Chapter 21
Assessment of
Cardiovascular Function
Overview of Anatomy and Physiology
 Three layers: endocardium,
myocardium, epicardium
 Four chambers: Right atrium
and ventricle, left atrium and
ventricle
 Atrioventricular valves:
tricuspid and mitral
 Semilunar valves: aortic and
pulmonic
 Coronary arteries
 Cardiac conduction system
(electrophysiology)
 Cardiac hemodynamics
Anatomy of the Heart
Cardiac Conduction System:
Electrophysiology
Cardiac Action Potential
 Depolarization: electrical activation
of cell caused by influx of sodium
into cell while potassium exits cell
 Repolarization: return of cell to
resting state caused by reentry of
potassium into cell while sodium
exits
 Refractory periods
o Effective refractory period:
phase in which cells are
incapable of depolarizing
o Relative refractory period:
phase in which cells require
stronger-than-normal
stimulus to depolarize.
Cardiac Action Potential Cycle
Cardiac Cycle
 Refers to the events that occur in the
heart from the beginning of one
heartbeat to the next
 Number of cycles depends on heart
rate
 Each cycle has three major
sequential events:
o Diastole
o Atrial systole
o Ventricular systole
Cardiac Output #1
 Ejection fraction: percent of end
diastolic volume ejected with each
heart beat (left ventricle)
 Cardiac output (CO): amount of
blood pumped by ventricle in liters
per minute
 CO = SV × HR
Cardiac Output #2
 Stroke volume (SV): amount of blood
ejected with each heartbeat
o Preload: degree of stretch of
cardiac muscle fibers at end
of diastole
o Afterload: resistance to
ejection of blood from
ventricle
o Contractility: ability of
cardiac muscle to shorten in
response to electrical
impulse
Influencing Factors
 Control of heart rate
o Autonomic nervous system,
baroreceptors
 Control of stroke volume
o Preload: Frank–Starling Law
o Afterload: affected by
systemic vascular resistance,
pulmonary vascular
resistance
Contractility
 Contractility increased by
catecholamines, SNS, certain
medications
 Increased contractility results
in increased stroke volume
 Decreased by hypoxemia,
acidosis, certain medications
Assessment of the Cardiovascular System
 Health history
 Demographic information
 Family/genetic history
 Cultural/social factors
 Risk factors
o Modifiable
o Nonmodifiable
Health History
 Common symptoms
o Chest pain/discomfort
o Pain/discomfort in other
areas of the upper body
o SOB/dyspnea
o Peripheral edema, weight
gain, abdominal distention
o Palpitations
o Unusual fatigue, dizziness,
syncope, change in LOC
Past Health, Family, and Social History
 Medications
 Nutrition
 Elimination
 Activity, exercise
 Sleep, rest
 Self-perception/self-concept
 Roles and relationships
 Sexuality and reproduction
 Coping and stress tolerance
Physical Assessment of the Cardiovascular
System
 General appearance
 Skin and extremities
 Pulse pressure
 Blood pressure; orthostatic changes
 Arterial pulses
 Jugular venous pulsations
 Heart inspection, palpation,
auscultation
 Assessment of other systems
Laboratory Tests
 Cardiac biomarkers
 Blood chemistry, hematology,
coagulation
 Lipid profile
 Brain (B-type) natriuretic peptide
 C-reactive protein
 Homocysteine
Electrocardiography
 12-lead ECG
 Continuous monitoring
o Hardwire
o Telemetry
o Lead systems
o Ambulatory monitoring
Cardiac Stress Testing
 Exercise stress test
o Patient walks on treadmill
with intensity progressing
according to protocols
o ECG, V/S, symptoms
monitored
o Terminated when target HR is
achieved
 Pharmacologic stress testing
o Vasodilating agents given to
mimic exercise
Diagnostic Tests  Minimally invasive cardiac output
 Radionuclide imaging: monitoring devices
o Myocardial perfusion
imaging Pulmonary Artery Catheter and Pressure
o Positron emission Monitoring System
tomography
o Test of ventricular function,
wall motion
o Computed tomography
o Magnetic resonance
angiography

Echocardiography
 Noninvasive ultrasound test that is
used to:
o Measure the ejection
fraction
o Examine the size, shape, and
motion of cardiac structures
 Transthoracic
 Transesophageal
Chapter 22
Cardiac Catheterization
 Invasive procedure used to diagnose Management of Patients with Arrhythmias
structural and functional diseases of and
the heart and great vessels Conduction Problems
 Right heart catheterization
o Pulmonary artery pressure Arrhythmias #1
and oxygen saturations may  Disorders of formation or
be obtained; biopsy of conduction (or both) of electrical
myocardial tissue may be impulses within heart
obtained  Can cause disturbances of
 Left heart catheterization o Rate
o Involves use of contrast o Rhythm
agent o Both rate and rhythm
 Potentially can alter blood flow and
Nursing Interventions cause hemodynamic changes
 Observe cath site for bleeding,  Diagnosed by analysis of
hematoma electrographic waveform
 Assess peripheral pulses
 Evaluate temperature, color, and Arrhythmias #2
capillary refill of affected extremity  Atrial
 Screen for arrhythmias o Premature atrial complex
 Maintain bed rest 2 to 6 hours o Atrial flutter
 Instruct patient to report chest pain, o Atrial fibrillation
bleeding  Ventricular
 Monitor for contrast-induced o Premature ventricular
nephropathy complex
 Ensure patient safety o Ventricular tachycardia
o Ventricular fibrillation
Hemodynamic Monitoring o Ventricular asystole
 Central venous pressure Normal Electrical Conduction
 Pulmonary artery pressure  SA node (sinus node)
 Intra-arterial B/P monitoring
  AV node o QRS complex
 Conduction o T wave
 Bundle of His o U wave
 Right and left bundle branches o PR interval
 Purkinje fibers o ST segment
 Depolarization = stimulation = o QT interval
systole o TP interval
 Repolarization = relaxation = diastole o PP interval
Conduction Abnormalities
 First-degree AV block Analyzing the EC Rhythm Strip
 Second-degree AV block, type I  Normal sinus rhythm
(Wenckebach)  Sinus node arrhythmias
 Second-degree AV block, type II o Sinus bradycardia
 Third-degree AV block o Sinus tachycardia

