Comparison of Selected Cardiac Dysrhythmias

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.
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 4-6 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.
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) precedes angina pectoris and myocardial infarction.
1. Pathophysiology:
1. Atherosclerotic plaque, discrete lumpy thickening of arterial wall; cholesterol-lipidcalcium deposits in lining.
2. Narrows lumen, can occlude vessel.
2. Risk factors:
1. Increased serum cholesterol (low-density lipids 2:160 mg/dL).
2. Hypertension.
3. Cigarette smoking.
4. Diabetes mellitus.
5. Family history of premature CHD.


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.
1. Type: squeezing, pressing, burning.
2. Location: retrosternal, substernal, left of sternum, radiates to left arm.
3. Duration: short, usually 3-5 minutes, <30 minutes
4. Cause: emotional stress, overeating, physical exertion, exposure to cold; may occur at rest.
5. Relief: rest, nitroglycerin.
2. Dyspnea.
3. Palpitations.
4. Dizziness; faintness.
5. 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. Nitroglycerin 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.
2. Medication: 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. Diet: restricted calories if weight loss indicated; restricted fat, cholesterol, gasproducing foods; small, frequent meals.
4. Diagnostic tests if ordered (e.g., thallium stress test, cardiac catheterization).
5. Exercise: regular, graded, to promote coronary circulation.
6. Prepare for coronary bypass 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; 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 (35-70 year).
2. Men more than women until menopause.
3. Lifestyle: obesity, smoking, sedentary, amphetamine or cocaine use.
4. Stress or type A personality.
5. High-cholesterol, low-density lipoproteins, and serum triglyceride levels.
6. Chronic illness (diabetes, hypertension).
3. Assessment:
1. Subjective data
1. Pain
1. Type: sudden, severe, crushing, heavy tightness. May be absent in elderly or diabetics.
2. Location: substernal; radiates to one or both arms, jaw, neck. May be confused with indigestion.
3. Duration: >30 minutes.
4. Cause: unrelated to exercise; frequently occurs when sleeping (REM stage).
5. Relief: 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°-103°F).
2. Skin: ashen or clammy; diaphoretic.
3. Emotional: restless.
4. Lab data: increased - WBC (12000 - 15000/p,L), serum enzymes (CK-MB, LDH, > LDH₂ - “flipped LDH”); changes - ECG (elevated ST segment, inverted T wave, arrhythmia).

Comparison of Physical Causes of Chest Pain

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. Narcotics - morphine, possibly meperidine HCl (Demerol) or hydromorphone (Dilaudid); note response. Avoid IM.
2. Humidified oxygen 2-4 L/min; mouth care - oxygen is drying.
3. Position: 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. Monitor ECG for arrhythmias.
3. Give medications as ordered: antiarrhythmics - lidocaine HCl, atropine, quinidine HCl, procainamide (Pronestyl), bretylium (Bretylol); propranolol (Inderal); verapamil; anticoagulants - heparinsodium, bishydroxycoumarin or dicoumarin; thrombolytic agents - streptokinase (tPA), APSAC/anistreplase (Eminase).
4. Recognize heart failure: edema, cyanosis, dyspnea, cough, crackles.
5. Check lab data - normal; serum enzymes (CK 20-220 IU/L depending on gender; CK-MB 0-12 IU/L; LDH <115 IU/L; LDH₁ < LDH₂); blood gases (pH 7.35-7.45; Pco₂ 35-45 mEq/L; PO₂ 80-100 mm Hg; HCO₃ 22-26); electrolytes (K⁺ 3.5-5.0 mEq/L); clotting time (aPTT 25-41 seconds; PT 11-15 seconds).
6. CVP - zero level at right atrium; fluctuates with respiration; normal range 5-15 cm H₂O; note trend; increases with heart failure.
7. ROM of lower extremities; TED hose/ antiembolic stockings.
3. Goal: decrease oxygen demand/promote oxygenation, reduce cardiac workload.
1. O₂ as ordered.
2. Activity: bed rest (24-48 hours) with bedside commode; planned rest periods; control visitors.
3. Position: semi-Fowler’s to facilitate lung expansion and decrease venous return.
4. Anticipate needs of patient: call light, water.
5. Assist with feeding, turning.
6. Environment: quiet, comfortable.
7. Reassurance; stay with anxious patient.
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; urine output - 30 mL/hr.
2. Lab data within normal limits (Na⁺ 135-145 mEq/L; K⁺ 3.5-5.0 mEq/L).
3. Monitor ECG - hyperkalemia: peaked T wave; hypokalemia: depressed T wave.
4. Diet: progressive low calorie, low sodium, low cholesterol, low fat, without caffeine.
5. Goal: facilitate fecal elimination.
1. •Da. 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. 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
3. closure of valve due to contraction of chordae tendineae, papillary muscles; or to calcification, scarring of leaflets. Results in regurgitation.
4. Mitral stenosis:
1. Most common residual cardiac lesion of rheumatic fever.
2. Affects women <45 yr more often than men.
3. Narrowing of mitral valve.
4. Interferes with filling of left ventricle.
5. Produces pulmonary hypertension, right ventricular failure.
5. Mitral insufficiency:
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.
6. 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.
7. 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:
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 on cardiac surgery.
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, 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 coronary angioplasty).
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. 0 b. Angiography/arteriography: done during left-heart catheterization.
2. Precatheterization
1. Assessment:
1. Subjective data
1. Allergies: iodine, seafood.
2. Anxiety.
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 6-8 hours before).
3. Have patient urinate before going to lab.
4. Give sedatives, as ordered, 30 minutes before procedure (e.g., midazolam HCl [Versed] IV, diazepam [Valium] PO).
2. Goal: health teaching.
1. Procedure: length (1-3 hours).
2. Expectations (strapped to table for safety, must he 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 contrast-medium 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.
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. Bed rest: depends on size of catheter and closure procedure - Perclose dissolvable suture, 30 minute; Angioseal (collagen plug), 2 hours; compression pump or 15 minutes manual compression followed by sandbag, 4-5 hours; 12-24 hours with sheath or antiplatelet drip (abciximab ReoPro).
2. Vital signs: record ql5min for 1 hour, q30 minutes 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. ECG: monitor, document rhythm.
5. Give medications as ordered: sedatives; mild narcotics; antiarrhythmics; antiplatelet (Plavix, aspirin) or lowmolecular-weight heparin (enoxaparin [Lovenox]) with stent insertion.
2. Goal: provide emotional support.
1. Explanations: brief, accurate; patient 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: no lifting >10 lb and no vigorous exertion for 1-2 weeks; return to normal work and sexual activity in 2-3 days.
4. Evaluation/outcome criteria: no complications (e.g., cardiac arrest, hematoma at insertion site).

