b. Infective endocarditis c. Myocarditis d. Pericarditis e. Valvular disease f. Heart failure 3. Describing the diagnostic results used to confirm the diagnosis of cardiac disorders 4. Discussing the interprofessional management of: ESSENTIAL TERMS Acute coronary syndrome Angina
coronary angioplasty (PTCA) Pericardial effusion Pericardiocentesis Pericarditis Prinzmetal’s/variant angina Pulmonary edema Orthopnea Regurgitation Stable angina Stenosis Tamponade Transcatheter aortic valve replacement Unstable angina
Cardiac
Maximize oxygenation and promote comfort l Medication administration as ordered: • Administer diuretics. Diuretics decrease volume, thus preload. • Administer ACE inhibitors, ARBs, ARNIs, and vasodilators. Angiotensin-converting enzyme inhibitors, ARBs, ARNIs, and vasodilators decrease afterload, which helps to decrease the workload on the heart and decrease myocardial oxygen consumption. • Administer beta blockers. Beta blockers decrease the sympathetic response (heart rate), thus reducing myocardial oxygen consumption. • Administer inotropic agents. Enhance contractility • Administer sodium glucose cotransporter 2 inhibitors (STGLC2i) Promote fluid excretion l Fluid and sodium restriction To prevent fluid overload ■ Teaching l Medication management Understanding and adhering to the medication treatment plan are essential for effective medication treatment. l Maintain activity as tolerated. Alternate rest and activity periods. To reduce muscle wasting and functional losses; to decrease workload on the heart l Low-salt diet To prevent fluid retention and exacerbation of HF l Daily weight at home at the same time each day, preferably in the morning after voiding Evaluate fluid retention and need to call provider l Cardiac rehabilitation l Oxygenation l Perfusion Aortic stenosis Atherosclerosis Cardiac rehabilitation Compensatory mechanism Coronary artery bypass graft (CABG) Coronary artery disease (CAD) Ejection fraction Embolization Exercise stress test Friction rub Heart failure Infective endocarditis (IE) Ischemia
tions due to even small changes in fluid status, salt intake, or being exposed to common ailments such as a cold. Reducing stressors that can lead to exacerbations is key. Successful management requires collaboration with the patient and family and the interprofessional team (phy- sician, pharmacist, respiratory care therapist, dietitian, diagnostic technicians, social workers, and palliative care) to develop and implement a treatment plan. That plan should include frequent assessment, comprehensive patient education, and self-management. A well-managed patient has reduced dyspnea and fatigue, is able to actively participate in activities of daily living, and has reduced hospitalizations. rehabilitation Compensatory mechanism Coronary artery bypass graft (CABG) Coronary artery disease (CAD) Ejection fraction Embolization Exercise stress test
ING OUTCOMES this chapter is designed to assist in: g the epidemiology of cardiac disorders g clinical manifestations to pathophysiological processes of: ry artery disease e endocarditis ditis ditis r disease ailure g the diagnostic results used to confirm the diagnosis of cardiac
Murmur Myocardial tissue Myocarditis Percutaneous transluminal coronary angioplasty (PTCA) Pericardial effusion Pericardiocentesis Pericarditis Prinzmetal’s/variant angina Pulmonary edema Orthopnea Regurgitation Stable angina Stenosis Tamponade Transcatheter aortic valve replacement Unstable angina
a. Coronary artery disease b. Infective endocarditis
STEP #1 Build a solid foundation. CONCEPTS c. Myocarditis d. Pericarditis e. Valvular disease f. Heart failure 5. Developing a comprehensive plan of nursing care for patients with cardiac disorders 6. Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with cardiac disorders TEXT
Friction rub Heart failure Infective endocarditis (IE) Ischemia
Making Connections
g the interprofessional management of: ry artery disease e endocarditis