Relationship of EC Comple,, EC raph and Commonly Measured

Lead System, and Electrical Impulse Components

Normal Sinus Rhythm

EC Electrode Placement

Sinus Bradycardia

Sinus Tachycardia
The Electrocardiogram (EC )
 Electrode placement
o Electrode adhesion
 Types of ECG
 ECG interpretation
o P wave
Sinus Arrhythmia
Assessment of the Patient with an
Arrhythmia #1
 Causes of arrhythmia, contributing
factors, the arrhythmia’s effect on
the heart’s ability to pump an
adequate blood volume
 Assess indicators of cardiac output
and oxygenation
 Health history: previous occurrences
of decreased cardiac output,
possible causes of the arrhythmia
 All medications (prescribed and
over-the-counter)
 Psychosocial assessment: patient’s
“perception” of arrhythmia
Assessment of the Patient with an
Arrhythmia #2
 Physical assessment include
o Skin (pale and cool)
o Signs of fluid retention (JVD,
lung auscultation)
o Rate, rhythm of apical,
peripheral pulses
o Heart sounds
o Blood pressure, pulse
pressure
Collaborative Problems and Potential
Complications
 Cardiac arrest
 Heart failure
 Thromboembolic event, especially
with atrial fibrillation
Planning and oals for the Patient with an
Arrhythmia
 Goals
o Eradicating or decreasing
occurrence of arrhythmia to
maintain cardiac output
o Minimizing anxiety
o Acquiring knowledge about
arrhythmia and its treatment
Nursing Interventions for the Patient with
an Arrhythmia
 Monitor and manage the arrhythmia
 Reduce anxiety
 Promote home- and community-
based care
 Educate the patient about self-care
 Continuing care
Nursing Intervention: Monitor and Manage
the Arrhythmia
 Assess vital signs on an ongoing
basis
 Assess for lightheadedness,
dizziness, fainting
 If hospitalized
o Obtain 12-lead ECG
o Continuous monitoring
o Monitor rhythm strips
periodically
 Antiarrhythmic medications
o “6-minute walk test”
Nursing Intervention: Minimize An,iety
 Stay with patient
 Maintain safety and security
 Discuss emotional response to
arrhythmia
 Help patient develop a system to
identify factors that contribute to
episodes of the arrhythmia
 Maximize the patient’s control
Nursing Intervention: Promote Home and
Community-Based Care
 Educate the patient
o Treatment options
o Therapeutic medication
levels
o How to take pulse before
medication administration
o How to recognize symptoms
of the arrhythmia
o Measures to decrease
recurrence
o Plan of action in case of an
emergency
o CPR (family teaching)
Nursing Intervention: Continuing Care
 Referral for home care
o Hemodynamically unstable
with signs of decreased CO
 o Significant comorbidities
o Socioeconomic issues
o Limited self-management
skills
o Electronic device recently
implanted
Evaluation of the Patient with an
Arrhythmia
 Maintain cardiac output
o Stable VS, no signs of
arrhythmia
 Experience reduced anxiety
o Positive attitude, confidence
in ability to act if an
emergency occurs
 Express understanding of arrhythmia
and treatment
Adjunctive Modalities and Management
 Used when medications alone are
ineffective against arrhythmias
 Pacemakers
 Cardioversion
 Defibrillation
 Nurse responsible for assessment of
the patient’s understanding
regarding the mechanical therapy
Pacemakers
 Electronic device that provides
electrical stimuli to heart muscle
 Types
o Permanent
o Temporary
 Pacemaker generator functions
o NASPE-BPEG code for
pacemaker function
Implanted Transvenous Pacemaker
Complications of Pacemaker Use
 Infection
 Bleeding or hematoma formation
 Dislocation of lead
 Skeletal muscle or phrenic nerve
stimulation
 Cardiac tamponade
 Pacemaker malfunction
Cardioversion and Defibrillation
 Treat tachyarrhythmias by delivering
electrical current that depolarizes
critical mass of myocardial cells
o When cells repolarize, sinus
node is usually able to
recapture role as heart
pacemaker
 In cardioversion, current delivery is
synchronized with patient’s ECG
 In defibrillation, current delivery is
unsynchronized
Paddle Placement for Defibrillation
Safety Measures for Defibrillation
 Ensure good contact between skin,
pads, and paddles
o Use conductive medium, 20
to 25 pounds of pressure
 Place paddles so they do not touch
bedding or clothing and are not near
medication patches or oxygen flow
 If cardioverting, turn synchronizer on
 If defibrillating, turn synchronizer off
 Do not charge device until ready to
shock
 Call “clear” three times; follow
checks required for clear
o Ensure no one is in contact
with patient, bed, or
equipment
Implantable Cardioverter Defibrillator (ICD)
 Device that detects and terminates Pathophysiology of Atherosclerosis
life-threatening episodes of
tachycardia and fibrillation
 NASPE-BPEG code
 Antitachycardia pacing

Implantable Cardioverter Defibrillator (ICD)

