furosemide, metolazone.
          5. Tranquilizers—phenobarbital, diazepam (Valium), chlordiazepoxide HCl (Librium).
          6. Vasodilators—hydralazine, isosorbide.
      3. Goal: provide for special safety needs.
        1. Skin care:
          1. Inspect, massage, lubricate bony prominences.
          2. Use foot cradle, heel protectors; sheepskin.
        2. Side rails up if hypoxic (disoriented).
        3. Vital signs: monitor for signs of fatigue, pulmonary emboli.
        4. ROM: active, passive; elastic stockings, DVT prophylaxis.
      4. Goal: maintain fluid and electrolyte balance, nutritional status.
        1. Urine output: 30 mL/hr minimum; estimate insensible loss in client who is diaphoretic. Monitor: BUN, serum creatinine, and electrolytes, B-type natriuretic peptide (BNP).
        2. pillImageDaily weight; same time, clothes, scale.
        3. IV: IV infusion pump to avoid circulatory overloading; strict I&O.
        4. foodImageDiet:
          1. Low sodium as ordered.
          2. Small, frequent feedings.
          3. Discuss food preferences with client.
      5. Goal: health teaching.
        1. Diet restrictions; meal preparation.
        2. Activity restrictions, if any; planned rest periods.
        3. foodImageMedications: schedule (e.g., diuretic in early morning to limit interruption of sleep), purpose, dosage, side effects (importance of daily pulse taking, daily weights, intake of potassium-containing foods).
        4. Refer to available community resources for dietary assistance, weight reduction, exercise program.
    6. Evaluation/outcome criteria:
      1. Increase in activity level tolerance—fatigue decreased.
      2. No complications—pulmonary edema, respiratory distress.
      3. Reduction in dependent edema.
  13. PULMONARY EDEMA: sudden transudation of fluid from pulmonary capillaries into alveoli. Life-threatening condition.
    1. Pathophysiology: increased pulmonary capillary permeability; increased hydrostatic pressure (pulmonary hypertension); decreased blood colloidal osmotic pressure; fluid accumulation in alveoli → decreased compliance → decreased diffusion of gas → hypoxia, hypercapnia.
    2. Risk factors:
      1. Left ventricular failure.
      2. Pulmonary embolism.
      3. Drug overdose.
      4. Smoke inhalation.
      5. CNS damage.
      6. Fluid overload.
      7. Valvular disorders.
    3. Assessment:
      1. Subjective data:
        1. Anxiety.
        2. Restlessness at onset, progressing to agitation.
        3. Stark fear.
        4. Intense dyspnea, orthopnea, fatigue.
      2. Objective data:
        1. Vital signs:
          1. Pulse: tachycardia; gallop rhythm.
          2. Respirations: tachypnea, moist, bubbling, wheezing, labored, ↓ O2 saturation.
          3. Temperature: normal to subnormal.
        2. Skin: pale, cool, diaphoretic, cyanotic.
        3. Auscultation: crackles, wheezes.
        4. Cough: productive of large quantities of pink, frothy sputum.
        5. Right ventricular heart failure: distended (bulging) neck veins, peripheral edema, hepatomegaly, ascites.
        6. Mental status: restless, confused, stuporous.
        7. Arterial blood gases: hypoxia; pulse oximetry: decreased O2 saturation.
        8. Chest x-ray: haziness of lung fields, cardiomegaly. Echocardiogram.
    4. Analysis/nursing diagnosis:
      1. Decreased cardiac output related to decreased myocardial contractility.
      2. Impaired gas exchange related to pulmonary congestion.
      3. Altered tissue perfusion related to inadequate blood flow.
      4. Anxiety, severe, related to difficulty breathing.
      5. Fear related to life-threatening situation.
    5. Nursing care plan/implementation:
      1. Goal: promote physical, psychological relaxation measures to relieve anxiety.
        1. pillImageSlow respirations: morphine sulfate 3 to 10 mg IV/SQ/IM, as ordered, to reduce respiratory rate, sedate, and produce vasodilation.
        2. Remain with client.
        3. Encourage slow, deep breathing; assist with coughing.
        4. Work calmly, confidently, unhurriedly.
        5. Frequent rest periods.
      2. Goal: improve cardiac function, reduce venous return, relieve hypoxia.
        1. pillImageO2: slow respiratory rate, provide uniform ventilation via nasal cannula, ventimask, 100% non-rebreather mask, or intubation, depending on O2 need. Possibly PEEP. Smallvolume nebulizer treatment with ipratropium (Atrovent) or albuterol (Proventil).
