Cardiology with pharmacology for nurses

Cardiology with
Pharmacology for Nurses
Compiled from ati review modules, kaplan
study guides, and other sources.
Assembled by Tentance

Vascular System Overview
Structure
Arteries - originate in the aorta or its branches; transport blood to the systemic circulation
Aorta - assists the flow of blood to the arteries or acts as a reservoir for blood during
ejection of the ventricles
Pulmonary artery - originates in the right ventricle and transports deoxygenated
blood from the circulation to the lungs to be oxygenated (only artery carrying
deoxygenated blood)
Gerontologic considerations—loss of arterial elasticity, blood vessel lumen
narrows

Veins
Carry deoxygenated blood and body waste from the systemic circulation to the right
atrium by way of the inferior and superior vena cava
Superior vena cava and inferior vena cava—largest veins in the body; bring
deoxygenated blood from the upper and lower body to the right atrium
Pulmonary veins—return oxygenated blood from the lungs to the left atrium (only
vein carrying oxygenated blood)
Veins have valves to ensure unidirectional blood flow

Capillaries
Arterioles—smallest arteries
Venules—smallest veins
Layers
Tunica intima—smooth lining of blood vessel
Tunica media—muscle layer
Tunica adventitia—connective tissue binds vessels to adjacent structures

Vascular System Function
Oxygenated blood leaves left ventricle, travels though aorta and arterioles (smaller
branches)
Deoxygenated blood returns to the right side of heart by inferior and superior venae
cavae
Coronary circulation - circulation to the myocardium
Peripheral circulation - circulation through the periphery (extremities)
Delivers oxygen, nutrients, hormones, and antibodies to organs, tissues, and cells
Removes end products of metabolism from tissues and cells

Vascular System Mechanics
1. Autonomic nervous system—regulates heart rate, influences arteriolar constriction
and blood pressure
a. Neural reflexes are controlled via vasomotor center in the medulla oblongata
b. Stimulation and inhibition of the circulatory system
i. Pressoreceptors (baroreceptors)—specialized nerve endings affected by
changes in pressure of blood in arteries
ii. Chemoreceptors—located in the aortic arch and carotid bodies; sensitive
to lack of oxygen, increased blood CO2, and decreased pH
iii. Medullary ischemic reflex—produces vasoconstriction of small blood
vessels in response to stimulation of the vasoconstrictor center by excess
CO2 and lack of oxygen

c. Sympathetic branch (“fight or flight”)
1) Increases blood pressure, heart rate, respiratory rate, blood glucose, and
blood flow to the muscles of the legs
2) Inhibits blood flow to the GI tract
d. Parasympathetic branch (“rest and relax”)
1) Counterbalances the sympathetic branch to maintain blood pressure, heart
rate, and respiratory rate within normal limits
2) Stimulates blood flow to the GI tract

Peripheral Vascular Disease
Intermittent claudication - severe pain in calf muscle that occurs with walking and is
caused by ischemia and a buildup of lactic acid; pain often described as cramping
Exercise increases metabolic needs of tissues
Damaged arteries are unable to dilate and supply tissues with oxygen
Rest pain - sudden blockage of a vessel by a thrombus reduces blood supply to tissues
and produces ischemic pain; pain relieved by dependent position
Coldness and pallor of extremities during elevation
Cyanosis of the tissues - occurs when blood contains too little oxygen

Dependent rubor - tissues of the extremities are reddish blue in color
Indicative of peripheral vessel damage where vessels remain permanently dilated
Develops after prolonged anoxia or exposure to severe cold
Trophic changes - adverse changes in the skin and nails of the extremities result from
prolonged ischemia of tissues (loss of lower extremity hair)
Leg ulcers and cellulitis
Venous stasis is a consequence of venous insufficiency
Venous stasis provides a medium for bacterial growth, which results in ulcerations
Gangrenous changes—death and decay of tissues of the extremities result from severe
and prolonged ischemia

The nurse cares for the client diagnosed with an abdominal aortic aneurysm (AAA).
Which postoperative intervention should the nurse include in the client's plan of care?
1. Performing circulation checks distal to the graft.
2. Elevating extremities during rest periods.
3. Instructing the client on application of warm soaks to the lower extremities.
4. Placing the client on a high protein and low carbohydrate diet.

