Cardiovascular Disease

Transcription

1 Cardiovascular Disease Assessment Nursing Implications Therapy Implications Chest pain Hypertension (BP greater than or equal to 140 systolic or 90 diastolic) Tachycardia (Pulse greater than 100 beats per minute) Bradycardia (Pulse less than 60 beats per minute) Hypotension (BP less than or equal to 95 systolic or 60 diastolic) Pain in extremity Shortness of breath Stop any activity and have patient sit or lie down. Assess how long the pain has been occurring and whether any intervention relieves the pain. Have they experienced pain like this before? How severe is the pain on a scale of 1-10 using the Angina rating scale. Assess heart rate, heart regularity, and blood pressure. Does the patient have nitroglycerin, and if so, have they taken it? If no relief, notify physician or call 911. Assess heart rate and regularity. Assess for compliance with medication, especially ACEI, ARBs, calcium channel blockers, and beta blockers. Assess for signs of lightheadedness, dizziness, headache, or orthostatic blood pressure changes. Assess blood pressure and heart rate regularity. Assess adherence to medication regimen, especially beta blockers and calcium channel blockers. Assess barriers to medication management. Assess other indications for cause of tachycardia: caffeine, pain, activity, hypoxia, etc. Assess blood pressure and heart regularity. Assess medications, paying particular attention to beta blockers, calcium channel blockers, and digoxin. Determine whether patient has a pacemaker and, if so, consider interrogation. Assess use of narcotic medication, if ordered. Assess heart rate and rhythm. Assess medications, paying particular attention to ACEI, ARBs, calcium channel blockers, nitrates, beta blockers, and other vasodilators. Assess for signs and symptoms of infection, including temperature. Assess for signs of orthostatic hypotension, dehydration, lightheadedness, or dizziness. Assess for quality and duration of the pain. Assess for pulses in the extremity. Assess for color, temperature, and swelling to the extremity. For severe, unrelenting pain with a sudden onset and absent pulses, call 911. Assess breath sounds and VS (normal respiratory rate is 12-20). Check pulse oximetry if ordered for patient. Assess need for rescue inhaler (if applicable). Assess for confusion, chest pain, dizziness, or faintness. Assess level of dyspnea. If does not resolve with rest, notify MD or call 911. Medications Stop any activity and have the patient sit or lie down. Assess level of pain and vital signs. Does the patient take nitroglycerin? If so, have them take it. Consult with nursing, M.D., or call 911 if no resolution in symptoms. Some patients can use prophylactic nitroglycerin to avoid angina or chest pain with exercise. Assess other vital signs and consult with nursing on findings. Assess for medication compliance, headache, dizziness, or lightheadedness. Hold exercise for blood pressure greater than 180 systolic and/or 100 diastolic. If systolic BP has a great than 10mmHg drop from baseline despite increase in workload during exercise, immediately stop the exercise and assess the patient. Assess other vital signs and consult with nursing on findings. Hold exercise for heart rate greater than 100 at rest. Refer to the Vital Sign Monitoring and Absolute and Relative Indications for Stopping Exercise and Activities Job Aids. Assess other vital signs and consult with nursing on findings. Refer to the Vital Sign Monitoring and Absolute and Relative Indications for Stopping Exercise and Activities Job Aids. Assess other vital signs and consult with nursing on findings. Assess for medication compliance, dehydration, dizziness or lightheadedness. Assess for signs/symptoms of infection. If systolic BP >200mmHg and/or diastolic BP >100mmHg during exercise, stop the activity, assess the patient, and adjust the exercise routine. Assess for quality and duration of the pain. Assess for pulses in the extremity. Assess for color, temperature, and swelling to the extremity. Consult with nursing on findings. For leg cramps or an increase in leg pain during exercise, stop the exercise, assess the patient, and adjust the exercise routine. For severe, unrelenting pain with a sudden onset and absent pulses, call 911. Assess VS and breath sounds. For severe shortness of breath during exercise, stop immediately and assess the patient. For shortness of breath with fatigue or increase in wheezing during exercise, stop the activity, assess the patient, and adjust the exercise routine. Nitroglycerine is a vasodilator used to treat angina. For prn use, have patients take one dose at onset of chest pain and repeat every 5 minutes until chest pain is relieved, to a maximum of three doses. If pain is not relieved after 15 minutes, notify M.D. or call 911. Anticoagulants/Antithrombolytics are medications used to reduce risk for blood clots. Monitor patients on blood thinners closely for bleeding, such as at the gum lines while brushing teeth, blood in stool, etc. Monitor PT/INR for patients on Coumadin: warfarin [Coumadin], clopidogrel bisulfate [Plavix]) Antiarrhythmics are medications used to keep the heart in its normal rhythm. Monitor patients closely for signs of an arrhythmia or increased extra heart beats. Monitor patients on amiodarone [Cordarone] closely for pulmonary complications; any increases in shortness of breath should be reported to the prescriber: flecainide acetate [Tambocor], propafenone hydrochloride [Rythmol])