9. Percutaneous transluminal coronary angioplasty (PTCA): a balloon-tipped catheter is threaded to site of coronary occlusion and inflated repeatedly until blood flow increases distal to the obstruction; a nonsurgical alternative to bypass surgery for coronary artery occlusion; recommended in patients 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 patients; approximately 30% restenose by 3 months. Rotational atherectomy may also be done; a high-speed drill pulverizes plaque into small particles. An intravascular stent, steel mesh or coil spring, may be placed in the coronary artery; the stent acts as a mechanical scaffold to reopen the blocked artery. The patient receives low-molecular-weight heparin and/or platelet therapy following the procedure.

Arterial balloon angioplasty.

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; Establish complete baseline: daily weight; vital signs - integrity of all pulses, BP both arms; CVP or pulmonary artery pressures (Swan-Ganz); neurological status; emotional status; nutritional and elimination patterns; laboratory values (urine, electrolytes, enzymes, coagulation studies); pulmonary function studies.
2. Analysis/nursing diagnosis:
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.
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 surgery).
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).
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.
3. CVP or Swan-Ganz (elevated in cardiac failure); temperature (normal postop: 98.6°-101.6°F oral).
4. GI: nausea, vomiting, distention.
5. Renal: urine - minimum output (30 mL/hour); 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 related to incision.
3. Inejfective 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, CheyneStokes respiration, dusky/cyanotic skin; assisted or controlled ventilation via endotracheal tube common 6-24 hours; supplemental O₂ after extubation.
2. Suctioning; cough, deep breathe.
3. Elevate head of bed.
4. Position chest tube to facilitate drainage; mediastinal sump tube maintains patency - “milking” not necessary.
2. Cardiovascular:
1. Vital signs: BP >80-90 mm Hg systolic; CVP: range 5-15 cm H₂O unless otherwise ordered; pulmonary artery line (Swan-Ganz): mean pressure 4-12 mm Hg; I&O: report <30 mL/hr of urine from indwelling urinary catheter.
2. ECG; 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. Inspect dressing for bleeding.
4. Medications according to therapeutic directives - cardiotonics (digoxin);coronary vasodilators (nitrates); antibiotics (penicillin); analgesics; anticoagulants (with valve replacements); antiarrhythmics (quinidine, procainamide HC1 [Pronestyl]).
2. Goal: promote comfort, pain relief.
1. Medicate: Demerol or morphine sulfate - severe pain lasts 2-3 days.
2. Splint incision when moving or coughing.
3. Mouth care: keep lips moist.
4. Position: 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/hour for first 4-6 hours.
3. Give fluids as ordered; maintain IV patency.
4. Diet: clear fluids —» solid food if no nausea, GI distention; sodium intake restricted, low fat.
4. Goal: promote emotional adjustment.
1. Anticipate behavior disturbances (depression, disorientation often occur 3 days postop) related to medications, fear, sleep deprivation.
2. Calm, oriented, supportive environment, as personalized as possible.
3. Encourage verbalization of feelings (family and patient).
4. Encourage independence to avoid cardiac-cripple role.
5. Goal: health teaching.
1. Alterations in lifestyle; activity, diet, work; resumption of sexual activity usually when patient can climb two flights of stairs.
2. 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.
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 patients in whom sternotomy and cardiopulmonary bypass is contraindicated or unnecessary. The left internal mammary is anastomosed to the left anterior descending coronary artery through a thoracic incision without bypass.
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 50-60% of heart disease patients.
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.
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
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. Position: 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. Support: stay with anxious patient; have supportive family member 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 (5-10 minutes q2h); auscultate breath sounds for congestion, pulmonary edema.