The nurse cares for the client diagnosed with an abdominal aortic aneurysm (AAA). Which postoperative
intervention should the nurse include in the client's plan of care?
1. Correct: Performing circulation checks distal to the graft.
Due to the nature of the aortic repair, distal pulses should be marked preoperatively. Postoperatively, hourly
circulation checks should be performed to document the rate, rhythm, and character of distal pulses. Abdominal
aortic aneurysm is the localized enlargement of the abdominal aorta's wall; may be asymptomatic or client may
complain of abdominal and low back pain; other symptoms include pulsating mass in periumbilical area, bruit
over aorta, and blood pressure may be lower in legs than arms; nursing considerations include monitoring
blood pressure frequently, monitoring renal function, CBC, and instructing client to avoid bending lifting, and
constipation.
2. Incorrect: Elevating extremities during rest periods.
The client should remain flat in bed without flexion of extremities to avoid compression of lower extremity
arteries.
3. Incorrect: Instructing the client on application of warm soaks to the lower extremities.
Warm soaks are not indicated. The nurse should prevent thrombophlebitis by applying elastic or sequential
compression stocking.
4. Incorrect: Placing the client on a high protein and low carbohydrate diet.
A low cholesterol, low fat diet is indicated for this client postoperatively

Thrombophlebitis
The inflammation of a vessel wall caused by the attachment of a blood clot to that wall
with consequential partial occlusion of the vessel.
Superficial venous thrombosis involving the saphenous or surface veins.
Deep vein thrombosis (DVT) involving the deep venous system and can extend from
the foot to the iliofemoral region.
Thrombophlebitis can lead to a pulmonary embolism

Nursing interventions for thrombophlebitis
Providing client education and encouragement pertaining to measures for
prevention of thrombophlebitis.
Early and frequent ambulation.
Avoiding prolonged periods of standing, sitting, or immobility.
Elevating legs when sitting.
Avoiding crossing legs, which will reduce the circulation and exacerbate venous
stasis.
Facilitate bed rest and elevation of the client’s extremity above the level of the heart
(avoid using a knee gatch or pillow under knees).
Maintaining fluid intake of 2,500 mL per day to prevent dehydration, which causes
circulation to be sluggish.
Discontinuing smoking, which is known to be a risk factor.
Measuring lower extremities for fitted elastic support hose/TED (thromboembolic
disorder) hose to lower extremities.

Deep Vein Thrombosis
The most common complication following trauma, surgery, or disability related to
immobility
Apply pneumatic compression stockings and/or elastic stockings.
Reposition the client every 2 hr and ambulate early and regularly.
Administer low-level anticoagulants as prescribed.
Monitor the client’s extremities for calf pain, warmth, erythema, and edema
Facilitate bed rest and elevation of the client’s extremity above the level of the heart
(avoid using a knee gatch or pillow under knees).
Administer intermittent or continuous warm moist compresses.
Do NOT massage the affected limb to prevent thrombus from dislodging and
becoming an embolus.
Monitor the client’s leg circumferences.
Administer analgesics (nonsteroidal anti-inflammatory agents).

Nursing interventions for deep venous thrombosis
Administering anticoagulants as prescribed.
Initially, intravenous heparin is administered by continuous infusion for 5
to 7 days with doses adjusted according to coagulation studies. Protamine
sulfate, the heparin antidote, should be readily available to counteract the
development of heparin-induced antiplatelet antibodies.
Warfarin (Coumadin) is then administered orally and is continued by the
client for approximately 3 months. Vitamin K, the warfarin antidote, should be
readily available for prolonged clotting times.
Elevating the affected extremity during bedrest.
Administering analgesia.
Encouraging TED hose use when the client is being permitted to ambulate.

Heparin sodium Subcutaneously every 12 hr, continuous or intermittent IV infusion
Monitor activated partial thromboplastin time (aPTT). Keep value at 1.5 to 2
times the baseline.
Stop heparin if platelet count is less than 100,000/mm3.
For toxicity, administer protamine sulfate
Enoxaparin, dalteparin sodium, tinzaparin: Subcutaneously every 12 hr for 2 to 8 days
No monitoring required so may be used at home with appropriate teaching.
Stop enoxaparin if platelet count is less than 100,000/mm3.
Fondaparinux sodium: Subcutaneously every 12 hr for 5 to 9 days

Client teaching for anticoagulants.
Watch for bleeding from the gums or nose
Increased vaginal bleeding
Blood in the urine
Bruising easily
Avoid taking aspirin or ibuprofen (increases bleeding tendencies).
Use an electric razor for shaving.
Avoid alcohol use (inhibits warfarin).
Brush teeth gently.
Avoid rubbing or massaging legs.
Avoid periods of prolonged sitting or crossing legs.