2 Heart Failure Assessment Findings Increased dyspnea with or without exertion Weight Gain of 2-3 pounds in 24 hours; Weight gain of more than 5 pounds in a week or less; or Increased amount of edema Fatigue or loss of appetite Vital sign changes Confusion Sleep pattern changes Nursing Implications Assess for fluid retention such as weight gain, S3 heart tone, rales, JVD and sleep pattern changes. Assess for vital sign changes. Evaluate compliance with medications and diet. Assess for signs of failure such as increased dyspnea, rales, S3 heart tone, JVD or sleep pattern changes. Assess for vital sign changes. Assess medication compliance, paying particular attention to diuretic therapy. Notify M.D. and anticipate need for increasing diuretic dose if standing orders do not already exist. Assess for fluid volume changes such as weight gain, S3, rales, or sleep pattern changes. Assess for vital sign changes. Consider digoxin toxicity if nausea or loss of appetite is present. Assess serum potassium for patients on a loop diuretic.. Assess CBC for signs of anemia. Assess medication compliance and tolerance. Assess heart rhythm for regularity. Assess for fluid volume retention such as weight gain, S3 heart tone, rales, JVD, and sleep pattern changes. Decreased blood flow to the brain can cause confusion. Assess vital signs for hypotension. Assess O2 saturation for hypoxia. Assess for dehydration. Assess serum sodium level. Assess for fluid volume retention such as weight gain, S3 heart tone, rales, JVD, and sleep pattern changes. Waking up with shortness of breath after 2 to 3 hours of sleep (paroxysmal nocturnal dyspnea) is often an early sign of heart failure. Assess for fluid retention and changes in vital signs. Determine whether the patient is requiring additional pillows or sitting in a recliner to sleep at night. Medications Therapy Implications Assess for signs of fluid retention such as edema or weight gain. Assess vital signs for changes from baseline and consult with nursing on your findings. Hold exercise until symptoms are controlled. Assess for increasing dyspnea or fatigue. Assess for vital sign changes. Conference with nursing about findings and appropriateness of continuing with exercise/activity program. Assess for increased dyspnea, lightheadedness, or mental status changes. Assess for weight gain or increased edema. Assess vital signs and heart rhythm for regularity. Conference with nursing about findings and appropriateness for continuing with exercise/activity program. Assess for signs of fluid retention and increased dyspnea. Conference with nursing about finding and appropriateness for continuing with exercise/activity program. Refer to the Vital Sign Monitoring and Absolute and Relative Indications for Stopping Exercise and Activities Job Aids. Assess for signs of fluid retention such as edema or weight gain. Assess vital signs for changes from baseline, O2 saturation for hypoxia, and consult with nursing on your findings. Hold exercise program until symptoms have resolved. This characteristic is commonly seen in patients in early stages of heart failure as the lungs fill with fluid when the patient lays down to go to sleep. Assess for additional signs of fluid retention and for changes in vital signs. Evaluate dyspnea at rest and consult with nursing prior to exercise or activity. Angiotensin Converting Enzyme Inhibitors (ACEI) are used to reduce the workload of the heart in patients with heart failure. Monitor for hypotension, cough, angioedema, potassium retention, and renal failure: captopril [Capoten], ramipril [Altace]) Angiotensin Receptor Blockers (ARBs) are medications commonly used in patients who cannot tolerate ACEI inhibitors. Monitor for orthostatic changes as well as other signs of hypotension such as dizziness: losartan [Cozaar], valsartan [Diovan]) Diuretics reduce fluid build up by causing the kidneys to excrete water. Monitor patients on loop diuretics such as Lasix closely for hypokalemia and signs of dehydration: furosemide [Lasix], bumetanide [Bumex]) Aldosterone Antagonists are used for signs of hyperkalemia and renal failure: spironolactone [Aldactone]) Digoxin helps the heart pump more effectively, but the patient must be monitored closely for signs of toxicity such as nausea, vomiting, headache, bradycardia, and blurred or yellow vision. Beta Blockers are medications that slow the heart rate and lower the blood pressure; therefore it is important to monitor these patients closely for hypotension or bradycardia associated with their medication dosages. Beta blockers can also mask the signs of hypoglycemia in diabetic patients: metoprolol [Lopressor], carvedilol [Coreg])