2. Position: elevating head of bed 20-25 cm (8-10 in) alleviates pulmonary congestion.
3. Medications 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 (Librium) HC1.
6. Vasodilators-hydrolazine, 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.
4. Goal: maintain fluid and electrolyte balance, nutritional status.
1. Urine output: 30 mL/hr minimum; estimate insensible loss in diaphoretic patient. Monitor BUN, serum creatinine, and electrolytes.
2. Daily weight; same time, clothes, scale.
3. IV: use microdrip to avoid circulatory overloading.
4. Diet:
1. Low sodium as ordered.
2. Small, frequent feedings.
3. Discuss food preferences with patient.
5. Goal: health teaching.
1. Diet restrictions; meal preparation.
2. Activity restrictions, if any; planned rest periods.
3. Medications: 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. 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. Lifethreatening 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, hypercapnea.
2. Risk factors:
1. Left ventricular failure.
2. Pulmonary embolism.
3. Drug overdose.
4. Smoke inhalation.
5. CNS damage.
6. Fluid overload.
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. Respiration: tachypnea, moist, bubbling, wheezing, labored.
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.
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. Slow respirations: morphine sulfate 3-10 mg IV/SC/IM, as ordered, to reduce respiratory rate, sedate, and produce vasodilation.
2. Remain with patient.
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. O₂: 100%, preferably by demand valve to slow respiratory rate, provide uniform ventilation, reduce venous return, and inhibit “leaky capillary” syndrome. Possibly PEEP.
2. IV:D₅W
3. Give aminophylline, as ordered, to lower venous pressure and increase cardiac output.
4. Position: high Fowler’s, extremities in dependent position, to reduce venous return and facilitate breathing.
5. Medications as ordered: digitalis; diuretics - furosemide (Lasix); inotropic agents -dobutamine (Dobutrex), dopamine; nitroglycerin, nitroprusside.
6. Vital 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. Diet: low sodium.
4. Signs of complications: edema; weight gain of 2-3 lb (0.9-1.4 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 de-
3. creased cardiac output —> pulmonary congestion, hypoxia —> inadequate circulation; high mortality rate.
4. 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, 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.
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 <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).
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 —> unresponsive.
4. CVP
1. Below 5 cm H₂O with hypovolemic shock.
2. Above 15 cm H₂O with cardiogenic, possibly septic 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 vasoconstriction 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.
4. Altered urinary elimination related to decreased renal perfusion.
5. Fluid volume deficit related to blood loss.
6. Anxiety related to severity of condition.
7. Risk for injury related to death.
4. Nursing care plan/implementation: Goal: promote venous return, circulatory perfusion.
1. Position: foot of bed elevated 20 degrees (12-16 inches), knees straight, trunk horizontal, head slightly elevated; avoid Trendelenburg position.
2. Ventilation: monitor respiratory effort, loosen restrictive clothing; O₂ as ordered.
3. Fluids: maintain IV infusions; give blood, plasma expanders as ordered (exception - stop blood immediately in anaphylactic shock).
4. Vital signs:
1. CVP (decreased with hypovolemia) arterial line, Swan-Ganz (increased pulmonary artery wedge pressue indicating cardiac failure).
2. Urine output (insert catheter for hourly output).
3. Monitor ECG (increased rate, dysrhythmias).
5. Medications (depending on type of shock) as ordered:
1. Antihypotensives - epinephrine (Adrenalin), norepinephrine (Levophed), isoproterenol (Isuprel), dopamine (Intropin).
2. Antiarrhythmics.
3. Cardiac glycosides.
4. Adrenocorticoids.
5. Antibiotics.
6. Vasodilators.
7. Beta-adrenergies.
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 >30 mL/hr.