The home health nurse visits the client who had a hip fracture repaired. In assessing the
client, the nurse is especially aware of the complications of long-term immobility. The
nurse should assess for which sign?
1. Homan's sign.
2. Kernig's sign.
3. Brudzinski's sign.
4. Chadwick's sign.

The home health nurse visits the client who had a hip fracture repaired. In assessing the client, the nurse is
especially aware of the complications of long-term immobility. The nurse should assess for which sign?
X 1. Homan's sign.
A positive Homan's sign is pain in the calf on dorsiflexion of ankle. It suggests possible development of deep vein thrombosis, a complication
of immobility. Deep vein thrombosis is an aggregate of platelets attached to a vein wall; risk factors include pregnancy, immediate
postpartum period, prolonged immobility, use of oral contraceptives, sepsis, smoking, dehydration, CHF, and trauma; indications include calf
pain, localized edema of one extremity, possible warm skin over the affected leg, possible fever, chills, and perspiration; treatment includes
bed rest, elevating extremity, anticoagulants, possible thrombolytic drugs, and possible surgery; nursing care includes maintaining bed rest,
raising extremity, elastic stockings after acute stage, and administering prescribed analgesics. Hazards of immobility include pressure ulcers,
osteoporosis, hypercalcemia, negative nitrogen balance, increased cardiac workload, orthostatic hypotension, stasis of respiratory
secretions, boredom, and depression; nursing considerations include turning frequently, providing good skin care, giving high protein diet
with small frequent feedings, having the client rise from bed slowly, turn, cough, and breathe deeply.
2. Kernig's sign.
A positive Kernig's sign is the inability of a supine client to completely extend his leg when the thigh is flexed
on his abdomen. It is seen in meningitis.
3. Brudzinski's sign.
A positive Brudzinski's sign is when flexion of the hips and knees is produced when a supine client's neck is
flexed. It is seen in meningitis.
4. Chadwick's sign.
Chadwick's sign is the blue tinge a cervix has in early pregnancy.

Vena cava filter
Insertion of a filter in the vena cava to prevent further emboli from reaching the
pulmonary vasculature
Nursing actions
Prepare clients for the procedure (NPO status, informed consent).
Monitor postoperatively (vital signs, SaO2, incision drainage, pain management).

A postpartum nurse is caring for a client who has deep vein thrombosis. Which of the
following are risk factors for development of this disorder? (Select all that apply.)
Smoking
Multiparity
Diabetes mellitus
Polyhydramnios
Maternal age greater than 35

A postpartum nurse is caring for a client who has deep vein thrombosis. Which of the
following are risk factors for development of this disorder? (Select all that apply.)
X Smoking
X Multiparity
X Diabetes mellitus
Polyhydramnios
X Maternal age greater than 35
Risk factors for the development of deep vein thrombosis include pregnancy, immobility,
obesity, smoking, cesarean birth, multiparity, previous thromboembolism, diabetes
mellitus, and maternal age greater than 35 years. Polyhydramnios is not a risk factor
associated with deep vein thrombosis.

Blood pressure
The pressure exerted by the blood against the walls of vessels
Systolic blood pressure - maximum pressure of blood exerted against the arterial
wall when the heart is contracting
Diastolic blood pressure - lowest pressure of blood exerted against the wall of the
artery when the heart is at rest
Pulse pressure - difference between systolic and diastolic blood pressure

Arterial Lines
Arterial lines are placed in the radial (most common), brachial, or femoral artery, and
provide continuous information about changes in blood pressure, and permit the
withdrawal of samples of arterial blood. Intra-arterial pressures can differ from cuff
pressures.
The integrity of the arterial waveform should be assessed to verify the accuracy of
blood pressure readings.
Monitor circulation in the limb with the arterial line (capillary refill, temperature,
color).
Arterial lines are not to be used for intravenous fluid infusion.

