The Client with Alterations in Cardiovascular Function

CHAPTER 5


The Client with Alterations in Cardiovascular Function



ABDOMINAL AORTIC ANEURYSM


An abdominal aortic aneurysm is an abnormal dilation of the wall of the abdominal aorta. The aneurysm usually develops in the segment of the vessel that is between the renal arteries and the iliac branches of the aorta. The most common cause of an abdominal aortic aneurysm is atherosclerosis. The plaque that forms on the wall of the artery causes degenerative changes in the medial layer of the vessel. These changes lead to loss of elasticity, weakening, and eventual dilation of the affected segment. Some other causes of abdominal aortic aneurysm include inflammation (arteritis), trauma, infection, congenital abnormalities of the vessel, and connective tissue disorders that cause vessel wall weakness.


Most abdominal aortic aneurysms are asymptomatic and are discovered during a routine physical examination (signs include palpation of a pulsatile mass in the abdomen and/or auscultation of a bruit over the abdominal aorta) or during a review of x-ray results of the abdomen or lower spine. The presence of symptoms such as mild to severe abdominal, lumbar, or flank pain and/or lower extremity arterial insufficiency is usually indicative of a large aneurysm that is exerting pressure on surrounding tissues or an aneurysm that is leaking.


Surgical repair of an aneurysm is usually performed if the aneurysm is growing rapidly and/or reaches a size of 5 to 6 cm or larger, or if the client experiences symptoms. The procedure often involves the use of a synthetic graft, which is inserted to replace or support the weakened vessel.


This care plan focuses on the adult client hospitalized for surgical repair of an abdominal aortic aneurysm. Much of the postoperative information is applicable to clients receiving follow-up care in an extended care facility or home setting.







Nursing/Collaborative Diagnosis RISK FOR IMBALANCED FLUID NDx AND RISK FOR ELECTROLYTE IMBALANCE NDx


Definition: At risk for a decrease, increase, or rapid shift from one to the other of intravascular, interstitial, and/or intracellular fluid; at risk for a change in serum electrolyte levels


Related to:



• Third-spacing of fluid related to:



• Excess fluid volume NDx related to:



• Deficient fluid volume NDx related to restricted oral fluid intake before, during, and after surgery; blood loss; and loss of fluid associated with nasogastric tube drainage


• Hypokalemia, hypochloremia, and metabolic alkalosis related to loss of electrolytes and hydrochloric acid associated with nasogastric tube drainage





CLINICAL MANIFESTATIONS:






DESIRED OUTCOMES: The client will experience resolution of third-spacing as evidenced by:



The client will not experience excess fluid volume as evidenced by:



The client will not experience deficient fluid volume, hypokalemia, hypochloremia, or metabolic acidosis as evidenced by:








Collaborative Diagnosis RISK FOR HYPOVOLEMIC SHOCK


Definition: A type of low blood flow shock that occurs when there is a loss of intravascular fluid volume. Loss of fluid volume may be absolute, resulting from fluid lost from hemorrhage, diuresis, or gastrointestinal losses


Related to: Hypovolemia associated with blood loss during surgery, third-space fluid shift, and hemorrhage (can occur as a result of inadequate wound closure and/or stress on and subsequent leakage or rupture of anastomotic sites)







Collaborative Diagnosis RISK FOR CARDIAC DYSRHYTHMIAS


Definition: Abnormal cardiac rhythms


Related to: Altered nodal function and myocardial conductivity associated with:








Collaborative Diagnosis IMPAIRED RENAL FUNCTION


Definition: Impaired ability to excrete metabolic waste products and water leading to functional disturbances of all body systems


Related to: Insufficient blood flow to the kidneys associated with hypovolemia and prolonged aortic clamp time







Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE HEALTH MAINTENANCE NDx; OR INEFFECTIVE SELF-HEALTH MANAGEMENT* NDx


Definition: Absence or deficiency of cognitive information related to specific topic; (lack of specific information necessary for clients/significant others to make informed choices regarding condition/treatment/lifestyle changes); inability to identify, manage, and/or seek out help to manage health; pattern of regulating and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals










ANGINA PECTORIS


Angina pectoris is transient chest pain or discomfort that is caused by an imbalance between myocardial oxygen supply and demand. The discomfort typically occurs in the retrosternal area; may or may not radiate; and is described as a tight, heavy, squeezing, burning, or choking sensation. The most common cause of angina pectoris is decreased coronary blood supply due to atherosclerosis of a major coronary artery. The atherosclerosis causes narrowing of the vessel lumen and an inability of the vessel to dilate and supply sufficient blood to the myocardium at times when myocardial oxygen needs are increased. Other conditions that can compromise coronary blood flow (e.g., spasm and/or thrombosis of a coronary artery, hypovolemia) and conditions that reduce oxygen availability and/or increase myocardial workload and oxygen demands (e.g., anemia, smoking, exercise, heavy meals, increased altitude, exposure to cold, stress) may precipitate or increase the frequency of angina attacks by widening the gap between oxygen needs and availability.


The two major types of angina pectoris are stable (classic exertional) angina and unstable angina. Stable angina, the most common type, is usually precipitated by physical exertion or emotional stress, lasts 3 to 5 minutes, and is relieved by rest and nitroglycerin. Unstable angina is characterized by an increasing frequency and/or severity of attacks that occur with less provocation or at rest. It is considered to be an acute coronary syndrome, which is associated with thrombus formation in a coronary artery. Persons with unstable angina are usually hospitalized and treated with heparin and antiplatelet agents while decisions regarding medical versus surgical treatment are made. A third type of angina is Prinzmetal’s variant angina. It is less common than stable or unstable angina and is caused by severe focal spasm of a coronary artery.