        2. pillImageGive aminophylline, as ordered, to lower venous pressure and increase cardiac output.
        3. IV: D5W.
        4. pillImagePosition: high Fowler's, extremities in dependent position, to reduce venous return and facilitate breathing.
        5. infoImageMedications as ordered: digitalis; diuretics—furosemide (Lasix); inotropic agents—dobutamine (Dobutrex), dopamine; nitroglycerin, nitroprusside.
        6. pillImageVital signs; auscultate breath sounds.
        7. Diet: low sodium; fluid restriction as ordered.
      3. Goal: health teaching (include family or significant other).
        1. Medications.
          1. Side effects.
          2. Potassium supplements if indicated.
          3. Pulse taking.
        2. Exercise; rest.
        3. foodImageDiet: low sodium.
        4. Signs of complications : edema; weight gain of 2 to 3 lb (0.9 to 1.4 kg) in a few days; dyspnea.
    6. Evaluation/outcome criteria:
      1. No complications; vital signs stable; clear breath sounds.
      2. No weight gain; weight loss if indicated.
      3. Alert, oriented, calm.
  14. SHOCK: a critically severe deficiency in nutrients, oxygen, and electrolytes delivered to body tissues, plus deficiency in removal of cellular wastes; results from: cardiac failure, insufficient blood volume, or increased vascular bed size.
    1. Types, pathophysiology, and risk factors:
      1. Hypovolemic (hemorrhagic, hematogenic)—markedly decreased volume of blood (hemorrhage or plasma loss from intestinal obstruction, burns, physical trauma, or dehydration) → decreased venous return, cardiac output → decreased tissue perfusion.
      2. Cardiogenic—failure of cardiac muscle pump (myocardial infarction) → generally decreased cardiac output → pulmonary congestion, hypoxia → inadequate circulation; high mortality rate.
      3. Distributive:
        1. Neurogenic—massive vasodilation from reduced vasomotor, vasoconstrictor tone (e.g., spinal shock, head injuries, anesthesia, pain); interruption of sympathetic nervous system; blood volume is normal but inadequate for vessels → decreased venous return → tissue hypoxia.
        2. Vasogenic (anaphylactic, septic, systemic inflammatory response syndrome [SIRS], endotoxic)—severe reaction to foreign protein (insect bites, drugs, toxic substances, aerobic, gram-negative organisms) → histamine release vasodilation, venous stasis → diminished venous return.
    2. Assessment: varies, depending on degree of shock (Table 6.22. Signs of Hypovolemic Shock).
      1. Subjective data:
        1. Anxiety; restlessness.
        2. Dizziness; fainting.
        3. Thirst.
        4. Nausea.
      2. Objective data:
        1. Vital signs:
          1. BP—hypotension (postural changes in early shock; systolic less than 70 mm Hg in late shock).
          2. Pulse—tachycardia, thready; irregular (cardiogenic shock); could be slow if conduction system of heart damaged.
          3. Respirations—increased depth, rate; wheezing (anaphylactic shock), O2 saturation ↓ 90%.
          4. Temperature—decreased (elevated in septic shock).
        2. Skin:
          1. Pale (or mottled), cool, clammy (warm to touch in septic shock).
          2. Urticaria (anaphylactic shock).
        3. Level of consciousness: alert, oriented → acute alteration in mental status → unresponsive.
        4. CVP:
          1. Below 5 cm H2O with hypovolemic shock, also anaphylactic or septic shock.
          2. Above 15 cm H2O with cardiogenic shock.
        5. Urine output: decreased (<30 mL/hr).
        6. Capillary refill: slowed; normally nailbed "pinks up" within 2 seconds after blanching (nailbed pressure).
    3. Analysis/nursing diagnosis:
      1. Altered tissue perfusion related to vasodilation or decreased myocardial contractility.
      2. Impaired gas exchange related to ventilationperfusion imbalance.
      3. Decreased cardiac output related to loss of circulating blood volume or diminished cardiac contractility; peripheral vasodilation.