Pulmonary Artery Catheters
Pulmonary artery (PA) catheters have multiple ports and components that enable a variety of
hemodynamic measurements, the collection of blood samples, and the infusion of intravenous
fluids.
The PA catheter is inserted into a large vein (internal jugular, femoral, subclavian, brachial) and
threaded through the right atria and ventricle into a branch of the pulmonary artery.
Pulmonary artery catheters have multiple lumens.
Proximal lumen can be used to measure right atrial pressure (CVP), infuse intravenous
fluids, and to obtain venous blood samples.
Distal lumen can be used to measure pulmonary artery pressures (PA systolic, PA diastolic,
mean pulmonary artery pressure, and pulmonary artery wedge pressure). This lumen is not to
be used for intravenous fluid infusion.
Balloon inflation port is intermittently used for PAWP measurements. When not in use, it should
be left deflated and in the ‘locked’ position.
Thermistor measures temperature differences between the right atrium and the pulmonary artery
in order to determine cardiac output.
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Additional infusion ports may be indicated, depending on the brand.

Preprocedure Nursing Actions for Line Insertion
Ensure the client’s understanding of the procedure prior to obtaining consent.
Assemble the pressure monitoring system.
Purge all air from system.
Maintain sterility of connections.
Place the client in supine or Trendelenburg position.
Administer sedation and pain medications as prescribed.
Level transducer with phlebostatic axis (4th intercostal space, mid-axillary line).
Zero system with atmospheric pressure.
Hemodynamic pressure lines must be calibrated to read atmospheric pressure as zero,
and the transducer should be positioned at the right atrium (phlebostatic axis).
Obtain initial readings as prescribed.
Compare arterial blood pressure to non-invasive cuff pressure (NIBP).
Document the client’s response.

Postprocedure Nursing Actions
Obtain chest x-ray following the procedure to confirm catheter placement.
Continually monitor respiratory and cardiac status (vital signs, heart rhythm, SaO2).
Observe respiratory pattern and effort.
Compare NIBP to arterial blood pressure.
Maintain line placement and integrity.
Observe and document waveforms. Report changes in waveforms to the provider, as this
can indicate catheter migration or displacement.
Document catheter placement each shift and as needed (after movement for transport).
Monitor and secure connections between pressure tubing, transducers, and catheter ports.
Obtain readings from hemodynamic catheter as prescribed.
Place the client in supine position prior to recording hemodynamic values. Head of bed can
be elevated 15° to 30°.
Level the transducer at the phlebostatic axis before readings and with all position changes.
Zero system to atmospheric pressure.

Which of the following actions are necessary to obtain an accurate hemodynamic
reading? (Select all that apply.)
Place the client in high-Fowler’s position, with the head elevated no more than 30°.
Level transducer to phlebostatic axis.
Zero transducer to room air.
Record readings.
Compare readings to physical assessment.

Which of the following actions are necessary to obtain an accurate hemodynamic
reading? (Select all that apply.)
Place the client in high-Fowler’s position, with the head elevated no more than
30°.
X Level transducer to phlebostatic axis.
X Zero transducer to room air.
X Record readings.
X Compare readings to physical assessment.

Normal Values of Hemodynamic Monitoring
Central Venous Pressure (CVP) 1-8 mm Hg Measures Preload in
Right Heart
Pulmonary Artery Systolic (PAS) 15-26 mm Hg
Pulmonary Artery Diastolic (PAD) 5-15 mm Hg
Pulmonary Artery Wedge Pressure (PAWP) 4-12 mm Hg Measures Preload in Left
Heart
Cardiac Output (CO) 4-6 L/min
Mixed Venous Oxygen Saturation (SvO2) 60% to 80%
Afterload
Pulmonary Vascular Resistance - Right Heart
Systemic Vascular Resistance - Left Heart

A nurse has just obtained the following hemodynamic readings for a client:
PAS 34 mm Hg
PAD 21 mm Hg
PAWP 16 mm Hg
CVP 12 mm Hg
Which of the following conditions support these hemodynamic values? (Select all that apply.)
Heart failure
Cor pulmonale
Hypovolemic shock
Pulmonary hypertension

A nurse has just obtained the following hemodynamic readings for a client:
PAS 34 mm Hg
PAD 21 mm Hg
PAWP 16 mm Hg
CVP 12 mm Hg
Which of the following conditions support these hemodynamic values? (Select all that
apply.)
X Heart failure
X Cor pulmonale
Hypovolemic shock
X Pulmonary hypertension
These elevated hemodynamic measurements are consistent with left ventricular failure
and
pulmonary problems. Hypovolemic shock is characterized by low hemodynamic values.