3 COPD ASSESSMENT NURSE IMPLICATIONS THERAPY IMPLICATIONS Increased dyspnea & cough with increase in sputum & change in color or thickness Wheezing, chest tightness or pain, or increased fatigue Fever Hypoxemia, low SpO2 readings, or increased use of accessory muscles Acute onset confusion Signs of impending exacerbation. Assess for fluid retention, wheezing, cyanosis, restlessness, sleepiness, decreased appetite, and low SpO2 & notify MD. If severe or sudden onset, call 911. Differentiate between angina and respiratory causes. If respiratory, assess if patient has used rescue or shortacting medication & level of relief. Reinforce exercise strategies. Assess for other signs of impending exacerbation. Possible infectious exacerbation; assess for signs/symptoms of infection & notify MD if present (may need antibiotics). Assess medications as this could also indicate acute adrenal insufficiency if steroids are stopped suddenly. Apply O2 if present. Assess breath sounds, fluid retention, other VS. Assess for signs of impending exacerbation. Reinforce therapy exercise strategies. Could be hypercapnia (too much CO 2 ) due to depressed ventilation. Assess breath sounds, VS, and recent medications taken that could depress respirations. Patient will likely need emergent care. Pursed-lip breathing, energy conservation, work simplification, & aerobic exercises to increase functional capacity. Unidirectional breathing may help. If severe & occurs during exercise, stop immediately. No exercise if having chest pain. Assess relief by rescue medication. Conduct breathing exercises and strength training for respiratory muscle function. If during exercise then stop, assess, & adjust the routine. Sudden decrease in exercise tolerance could signal impending exacerbation so assess for other signs. Assess other vital signs and for signs/symptoms of infection. No exercise during acute illness. Assess medications as this could also indicate acute adrenal insufficiency if steroids are stopped suddenly. No exercise if SpO2 lower than normal for patient. Unsupported upper extremity exercise training to improve functional exercise capacity. Limited ventilatory reserve will not allow for compensation of increased CO 2 production with increased exercise or physical activity. Assess breath sounds, VS, and recent medications taken that could depress respirations. Notify nurse to discuss findings, but patient likely will need to seek emergent care. Muscle wasting or dysphagia Offer nutrition counseling for smaller, more frequent meals; high protein, high calorie, fruits & vegetables. Assess weights, coughing after meals or other signs of aspiration. Consider SLP consult. Reinforce therapy exercise strategies. Eating causes increased energy expenditure & possible fatigue. Conduct breathing exercises & strength training for respiratory muscle function. Exercises for UE & LE strengthening. Teach energy conservation & work simplification. SLP consult for screening, possible swallowing studies, training in breath support for speaking & when eating, & self-management techniques. Orthopnea, ankle edema, or fluid retention Abdominal pain, confusion, dehydration, dizziness, rapid HR, headache, joint pain, nausea, profound weakness, rapid RR Assess breath sounds & weight trends for signs of fluid retention. Acute adrenal crisis, likely from stopping steroids too quickly. Assess for signs/symptoms of infection. Activate 911 and send patient to the hospital. Breathing exercises & strength training. Assess RPE with activity. Observe for sudden changes in condition. Acute adrenal crisis, likely from stopping steroids too quickly. Assess for signs/symptoms of infection. Activate 911 and send patient to the hospital. MEDICATIONS Anticholinergics are indicated for relief of bronchospasm: short acting: ipratropium bromide [Atrovent] and long acting: tiotropium [Spiriva]) Short-acting ß2-agonists are "rescue" medications used for relief of acute reversible airflow obstruction: albuterol [Proventil] and levalbuterol [Xopenex]) Long-acting ß2-agonists are indicated for maintenance bronchodilation, bronchospasm control, & nocturnal symptoms: salmeterol [Serevent] and formoterol [Foradil]) Corticosteroids are anti-inflammatory and indicated for treatment of exacerbation or long-term management: budesonide [Pulmicort], fluticasone/salmeterol [Advair]) For exacerbations: inhaled bronchodilators, ß2-agonists, antibiotics, & systemic corticosteroids. Supplemental O 2, but only if receiving optimal bronchodilator therapy.