The Coronary Arteries

Nursing Management of the Patient

with a Permanent Electronic Device
 ECG assessment
 CXR
 Nursing assessment
o CO and hemodynamic
stability
o Incision site
o Signs of ineffective
coping
o Level of knowledge
and education needs
of family and patient
Chapter 23
Management of Patients with
Coronary Vascular Disorders
Coronary Atherosclerosis
 Atherosclerosis is the abnormal
accumulation of lipid deposits and
fibrous tissue within arterial walls
and lumen
 In coronary atherosclerosis,
blockages and narrowing of the
coronary vessels reduce blood flow
to the myocardium
 Cardiovascular disease is the leading
cause of death in the United States
for men and women of all racial and
ethnic groups
 Coronary artery disease (CAD) is the
most prevalent cardiovascular
disease in adults
Clinical Manifestations of Atherosclerosis
 Symptoms are caused by myocardial
ischemia
 Symptoms and complications are
related to the location and degree of
vessel obstruction
 Angina pectoris (most common
manifestation)
 Other symptoms: epigastric distress,
pain that radiates to jaw or left arm,
SOB, atypical symptoms in women
 Myocardial infarction
 Heart failure
 Sudden cardiac death
Risk Factors for Coronary Artery Disease
(CAD)
o Four modifiable risk factors
cited as major (cholesterol
abnormalities, tobacco use,
HTN, and diabetes)
 Elevated LDL: primary target for
cholesterol-lowering medication
  Framingham risk calculator
 Metabolic syndrome
 hs-CRP (high-sensitivity C-reactive
protein)
Prevention of CAD
 Control cholesterol
 Dietary measures
 Physical activity
 Medications
 Cessation of tobacco use
 Manage HTN
 Control diabetes
Cholesterol Medications
 Six types of lipid-lowering agents:
affect the lipid components
somewhat differently
o 3-Hydroxy-3-methylglutaryl
coenzyme A (HMG-CoA) (or
statins)
o Nicotinic acids
o Fibric acids (or fibrates)
o Bile acid sequestrants (or
resins)
o Cholesterol absorption
inhibitors
o Omega-3 acid-ethyl esters
Angina Pectoris
 A syndrome characterized by
episodes or paroxysmal pain or
pressure in the anterior chest caused
by insufficient coronary blood flow
 Physical exertion or emotional stress
increases myocardial oxygen
demand, and the coronary vessels
are unable to supply sufficient blood
flow to meet the oxygen demand
Assessment and Findings for Angina
 May be described as tightness,
choking, or a heavy sensation
 Frequently retrosternal and may
radiate to neck, jaw, shoulders, back
or arms (usually left)
 Anxiety frequently accompanies the
pain
 Other symptoms may occur:
dyspnea or shortness of breath,
dizziness, nausea, and vomiting
 The pain of typical angina subsides
with rest or NTG
 Unstable angina is characterized by
increased frequency and severity
and is not relieved by rest and NTG.
Requires medical intervention!
erontologic Considerations for Angina
 Diminished pain transition that
occurs with aging may affect
presentation of symptoms
 “Silent” CAD
 Teach older adults to recognize their
“chest pain–like” symptoms (i.e.,
weakness)
 Pharmacologic stress testing; cardiac
catheterization
 Medications should be used
cautiously!
Treatment of Angina Pectoris
 Treatment seeks to decrease
myocardial oxygen demand and
increase oxygen supply
 Medications
 Oxygen
 Reduce and control risk factors
 Reperfusion therapy may also be
done
Medications for Angina
 Nitroglycerin
 Beta-adrenergic blocking agents
 Calcium channel blocking agents
 Antiplatelet and anticoagulant
medications
 Aspirin
 Clopidogrel and ticlopidine
 Heparin
 Glycoprotein IIb/IIIa agents
Acute Coronary Syndrome (ACS) and
Myocardial Infarction (MI)
 Emergent situation
 Characterized by an acute onset of
myocardial ischemia that results in
myocardial death (i.e., MI) if
definitive interventions do not occur
promptly
 Although the terms coronary
occlusion, heart attack, and MI are
used synonymously, the preferred
term is MI
Effects of Ischemia, Injury, and Infarction
on EC
Assessment of the Patient with Angina
Pectoris
 Symptoms and activities, especially
those that precede and precipitate
attacks
 Risk factors, lifestyle, and health
promotion activities
 Patient and family knowledge
 Adherence to the plan of care
Collaborative Problems of the Patient with
Angina Pectoris
 ACS, MI, or both
 Arrhythmias and cardiac arrest
 Heart failure
 Cardiogenic shock
Planning and oals for the Patient with
Angina Pectoris
 Goals
o Immediate and appropriate
treatment of angina
o Prevention of angina
o Reduction of anxiety
o Awareness of the disease
process
o Understanding of prescribed
care and adherence to the
self-care program
o Absence of complications
Nursing Interventions for the Patient with
Angina Pectoris
 Treat angina
 Reduce anxiety
 Prevent pain
 Educate patients about self-care
 Continuing care
Nursing Intervention: Treat Angina
 Priority
 Patient is to stop all activities and sit
or rest in bed (semi-Fowler
positioning)
 Assess the patient while performing
other necessary interventions.
Assessment includes VS, observation
for respiratory distress, and
assessment of pain. In the hospital
setting, the ECG is assessed or
obtained
 Administer medications as ordered
or by protocol, usually NTG. Reassess
pain and administer NTG up to three
doses
 Administer oxygen 2 L/min by nasal
cannula
Nursing Intervention: Reduce An,iety
 Use a calm manner
 Stress-reduction techniques
 Patient teaching
 Addressing patient’s spiritual needs
may assist in allaying anxieties
 Address both patient and family
needs
Nursing Intervention: Preventing Pain
 Identify level of activity that causes
patient’s prodromal S&S
 Plan activities accordingly
 Alternate activities with rest periods
 Educate patient and family
Nursing Intervention: Patient Teaching #1
 Balance activity with rest
 Follow prescribed exercise regimen
 Avoid exercising in extreme
temperatures
 Use resources for emotional support
(counselor)
 Avoid over-the-counter medications
that may increase HR or BP before
consulting with health care provider
 Stop using tobacco products
(nicotine increases HR and BP)
 Diet low in fat and high in fiber
Nursing Intervention: Patient Teaching #2
 Medication teaching (carry NTG at
all times!)
 Follow up with health care provider
  Report increase in S&S to provider
 Maintain normal BP and blood
glucose levels
Assessment of the Patient with ACS
 Chest pain
o Occurs suddenly and
continues despite rest and
medication
o Other S&S: SOB; C/O
indigestion; nausea; anxiety;
cool, pale skin; increased HR,
RR
 ECG changes
o Elevation in the ST segment
in two contiguous leads is a
key diagnostic indicator for
MI
 Lab studies: cardiac enzymes,
troponin, creatine kinase, myoglobin
Collaborative Problems of the Patient with
ACS
 Acute pulmonary edema
 Heart failure
 Cardiogenic shock
 Arrhythmias and cardiac arrest
 Pericardial effusion and cardiac
tamponade
 Monitor and manage potential
complications
 Educate patient and family
 Provide continuing care
Nursing Management of the Patient with
ACS
 Oxygen and medication therapy
 Frequent VS assessment
 Physical rest in bed with head of bed
elevated
 Relief of pain helps decrease
workload of heart
 Monitor I&O and tissue perfusion
 Frequent position changes to
prevent respiratory complications
 Report changes in patient’s
condition
 Evaluate interventions!
Invasive Coronary Artery Procedures
 Percutaneous transluminal coronary
angioplasty (PTCA)
 Coronary artery stent
 Coronary artery bypass graft (CABG)
 Cardiac surgery
Percutaneous Coronary Intervention

Planning and oals for the Patient with

ACS
 Goals:
o Relief of pain or ischemic
signs (e.g., ST-segment
changes) and symptoms
o Prevention of myocardial
damage
o Maintenance of effective
respiratory function,
adequate tissue perfusion
o Reduction of anxiety Coronary Artery Bypass rafts
o Adherence to the self-care
program
o Early recognition of
complications

Nursing Interventions for the Patient with

ACS
 Relieve pain and S&S of ischemia
 Improve respiratory function
 Promote adequate tissue perfusion
 Reduce anxiety

Veins Commonly Used for Bypass raft
Procedures
Cardiopulmonary Bypass System
Nursing Management: Patient Requiring
Invasive Cardiac Intervention #1
 Assessment of patient
 Reduce fear and anxiety
 Monitor and manage potential
complications
 Provide patient education
 Maintain cardiac output
 Promote adequate gas exchange
 Maintain fluid and electrolyte
balance
 Minimize sensory–perception
imbalance
Nursing Management: Patient Requiring
Invasive Cardiac Intervention #2
 Relieve pain
 Maintain adequate tissue perfusion
 Maintain body temperature
 Promote health and community-
based care
Chapter 24
Management of Patients with Structural,
Infectious, and Inflammatory Cardiac
Disorders
Valvular Disorders
 Regurgitation: The valve does not
close properly, and blood backflows
through the valve
 Stenosis: The valve does not open
completely, and blood flow through
the valve is reduced
 Valve prolapse: The stretching of the
valve leaflet into the atrium during
systole
Valves of the Heart
Specific Valvular Disorders
 Mitral valve prolapse
 Mitral regurgitation
 Mitral stenosis
 Aortic regurgitation
 Aortic stenosis
Nursing Management of Patients with
Valvular Heart Disorders
 Patient education
 Monitor VS trends, heart and lung
sounds, peripheral pulses
 Monitor for complications
o Heart failure
o Arrhythmias
o Other symptoms: dizziness,
syncope, angina pectoris
 Medication schedule: plan and
education
 Daily weights: monitor for weight
gain
 Plan activity with rest periods

