Cardiac/Vascular Nurse Exam Secrets Study Guide (14 page)

Risk factors and treatment recommendations for peripheral artery disease (PAD) as endorsed by the PAD coalition and AHA

Patients with the greatest risk for PAD include individuals with diabetes, abnormal extremity pulses, known cardiac disease, high cholesterol, high blood levels of homocysteine, high blood pressure, impaired wound healing on extremities, age over 70 or a history of smoking. The presence of PAD in turn increases the patient’s risk for myocardial infarction and stroke.

Treatment includes smoking cessation and other risk management. Further interventions might include physical or exercise rehabilitation, medication (including thrombolytics, vasodilators and medications to treat related risk factors) and surgical interventions including stents or amputation in extreme cases.

Treatment priorities for aortic regurgitation

Aortic regurgitation is a condition created by valve inadequacy affecting the flow of blood from the aorta into the left ventricle and causes audible variances (murmur) in the heartbeat. Common causes include rheumatic heart disease and bacterial endocarditis. Whenever possible, treatment for aortic regurgitation is focused on surgical repair of the defective valve.

Monitor heart rate, oxygen saturation levels and administer medications such as inotropes, vasodilators, glycosides and antibiotics to promote stabilization while preparing for surgery. If surgical intervention is not possible begin chronic and/or end-of-life treatment plans.

Alternative therapies for cardiovascular patients

Alternative therapies are sought by approximately 36% of all cardiovascular patients. Those seeking out complementary therapies are generally younger patients, those of female gender or Asian descent, and those with higher education and income than the general population.

These individuals most often utilize herbal remedies such as echinacea, garlic, ginseng, ginkgo biloba and glucosamine to treat conditions unrelated to their cardiovascular disease.

Herbs are closely followed by physical interventions such as meditation, relaxation and deep breathing to improve mind-body connections and promote cardiac wellness and recovery. Interventions such as meditation and tai chi may be safely and effectively recommended for stress reduction. At this time, not enough research supports positive cardiovascular health changes associated with acupuncture or chelation (removal of heavy metals).

Regardless of the type of therapy used, the majority of those seeking complementary or alternative treatments report that they found the treatments helpful.

Physical signs and symptoms that suggest congestive heart failure

Key identifiers for many cardiovascular disorders are the presence of cyanosis (peripheral and central) and pallor. This, combined with shortness of breath related to position (supine) and exertion, fatigue, fluid retention and swelling, changes in heart rate, weight gain and wheezing and/or productive cough (white or pink fluid) all suggest the presence of congestive heart failure (CHF).

Treatment priorities include oxygenation and fluid reduction with diuretics. Other priorities, depending on individual patient needs, might include anxiety reduction and blood pressure reduction.

Coexisting cardiovascular risk factors associated with renovascular disease

A history of hypertension is positively related to the development of renal disease. In turn, the presence of renovascular disease and its progression to end-stage renal disease (ESRD) and chronic renal failure can often lead to the development of heart failure, hypertrophic cardiomyopathy, and coronary atherosclerosis. The presence of renovascular disease complicates the risk factors of surgical interventions that might be considered for the treatment of cardiovascular disease. Highest nursing concerns will often focus on blood pressure, electrolyte and fluid balances. Medications used to treat cardiac conditions often need to be adjusted and more closely monitored to accommodate for the reduced kidney function.

Angina pectoris vs. myocardial infarction

Angina pectoris often serves as a warning sign for myocardial infarction.

Angina is chest pain occurring from reduced blood flow to the myocardium. This pain is described as squeezing, burning or pressure and is focused on the chest cavity. It is intermittent, often correlating with increased activity and dissipating with rest and/or the use of nitroglycerine.

Myocardial infarction occurs when the lack of oxygen perfusion to the heart causes myocardial tissue death. This pain is more extreme, often referred to as crushing, and extends beyond the chest to radiate out toward the back, shoulder, neck and jaw. Rest and nitroglycerin will have no effect on this type of pain. Initial treatments will include oxygen and morphine sulfate for pain control.

Angina may be diagnosed with an exercise stress test. In the face of an MI, an electrocardiogram will show ST changes and laboratory results will show elevated troponin and creatinine levels.

Common types of congenital heart disease found in an adult patient

Atrial septal defects: The most common congenital deformity is created from the incomplete closure of the patent foramen ovale after birth, leaving a small opening that increases the risk of the patient forming emboli that may lead to cerebrovascular incidents or peripheral artery blockage. This deformity may be repaired with a transseptal patch or left untreated if it is small enough. Patients with septal defects are generally only treated for embolisms if they become symptomatic.

Marfan syndrome: A genetic connective tissue disorder that affects cardiac tissue, causing deformity of the valves and/or weakness of vessels that can cause aortic aneurysm. Physical signs might include unusually elongated limbs and a deformity of the chest area (either appearing sunken in or protruding outward).

Evidence-based interventions that could be performed on the patient experiencing paroxysmal supraventricular tachycardia (PSVT)

PSVT refers to occasional, intermittent rapid heart rate which lasts from a few minutes to several hours. This most often occurs in younger patients and can be brought on by alcohol, caffeine, smoking, illicit drug use or digitalis toxicity. Intervention of any kind might not be needed unless the patient is presenting symptoms such as anxiety, dizziness, shortness of breath, an uncomfortable feeling of chest tightness, racing heart or fainting. Emergency treatment options might include the Valsalva maneuver (instructing the patient to bear down as if having a bowel movement), splashing the face with ice water, IV adenosine or cardioversion. Long-term stability may be maintained by oral medications such as propafenone, flecainide, moricizine, sotalol, and amiodarone; the use of a pacemaker; or, more often, radiofrequency catheter ablation.