This care plan focuses on the adult client hospitalized during an episode of chest pain/discomfort suspected to be unstable angina.



OUTCOME DISCHARGE CRITERIA


The client will:



1. Perform activities of daily living and ambulate without angina


2. Have angina controlled by oral medication


3. Have no signs and symptoms of complications


4. Verbalize a basic understanding of angina pectoris


5. Identify factors that may precipitate angina attacks and ways to control these factors


6. Identify modifiable cardiovascular risk factors and ways to alter these factors


7. Verbalize an understanding of the rationale for and components of a diet designed to lower serum cholesterol and triglyceride levels


8. Demonstrate accuracy in counting pulse


9. Verbalize an understanding of medications ordered including rationale, food and drug interactions, side effects, schedule for taking, and importance of taking as prescribed


10. State signs and symptoms to report to the health care provider


11. Identify community resources that can assist in making necessary lifestyle changes and adjusting to the effects of angina pectoris


12. Verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider.



Nursing Diagnosis ACTUAL/RISK FOR DECREASED CARDIAC OUTPUT NDx


Definition: Risk for or actual inadequate volume of blood being pumped by the heart per minute to meet the metabolic demands of the body


Related to: Mechanical and/or electrical dysfunction of the heart associated with severe or prolonged myocardial ischemia












Nursing Diagnosis ACUTE PAIN NDx (RADIATING OR NONRADIATING CHEST PAIN/DISCOMFORT)


Definition: Unpleasant sensory and emotional expenence arising from actual or potential tissue damage


Related to: Decreased myocardial oxygenation (an insufficient oxygen supply forces the myocardium to convert to anaerobic metabolism; the end products of anaerobic metabolism act as irritants to myocardial neural receptors)






Collaborative Diagnosis RISK FOR CARDIAC DYSRHYTHMIAS


Definition: A disturbance of the heart’s normal rhythm. Dysrhythmias can range in severity from missed or rapid beats to serious disturbances that impair the pumping ability of the heart


imageRelated to: Myocardial irritability associated with myocardial hypoxia






Collaborative Diagnosis RISK FOR MYOCARDIAL INFARCTION


Definition: Irreversible myocardial damage


Related to: Persistent ischemia or complete occlusion of a coronary artery







Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT NDx; OR INEFFECTIVE SELF-HEALTH MANAGEMENT NDx*


Definition: Absence or deficiency of cognitive information related to specific topic (lack of specific information necessary for clients/significant others to make informed choices regarding condition/treatment/lifestyle changes); pattern of regulating and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals; inability to identify, manage, and/or seek out help to manage health















CARDIAC DYSRHYTHMIAS


Cardiac dysrhythmias are disturbances in the normal heart rate or rhythm that are caused by a disorder in the initiation and/or conduction of intrinsic electrical impulses. Dysrhythmias can be classified according to the site of impulse formation and the site or degree of conduction block. Supraventricular dysrhythmias (e.g., sinus dysrhythmia, sinus tachycardia, sinus bradycardia, premature atrial contractions, atrial flutter, atrial fibrillation, junctional rhythm) originate above the ventricle. Ventricular rhythms (e.g., premature ventricular contractions, idioventricular rhythm, ventricular tachycardia, Torsades de pointes, ventricular fibrillation) originate in the ventricle. Impulse conduction defects (e.g., first-degree atrioventricular [AV] block, second-degree AV block, third-degree AV block, bundle branch block) result from a delay or block in the transmission of impulses. Causes of dysrhythmias include myocardial ischemia, cardiomyopathy, valvular heart disease, hypoxemia, electrolyte and acid-base imbalances, thyroid dysfunction, certain medications, infection, anemia, excessive caffeine or alcohol intake, smoking, pain, and emotional distress.


Dysrhythmias vary in severity and their effect on cardiac function. They can be benign and require no treatment or be life-threatening. The etiological factors and the clinical significance of the dysrhythmia determine the therapeutic management. Drug therapy is often successful at controlling a dysrhythmia. Other treatment options, depending on the type and severity of the dysrhythmia, include electrical cardioversion, a pacemaker, an implantable cardioverter-defibrillator (ICD), radiofrequency catheter ablation, surgery (e.g., elimination of offending area of myocardium by surgical excision, cryosurgery, or laser; maze procedure), and cardiopulmonary resuscitation and defibrillation.


This care plan focuses on the adult client needing acute management of a dysrhythmia in a medical setting.



OUTCOME DISCHARGE CRITERIA


The client will:




Nursing Diagnosis RISK FOR DECREASED CARDIAC OUTPUT NDx


Definition: Risk for inadequate volume of blood being pumped by the heart per minute to meet the metabolic demands of the body


Related to:













Nursing Diagnosis RISK FOR ACTIVITY INTOLERANCE NDx


Definition: At risk for experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activities


Related to:






CLINICAL MANIFESTATIONS:










Subjective Objective
Verbal reports of exertional discomfort; fatigue; weakness Abnormal blood pressure response to activity (e.g., excessive rise in blood pressure–systolic >180 or diastolic >110 mm Hg; excessive hypotension—drop in systolic blood pressure of 10 mm Hg from baseline blood pressure); abnormal heart rate response to activity (e.g., inappropriate bradycardia—drop in heart rate >10 beats per minute; increased heart rate >100 beats per minute); EKG changes reflecting arrhythmias or ischemia

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Feb 11, 2017 | Posted by in NURSING | Comments Off on The Client with Alterations in Cardiovascular Function

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