Surgical Management of Valvular Heart
Disorders
 Valvuloplasty
o Commissurotomy
o Balloon valvuloplasty
o Annuloplasty
o Leaflet repair
o Chordoplasty
 Valve replacement
o Mechanical
o Tissue
o Bioprosthesis
o Homografts
o Autografts
Nursing Management of the Patient with
Valvuloplasty or Valve Replacement #1
 Balloon valvuloplasty
o Monitor for heart failure and
emboli
o Assess heart sounds every 4
hours
o Same care as after cardiac
catheterization
 Surgical valvuloplasty or valve
replacements
o Focus is hemodynamic
stability and recovery from
anesthesia
o Frequent assessments with
attention to neurologic,
respiratory, and
cardiovascular systems
Nursing Management of the Patient with
Valvuloplasty or Valve Replacement #2
 Patient education
o Anticoagulation therapy
o Prevention of infective
endocarditis
o Follow‐up
o Repeat echocardiograms
Cardiomyopathy
 Cardiomyopathy is a series of
progressive events that culminates
in impaired cardiac output
 Types
o Dilated cardiomyopathy
(DCM)
o Hypertrophic
cardiomyopathy (HCM)
o Restrictive/constrictive
cardiomyopathy (RCM)
o Arrhythmogenic right
ventricular
cardiomyopathy/dysplasia
(ARVC/D)
o Unclassified cardiomyopathy
Cardiomyopathies that Lead to
Congestive Heart Failure
Assessment of the Patient with
Cardiomyopathy
 History (predisposing factors, family
history)
 Chest pain
 Review of systems: presence of
orthopnea, syncope
 Review of diet (Na reduction,
vitamin supplements)
 Psychosocial history: impact on
family, stressors, depression
 Physical assessment: VS, pulse
pressure; pulsus paradoxus; weight
gain or loss; PMI; murmurs; S3 or S4;
pulmonary auscultation for crackles,
JVD, and edema
Collaborative Problems and Potential
Complications of the Patient with
Cardiomyopathy
 Heart failure
 Ventricular arrhythmias
 Atrial arrhythmias
 Cardiac conduction defects
 Pulmonary or cerebral embolism
 Valvular dysfunction
Planning and oals for the Patient with
Cardiomyopathy
 Goals
 o Improvement of cardiac
output and peripheral blood
flow
o Increased activity tolerance
o Reduction of anxiety
o Decreased sense of
powerlessness
o Effective management of
self-care
Nursing Interventions for the Patient with
Cardiomyopathy #1
 Improve cardiac output and
peripheral blood flow
o Rest, positioning (legs down),
supplemental O2,
medications, low Na diet,
avoid dehydration
 Increase activity tolerance and
improve gas exchange
o Cycle rest and activity, ensure
patient recognizes symptoms
that indicate the need for
rest
 Reduce anxiety
o Eradicate or alleviate
perceived stressors, educate
family about diagnosis, assist
with anticipatory grieving
Nursing Interventions for the Patient with
Cardiomyopathy #2
 Decrease the sense of
powerlessness
o Assist patients in identifying
things that have been lost
(i.e., ability to play sports),
assist patients in identifying
amount of control they still
have left
 Promote home and community-
based care
o Educate patients about ways
to balance lifestyle and work
while accomplishing
therapeutic activities
o Assess patient and family and
their adjustment to lifestyle
changes, educate family
about CPR and AEDs,
establish trust
Evaluation of the Patient with
Cardiomyopathy #1
 Maintains or improves cardiac
function
o HR and RR WNL, decreased
dyspnea and increased
comfort, maintain or improve
gas exchange, absence of
weight gain, maintain or
improve peripheral blood
flow
 Maintains or increases activity
tolerance
o Carries out activities of daily
living (e.g., brush teeth, feed
self), reports increased
tolerance to activity
Evaluation of the Patient with
Cardiomyopathy #2
 Is less anxious
o Discusses prognosis,
verbalizes fears and
concerns, participates in
support groups,
demonstrates appropriate
coping mechanisms
 Decreases sense of powerlessness
o Identifies emotional
response to diagnosis,
discusses control that they
have
 Effectively manages self-care
program
o Takes medications as
prescribed, modifies diet to
accommodate sodium and
fluid recommendations,
modifies lifestyle, identifies
S&S to be reported
Infectious Diseases of the Heart
 Any of the three layers of the heart
may be affected by an infectious
process
 Diseases are named by the layer of
the heart that is affected
 Diagnosis is made by patient
symptoms and echocardiogram
 Management for all infectious
diseases is prevention
  IV antibiotics usually are necessary
once an infection has developed in
the heart
Types of Infectious Disease of the Heart #1
 Rheumatic endocarditis
o Occurs most often in school-
age children after group A
beta-hemolytic streptococcal
pharyngitis; need to
promptly recognize and treat
“strep” throat to prevent
rheumatic fever
 Infective endocarditis
o Usually develops in people
with prosthetic heart valves
or structural cardiac defects;
also occurs in patients who
are IV drug abusers and in
those with debilitating
diseases, indwelling
catheters, or prolonged IV
therapy
Types of Infectious Disease of the Heart #2
 Pericarditis
o Inflammation of the
pericardium; many causes;
potential complications:
pericardial effusion and
cardiac tamponade
 Myocarditis
o An inflammatory process
involving the myocardium;
most common pathogens
involved in myocarditis tend
to be viral; in endocarditis,
they tend to be bacterial;
complications:
cardiomyopathy and heart
failure
Clinical Manifestations of Infectious
Diseases of the Heart
 Fever
 New heart murmur, friction rub at
left lower sternal border
(pericarditis)
 Osler nodes, Janeway lesions, Roth
spots, and splinter hemorrhages in
nailbeds (rheumatic)
 Cardiomegaly, heart failure,
tachycardia, splenomegaly
 Fatigue, dyspnea, syncope,
palpitations, chest pain (myocarditis)
 Diagnostic tools: blood cultures,
echocardiogram, CBC, rheumatoid
factor, ESR, CRP, ECG, cardiac
catheterization, TEE, CT scan
Prevention of Infectious Diseases of the
Heart
 Antibiotic prophylaxis before certain
procedures
 Ongoing oral hygiene
 Female patients are advised NOT to
use IUDs
 Meticulous care should be taken in
patients “at risk” who have catheters
 Catheters should be removed as
soon as they are no longer needed
 Immunizations
Chapter 25
Management of Patients with
Complications from Heart Disease
Heart Failure #1
 Cardiovascular disease is the leading
cause of death in the United States
 Heart disease remains a chronic and
often progressive condition,
associated with serious
comorbidities, such as heart failure
 Heart failure (HF) is a clinical
syndrome resulting from structural
or functional cardiac disorders that
impair the ability of a ventricle to fill
or eject blood; the heart is unable to
pump enough blood to meet the
body’s metabolic demands or needs
Heart Failure #2
 The term heart failure indicates
myocardial disease, in which there is
a problem with the contraction of
the heart (systolic dysfunction) or
filling of the heart (diastolic
dysfunction) may cause pulmonary
or systemic congestion
 Some cases are reversible depending
on the cause
 Most HF is a chronic, progressive
condition managed with lifestyle
changes and medications

