SAMPLE HLTEN610A. TAFE NSW Training and Education Support Industry Skills Unit, Meadowbank. Practise in the cardiovascular nursing environment

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1 TAFE NSW Training and Education Support Industry Skills Unit, Meadowbank HLTEN610A Practise in the cardiovascular nursing environment Version 1.0 Flexible Learner Resource Product Code: ISO 9001

2 HLTEN610A Practise in the cardiovascular nursing environment V1.0 i Acknowledgments TAFE NSW Training and Education Support, Industry Skills Unit, Meadowbank would like to acknowledge the support and assistance of the following people in the production of this resource package. Writers: Kylie Brennan Reviewer/Editor: Di Dawbin Project Manager: Di Dawbin R/Education Programs Manager Training and Education Support, Industry Skills Unit, Meadowbank Acknowledgements are also given to all teachers of the Enrolled Nurse Education Program. Enquiries: Enquiries about this and other publications can be made to: TAFE NSW Training and Education Support, Industry Skills Unit, Meadowbank Locked Bag No. 6 MEADOWBANK NSW 2114 Tel: Fax: The State of New South Wales, Department of Education and Training, TAFE NSW, Training and Education Support, Industry Skills Unit, Meadowbank, Copyright of this material is reserved to Training and Education Support, Industry Skills Unit, Meadowbank, TAFE NSW. Reproduction or transmittal in whole or in part, other than for the purposes of private study or research, and subject to the provisions of the Copyright Act, is prohibited without the written authority of Training and Education Support, Industry Skills Unit, Meadowbank, TAFE NSW. ISBN ISO 9001

3 HLTEN610A Practice in the cardiovascular nursing environment V1.0 v TABLE OF CONTENTS INTRODUCTION... 1 LEARNER INFORMATION... 2 TOPIC 1 Apply pathophysiology of cardiovascular conditions TOPIC 2 Determine cardiovascular health status TOPIC 3 Multi-disciplinary health care team TOPIC 4 Nursing care plan TOPIC 5 Complex nursing interventions TOPIC 6 Pre, intra and post-care of cardiovascular diagnostic procedures TOPIC 7 Evaluate effectiveness of interventions TOPIC 8 Legal and ethical applications Assessment requirements Resource List ISO 9001

4 HLTEN610A Practice in the cardiovascular nursing environment V TOPIC 1 Apply pathophysiology of cardiovascular conditions The core unit HLTEN606A Assess clients and manage client care provided the learner with an in-depth knowledge of the pathophysiology of the human body. It also provided the learner with the skills and knowledge to understand the development of diseases and the effect they have on the body. This unit will provide the learner with the skills, knowledge and attitudes to practise in the cardiovascular nursing environment. Topic 1 of this unit will explore the pathophysiology of the cardiovascular system and will focus on the clinical manifestations and treatment of common cardiovascular conditions. Please note: You will require a human anatomy and physiology textbook to assist you in reviewing the anatomy and physiology of the human body. It is advised that the learner review the anatomy and physiology of the cardiovascular system by reading Topic 1 In-depth understanding of pathophysiology of the human body in HLTEN606A Assess clients and manage client care. Pathophysiology is one way of discovering what happens inside the body when the normal functioning of the body is interrupted. A simple definition of pathophysiology is a change in function in an individual due to a disease. ACTIVITY 1 From the following list of disorders/conditions of the cardiovascular system, choose five (5) and answer the following questions. You may use the internet or relevant textbook. Congestive cardiac failure Acute pulmonary oedema Pulmonary embolism Arrhythmia Congenital heart defects Ischaemic heart disease Heart valve dysfunction Sub-acute bacterial endocarditis Pericarditis Acute chest pain Cardiomyopathy Carotid stenosis Abdominal aortic aneurysm Peripheral vascular disease Deep vein thrombosis 1. Define the disease/condition. 2. Describe the pathophysiology of the disease/condition. 3. List the clinical manifestations of the disease/condition. 4. Outline the treatment of the disease/condition. The specific nursing care of these conditions will be reviewed in Topic 4.