      4. Altered urinary elimination related to decreased renal perfusion.
      5. Fluid volume deficit related to blood loss.
      6. Anxiety related to severity of condition.
    4. Nursing care plan/implementation: Goal: promote venous return, circulatory perfusion.
      1. infoImagePosition: foot of bed elevated 20 degrees (12 to 16 inches), knees straight, trunk horizontal, head slightly elevated; avoid Trendelenburg position.
      2. Ventilation: monitor respiratory effort, loosen restrictive clothing; O2 as ordered.
      3. pillImageFluids:
        1. Maintain IV infusions—with sepsis, may receive 2 to 6 L to keep CVP greater than 12 mm Hg to prevent end organ hypoxia and organ failure. Mean arterial pressure greater than 60 mm Hg.
        2. Give blood, plasma expanders as ordered (exception—stop blood immediately in anaphylactic shock).
      4. Vital signs:
        1. CVP ( decreased with hypovolemia) arterial line, PA catheter ( increased pulmonary artery wedge pressure indicating cardiac failure). Check central venous O2 (scvO2).
        2. Urine output (insert catheter for hourly output).
        3. Monitor ECG (increased rate, dysrhythmias).
      5. pillImageMedications (depending on type of shock) as ordered:
        1. Adrenergics—dobutamine, norepinephrine (Levophed), isoproterenol (Isuprel), dopamine (Intropin) ( cardiogenic, neurogenic, septic shock).
        2. Antiarrhythmics ( cardiogenic shock).
        3. Cardiac glycosides ( cardiogenic shock).
        4. Adrenocorticoids ( anaphylactic shock).
        5. Antibiotics ( septic shock).
        6. Vasodilators—nitroprusside ( cardiogenic shock).
        7. Antihistamines—epinephrine, vasopressin, Benadryl IV, methlyprednisone.
      6. Mechanical support: military (or medical) antishock trousers (MAST) or pneumatic antishock garment (PASG); used to promote internal autotransfusion of blood from legs and abdomen to central circulation; at lower pressures may control bleeding and promote hemostasis; do not remove (deflate) suddenly to examine underlying areas or BP will drop precipitously; compartment syndrome may result with prolonged use and high pressure; controversial.
    5. Evaluation/outcome criteria:
      1. Vital signs stable, within normal limits.
      2. Alert, oriented.
      3. Urine output greater than 30 mL/hr.
  15. DISSEMINATED INTRAVASCULAR COAGULATION (DIC): diffuse or widespread coagulation initially within arterioles and capillaries leading to hemorrhage.
    1. Pathophysiology: activation of coagulation system from tissue injury → fibrin microthrombi form throughout the vascular system → microinfarcts, tissue necrosis → red blood cells, platelets, prothrombin, other clotting factors trapped in capillaries, destroyed in process → excessive clotting → release of fibrin split products → inhibition of platelet clotting → profuse bleeding.
    2. Risk factors:
      1. Obstetric complications (50% of cases).
      2. Neoplastic disease.
      3. Low perfusion states (e.g., burns, hypothermia); hypovolemia.
      4. Infections, sepsis.
    3. Assessment—objective data:
      1. Skin, mucous membranes: petechiae, ecchymosis.
      2. Extremities (fingers, toes): cyanosis.
      3. Bleeding: venipuncture sites, wound, oral, rectal, vaginal.
      4. Urine output: oliguria → anuria.
      5. Level of consciousness: ↓ LOC progressing to coma.
      6. Laboratory data: prolonged—prothrombin time (PT) greater than 15 seconds; decreased—platelets, fibrinogen level.
    4. Analysis/nursing diagnosis:
      1. Altered tissue perfusion related to peripheral microthrombi.
      2. Risk for injury (death) related to bleeding.
      3. Risk for impaired skin integrity related to ischemia.
      4. Altered urinary elimination related to renal tubular necrosis.
    5. Nursing care plan/implementation: Goal: prevent and detect further bleeding.
      1. Carry out nursing measures designed to alleviate underlying problem (e.g., shock, birth of fetus, surgery/irradiation for cancer, antibiotics for infection).
      2. pillImageMedications: heparin sodium IV, 1,000 units/hr, if ordered, to reverse abnormal clotting (controversial). Possible human recombinant activated protein C.
      3. pillImageIVs: blood to lessen shock; platelets, cryoprecipitate, fresh plasma to restore clotting factors, fibrinogen.