Chronic Heart Failure
 The incidence of HF increases with
age
 Approximately 6 million people in
the United States have HF, and
870,000 new cases are diagnosed
each year
 Most common reason for
hospitalization of people older than
65 years and the second most
common reason for visits to a
provider’s office
 Approximately 20% of patients
discharged after treatment for HF
are readmitted to the hospital within
30 days and nearly 50% are
readmitted to the hospital within 6
months
Pathophysiology of Heart Failure
Clinical Manifestations of Heart Failure
Right Sided
 Viscera and peripheral congestion
 Jugular venous distention (JVD)
 Dependent edema
 Hepatomegaly
 Ascites
 Weight gain
Left Sided
 Pulmonary congestion, crackles
 S3 or “ventricular gallop”
 Dyspnea on exertion (DOE)
 Low O2 sat
 Dry, nonproductive cough initially
 Oliguria
Medical Management of the Patient with
Heart Failure
 Vary according to the severity of the
patient’s condition, comorbidities,
and cause
 Treatment may include
o Oral and IV medications
o Lifestyle modifications
o Supplemental O2
o Surgical interventions: ICD
and heart transplant
 Comprehensive education and
counseling to patient and family is
needed
Medications Used to Treat HF #2
 Ivabradine: decreases rate of
conduction through the SA node;
observe for decrease HR and BP
 Hydralazine and isosorbide dinitrate:
alternative to ACE inhibitors;
observe for decreased BP
 Digitalis: improves contractility;
monitor for digitalis toxicity
especially if patient is hypokalemic
Medications Used to Treat HF #3
 IV medications: indicated for
hospitalized patients admitted for
acute decompensated HF
o Dopamine: vasopressor to
increase BP and myocardial
contractility; adjunct with
loop diuretics
o Dobutamine: used for
patients with left ventricular
dysfunction; increases
cardiac contractility and renal
perfusion
o Milrinone: decreases preload
and afterload; causes
hypotension and increased
risk of dysrhythmias
o Vasodilators: IV nitro,
nitroprusside, nesiritide;
enhance symptom relief
erontologic Considerations
 May present with atypical signs and
symptoms such as fatigue,
weakness, and somnolence
 Decreased renal function can make
older patients resistant to diuretics
 and more sensitive to changes in
volume
 Administration of diuretics to older
men requires nursing surveillance
for bladder distention caused by
urethral obstruction from an
enlarged prostate gland
Assessment of the Patient with Heart
Failure
 Focus
o Effectiveness of therapy
o Patient’s self-management
o S&S of increased HF
o Emotional or psychosocial
response
 Health history
 PE
o Mental status; lung sounds:
crackles and wheezes; heart
sounds: S3; fluid status or
signs of fluid overload; daily
weight and I&O; assess
responses to medications
Collaborative Problems and Potential
Complications of the Patient with HF
 Pulmonary edema
 Hypotension, poor perfusion, and
cardiogenic shock
 Arrhythmias
 Thromboembolism
 Pericardial effusion
Planning and oals for the Patient With
Heart Failure
 Goals
o Promote activity and reduce
fatigue
o Relieve fluid overload
symptoms
o Decrease anxiety or increase
the patient’s ability to
manage anxiety
o Encourage the patient to
verbalize his or her ability to
make decisions and influence
outcomes
o Educate the patient and
family about management of
the therapeutic regimen
Nursing Interventions for the Patient with
Heart Failure #1
 Promote activity tolerance
o Bed rest for acute
exacerbations
o Encourage regular physical
activity; build up to about 30
minutes daily
o Exercise training
o Pacing of activities; wait 2
hours after eating for
physical activity
o Avoid activities in extreme
hot, cold, or humid weather
o Modify activities to conserve
energy
o Positioning; elevation of the
head of bed to facilitate
breathing and rest, support
of arms
Nursing Interventions for the Patient with
Heart Failure #2
 Manage fluid volume
o Assess for symptoms of fluid
overload
o Daily weight
o I&O
o Diuretic therapy; timing of
meds
o Fluid intake; fluid restriction
o Maintenance of sodium
restriction
Patient Education for the Patient with
Heart Failure
 Medications
 Diet: low-sodium diet and fluid
restriction
 Monitor for signs of excess fluid,
hypotension, and symptoms of
disease exacerbation, including daily
weight
 Exercise and activity program
 Stress management
 Prevention of infection
 Know how and when to contact
health care provider
 Include family in education
Management of Pulmonary Edema
 Easier to prevent than to treat
 Early recognition: monitor lung
sounds and for signs of decreased
 activity tolerance and increased fluid
retention
 Minimize exertion and stress
 Oxygen; nonrebreather
 Medications
o Diuretics (furosemide),
vasodilators (nitroglycerin)
Nursing Interventions for the Patient with
Pulmonary Edema
 Positioning the patient to promote
circulation
o Positioned upright with legs
dangling
 Providing psychological support
o Reassure patient and provide
anticipatory care
 Monitoring medications
 I&O
End-of-Life Considerations
 HF is a chronic and often progressive
condition
o Need to consider issues
related to the end of life
o When palliative or hospice
care should be considered
Cardiogenic Shock
 A life-threatening condition with a
high mortality rate
 Decreased CO leads to inadequate
tissue perfusion and initiation of
shock syndrome
 Commonly occurs following acute MI
when a large area of myocardium
becomes ischemic and hypokinetic
 Can occur as a result of end-stage
HF, cardiac tamponade, pulmonary
embolism (PE), cardiomyopathy, and
arrhythmias
Thromboembolism
 Patients with cardiovascular
disorders are at risk for the
development of arterial
thromboemboli and venous
thromboemboli (VTE)
 Decreased mobility and circulation
increase the risk for
thromboembolism in patients with
cardiac disorders, including those
with HF
 Intracardiac thrombi can form in
patients with atrial fibrillation
because the atria do not contract
forcefully, and increasing the
likelihood of thrombus formation
 Pulmonary embolism: blood clot
from the legs moves to obstruct the
pulmonary vessels
Pericardial Effusion and Cardiac
Tamponade
 Pericardial effusion is the
accumulation of fluid in the
pericardial sac
 Cardiac tamponade is the restriction
of heart function because of this
fluid, resulting in decreased venous
return and decreased CO
 Clinical manifestations: ill-defined
chest pain or fullness, pulsus
paradoxus, engorged neck veins,
labile or low BP, shortness of breath
 Cardinal signs of cardiac tamponade:
falling systolic BP, narrowing pulse
pressure, rising venous pressure,
distant heart sounds
Medical Management of Pericardial
Effusion and Cardiac Tamponade
 Pericardiocentesis
o Puncture of the pericardial
sac to aspirate pericardial
fluid
 Pericardiotomy
o Under general anesthesia, a
portion of the pericardium is
excised to permit the
exudative pericardial fluid to
drain into the lymphatic
system
Sudden Cardiac Death or Cardiac Arrest
 Emergency management:
cardiopulmonary resuscitation
o A: airway
o B: breathing
o C: circulation
o D: defibrillation for VT and VF
 Chapter 26
Assessment and Management of Patients
with Vascular Disorders and Problems of
Peripheral Circulation
Vascular System
 Consists of two interdependent
systems
o Right side of the heart pumps
blood through the lungs to
the pulmonary circulation
o Left side of the heart pumps
blood to all other body
tissues through the systemic
circulation
 Arteries and arterioles
 Capillaries
 Veins and venules
 Lymphatic vessels
Function of the Vascular System
 Circulatory needs of tissues
 Blood flow
 Blood pressure
 Capillary filtration and reabsorption
 Hemodynamic resistance
 Peripheral vascular regulating
mechanisms
Pathophysiology of the Vascular System
 Pump failure
 Alterations in blood and lymphatic