4 Cardiac Surgery ASSESSMENT NURSING IMPLICATIONS THERAPY IMPLICATIONS Arrhythmia with rapid, uneven pulse Assess pulse for rate, rhythm, & regularity, assess for weakness, chest pain, dyspnea, confusion, lightheadedness, or hypotension. Notify the MD. If associated with chest pain, seek emergent care. Assess pulse for rate, rhythm, and regularity. Assess for weakness, chest pain, dyspnea, confusion, lightheadedness, or hypotension. Notify the MD. If associated with chest pain, seek emergent care. Sudden shortness of breath, chest pain, & cough which may have bloody sputum Possible pulmonary embolism. Assess VS, pain, wheezing, leg edema, rapid HR with weak pulse, & cyanosis. Chest pain will worsen w/activity, but not be relieved with rest. Notify physician & call EMS for emergent care as this is a life threatening condition. Pulmonary embolism can occur at rest or w/activity. Stop activity immediately, assess VS, & notify MD. Call EMS for emergent care as this is life threatening. Crunching, popping, or cracking sound, feels like sternum moves Elevated temperature / fever Ankle or lower extremity edema, orthopnea, dyspnea Weight loss, poor appetite Drainage from incision Possible sternal dehiscence. Notify the physician. Avoid overhead arm movement or exercises until sternum completely healed. Assess for possible wound infection or respiratory infection. Assess frequency of using incentive spirometry & instruct on coughing & deep breathing exercises. Observe for hyperglycemia if diabetic. Assess breath sounds and VS. Assess activity level of patient. If not getting enough activity, will contribute to LE edema. Assess if patient is keeping legs elevated during rest periods, not crossing legs, & walking daily. Assess nutrition, hydration, & nausea. Educate on ways to stimulate appetite, cope with nausea, & positive effect of nutrition on healing from surgery. If dehydrated, assess medications for diuretics and notify MD. Assess temperature & wound. Assess sign/symptoms of infection or dehiscence of wound. Report findings to MD for possible antibiotic or wound care orders. Instruct patient regarding proper incision care. If the patient is diabetic, instruct patient to watch for hyperglycemia. Possible sternal dehiscence. Notify the physician. Avoid overhead arm movement or exercises until sternum completely healed. Assess for signs/symptoms of infection. Instruct to increase incentive spirometer use w/coughing & deep breathing. Observe for hyperglycemia if diabetic. Reinforce nurse teaching. Assess need for compression stockings. If not improved or becomes painful along with increased fatigue and dyspnea, notify MD. Assess hydration & nutrition status. Communicate findings to nurse. Adjust exercise plan accordingly. Assess wound for infection. Communicate findings with the nurse and notify MD. Upper back & shoulder pain, respiratory difficulty Depression, lethargy, weakness, fatigue Constipation Conduct pain assessment and auscultate breath sounds. Utilize pain control techniques, incentive spirometer usage, and coughing & deep breathing exercises. Educate that walking, daily activities, and time will lessen discomfort. Assess for anemia, arrhythmia, GI bleed, pneumonia, infection, and for proper nutrition & exercise. Encourage patient to resume hobbies & to visit with family or friends. Advise on support groups. If no resolution or if worsens, instruct patient to discuss with their physician. Educate regarding post-op constipation, ways to avoid, and ways to treat. Advise patient not to strain or illicit the Valsalva maneuver due to increases in intrathoracic pressure, which could cause bradycardia. Utilize pain control techniques, incentive spirometer usage, and coughing & deep breathing exercises. Instruct on shoulder exercises. Educate that walking, daily activities, and time will lessen discomfort. Encourage increased activity and exercise. Stop exercise if fatigue is severe & sudden. Communicate findings to nurse. Advise against straining or causing Valsalva maneuver, which could cause bradycardia. Instruct on benefits of exercise in relation to constipation.