      4. Observe: vital signs, CVP (normal 5 to 15 mm Hg), PA pressure (normal 20 to 30 systolic and 8 to 12 diastolic), and I&O for signs of shock or fluid overload from frequent infusions; specimens for occult blood (urine, stool).
      5. Precautions: avoid IM injections if possible; pressure 5 minutes to venipuncture sites; no rectal temperatures.
    6. Evaluation/outcome criteria:
      1. Clotting mechanism restored (increased platelets, normal PT).
      2. Renal function restored (urine output >30 mL/hr).
      3. Circulation to fingers, toes; no cyanosis.
      4. No irreversible damage from renal, cerebral, cardiac, or adrenal hemorrhage.
  16. PERICARDITIS: inflammation of parietal or visceral pericardium or both; acute or chronic condition; may occur with or without effusion. Cardiac tamponade may result.
    1. Pathophysiology: fibrosis or accumulation of fluid in pericardium → compression of cardiac pumping → decreased cardiac output → increased systemic, pulmonic venous pressure.
    2. Risk factors:
      1. Bacterial, viral, fungal infections.
      2. Tuberculosis.
      3. Collagen diseases.
      4. Uremia.
      5. Transmural MI.
      6. Trauma.
    3. Assessment:
      1. Subjective data:
        1. Pain:
          1. Type—sharp, moderate to severe.
          2. Location—wide area of pericardium, may radiate: right arm, jaw/teeth.
          3. Precipitating factors—movement, deep inspiration, swallowing.
        2. Chills; sweating.
        3. Apprehension; anxiety.
        4. Fatigue.
        5. Abdominal pain.
        6. Shortness of breath.
      2. Objective data:
        1. Vital signs:
          1. BP: decreased pulse pressure; pulsus paradoxus—abnormal drop in systolic BP of greater than 8 to 10 mm Hg during inspiration.
          2. Pulse: tachycardia.
          3. Temperature: elevated; erratic course; low grade.
        2. Pericardial friction rub.
        3. Increased CVP; distended neck veins; dependent pitting edema; liver engorgement.
        4. Restlessness.
        5. Laboratory data: elevated aspartate aminotransferase (AST, or serum glutamic-oxaloacetic transaminase [SGOT]), WBC count; CT or magnetic resonance imaging (MRI)—pericardial thickening; troponin, LDH.
        6. Serial ECGs: increased ST segment; echocardiogram: pericardial fluid.
    4. Analysis/nursing diagnosis:
      1. Decreased cardiac output related to impaired cardiac muscle contraction.
      2. Pain related to pericardial inflammation.
      3. Anxiety related to unknown outcome.
      4. Fatigue related to inadequate oxygenation.
    5. Nursing care plan/implementation:
      1. Goal: promote physical and emotional comfort.
        1. infoImagePosition: semi-Fowler's (upright or sitting); bedrest.
        2. Vital signs: q2–4h and prn; apical and radial pulse; notify physician if heart sounds decrease in amplitude or if pulse pressure narrows, indicating cardiac tamponade; see i below.
        3. pillImageO2 as ordered.
        4. Medications as ordered:
          1. Analgesics—aspirin, morphine sulfate, meperidine or codeine.
          2. Nonsteroidal anti-inflammatory agents—indomethacin, ketorolac [Toradol].
          3. Antimicrobial.
          4. Digitalis and diuretics, if heart failure present.
        5. infoImageAssist with aspiration of pericardial sac (pericardiocentesis) if needed: medicate as ordered; elevate head 60 degrees; monitor ECG; have defibrillator and pacemaker available.
        6. Prepare for pericardiectomy (excision of constricting pericardium) as ordered.
        7. Continual emotional support.
        8. Enhance effects of analgesics: positioning; turning; NPO.
        9. Monitor for:
          Signs of cardiac tamponade: tachycardia; tachypnea; hypotension; pallor; narrowed pulse pressure; pulsus paradoxus; distended neck veins; ECG changes.
      2. Goal: maintain fluid, electrolyte balance.
        1. pillImageParenteral fluids as ordered; strict I&O.
        2. foodImageAssist with feedings; low-sodium diet may be ordered.
    6. Evaluation/outcome criteria:
      1. Relief of pain, dyspnea.
      2. No complications (e.g., cardiac tamponade).
      3. Return of normal cardiac functioning.
  17. CHRONIC ARTERIAL OCCLUSIVE DISEASE: arteriosclerosis obliterans most common occlusive disorder of the arterial system (aorta, large and medium-size arteries); frequently involves the femoral, iliac, and popliteal arteries (Buerger's disease).