vessels
 Circulatory insufficiency of the
extremities
erontologic Considerations
 Aging produces changes in the walls
of the blood vessels that affect the
transport of oxygen and nutrients to
the tissues
 Changes cause vessels to stiffen and
results in:
o Increased peripheral
resistance
o Impaired blood flow
o Increased left ventricular
workload
Assessment of the Vascular System
 Health history
o Intermittent claudication,
o “Rest pain”
o Location of the pain
 Physical assessment
o Skin (cool, pale, pallor, rubor,
loss of hair, brittle nails, dry
or scaling skin, atrophy, and
ulcerations)
o Pulses
Diagnostic Evaluation
 Doppler ultrasound flow studies
o Ankle-brachial index (ABI)
 Exercise testing
 Duplex ultrasonography
 Computed tomography scanning
 Angiography and magnetic
resonance angiography
 Contrast phlebography (venography)
 Lymphoscintigraphy
Continuous wave (CW) Doppler Ultrasound
 Handheld ultrasound device that
detects blood flow, combined with
computation of ankle or arm
pressures
 Signals are reflected by the moving
blood cells
 Diagnostic technique helps
characterize the nature of peripheral
vascular disease
Assessment of the Patient with Peripheral
Vascular Problems
 Health history
 Medications
 Risk factors
 Signs and symptoms of arterial
insufficiency
 Claudication and rest pain
 Color changes
 Weak or absent pulses
 Skin changes and skin breakdown
Planning and oals for the Patient with
Peripheral Vascular Problems
 Major goals include:
o Increased arterial blood
supply
o Decrease in venous
congestion
o Promotion of vasodilatation
and prevention of vascular
compression
o Relief of pain
 o Attainment/maintenance of
tissue integrity
o Adherence to the self-care
program
Improving Peripheral Arterial Circulation
 Positioning strategies—body part
below the level of the heart
 Exercise program and activities:
walking, graded isometric exercises
o Consult primary provider
before engaging in an
exercise routine
 Temperature; effects of heat and
cold
 Discourage use of nicotine
 Stress reduction
Arterial Disorders
 Arteriosclerosis and atherosclerosis
 Peripheral artery disease
 Upper extremity arterial disease
 Aortoiliac disease
 Aneurysms (thoracic, abdominal,
other)
 Aortic dissection
 Arterial embolism and arterial
thrombosis
 Raynaud’s phenomenon and other
acrosyndromes
Arteriosclerosis and Atherosclerosis
 Arteriosclerosis
o Hardening of the arteries
o Diffuse process whereby the
muscle fibers and the
endothelial lining of the walls
of small arteries and
arterioles become thickened
 Atherosclerosis
o Different process, affecting
the intima of large and
medium-sized arteries
o Accumulation of lipids,
calcium, blood components,
carbohydrates, and fibrous
tissue on the intimal layer of
the artery
o Atheromas or plaques
Risk Factors for Atherosclerosis and PAD
Modifiable
 Nicotine use
 Diabetes
 Hypertension
 Hyperlipidemia
 Diet
 Stress
 Sedentary lifestyle
 C-reactive protein
 Hyperhomocysteinemia
Nonmodifiable
 Increasing age
 Familial predisposition/genetics
Peripheral Artery Disease (PAD)
 Hallmark symptom is intermittent
claudication described as aching,
cramping, or inducing fatigue or
weakness
 Occurs with some degree of exercise
or activity
 Relieved with rest
 Pain is associated with critical
ischemia of the distal extremity and
is described as persistent, aching, or
boring (rest pain)
 Ischemic rest pain is usually worse at
night and often wakes the patient
Pharmacologic Therapy for PAD
 Phosphodiesterase III inhibitor
o Cilostazol
 Antiplatelet agents
o Aspirin
o Clopidogrel
 Statins
Aneurysms
 Localized sac or dilation formed at a
weak point in the wall of the artery
 Classified by its shape or form
 Most common forms of aneurysms
are saccular and fusiform
o Saccular aneurysm projects
from only one side of the
vessel
o When an entire arterial
segment becomes dilated, a
fusiform aneurysm develops
Raynaud’s Phenomenon
  Intermittent arterial vasoocclusion,
usually of the fingertips or toes
o Raynaud’s disease: primary
or idiopathic
o Raynaud’s syndrome:
associated with other
underlying disease such as
scleroderma
 Manifestations: sudden
vasoconstriction results in color
changes, numbness, tingling, and
burning pain
 Episodes brought on by a trigger
such as cold or stress
 Occurs most frequently in young
women
 Protect from cold and other triggers.
Avoid injury to hands and fingers
Venous Disorders
 Venous thromboembolism (VTE)
condition
o DVT and PE
 Chronic venous
insufficiency/postthrombotic
syndrome
 Leg ulcers
 Varicose veins
Venous Thromboembolism
 Risk factors
 Endothelial damage
o Venous stasis
o Altered coagulation
 Manifestations
o Deep veins
o Superficial veins
Preventive Measures
 Early ambulation and leg exercises
 Graduated compression stockings
 Intermittent pneumatic compression
devices
 Subcutaneous heparin or LMWH
 Lifestyle changes
o Weight loss
o Smoking cessation
o Regular exercise
Assessment of the Patient with Leg Ulcers
 History of the condition
 Assess pain, peripheral pulses,
edema
 Treatment depends on the type of
ulcer
 Assess for presence of infection
 Assess nutrition
Medical Management of the Patient with
Leg Ulcers
 Anti-infective therapy depends on
the infecting agent
o Oral antibiotics are usually
prescribed
 Compression therapy
 Débridement of wound
 Dressings
Collaborative Problems and Potential
Complications of the Patient with Leg
Ulcers
 Infection
 Gangrene
Nursing Interventions for the Patient with
Leg Ulcers
 Restoring skin integrity
o Cleansing wound;
positioning; avoiding trauma;
avoid heat sources
 Improving physical mobility
o Physical activity initially
restricted to promote
healing; gradual progression
of activity
o Activity to promote blood
flow; encourage patient to
move about in bed and
exercise upper extremities
o Diversional activities
o Analgesic agents before
scheduled activities
 Promoting adequate nutrition
o Protein; Vitamins C and A;
Iron; Zinc
Varicose Veins
 Prevention
o Avoid activities that cause
venous stasis (wearing socks
that are too tight at the top
or that leave marks on the
skin, crossing the legs at the
thighs, and sitting or standing
for long periods)
 o Elevate the legs 3 to 6 inches
higher than heart level
o Encourage to walk 30
minutes each day if there are
no contraindications
o Wear graduated compression
stockings
o Overweight patients should
be encouraged to begin
weight reduction plans
Lymphatic Disorders
 Lymphangitis: inflammation or
infection of the lymphatic channels
 Lymphadenitis: inflammation or
infection of the lymph nodes
 Lymphedema: tissue swelling related
to obstruction of lymphatic flow
o Primary: congenital
o Secondary: acquired
obstruction
Cellulitis
 S&S: localized swelling or redness,
fever, chills, sweating
 Treat with oral or IV antibiotics
based on severity
 Nursing
o Elevate affected area 3 to 6
inches above heart level
o Warm, moist packs to site
every 2 to 4 hours
o Educate regarding prevention
of recurrence
o Reinforce education about
skin and foot care
Chapter 27
Assessment and Management of Patients
with Hypertension
Hypertension
 High blood pressure
 Most common chronic disease
among U.S. adults
 Defined by the American College of
Cardiology (ACC)/American Heart
Association (AHA) as a systolic blood
pressure (SBP) of 130 mm Hg or
higher or a diastolic blood pressure
(DBP) of 80 mm Hg or higher
Classification of Blood Pressure for Adults
Age 18 Years and Older
 Normal Blood Pressure
o Systolic <120 mm Hg and
Diastolic <80 mm Hg
 Elevated Blood Pressure
o Systolic 120–129 mm Hg and
Diastolic <80 mm Hg
 Stage 1 hypertension
o Systolic 130–139 mm Hg or
Diastolic 80–89 mm Hg
 Stage 2 hypertension
o Systolic >140 mm Hg or
Diastolic >90 mm Hg
Incidence of Hypertension—“The Silent
Killer”
 Primary hypertension: essential
o 90–95% of patients;