Factors affecting cardiovascular performance
1. Cardiac output
a. Preload–ventricular end-diastolic pressure (VEDP)
1) Venous return–increased return increases VEDP
2) End-systolic volume– increased volume increases VEDP
3) Frank-Starling law of the heart–within a physiologic range of muscle
contraction, increased preload will increase cardiac output; excessive preload will
decrease cardiac output
b. Afterload–resistance to ejection of blood from the left ventricle; correlates with
aortic systolic pressure; increased afterload increases myocardial oxygen demand
c. Myocardial contractility–determined by preload, sympathetic nervous stimulation,
myocardial oxygen supply
d. Heart rate–tachycardia or bradycardia decrease cardiac output

Electrocardiography
Uses an electrocardiograph to record the electrical activity of the heart over time. The
electrocardiograph is connected by wires (leads) to skin electrodes placed on various
areas of the body.
Nursing Actions
Position the client in a supine position with the chest exposed.
Wash the client’s skin to remove oils.
Attach one electrode to each extremity by applying electrodes to flat surfaces above the
wrists and ankles and the other six electrodes to the chest, avoiding chest hair. (On male
clients, chest hair may need to be shaved.)
Check for changes on serial ECGs.
Angina – ST depression and/or T-wave inversion (ischemia)
MI – T-wave inversion (ischemia), ST-segment elevation (injury), and an abnormal Q
wave (necrosis)

Cardiac cycle - one complete heartbeat
Two parts
1) Systole - contraction of (ejection of blood from) both atria and then both
ventricles; initiated by release of impulse by SA node
2) Diastole - relaxation and filling of both atria and then both ventricles
Cardiac output is stroke volume × heart rate
1) Stroke volume - the amount of blood ejected with each beat
2) Heart rate - the number of beats per minute
Cardiac output depends upon
1) Preload and Afterload
2) Contractility
3) Age—decreased beta receptor responsiveness with age; altered autonomic
nervous system control

Cardiac enzymes
Released into the bloodstream when the heart muscle suffers ischemia.
Creatine kinase Mb isoenzyme (CK-Mb) - more sensitive to myocardium
0% of total CK Initial: 4 to 6 hours, Duration: 3 days
Troponin T < 0.2 ng/l Initial: 3 to 5 hours, Duration: 14 to 21 days
Troponin I < 0.03 ng/l Initial: 3 hours, Duration: 7 to 10 days
Myoglobin < 90 mcg/l 2 Initial: 2 hours, Duration: 24 hr

Lipid Studies
Cholesterol - Screening test for heart disease
(total) < 200 mg/dl
Hdl - “good” cholesterol produced by the liver
Females – 35 to 80 mg/dl
Males – 35 to 65 mg/dl
LDL - “bad” cholesterol can be up to 70% of total cholesterol
< 130 mg/dl
Triglycerides - evaluating test for atherosclerosis
< 150 mg/dl

Echocardiogram
Ultrasound of the heart, used to diagnose valve disorders and cardiomyopathy.
Indications - Cardiomyopathy, Heart failure
Nursing Actions - Explain the reason for the test to the client. The test is pain free and
takes up to 1 hour.
Intraprocedure Nursing Actions Instruct the client to lie on left side and remain still.
Post procedure Nursing Actions Inform the client that the results of the test and a plan for
follow-up care will be provided by the provider. There is no specific post procedure
instructions that need to be followed.

Thallium Scans
Radioisotopes cannot reach areas with decreased or absent perfusion and they
appear as “cold spots.”
Nursing Actions
Instruct the client to avoid smoking and consuming caffeinated beverages
for 4 hours prior to the procedure. These can affect the test.