Signs of Hypovolemic Shock

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 in brain, kidneys, lungs —> microinfarcts, tissue necrosis —» red blood cells, platelets, prothrombin, other clotting factors trapped, destroyed in process —> excessive clotting —» release of fibrin split products —» inhibition of platelet clotting —» profuse bleeding.
2. Risk factors:
1. Obstetric complications.
2. Neoplastic disease.
3. Low perfusion states (e.g., burns, hypothermia).
4. Infections.
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: convulsions, coma.
6. Lab data: prolonged - prothrombin time (PT) >15 seconds; decreased - platelets, fibrinogen level.
4. Analysis/nursing diagnosis:
1. Altered tissue perfusion related to peripheral microthrombi.
2. Risk for injury 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. Medications: heparin sodium IV, 1000 U/hr, if ordered, to reverse abnormal clotting (controversial).
3. IVs: blood to lessen shock; platelets, cryoprecipitate, fresh plasma to restore clotting factors, fibrinogen.
4. Observe: vital signs, CVP (normal 5-15 mm Hg), PAP (normal 20-30 systolic and 8-12 diastolic), and intake and output 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 >8-10 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. jj _e. Lab data: elevated AST (SGOT), WBC;
6. CT or MR1 - pericardial thickening.
7. 3 f. 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. Position: semi-fowler’s (upright or sitting); bed rest.
2. Vital signs: q2-4h and pm; apical and radial pulse; notify physician if heart sounds decrease in amplitude or if pulse pressure narrows, indicating cardiac tamponade; cooling measures as indicated.
3. O₂ as ordered.
4. Medications as ordered:
1. Analgesics—aspirin, morphine sulfate, meperidine or codeine.
2. Nonsteroidal anti-inflammatory agents —indomethacin.
3. Antimicrobial.
4. Digitalis and diuretics, if heart failure present.
5. Assist with aspiration of pericardial sac (pericardiocentesis) if needed: medicateB 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; warm drinks.
9. Monitor for signs of cardiac tamponade: tachycardia; tachypnea; hypotension; pallor; narrowed pulse pressure; pulsus paradoxus; distended neck veins.
2. Goal: maintain fluid, electrolyte balance.
1. Parenteral fluids as ordered; strict I&O.
2. Assist 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.
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. Lab data: increased serum cholesterol, I triglycerides, CBC, platelets
3. J c. 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. Position: elevate head of bed on blocks (3-6 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 qid.
4. Medications:
1. Vasodilators.
2. Antiplatelet - ASA, tidopidine, 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. Diet: /ow-fat, heart-healthy diet to slow disease progression.
5. Lifestyle choices: avoid smoking.
6. Recognizes and reports 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; >6 cm 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.
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 are emergency conditions.
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. 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. IVs: may have 2-4 sites; lactated Ringer’s may be ordered.
3. Urine output: monitored every 15-30 minutes.
4. O₂: usually via nasal prongs.
5. Medications as ordered: antihypertensives to prevent extension of dissection.
6. Transport to operating room quickly.
7. General preoperative care.
2. Goal: prevent complications postoperatively.
1. Position: 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 -12 hr 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, guaiacpositive diarrhea, abdominal distention); may have nasogastric tube.
6. Measure abdominal girth; increase seen with graft leakage.
3. Goal: promote comfort.
1. Position: alignment, comfort; prevent heel ulcers.
2. Medication: narcotics.
4. Goal: 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. 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. Position: elevate legs q2-3h; elastic stockings or Ace wraps.
2. Goal: provide for safety.
1. Assist with early ambulation.
2. Surgical asepsis with wounds, leg ulcers.
3. Observe for hemorrhage - if occurs: elevate leg, apply pressure, notify physician.
4. Observe 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 patient 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. Patient stands with tourniquet in
4. Filling of veins is observed.
5. Normal response is slow filling from below in 20-30 seconds, with no change in rate when tourniquet is removed.
6. Incompetent veins distend very quickly with back flow.
4. Prepare for sclerotherapy or vein ligation and stripping.
6. Evaluation/outcome criteria:
1. Relief or control of symptoms.
2. Activity without pain.

20. Vein ligation and stripping: surgical intervention for advancing varicosities, stasis ulcerations, and cosmetic needs of patient. 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. Nursing care plan/implementation:
1. Goal: prevent complications after discharge.
1. Position: elevate legs as instructed.
2. Activity:
1. No chair sitting to prevent venous pooling, thrombus formation. Avoid standing in one place.
3. Bleeding: report to MD
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.
2. 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. Resume daily activities; free of pain.


21. 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 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, bed rest, obesity, pregnancy.
2. Venous disease.
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 (Homan's 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. Bed rest until therapeutic level of heparin reached (5 - 7 days with traditional heparin; after 24 hours with low-molecularweight heparin).
2. Position: 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. 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. Medications: anticoagulants (sodium heparin, enoxaparin, Coumadin); streptokinase (Varidase), tissue plasminogen activator.
4. Bleeding: hematuria, epistaxis, ecchymosis.
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. Carry 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.

12. 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.

Nursing Responsibilities with Anticoagulant Therapy