    1. Pathophysiology: fatty deposits in intimal, medial layer of arterial walls; plaque formation → narrowed arterial lumens; decreased distensibility → decreased blood flow; ischemic changes in tissues.
    2. Risk factors:
      1. Age (>50).
      2. Sex (men).
      3. Diabetes mellitus.
      4. Hyperlipidemia—obesity.
      5. Cigarette smoking.
      6. Hypertension.
      7. Family history.
    3. Assessment:
      1. Subjective data:
        1. Pain:
          1. Type—cramplike.
          2. Location—foot, calf, thigh, buttocks.
          3. Duration—variable, may be relieved by rest.
          4. Precipitating causes—exercise (intermittent claudication), but occasionally may occur when at rest.
        2. Tingling, numbness in toes, feet.
        3. Persistent coldness of one or both lower extremities.
      2. Objective data:
        1. Lower extremities:
          1. Pedal pulses—absent or diminished.
          2. Skin—shiny, glossy; dry, cold, chalky white, decreased/absent hair, ulcers, gangrene.
        2. Laboratory data: increased serum cholesterol, triglycerides, complete blood count (CBC), platelets.
        3. Arteriography—indicates location, nature of occlusion. Noninvasive: ultrasound, segmental limb pressure, exercise testing.
    4. Analysis/nursing diagnosis:
      1. Altered tissue perfusion related to peripheral vascular disease.
      2. Risk for activity intolerance related to pain and sensory changes.
      3. Pain related to ischemia.
      4. Risk for impaired skin integrity related to poor circulation.
      5. Risk for injury related to numbness of extremities.
    5. Nursing care plan/implementation:
      1. Goal: promote circulation; decrease discomfort.
        1. infoImagePosition: elevate head of bed on blocks (3 to 6 inches), because gravity aids perfusion to thighs, legs; elevating legs increases pain.
        2. Comfort: keep warm: avoid chilling or use of heating pads, which may burn skin; apply bed socks.
        3. Circulation: check pedal pulses, skin color, temperature four times daily.
        4. pillImageMedications:
          1. Vasodilators.
          2. Antiplatelet—acetylsalicylic acid (ASA), ticlopidine, dipyridamole.
          3. Dihydropyridines—nifedipine, amlodipine.
          4. Xanthine derivatives—pentoxifylline.
      2. Goal: prevent infection, injury.
        1. Skin care: use bed cradle, sheepskin, heel pads; mild soap; dry thoroughly; lotion; do not massage, to prevent release of thrombus.
        2. Foot care: wear properly fitting shoes, slippers when out of bed; inspect for injury or pressure areas; nail care by podiatrist.
      3. Goal: health teaching.
        1. Skin care; inspect daily.
        2. Activity: balance exercise, rest to increase collateral circulation; walk only until painful.
        3. Exercises: walking, Buerger-Allen exercises (gravity alternately fills and empties blood vessels).
        4. foodImageDiet: low-fat, heart-healthy diet to slow disease progression.
        5. Lifestyle choices: avoid smoking.
        6. Recognize and report signs of occlusion (e.g., pain, cramping, numbness in extremities; color changes—white or blue; temperature changes—cool to cold).
    6. Evaluation/outcome criteria:
      1. Decreased pain.
      2. Skin integrity preserved; no loss of limb.
      3. Quits smoking.
      4. Does exercises to increase collateral circulation.
  18. ANEURYSMS (thoracic or abdominal aortic): localized or diffuse dilations/outpouching of a vessel wall, usually an artery; exerts pressure on adjacent structures; affects primarily men over age 60; greater than 6 cm in diameter, 50% will rupture; resected surgically, reconstructed with synthetic or vascular graft.
    1. Risk factors:
      1. Atherosclerosis.
      2. Trauma.
      3. Syphilis.
      4. Congenital weakness.
      5. Local infection.
      6. Cigarette smoking.
      7. Uncontrolled hypertension.
    2. Assessment:
      1. Subjective data:
        1. Pain:
          1. Constant, boring, neuralgic, intermittent—low back, abdominal.
          2. Angina—sudden onset may mean rupture or dissection, which is an emergency condition.
        2. Dyspnea; orthopnea—pressure on trachea or bronchus.
      2. Objective data:
        1. Vital signs:
          1. Radial pulses differ.
          2. Tachycardia.
          3. Hypotension following rupture leading to shock.
        2. Pulsating mass: abdominal, chest wall pulsation; edema of chest wall ( thoracic aneurysm); periumbilical ( abdominal aneurysm); audible bruit over aorta.