Stress Testing
Patient walks on a treadmill, working the heart. Once the client’s heart rate reaches a
certain rate, the test is discontinued.
Indications - Angina, Heart Failure, Myocardial Infarction, Dysrhythmia
Preprocedure Nursing Actions - Ensure that informed consent has been obtained.
Explain to the client that he will be walking on a treadmill, and comfortable
shoes and clothing are recommended.
If the client is disabled or unable to be physically challenged, the provider can
order the test be a pharmacological stress test, where a drug, such as adenosine
(Adenocard), is given to stress the heart instead of walking on the treadmill.
The client is instructed to fast 2 to 4 hours before the procedure according to
agency policy and to avoid tobacco, alcohol, and caffeine before the test.

Intraprocedure Nursing Actions - Remind the client that once the heart reaches a certain
rate, the test will be discontinued.
Postprocedure Nursing Actions - The client is monitored by ECG and his blood pressure
is checked frequently until he is stable.
The provider will discuss findings with client. There are no specific postprocedure
considerations for this test.

Angiography
Cardiac catheterization, is an invasive diagnostic procedure used to evaluate the
presence and degree of coronary artery blockage. It can be done on the lower
extremities to determine blood flow and areas of blockage. Angiography involves the
insertion of a catheter into a femoral (sometimes brachial) vessel and threading it into the
right or left side of the heart. Coronary artery narrowings and/or occlusions are identified
by the injection of contrast media under fluoroscopy.
Preprocedure Nursing Actions
Ensure that the consent form is signed.
Maintain the client on NPO status for at least 8 hr (risk for aspiration when lying
flat for the procedure).
Assess that the client and family understand the procedure.
Smoking can change the test results, ensure the client refrains from smoking.

Assess for iodine/shellfish allergy (contrast media).
Assess renal function prior to introduction of contrast dye.
Administer premedication as prescribed [methylprednisone (Solu-Medrol),
diphenhydramine (Benadryl)].
Client Education
Instruct the client that he can be awake and sedated during procedure. A local
anesthetic should be used. A small incision is made, often in the groin to insert
the catheter. The client can feel warmth and flushed when the dye is inserted.
After the procedure, the client must keep the affected leg straight. Pressure (a
sandbag) can be placed on the incision to prevent bleeding.
Intraprocedure Nursing Actions
Administer sedatives and analgesia as prescribed.
Continually monitor vital signs and heart rhythm.

Be prepared to intervene for dysrhythmias.
Have resuscitation equipment and emergency medications readily available.
Postprocedure Nursing Actions
Assess vital signs every 15 min x 4, every 30 min x 2, every hour x 4, and then every 4 hr
(follow hospital protocol).
Assess the groin site at the same intervals for:
Bleeding and hematoma formation
Thrombosis; document pedal pulse, color, temperature
Maintain bed rest in supine position with extremity straight for prescribed time.
A vascular closure device may be used to hasten hemostasis following catheter removal.
Older adult clients can have arthritis, which can make lying in bed for 4-6 hr after the
procedure painful. The provider can be notified for prescribed medication.

A nurse is caring for a client following an angioplasty that was inserted through the
femoral artery. While turning the client, the nurse discovers blood underneath the client’s
lower back. The nurse should suspect
A. retroperitoneal bleeding.
B. cardiac tamponade.
C. bleeding from the incisional site.
D. heart failure

A nurse is caring for a client following an angioplasty that was inserted through the
femoral artery. While turning the client, the nurse discovers blood underneath the client’s
lower back. The nurse should suspect
A. retroperitoneal bleeding.
B. cardiac tamponade.
X C. bleeding from the incisional site.
D. heart failure
The incisional site is most likely leaking blood that is seeping under the client. The nurse
should assess the incision for drainage, apply pressure, monitor blood pressure and
heart
rate, and notify the surgeon. Retroperitoneal bleeding, cardiac tamponade, and heart
failure would not be indicative of these findings.