unidentifiable cause
 Secondary hypertension
o 5–10% of patients; renal
disease, sleep apnea,
pregnancy related
 About 33% of the adult population
of the United States has
hypertension
 About 46% do not have it under
control
 Highest prevalence in African
Americans
Manifestations of Hypertension
 Usually no symptoms other than
elevated blood pressure
 Symptoms related to organ damage
are seen late and are serious
o Retinal and other eye
changes
o Renal damage
o Myocardial infarction
o Cardiac hypertrophy
o Stroke
Pathophysiologic Processes
 Can result from increases in cardiac
output, peripheral resistance, or
both
 Must also be a problem with the
body’s control system
  Dysfunction of the autonomic
nervous system
 Increased renin–angiotensin–
aldosterone system
 Resistance to insulin action
 Activation of the immune system
Measuring Blood Pressure
 Correct arm cuff size
 Sit quietly with arm at the level of
the heart
 Confirmation of diagnosis by average
of two blood pressure readings
 Can also evaluate lifestyle
modifications and success of
prescription medications
Alternative Manifestations
 Masked hypertension
o Blood pressure that is
suggestive of hypertension
that is paradoxically normal
in health care settings
 White coat hypertension
o Hypertensive blood pressure
readings in the health care
setting that is paradoxically
normal ranges in other
settings
Abnormal Physical E,amination Findings
 Absent or weak pulses
 Additional cardiac sounds
 Retinal hemorrhages
 Distended jugular veins
 Renal artery bruit
Major Risk Factors
 Smoking
 Obesity
 Physical inactivity
 Dyslipidemia
 Diabetes mellitus
 Microalbuminuria or GFR <60
mL/min
 Older age
 Family history
Patient Assessment
 History and physical examination
o Retinal exam
 Laboratory tests
o Urinalysis
o Blood chemistry
 ECG
Medical Management #1
 Maintain blood pressure
o <130/80 mm Hg
 Lifestyle modifications
o Weight reduction
o DASH diet, decreased sodium
intake
o Regular physical activity
o Reduced alcohol
consumption
Medical Management #2
 Pharmacologic therapy
o Decrease peripheral
resistance, blood volume
o Decrease strength and rate of
myocardial contraction
 Diuretics, beta-blockers, alpha1-
blockers, combined alpha- and beta-
blockers, vasodilators, ACE
inhibitors, ARBs, calcium channel
blockers, dihydropyridines, and
direct renin inhibitors
Medication Treatment
 Stage I hypertension:
o African American and
patients >60 years: calcium
channel blocker or thiazide
diuretic
o Non African American and
patients <60 years: ACE-I or
ARB
 Low doses are initiated, and the
medication dosage is increased
gradually if blood pressure does not
reach target goal
 Multiple medications may be
needed to control blood pressure
Assessment
 History and risk factors
 Assess potential symptoms of target
organ damage
o Angina, shortness of breath,
altered speech, altered
vision, nosebleeds,
headaches, dizziness,
balance problems, nocturia
o Cardiovascular assessment:
apical and peripheral pulses
 Personal, social, and financial factors
that will influence the condition or
its treatment
Collaborative Problems and Potential
Complications
 Left ventricular hypertrophy
 Myocardial infarction
 Heart failure
 Transient ischemic attack (TIA)
 Cerebrovascular disease (CVA,
stroke, or brain attack)
 Renal insufficiency and chronic
kidney disease
 Retinal hemorrhage
Planning and oals
 Understanding of the disease
process and its treatment
 Participation in a self-care program
 Absence of complications
Interventions
 Support and educate the patient
about the treatment regimen
 Reinforce and support lifestyle
changes
 Taking medications as prescribed
 Follow-up care
 Monitoring for potential
complications
Evaluation and Outcomes #1
 Reports knowledge of disease
management sufficient to maintain
adequate tissue perfusion
o Maintains blood pressure at
less than 130/80 mm Hg with
lifestyle modifications,
medications, or both
o Demonstrates no symptoms
of angina, palpitations, or
vision changes
o Has stable BUN and serum
creatinine levels
o Has palpable peripheral
pulses
Evaluation and Outcomes #2
 Effectively manages health program
o Adheres to the dietary
regimen as prescribed:
reduces calorie, sodium, and
fat intake; increases fruit and
vegetable intake
o Exercises regularly
o Takes medications as
prescribed and reports side
effects
o Measures BP routinely
o Abstains from tobacco and
excessive alcohol intake
o Keeps follow‐up
appointments
Evaluation and Outcomes #3
 Has no complications
o Reports no changes in vision;
exhibits no retinal damage on
vision testing
o Maintains pulse rate and
rhythm and respiratory rate
within normal ranges;
reports no dyspnea or edema
o Maintains urine output
consistent with intake; has
renal function test results
within normal range
o Demonstrates no motor,
speech, or sensory deficits
o Reports no headaches,
dizziness, weakness, changes
in gait, or falls
erontologic Considerations
 Medication regimen can be difficult
to remember
 Expense can be a challenge
 Monotherapy, if appropriate, may
simplify the medication regimen and
make it less expensive
  Ensure that older adult patients  Assess for potential evidence of
understand the regimen and can see target organ damage
and read instructions, open
medication containers, and get
prescriptions refilled
 Include family and caregivers in Chapter 28
educational program
Assessment of Hematologic Function and
Treatment Modalities
Hypertensive Crises
 Hypertensive emergency Hematologic System
o Blood pressure >180/120  The blood and the blood‐forming
mm Hg and must be lowered sites, including the bone marrow
immediately to prevent and the reticuloendothelial system
further damage to target (RES)
organs  Blood
 Hypertensive urgency o Plasma: fluid portion of
o Blood pressure >180/120 blood
mm Hg but no evidence of o Blood cells: erythrocytes,
immediate or progressive leukocytes, thrombocytes
target organ damage  Hematopoiesis
Hypertensive Emergency
Bone Marrow
 Reduce blood pressure by no more  Stem cells
than 25% in first hour o Myeloid
 Reduce to 160/100 mm Hg within 2  Erythrocytes (RBC)
to 6 hours  Leukocytes (WBC)
 Then gradual reduction to normal 24  Platelets
to 48 hours of treatment o Lymphoid
 Exceptions are ischemic stroke and  Lymphocytes
aortic dissection  Stroma
 Medications
o IV vasodilators: sodium Red Blood Cells: Erythrocytes
nitroprusside, nicardipine,  Types—
fenoldopam mesylate, o Hemoglobin
enalaprilat, nitroglycerin o Reticulocytes
 Need very frequent monitoring of BP  Erythropoiesis
and cardiovascular status  Iron stores and metabolism
 Vitamin B12 and folic acid
 Destruction
Hypertensive Urgency
 Oral agents can be administered White Blood Cells: Leukocytes
with the goal of normalizing blood  Granulocytes
pressure within 24 to 48 hours o Eosinophils
 Fast-acting oral agents: o Basophils
o Beta-adrenergic blocker— o Neutrophils
labetalol  Bands: left shift
o Angiotensin-converting  Agranulocytes
enzyme inhibitor—captopril o Monocytes
o Alpha2-agonist—clonidine o Lymphocytes
 Patient requires close monitoring of  T cells and B cells
blood pressure and cardiovascular
status Platelets: Thrombocytes
 Thrombopoietin
  Fibrin  Patient education
 Transfusion process
 Correct
administration
techniques per
Plasma and Plasma Proteins agency’s policies and
procedures
 Albumin
 Globulins
o Alpha Transfusion Complications
o Beta  Febrile nonhemolytic reaction
o Gamma  Acute hemolytic reaction
 Impact on fluid balance  Allergic reaction
 Transfusion-associated circulatory
overload
Reticuloendothelial System  Bacterial contamination
 Histiocytes  Transfusion-related acute lung injury
o Kupffer cells  Delayed hemolytic reaction
o Peritoneal macrophages  Disease acquisition—Chart 28-6
o Alveolar macrophages  Long-term transfusion therapy
 Spleen