        3. Skin: cyanosis, mottled below level of aneurysm.
        4. Veins: dilated, superficial—neck, chest, arms.
        5. Cough: paroxysmal, brassy.
        6. Diaphoresis, pallor, fainting following rupture.
        7. Peripheral pulses:
          1. Femoral present.
          2. Pedal weak or absent.
        8. Stool: bloody from irritation.
    3. Analysis/nursing diagnosis:
      1. Risk for injury related to possible aneurysm rupture.
      2. Pain related to pressure on lumbar nerves.
      3. Anxiety related to risk of rupture.
    4. Nursing care plan/implementation:
      1. Goal: provide emergency care before surgery for dissection or rupture.
        1. Vital signs: frequent, depending on severity (systolic BP <100 mm Hg and pulse >100 with rupture).
        2. pillImageIVs: may have 2 to 4 sites; lactated Ringer's solution may be ordered.
        3. Urine output: monitored every 15 to 30 minutes.
        4. pillImageO2: usually via nasal prongs.
        5. Medications as ordered: antihypertensivesto prevent extension of dissection.
        6. Transport to operating room quickly.
        7. See THE PERIOPERATIVE EXPERIENCE, The Perioperative Experience, for general preoperative care.
      2. Goal: prevent complications postoperatively.
        1. infoImagePosition: initially flat in bed; avoid sharp flexion of hip and knee, which places pressure on femoral and popliteal arteries; turn gently side to side; note erythema on back from pooled blood.
        2. Vital signs: CVP; hourly peripheral pulses distal to graft site, including neurovascular check of lower extremities; absent pulses for 6 to 12 hours indicates occlusion; check with Doppler blood flow detector.
        3. Urine output: hourly from indwelling catheter.
          1. Immediately report anuria or oliguria (<30 mL/hr).
          2. Check color for hematuria.
          3. Monitor daily blood urea nitrogen (BUN) and creatinine.
        4. Observe for signs of atheroembolization (patchy areas of ischemia); report change in color, motor ability, or sensation of lower extremities.
        5. Observe for signs of bowel ischemia (decreased/absent bowel sounds, pain, guaiac-positive diarrhea, abdominal distention); may have nasogastric tube.
        6. Measure abdominal girth; increase seen with graft leakage.
      3. Goal: promote comfort.
        1. infoImagePosition: alignment, comfort; prevent heel ulcers.
        2. Medication: narcotics.
      4. pillImageGoal: health teaching.
        1. Minimize recurrence: avoid trauma, infection, smoking, high-cholesterol diet, obesity.
        2. Regular medical supervision.
    5. Evaluation/outcome criteria:
      1. Surgical intervention before rupture.
      2. No loss of renal function.
  19. RAYNAUD'S PHENOMENON: a primary vasospastic disease that affects digits of both hands (rarely feet).
    1. Pathophysiology: constriction of small arteries and arterioles from vasospasm or obstruction → spasm → hypoxia → hyperthermia as spasm stops.
    2. Risk factors:
      1. Cigarette smoking.
      2. Caffeine.
      3. Cold temperature.
      4. Emotional upsets (stress reaction).
      5. Autoimmune conditions:
        1. Systemic lupus erythematosus (SLE).
        2. Rheumatoid arthritis (RA).
        3. Scleroderma.
      6. Women between teenage years and age 40.
    3. Assessment:
      1. Subjective data:
        1. Numbness and sensations of cold. Pain.
        2. During "red phase": throbbing, paresthesia, tingling in one or more digits.
      2. Objective data:
        1. Intermittent episodes of classic color changes, occurring in sequence in digits: pallor (arterial spasm starts) → bluish (cyanosis from hypoxia) → redness (hyperthermia, as arterial spasm stops); ↓ capillary refill.