5 HLTEN610A Practice in the cardiovascular nursing environment V TOPIC 2 Determine cardiovascular health status In determining a client s cardiovascular health status the nurse is performing the first stage of the nursing process: assessment. This assessment includes an interview of the client (and significant other) and a physical examination. This will enable the nurse to identify the needs of the client and implement appropriate nursing interventions. By conducting a client interview, the nurse will be able to obtain vital information that will assist in determining the client s cardiovascular health status. This information should include the client s past history such as recent surgery, coexisting conditions, allergies and current medications. Information should be obtained from the client on specific cardiac related disorders such as hypertension, rheumatic fever and hyperlipidemia. The client s family and social history should also be explored. The client s diet and exercise patterns should also be investigated along with any areas of stress including jobs, relationship and finances. The nurse should also question the cardiovascular client about the presence of chest, arm, neck or jaw discomfort or pain, dyspnoea, weakness, fatigue, dizziness and palpitations. If any of these clinical manifestations are present, the nurse should further question the client about their nature and extent. ACTIVITY 1 What questions would you ask of a client who, during a cardiovascular assessment, complained of a chest pain? During the assessment of the client, it is important that the client and significant others knowledge is assessed regarding the cardiovascular condition, management of the condition and individual treatment regimes (if already established) are reviewed. Initially, when an assessment on a client is conducted to determine their cardiovascular health status the nurse should conduct a physical examination. A physical examination of a client involves an investigation of the body to determine its state of health using any or all of the techniques of inspection, palpation, auscultation, percussion and smell (Anderson, DM, Keith, J, Novak, PD and Elliot, MA 2006). The assessment also involves the taking and recording of vital signs, height and weight. Inspection is the first step in a physical examination and involves a visual examination of the client. This skill is used to assess colour, rashes, scars, body shape, facial expressions and body structures and is an active process rather than a passive one. When conducting a cardiovascular assessment, the nurse should focus on the client s: weight and muscle composition skin turgor, integrity and colour energy level appearance compared with age comfort level or apparent level of anxiety.

6 20 HLTEN610A Practice in the cardiovascular nursing environment V1.0 The client s arms and legs should also be assessed for distribution of hair. The norm is that body hair will be distributed symmetrically and should grow thicker on the anterior surface of the arms and legs. If this is not found, it may indicate a diminished arterial blood supply to the limbs and will require further investigation. The extremities are also assessed for oedema, thrombophlebitis, cyanosis, varicose veins and lesions such as ulcers. The nails are also assessed for peripheral cyanosis. The nurse may further inspect the nails to estimate the rate of peripheral blood flow by assessing capillary refill in the fingernails. This involves applying pressure to the nails for 5 seconds and releasing. In clients with adequate arterial supply, the pink colour should return after less than three seconds. Delayed refill indicates reduced circulation or could be an indication of decreased cardiac output. The client s chest and the general appearance of the thorax are also assessed. Another important part of the inspection of the cardiovascular client is the assessment of the jugular vein. ACTIVITY 2 1. How should the client be positioned to assess for jugular vein distention? 2. What does a distended vein indicate? A vital part of the assessment of the cardiovascular client is the palpation of the peripheral pulses. ACTIVITY 3 1. List the seven (7) main arterial pulses that should be palpated during a cardiovascular assessment. 2. What is included in an assessment of an arterial pulse? Pulses are often graded on a scale.

7 HLTEN610A Practice in the cardiovascular nursing environment V ACTIVITY 4 Complete the following table. Grading Description Auscultation is the process of listening to sounds produced within the body and is vital in the assessment of the cardiovascular client. During auscultation heart sounds, rates and rhythms are assessed. A heart sound is created by the opening and closing of the heart valves. Illustration of auscultation ACTIVITY A.D.A.M., Inc. 1. What are the four (4) cardiac auscultation sites? The two normal heart sounds are called S1 and S2. S1 is the first heart sound and occurs at the outset of ventricular systole. It is linked with the closure of the mitral and tricuspid valve and is synchronous with the apical pulse. S2 is the second heart sound and occurs at the outset of ventricular diastole. It is linked with the closure of the aortic and pulmonic valve (Anderson, DM et al 2006).

8 22 HLTEN610A Practice in the cardiovascular nursing environment V1.0 Abnormal heart sounds include clicks, gallops, murmurs, rubs and snaps. Clicks are high pitched abnormal heart sounds that result from tensing of the chordae tendineae structures and mitral valve cusps. S3, also known as ventricular gallop, is a low-pitched sound that occurs when ventricles fill rapidly. It is common in children and clients with a high cardiac output. S4 is also known as an atrial gallop and is a result of increased resistance to ventricular filling. It can be heard after acute myocardial infarction. Murmurs are blowing, whooshing or rasping sounds produced by turbulent blood flow through the heart valves or near the heart. Murmurs occur when a valve does not close tightly (such as with mitral regurgitation) and blood leaks backward, or when the blood flows through a narrowed or stiff valve (such as with aortic stenosis). Rubs are a result of pericarditis and produce a scraping sound. It is heard during both systole and diastole. Snaps are a result of a stenotic valve attempting to open. ACTIVITY 6 1. Access the following website to hear some heart sounds 2. Complete the table below on heart murmur grades. Grade I II III IV V VI Description Percussion is not routinely performed on the cardiovascular client. Suggested websites