5 BORG SCALE How hard is the exercise? MODIFIED BORG SCALE How short of breath? 6 No exertion at all 0 Nothing at all 7 Extremely light 1 Very slightly 8 2 Slightly 9 Very light 3 Moderately 10 4 Somewhat severely 11 Light 5 Severely Somewhat hard Very severely 15 Hard 9 Very, very severely Maximally 17 Very hard Extremely hard 20

6 2 Minute Walk Test ASSESSMENT NURSING IMPLICATIONS THERAPY IMPLICATIONS Conducting the Test Clinician Guidelines Pretest Safety Guidelines Normal Aging and the Cardiovascular System Location: You can perform this test indoors or outdoors, weather & temperature permitting. Ensure that the location is safe (as free of clutter and obstacles as possible). Remember, cardiopulmonary patients should not exercise in extreme temperatures. Set-up: Mark off a walking path using a tape measure and brightly colored tape or flag markers. Include at least two turnaround points. Equipment: Make sure you have a stopwatch, tape measure, portable chair, blood pressure cuff, and the Borg RPE and Dyspnea Scales. Instructions: Tell the patient: You will be walking laps on a course that I have marked off for you. When I say go, walk as fast as you can for 2 minutes. I will time the 2 minutes using this stopwatch. You can stop to rest if you get short of breath, feel weak, fatigued or have chest or leg pain. If you have to rest, the stopwatch will continue to run. Once you are ready to go again, you can continue to walk for the amount of time left in the test. Take the following vital signs at the time points indicated o Before test: heart rate (HR), blood pressure (B/P) and respiratory rate (RR) o During test: HR and if possible B/P and RR o At end of test: HR, B/P, and RR o If available, you may also take SpO2 using pulse oximeter. Instruct the patient on use of the appropriate Rating of Perceived Exertion (RPE) Scale (Borg RPE or Dyspnea scale) prior to starting the test. Explain to the patient that the response to exercise using the scale will be conducted at the end of the test. Have patient wear appropriate and comfortable shoes Assistive devices (cane, walker, etc) may be used during the test Instruct patient not to eat within 1 hour before the test when possible Instruct patient to take medications as prescribed Walk behind the patient, however, do not coax them Inform the patient of the time after each minute has passed Conserve the patient s cardio-respiratory capacity by keeping conversation to a minimum and asking them not to talk during the test. At the end of the test, have the patient sit down in the chair Take the vital signs at that time, starting with HR (HR drops from peak rate more rapidly than BP, at a rate of about one beat per second elapsed) Have the patient rate their response to exercise intensity using the appropriate RPE scale. Calculate and document the total distance in that [2 or 6] minute time period. Do Not Start the Test If: Resting Systolic BP > 180mmHg Resting Diastolic BP > 100mmHg Resting Heart Rate > 100bpm or < 45bpm Resting Respiratory rate > 24/min (too breathless to converse) Assess the patient for peripheral edema, dyspnea at rest/minimal exertion, S3 heart sound, crackles/fine respiratory rales in lower lung bases, or other adventitious breath sounds prior to test. Keep the following facts in mind when conducting this test on older adult patients: Heart rate may not rise as quickly or as much as in younger population Heart rate during exercise should be under bpm Beta blockers may affect heart rate response to exercise. Therefore HR may not be a reliable indicator, use the appropriate RPE scale to measure response to exercise. While patient performance will vary based on diagnosis and comorbidities, average distances that are considered normal for healthy, community dwelling older adults are listed in the table below (Steffan et al, 2002). Age Years Years Years Distance Feet (Meters) Male 1876 (572) 1728 (527) 1368 (417) Female 1765 (538) 1545 (471) 1286 (392)