Coronary Artery Bypass Surgery
To increase blood flow to heart muscle in patients with severe angina. Saphenous vein is
used for graft; as many as five arteries are bypassed
Preoperative Nursing Care: Education and psychological preparation
Postoperative Nursing Care
Provide intensive evaluation of organ systems
Provide chest drainage
Pain relief
Be alert to psychological state of disorientation or depression
Provide activity as tolerated with progress as ordered from foot dangling over side of
bed, to sitting in chair, to walking in room by third day
Provide guidance concerning long-term care and follow-up

Hypertension
Persistent elevation of the systolic blood pressure above 140 mmHg and of diastolic
blood pressure above 90 mmHg
Assessment
There may be no symptoms, or there could be: headache, dizziness; facial flushing,
anginal pain (insufficient blood flow through coronary arteries to the myocardium),
intermittent claudication (decreased adequacy of blood supply to the legs during periods
of activity), retinal hemorrhages and exudates (damage to arterioles that supply the
retina), severe occipital headaches associated with nausea, vomiting, drowsiness,
giddiness, anxiety, and mental impairment due to vessel damage within the brain,
polyuria, nocturia, protein, and RBCs in urine, and diminished ability of kidneys to
concentrate urine (hardening of arterioles within the kidney causing arteriolar
nephrosclerosis), dyspnea upon exertion from left-sided heart failure, edema of the
extremities from right-sided heart failure

Patient’s history should include
Age of onset (all ages, but more common with increasing age)
Family history
History of renal or cardiovascular disease
Recent complaints of dyspnea, fatigue, weakness, anginal-type pain, swelling of
feet, or nocturia
Sudden gain or loss of weight
Recent severe headaches or drenching sweats
Personality type
Activity level
Alcohol intake
Diet, including sodium intake

Physical Examination for Hypertension
a. Blood pressure reading on both arms in supine and erect positions and on one leg:
readings should be taken every one to two hours over an eight-hour period for one to two
days (a single blood pressure reading is almost always inaccurate)
b. Ophthalmoscopic examination for evidence of vascular changes
c. Examination of the heart and aorta by means of auscultation, EKG readings, and
aortography
d. Palpation of the arteries in the neck, wrists, femoral areas, and feet for evidence of
coarctation of the aorta (decreased amplitude of pulses and lower blood pressure in the
legs than in the arm)
e. Neurological examination for signs of cerebral thrombosis or hemorrhage
f. Gerontologic considerations - high incidence of hypertension; parameters are the same
as for younger adults; increased systolic blood pressure common; treatment goal is
<140/90 mm Hg or <130/80 mmHg in diabetic clients; consider effects of antihypertensive
medications

Laboratory Studies to determine Hypertension
Urinalysis and urine cultures to determine the presence of protein, RBCs, pus cells, and
casts (all indicative of renal disease)
Blood count and sedimentation rate
Serum sodium, potassium, chloride, and carbon dioxide (all indicative of primary
aldosteronism)
Urinary catecholamine metabolites (indicative of pheochromocytoma)
Urine 17-ketosteroids and blood corticoids (both indicative of Cushing’s disease)
Intravenous pyelogram, urine cultures, radioisotope renogram, renal arteriography,
intravenous urograms (all tests for renal disease)
BUN and creatinine

If clinical workup indicates no evidence of coarctation of the aorta, adrenal disease, or
primary renal disease, then the condition is diagnosed as essential hypertension
Primary (essential or idiopathic)—constitutes 90% of all cases; may be benign (gradual
onset and prolonged course) or malignant (abrupt onset and short dramatic course,
which is rapidly fatal unless treated)
Secondary—develops as a result of another primary disease of the cardiovascular
system, renal system, adrenal glands, or neurological system

Plan/Implementation for Hypertension
1. Medications
2. Nursing management
a. Provide a restful, quiet hospital environment
b. Provide complete explanations of all procedures and diagnostic studies
c. Listen to the patient’s fears and worries and offer reassurance
d. Completely explain dietary restrictions (i.e., salt restriction, low fat)
e. Document patient’s blood pressure both standing and lying down
f. Encourage weight loss if patient is obese
g. Provide moderate salt-restricted diet
h. Plan program of regular physical exercise

i. Encourage changes in job or domestic settings for patients who live or work under
considerable stress
j. Educate patient regarding drug therapy
1) Lie down immediately if faintness, weakness, nausea, or vomiting occurs
2) Avoid hot baths, excessive amounts of alcohol, and immobility following exercise
3) Always rise slowly from a lying to a sitting position and from sitting to standing to
allow the vascular system to adjust to positional changes
4) Avoid standing motionless, especially within the first hour or two after receiving
medication (standing causes leg vessels to relax, allowing blood to pool within lower
extremities)
5) Use caution when driving an automobile or when operating heavy or dangerous
machinery, especially with medications causing sedation
6) Avoid constipation because it may cause either an increased or irregular absorption
of hypotensive drugs, which can result in critical hypotensive reactions
7) Should hypotensive crises occur frequently, wrap legs firmly with elastic bandages
when ambulating to promote venous return