Role of a case manager

The American Nurses Credentialing Center defines a nursing case manager as someone who provides a dynamic, orderly, efficient and cooperative approach to client care that improves healthcare continuity and provides the patient with quality care options. The case manager is responsible for coordinating efforts between multiple care professions to make sure the patient’s needs are met in a timely, efficient and cost-effective manner. He/she ensures that health education needs are met to allow for informed care decisions while acting as a patient advocate and facilitator of effective healthcare relationships between patient, family and significant others as well as the healthcare team.

Priority nursing diagnoses and best practices for management of hypertension (HTN)

Potential nursing diagnoses for hypertension might include decreased cardiac output, pain (headache), activity intolerance, ineffective coping and knowledge deficits. Nursing care priorities should first focus on blood pressure (and related pain) control with medication. Initial treatment choices would include a combination of a thiazide diuretic and ACE inhibitor, beta-blocker or calcium-channel blocker.

Further interventions should focus on careful monitoring to reduce risk of HTN-related cardiovascular emergencies; educational interventions to promote lifestyle changes including smoking cessation, diet and exercise; and being a patient advocate to support patient decisions regarding care.

Priority nursing diagnoses and the best practices for chronic heart failure (CHF)

Potential nursing diagnoses for CHF include decreased cardiac output, excess fluid volume, activity intolerance, deficient knowledge, risk for impaired gas exchange and impaired skin integrity.

Medical treatment is a careful balancing act between medications, lifestyle adaptations and surgical interventions.

Medication choices might include angiotensin-converting enzyme (ACE) inhibitors to lower blood pressure and improve blood flow. Other options might include angiotensin II receptor blockers and beta-blockers. Diuretics may be used to try and maintain proper fluid balances and improve lung perfusion. If diuretics are used, carefully monitor the patient’s electrolytes as well as blood pressure.

Other areas to monitor include oxygen saturation levels and activity tolerance. Education efforts and long-term planning might include energy conservation, diet and cardiac rehabilitation to increase activity tolerance levels.

Surgical procedures might include coronary bypass to relieve severely blocked arteries, heart valve surgery, pacemaker placement, implantable cardioverter-defibrillators (ICD) or ventricular assist devices (pumps).

Nursing diagnoses for common arrhythmias

Arrhythmias include any malfunction of the normal beating of the heart. This can include beating too fast, too slow, or beating irregularly. An arrhythmia may be constantly present when not controlled or appear sporadically due to known or unknown causes. Nursing diagnoses might include decreased cardiac output, deficient knowledge, and in the case of digitalis, toxicity poisoning. Treatment for an arrhythmia may only occur in the symptomatic patient; this treatment might include cardiac monitoring, medication, cardioversion or use of a pacemaker.

Assessment findings and treatment priorities for pulmonary embolism

Pulmonary embolism is the second leading cause of sudden death. Immediate recognition and treatment for pulmonary embolism is crucial to the patient’s chances of survival. Symptoms can be vague and nonspecific but might include chest pain, dyspnea, tachypnea, cough, abnormal lung sounds, low blood pressure or even just a sense of impending doom or nonspecific agitation. Pulmonary angiography or CT angiography is used to make a positive diagnosis. Priority care is given to basic life functions, including monitoring oxygen saturation levels and administering oxygen as needed. Anticoagulants and thrombolytics may be used to dissolve the clot, or it may need to be surgically removed. Nitroglycerin, ACE inhibitors and loop diuretics may also be administered. A vein filter may also be inserted to prevent further clots from reaching the lungs.

Aneurysm treatment

Treatment recommendations for aneurysms are based on the size and location of the aneurysm. Typically, aneurysms found early can be treated with aggressive risk factor modification including cessation of smoking, lowering cholesterol, treating hypertension, diet, exercise, and treatment with antiplatelet agents. However, surgery is often necessary if an aneurysm is large and at risk for rupture.

Once an aneurysm has ruptured, the goals of treatment are to surgically stop the bleeding, reestablish blood flow to prevent permanent end organ damage as well as to reduce the risk of recurrence. Although repair of a ruptured aneurysm is possible, the likelihood of survival in patients with ruptured cerebral, abdominal, or thoracic aneurysms remains low.

Treatment of aneurysms involves management with pharmacologic agents such as antihypertensive, anticoagulant, antiarrhythmia agents targeted at decreasing blood pressure, and/or heart rate. By decreasing blood pressure and heart rate, practicing clinicians can manage the patient’s risk of stroke, heart attack, and death.

The guidelines used for the treatment of aneurysms depend on the size of the aneurysm and the types of symptoms the patient is experiencing.

For patients with an abdominal or thoracic aortic aneurysm with a diameter less than 3 cm without symptoms, follow-up screening should be conducted within 5 to 10 years. For patients with an aorta of 3 to 4 cm in diameter, follow-up screening should be performed on a yearly basis.

For patients with a diameter of greater than 4 cm, careful follow-up needs to be performed on a bi-yearly basis. If a patient presents with an aorta with a diameter greater than 5 cm, surgery is recommended, which would include abdominal or open chest repair or endovascular repair.

Treatment of cerebral aneurysms is dependent on the size and location of the aneurysm in the brain. If the aneurysm is small and not causing symptoms, follow-up screening is recommended. However, surgery is recommended for large, symptomatic aneurysms due to their risk of rupture and stroke. Currently there are 2 surgical approaches for brain aneurysms including surgical clipping or endovascular coiling. If an aneurysm is infected, pharmacologic treatment is necessary.

For thoracic or abdominal aneurysms less than 5 cm in diameter and not causing symptoms, pharmacologic approaches are typically used in combination with continuous monitoring. Surgical or interventional repair are options reserved for large unruptured aneurysms where the risk of rupture exceeds the risk of surgery.