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Chapter 30 Coordinating Care for Patients With Cardiac Disorders
■ Teaching z Medication teaching Understanding and adhering to the medication treatment plan are essential for effective medication treatment. z Consider prophylactic antimicrobials for dental proce- dures only for patients at high risk. Prevent (re)occurrence of infectious valvular disease. z Strict adherence to anticoagulation regimen if pros- thetic valve Prevent thrombotic/embolic events (i.e., stroke). z Anticoagulation precautions: avoid activities/sports that have a high risk for injury, report any injuries or falls to your provider, report anticoagulant use before any procedure, take care with shaving (electric razor preferred), take care with flossing to avoid bleeding, and limit alcohol consumption. Avoid activities/actions that increase bleeding risk. z Maintain consistent intake of green leafy vegetables if taking warfarin. Green leafy vegetables impair the effectiveness of the anticoagulant warfarin. z Immunization needs Patients with valvular heart disease are at increased risk for complications of influenza, COVID, and pneumonia. Evaluating Care Outcomes Successful management of patients with valvular dis- ease requires maximizing cardiac output through repair or replacement of the damaged valve and controlling the symptoms of HF. Patients with valvular disease can achieve a high functional status by complying with the prescribed medical therapy, maintaining a healthy diet, and engag- ing in regular exercise. Vital signs within normal limits, increased energy, and an ability to actively participate in work and activities of daily living are indicative of disease control. The patient and family should be knowledgeable about the signs of decreased cardiac output and when they should report to their healthcare provider.
Nursing Diagnoses/Problem List z Decrease cardiac output related to decreased stroke volume secondary to valve disease z Activity intolerance related to decreased cardiac output secondary to HF due to valve disease z Bleeding z Thromboembolism Nursing Interventions ■ Assessments z Vital signs Hypertension, tachycardia, and tachypnea are indicative of HF due to increased resistance to flow and backflow of blood to the pulmonary system. Tachycardia occurs as a compensatory mechanism to increase cardiac output and oxygenation. Fever is indicative of infection and increases metabolic demands. Decreased SpO 2 occurs with pulmonary congestion. z Pain assessment Chest pain and palpitations may occur with some murmurs. z Monitoring for irregular heart rhythm Dysrhythmias, specifically atrial fibrillation, are common in valve disease. z Peripheral vascular assessment Poor color, cool extremities, weak peripheral pulses, delayed cap- illary refill, and edema can indicate inadequate cardiac output. z Breath sounds Crackles and orthopnea indicate pulmonary congestion. z Activity tolerance Dyspnea on exertion, weakness, and fatigue indicate worsening HF. z Auscultate heart sounds. Murmurs are typically the initial manifestation of valvular disease. z Daily weights, intake and output Weight increases and intake greater than output can be indicative of HF. z Monitor international normalized ratio (INR). Patients with valve replacements on warfarin need to maintain an INR that is two to three times normal. ■ Actions z Provide supplemental oxygen and elevate the head of the bed. Oxygen and positioning increase oxygenation and ventilation. z Administer medications as ordered: diuretics, ACE inhibitors, ARBs, ARNIs, beta blockers, antibiotics, anticoagulants. Medications are indicated for the relief of symptoms, not as a curative measure. Diuretics help decrease fluid overload; ACE inhibitors, ARBs, ARNIs, and beta blockers decrease heart rate and blood pressure, thus decreasing myocardial workload. Antibiotics are indicated if the valvular disease is caused by an infection such as IE. Anticoagulation decreases the risk of thrombus formation in patients with a prosthetic valve or patients in atrial fibrillation. z Restrict sodium and fluids. To decrease fluid overload and reduce HF symptoms
Safety Alert
Orthostatic Hypotension Moving from a supine to an upright posi-
tion is normally associated with a slight decrease in blood pressure. This is due to the pooling of blood in the lower extremities when the upright position is assumed, reducing the amount of blood returning to the heart and perfusion to the brain. In most people, the autonomic nervous system sends signals to the blood vessels in the lower extremities to constrict. Signals are also sent to the heart to increase rate. Both mechanisms increase cardiac output. In car- diac patients on many antihypertensive medications, the autonomic response can be impaired. Thus, moving to an upright position results in a feeling of dizziness and syn- cope, which puts the patient at risk for falls.
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