CASE STUDY: WRAP-UP Mr. Thompson’s ECG reveals atrial fibrillation with a heart rate of 130 to 140 bpm. His blood pressure continues to be high at 185/102 mm Hg. His respirations are still slightly labored and fast at 40 per minute. He continues on oxygen at 4 L/min via nasal cannula, with an oxygen saturation of 95%. The results of Mr. Thompson’s diagnostic tests reveal the following: • A chest x-ray indicates LV hypertrophy. • A transthoracic echocardiogram indicates an EF of 30%. • Cardiac biomarkers are negative for ischemia, with troponin I less than 0.1 ng/ml. • Renal function tests reveal borderline failure, with a creatinine of 1.5 mg/dL and a BUN of 30 mg/dL. • His BNP value is elevated to 500 pg/mL. • Serum electrolytes reveal elevated potassium at 6.0 mEq/L. It is determined that Mr. Thompson is in HF, and he begins treat- ment. A diuretic is administered; an ACE inhibitor and a beta blocker are ordered. His SOB and color begin to improve. His transient chest pain resolves with treatment. Case Study Questions 1. The nurse has received the following orders for Mr. Thomp- son. Which order should the nurse implement first? A. Furosemide (Lasix) 40 mg IV B. Insert a Foley catheter C. Low-sodium, low-fat diet D. Apply sequential compression device 2. The nurse correlates which finding with Mr. Thompson’s atrial fibrillation with a heart rate of 120 to 140 beats per minute? A. Acute decompensation requiring immediate cardioversion B. Loss of atrial kick requiring fluid resuscitation C. Increased workload of the heart requiring beta blockers D. Cardiac ischemia requiring immediate cardiac catheterization 3. The nurse understands that Mr. Thompson’s sublingual nitro- glycerin decreases chest pain through which mechanism of action? A. Dilating the coronary arteries to improve blood flow B. Decreasing preload to relieve symptoms of dyspnea C. Decreasing heart rate to decrease cardiac workload D. Converting atrial fibrillation into sinus rhythm 4. Which statement by Mr. Thompson indicates that teaching about hyperkalemia has been effective? A. “The water pill makes my potassium level high.” B. “I should eat bananas because they make my potassium go down.” C. “My liver is not working, so it holds on to the potassium.” D. “My kidneys are not working, which makes my potassium high.” 5. The nurse providing care for Mr. Thompson should include which of the following in the discharge teaching plan? (Select all that apply.) A. Sodium restriction B. Daily weight
ditis ditis r disease ailure ng a comprehensive plan of nursing care for patients with cardiac
l Caring l Infection l Inflammation
a teaching plan that includes pharmacological, dietary, and lifestyle tions for patients with cardiac disorders
Finding Connections
being nonadherent with his meds because “I feel okay.” He reports he was in his usual state of health until about 3 weeks ago. At that point, he reports feeling short of breath and fatigued unrelated to physical activity. Over the past 3 weeks, his symptoms have pro- gressed to the point where he sleeps in his recliner every night. He is admitted to the step-down unit for further management.
PTS
l Oxygenation l Perfusion
Cardiac rehabilitation reduces mortality, improves functional status, reduces hospitalization, and improves quality of life. l Signs and symptoms of worsening HF checklist (edema, SOB, fatigue, and orthopnea) Knowing the symptoms can expedite treatment and reduce hospitalizations. l Immunization needs Patients with HF are vulnerable to communicable diseases such as influenza, COVID, and pneumonia. being nonadherent with his meds because “I feel okay.” He reports he was in his usual state of health until about 3 weeks ago. At that point, he reports feeling short of breath and fatigued unrelated to physical activity. Over the past 3 weeks, his symptoms have pro- gressed to the point where he sleeps in his recliner every night. He is admitted to the step-down unit for further management. CASE STUDY: EPISODE 1 Follow this patient throughout the chapter. Mr. Walter Thompson is a 57-year-old man with no significant past medical history except high blood pressure. He admits to ..