        2. Skin and subcutaneous tissue: atrophy.
        3. Nails: brittle.
    4. Analysis/nursing diagnosis:
      1. Pain (acute/chronic) related to vasospasm/altered perfusion of affected tissues and ischemia of tissues.
      2. Altered peripheral tissue perfusion related to vasospastic disease.
      3. Risk for injury related to numbness.
    5. Nursing care plan/implementation:
      1. Goal: maintain warmth in extremities.
        1. Use wool gloves (when handling cold objects or touching refrigerator/freezer), wool socks and insulated shoes in cold weather.
        2. Avoid prolonged exposure to cold material, environment.
      2. Goal: increase hydrostatic pressure, and therefore circulation.
        1. pillImageVigorous exercise of arms.
        2. Meds: vasodilators, including calcium channel blockers, nitrates.
      3. Goal: health teaching:
        1. Avoid smoking.
        2. Biofeedback for stress management.
        3. Identify and avoid precipitating factors (e.g., cold, stress).
    6. Evaluation/outcome criteria:
      1. Severity and frequency of attacks are reduced.
      2. Tissue perfusion is maintained.
      3. Verbalization of less numbness and tingling. Relief from discomfort.
  20. VARICOSE VEINS: abnormally lengthened, tortuous, dilated superficial veins (saphenous); result of incompetent valves, especially in lower extremities; process is irreversible.
    1. Pathophysiology: dilated vein → venous stasis → edema, fibrotic changes, pigmentation of skin, lowered resistance to trauma.
    2. Risk factors:
      1. Heredity.
      2. Obesity.
      3. Pregnancy.
      4. Chronic disease (heart, liver).
      5. Occupations requiring long periods of standing.
    3. Assessment:
      1. Subjective data:
        1. Dull aches; heaviness in legs.
        2. Pain; muscle cramping.
        3. Fatigue in lower extremities, increased with hot weather, high altitude, history of risk factors.
      2. Objective data:
        1. Nodular protrusions along veins.
        2. Edema.
        3. Diagnostic tests: Trendelenburg test; phlebography; Doppler flowmeter.
    4. Analysis/nursing diagnosis:
      1. Altered tissue perfusion related to venous valve incompetence.
      2. Pain related to edema and muscle cramping.
      3. Risk for activity intolerance related to leg discomfort.
      4. Body image disturbance related to disfigurement of leg.
    5. Nursing care plan/implementation:
      1. Goal: promote venous return from lower extremities.
        1. Activity: walk every hour.
        2. Discourage prolonged sitting, standing, sitting with crossed legs.
        3. infoImagePosition: elevate legs q2–3h; elastic stockings or Ace wraps. Compression stockings.
      2. Goal: provide for safety.
        1. Assist with early ambulation.
        2. infoImageSurgical asepsis with wounds, leg ulcers.
        3. Observe for hemorrhage—if occurs: elevate leg, apply pressure, notify physician.
        4. pillImageObserve for allergic reactions if sclerosing drugs used; have antihistamine available.
      3. Goal: health teaching.
        1. Weight-reducing techniques, dietary approaches if indicated.
        2. Preventive measures: leg elevation; avoiding prolonged standing, sitting, high chairs, tight girdles, constrictive clothing; wear support hose.
        3. Expectations for Trendelenburg test:
          1. While client is lying down, elevate leg 65 degrees for approximately 1 minute to empty veins.
          2. Apply tourniquet high on upper thigh (do not constrict deep veins).
          3. Client stands with tourniquet in place.
          4. Filling of veins is observed.
          5. Normal response is slow filling from below in 20 to 30 seconds, with no change in rate when tourniquet is removed.
          6. Incompetent veins distend very quickly with backflow.
        4. Prepare for sclerotherapy or vein ligation and stripping.
    6. Evaluation/outcome criteria:
      1. Relief or control of symptoms.
      2. Activity without pain.
  21. VEIN LIGATION AND STRIPPING: surgical intervention for advancing varicosities, stasis ulcerations, and cosmetic needs of client. Procedure involves ligation of the saphenous vein at the groin, where it joins the femoral vein; saphenous stripping from the groin to the ankle; legs are wrapped with a pressure bandage. Frequently done as outpatient surgery.
    1. See preceding section on varicose veins for assessment data and nursing diagnosis of the client requiring surgery.
    2. Nursing care plan/implementation:
      1. Goal: prevent complications after discharge.
        1. infoImagePosition: elevate legs as instructed.