Assessment of Hematologic Health Nursing Management of Transfusion

 Health history Reactions
 Physical assessment
 Diagnostic evaluation  Stop
o Hematologic studies  Assess
o Bone marrow aspiration and  Notify primary provider and
biopsy implement prescribed treatments.
Continue to monitor
Therapeutic Approaches  Return blood
 Obtain any samples needed
 Splenectomy  Document
 Apheresis
 Hematopoietic stem cell
transplantation (HSCT) Transfusion Alternatives
 Phlebotomy  Growth factors
 Blood component therapy  Erythropoietin
 Special preparations  Granulocyte colony-stimulating
factor
Blood and Blood Products  Granulocyte-macrophage colony-
 Donor requirements stimulating factor
 Donation types  Thrombopoietin
o Directed
o Standard Chapter 29
o Autologous
o Intraoperative blood salvage Management of Patients with
o Hemodilution Nonmalignant Hematologic Disorders
 Complications of donation
 Blood processing Anemia
 Lower than normal hemoglobin and
Transfusion fewer than normal circulating
 Common settings erythrocytes; a sign of an underlying
 Pretransfusion assessment disorder
  Hypoproliferative: defect in
production of erythrocytes (RBCs)
o Caused by iron, vitamin B12,
or folate deficiency,
decreased erythropoietin
production, cancer, bone
marrow damage
 Hemolytic: excess destruction of
erythrocytes (RBCs)
o Caused by altered
erythropoiesis, or direct
injury to the erythrocyte.
Manifestations of Anemias
 Depends on the rapidity of the
development of the anemia,
duration of the anemia, metabolic
requirements of the patient,
concurrent problems, and
concomitant features
 Fatigue, weakness, malaise
 Pallor or jaundice
 Cardiac, GI, neurologic and
respiratory symptoms
 Tongue changes
 Nail changes
 Angular cheilitis
 Pica
Diagnostic Testing for Anemia
 Hemoglobin and hematocrit
 Reticulocyte count
 RBC indices
 Iron studies
 Vitamin B12
 Folate
 Haptoglobin and erythropoietin
levels
 Bone marrow aspiration
Medical Management of Anemias
 Correct or control the cause
 Transfusion of packed RBCs
 Treatment specific to the type of
anemia
o Dietary therapy
o Iron or vitamin
supplementation: iron,
folate, B12
o Transfusions
o Immunosuppressive therapy
Hemolytic Anemias
 Sickle cell disease
 Thalassemia
 Glucose-6-phosphate
dehydrogenase deficiency
 Immune hemolytic anemia
 Hereditary hemochromatosis
Hypoproliferative Anemias
 Iron deficiency anemia
 Anemia in renal disease
 Anemia of inflammation
 Aplastic anemia
 Megaloblastic anemia
o Folic acid deficiency
o Vitamin B12 deficiency
Neutropenia
 Decreased production or increased
destruction of neutrophils
(<2000/mm3)
 Increased risk for infection: monitor
closely
 Absolute neutrophil count (ANC)
 Medical management: treatment
depends on the cause
 Nursing management: patient
education, preventing and managing
complications
Lymphopenia
 Lymphocyte count less than
1500/mm3
 Causes
o Exposure to radiation
o Long-term use of
corticosteroids
o Infections
o Neoplasms
o Alcohol abuse
Polycythemia
 Increased volume of RBCs
 Secondary polycythemia
o Excessive production of
erythropoietin from reduced
amounts of oxygen, cyanotic
heart disease, nonpathologic
conditions or neoplasms
 Medical management
 o Treatment not needed if
condition is mild
o Treat underlying cause
o Therapeutic phlebotomy
Bleeding Disorders #1
 Failure of hemostatic mechanisms
 Causes
o Trauma
o Platelet abnormality
o Coagulation factor
abnormality
 Medical management: specific blood
products
 Nursing management: limit injury,
assess for bleeding, bleeding
precautions
Bleeding Disorders #2
 Secondary thrombocytosis
 Thrombocytopenia
 Immune thrombocytopenic purpura
(ITP)
 Platelet defects
 Hemophilia
 von Willebrand disease
Assessment of the Patient with Anemia
 Health history and physical exam
 Laboratory data
 Presence of symptoms and impact of
those symptoms on patient’s life;
fatigue, weakness, malaise, pain
 Nutritional assessment
 Medications
 Cardiac and GI assessment
 Blood loss: menses, potential GI loss
 Neurologic assessment
Collaborative Problems and Potential
Complications of the Patient with Anemia
 Heart failure
 Angina
 Paresthesias
 Confusion
 Injury related to falls
 Depressed mood
Planning and oals for the Patient with
Anemia
 Major goals include decreased
fatigue, attainment or maintenance
of adequate nutrition, maintenance
of adequate tissue perfusion,
compliance with prescribed therapy,
and absence of complications
Interventions for the Patient with Anemia
 Balance physical activity, exercise,
and rest
 Maintain adequate nutrition
 Maintain adequate perfusion
 Patient
 education to promote compliance
with medications and nutrition
 Monitor VS and pulse oximetry;
provide supplemental oxygen as
needed
 Monitor for potential complications
Assessment of the Patient with Sickle Cell
Disease
 Health history and physical exam
 Pain assessment
 Laboratory data: S-shaped
hemoglobin
 Presence of symptoms and impact of
those symptoms on patient’s life;
swelling, fever, pain
 Sickle cell crisis assessment
 Blood loss: menses, potential GI loss
 Cardiovascular and neurologic
assessment
Collaborative Problems and Potential
Complications of the Patient with Sickle
Cell Disease
 Hypoxia, ischemia, infection
 Dehydration
 CVA
 Anemia
 Acute and chronic kidney disease
 Heart failure
 Impotence
 Poor compliance
 Substance abuse
Interventions for the Patient with Sickle
Cell Disease
 Pain management
 Manage fatigue
 Infection prevention
 Promote coping
 Education of disease process
  Monitor for complications

Acquired Coagulation Disorders Planning and oals for the Patient with DIC
 Liver disease  Major goals may include
 Vitamin K deficiency maintenance of hemodynamic
 Complications of anticoagulant status, maintenance of intact skin
therapy and oral mucosa, maintenance of
 Disseminated intravascular fluid balance, maintenance of tissue
coagulation (DIC) perfusion, enhanced coping, and
 Thrombotic disorders absence of complications
 Hyperhomocysteinemia
 Antithrombin deficiency
 Protein C & S deficiency Interventions for the Patient with DIC
 Activated protein C resistance and  Assessment and interventions
factor V Leiden mutation should target potential sites of organ
 Acquired thrombophilia damage
 Malignancy  Monitor and assess carefully
 Avoid trauma and procedures that
Disseminated Intravascular Coagulation increase the risk of bleeding,
including activities that would
 Not a disease but a sign of an increase intracranial pressure
underlying disorder
 Severity is variable; may be life
threatening
 Triggers may include sepsis, trauma,
shock, cancer, abruptio placentae,
toxins, and allergic reactions
 Altered hemostasis mechanism
causes massive clotting in
microcirculation. As clotting factors
are consumed, bleeding occurs.
Symptoms are related to tissue
ischemia and bleeding
 Laboratory tests
 Treatment: treat underlying cause,
correct tissue ischemia, replace
fluids and electrolytes, maintain
blood pressure, replace coagulation
factors, use heparin or LMWH
Assessment of the Patient with DIC
 Be aware of patients who are at risk
for DIC and assess for signs and
symptoms of the condition
 Assess for signs and symptoms and
progression of thrombi and bleeding

Collaborative Problems and Potential

Complications of the Patient with DIC
 Kidney injury
 Gangrene
 Pulmonary embolism or hemorrhage
 Acute respiratory distress syndrome
 Stroke