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Unit VI Promoting Health in Patients With Circulatory or Perfusion Disorders
g Connections
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Complications The primary complication of CAD is ACS, which includes unstable angina and MI. Myocardial infarction is discussed in detail in Chapter 32. Coronary artery disease may also result in dysrhythmias and heart failure. Women and other vulnerable populations, such as persons from rural areas, persons with low socioeconomic status, and persons from underserved areas, have higher rates of adverse outcomes from CAD in general. These outcome differences have been attributed to healthcare provider biases such as gen- der and race, limited access to healthcare facilities and resources, delays in seeking care, limits in the diagnosis and treatment of nonobstructive CAD, and increased risks related to social determinants of health. Connection Check 30.1 After a percutaneous coronary angioplasty, what assess- ment should most concern the nurse? A. Back discomfort B. Chest pain C. Capillary refill of less than 3 seconds D. Hypoactive bowel sounds 4736_Ch30_628-657.indd 628 Connection Checks test your mastery of the chapter content.
l Pain assessment utilizing provoking factors, quality, region/radiation, severity, time (PQRST) Angina can be nonspecific in some patients; establishing lo tion and quality can aid in the diagnosis of cardiac chest p and disease progression. Headache can result from nitrogl erin administration. l Electrocardiogram and continuous cardiac monitor Depressed ST segment or flat or inverted T waves are ind ative of ischemia; ST elevations are indicative of acute inju Cardiac dysrhythmias may result from ischemia or infarct l Physical assessment Pallor, clamminess, nausea, vomiting, shortness of breath, and diaphoresis may indicate cardiac ischemia. Xanthoma raised, waxy, yellowish skin discolorations, are associated with hypercholesterolemia. l Patient history Evaluate CAD risk factors and anginal patterns. Fatigue and weakness may be indicative of CAD. Identify potentia noncardiac causes of chest pain, such as gastroesophageal reflux or respiratory disorders. l Recreational drug use Illicit drug use (i.e., cocaine) can cause vasospasm, obstruc ing blood flow and causing symptoms that resemble CAD. l Depression screening Depression may increase morbidity and mortality. l Laboratory values • Cardiac biomarkers: troponin Troponin levels (a protein released into the bloodstream when there is cardiac muscle damage) rise when the hea sustains an acute injury. Troponin can help differentiate between angina and MI pain. • Creatinine, blood urea nitrogen Assess renal function. The contrast dye used during hea rounding the manifestation include an e cardiac comp resonance im pain control ties include p of treatment of pericardia priorities inc heart attack t appropriately CHAPTER SUMMARY 05/04/23 4:58 PM 656 Unit VI Promoting Health in Patients With Circulatory or Perfusion Diso factors for C are used to r ing CAD is a with CAD is ping the agg endothelium of the endoth neous translu most commo care prioritie and administ factors and r understandin lifestyle to lim Infective e of the innerm heart valves transthoracic ing the prese IV antibiotic biotic therap ment. Nursin especially for of ongoing a nance of goo provider abo procedure. Myocardit dium most co mune disease dysrhythmias failure. Medi heart failure that may occ includes med Pericardit C. Medication teaching D. Vigorous daily exercise E. Carbohydrate counting Making Connections to Clinical Judgment 1. Recognizing Cues: What clinical findings of heart failure does Mr. Thompson have? 2. Analyzing Cues: How do the physical findings relate to the pathophysiology of heart failure? 3. Prioritizing Hypotheses: What are the highest priority findings that need to be addressed? Why? 4. Generating Solutions: What interventions would best address Mr. Thompson’s respiratory needs? 5. Taking Actions: What are the nursing intervention priorities? 6. Evaluating Outcomes: What are the findings related to fluid balance that would indicate an effective response? 05/04/23 4:58 PM 05/04/23 4:58 PM
STUDY: EPISODE 1 atient throughout the chapter.
er Thompson is a 57-year-old man with no significant al history except high blood pressure. He admits to
Case Studies help you make the connections. Finding Connections introduces a patient related to the chapter content. Follow the scenario as it unfolds throughout the chapter, illustrating key points and bringing the content to life. Making Connections provides a wrap-up of the case and concludes with questions to apply what you’ve learned. 4736_Ch30_628-657.indd 655
Nursing Management Assessment and Analysis Making Connections to Clinical Judgment presents questions aligning the case study to the six steps of the NCSBN Clinical Judgment Measurement Model to build your clinical judgment skills and prepare for the Next Gen NCLEX®. Suggested answers can be found online on Davis Advantage. Careful assessment of chest pain and other manifestations of CAD is required to identify those patients with CAD and those patients who have stable angina that may be progress- ing to ACS. The clinical manifestations of CAD are the result of the imbalance of oxygen supply and demand to the myocardial tissue. The most common symptom is chest pain.
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