        2. Activity: No chair sitting to prevent venous pooling, thrombus formation. Avoid standing in one place.
        3. Bleeding: report to physician.
      2. Goal: health teaching to prevent recurrence.
        1. Weight reduction.
        2. Avoid constricting garments.
        3. Change positions frequently.
        4. Wear support hose/stockings to enhance venous return.
        5. No crossing legs at knees.
    3. Evaluation/outcome criteria:
      1. No complications—hemorrhage, infection, nerve damage, deep vein thrombosis.
      2. No recurrence of varicosities.
      3. Adequate circulation to legs: strong pedal pulses.
      4. Resumes daily activities; free of pain.
  22. DEEP VEIN THROMBOSIS (THROMBOPHLEBITIS): formation of a blood clot in an inflamed vein, secondary to phlebitis or partial obstruction; may lead to venous insufficiency and pulmonary embolism. Deep vein thrombosis (DVT) is most serious form.
    1. Pathophysiology: endothelial inflammation → formation of platelet plug (blood clot) → slowing of blood flow → increase in procoagulants in local area → initiation of clotting mechanisms.
    2. Risk factors:
      1. Immobility/stasis—prolonged sitting, bedrest, obesity, pregnancy.
      2. Venous disease; history DVT.
      3. Age—increased incidence in elderly.
      4. Gender—more often women.
      5. Hypercoagulability of blood.
      6. Intimal damage—IVs, drug abuse.
      7. Fractures.
      8. Oral contraceptives (related to estrogen content).
    3. Assessment:
      1. Subjective data:
        1. Calf stiffness, soreness.
        2. Severe pain: walking, dorsiflexion of foot ( Homans' sign—may be unreliable).
      2. Objective data:
        1. Vein: redness, heat, hardness, threadiness.
        2. Limb: swollen, pale, cold.
        3. Vital signs: low-grade fever.
        4. Diagnostic tests: venogram, impedance plethysmography (electrical resistance to blood flow), ultrasonography.
    4. Analysis/nursing diagnosis:
      1. Altered peripheral tissue perfusion related to venous stasis.
      2. Pain related to inflammation.
      3. Activity intolerance related to leg pain.
      4. Risk for injury related to potential pulmonary emboli.
    5. Nursing care plan/implementation:
      1. Goal: provide rest, comfort, and relief from pain.
        1. pillImageBedrest until therapeutic level of heparin reached (5 to 7 days with traditional heparin; after 24 hours with low-molecular-weight heparin).
        2. infoImagePosition: as ordered; usually extremity elevated; watch for pressure points.
        3. Apply warm, moist heat to affected area as prescribed (cold may also be ordered).
        4. Assess progress of affected area: swelling, pain, soreness, temperature, color.
        5. pillImage Administer analgesics as ordered.
      2. Goal: prevent complications.
        1. Observe for signs of embolism (pain at site of embolism); allergic reaction (anaphylactic shock) with streptokinase.
        2. Precautions: no rubbing or massage of limb.
        3. pillImageMedications: anticoagulants (sodium heparin, enoxaparin, warfarin [Coumadin]); streptokinase (Varidase), tissue plasminogen activator (Table 6.23. Nursing Responsibilities with Anticoagulant Therapy).
        4. Bleeding: hematuria, epistaxis, ecchymosis. Check INR levels.
        5. Skin care, to relieve increased redness/maceration from hot or cold applications.
        6. ROM: unaffected limb.
      3. Goal: health teaching.
        1. Precautions: tight garters, girdles; sitting with legs crossed; oral contraceptives.
        2. Preventive measures: walking daily, swimming several times weekly if possible, wading, rest periods with legs elevated, elastic stockings (may remove at bedtime).
        3. Medication side effects: anticoagulants—pink toothbrush, hematuria, easily bruised.
          1. pillImageCarry Medic Alert card/bracelet.
          2. Contraindicated drugs—aspirin, glutethimide (Doriden), chloramphenicol (Chloromycetin), neomycin, phenylbutazone (Butazolidin), barbiturates.
        4. Prepare for surgery (thrombectomy, vein ligation).
    6. Evaluation/outcome criteria:
      1. No complications (e.g., embolism).
      2. No recurrence of symptoms.
      3. Free of pain—ambulates without discomfort.
  23. PERIPHERAL EMBOLISM: fragments of thrombi, globules of fat, clumps of tissue, calcified plaques, or air moves in the circulation and lodges in vessel, obstructing blood flow; thrombic emboli most common; may be venous or arterial.