8) Never take a larger dose of drug than prescribed without consulting the
doctor
9) Always take medication on time and do not skip a dose (noncompliance is
common)
10) Never suddenly discontinue a drug without the doctor’s permission to avoid
severe rebound hypertensive reaction
11) Always report side effects to the physician; impotence problems warrant
change of therapy
12) Consult with health care provider before taking any prescription or over-
the-counter medications

Gerontologic considerations for Hypertension
Blood pressure assessment—inflate cuff pressure to level above disappearance of
brachial or radial pulse
Assess for orthostatic blood pressure changes
Elderly may not tolerate systolic blood pressure <120 mm Hg
Elderly may have significant drop in blood pressure immediately after meals
Polypharmacy - interaction between NSAIDs and antihypertensive medications

Medications for Hypertension
Beta Blockers
Atenolol (Tenormin) Bradycardia Hypotension Bronchospasm
Once-a-day dose increases compliance, Check apical pulse; if <60 bpm, hold drug
and call physician, Don’t discontinue abruptly, Masks signs of shock and hypoglycemia
Metoprolol (Lopressor) Bradycardia Hypotension Heart failure Depression
Give with meals, Teach patient to check pulse before each dose; take apical pulse
before administration; withhold if pulse is <60 bpm
Nadolol (Corgard) Bradycardia Hypotension Heart failure
Teach client to check pulse before each dose; check apical pulse before
administering, Withhold if pulse <60 bpm, Don’t discontinue abruptly
Propranolol (Inderal) Weakness Hypotension Bronchospasm Bradycardia
Depression Blocks Sympathetic Innervation of Heart
Client should take pulse at home before each dose, Dosage should be reduced
gradually before discontinued

Alpha Blockers
Prazosin (Minipress) Drowsiness, dizziness Weakness Palpitations Nausea Blocks a-
mediated vasoconstriction
Assess for first-dose syncope, Orthostatic hypotension precautions
Alpha-2 Agonists
Methyldopa (Aldomet) Drowsiness, Dizziness, Bradycardia, Hemolytic Anemia, Fever,
Orthostatic Hypotension, Prevents reuptake of norepinephrine
Monitor CBC and liver function, Take at hs to minimize daytime drowsiness, Change
position slowly
Clonidine (Catapres) Drowsiness, Dizziness, Dry mouth, Headache, Dermatitis,
Severe rebound hypertension
Don’t discontinue abruptly, Apply patch to non-hairy area (upper outer arm, anterior
chest), Take orthostatic hypotension precautions, older adults are at a higher risk
orthostatic hypotension and CNS adverse effects

POTASSIUM-SPARING DIURETICS
Spironolactone Hyperkalemia GI upset
Weigh regularly, Monitor for symptoms of hyperkalemia
THIAZIDE DIURETICS
Hydrochlorothiazide Hypokalemia Dehydration Postural hypotension
Weigh regularly, Monitor for symptoms of hypokalemia, take postural hypotension
precautions
Vasodilators
Hydralazine (Apresoline) Headache, Palpitations, Edema, Tachycardia, Lupus
erythematosus-like syndrome, Dilates arteriolar smooth muscle
Give with meals, observe mental status, check for weight gain, edema
Morphine sulfate Hypotension, Respiratory depression, Decreased mental alertness,
Constipation, Reduces cardiac workload/preload/afterload pressures, Relieves pain,
reduces anxiety

ACE Inhibitors
Captopril (Capoten) Enalapril (Vasotec) Dizziness, Orthostatic hypotension, Persistent
cough, Hyperkalemia, Blocks conversion of Angiotensin I to Angiotensin II
Report swelling of face, lightheadedness. Report persistent cough.
Angiotensin II Receptor Blocker (ARB)
Losartan (Cozaar) Less likely to cause persistent cough and hyperkalemia than are ACE
inhibitors, Prevents binding of angiotensin II with tissue receptor sites
Maximal effects require 3 to 6 weeks, Can be used in combination with a diuretic for better BP
control
Calcium Channel Blockers
Nifedipine (Procardia) Verapamil (Calan) Diltiazem (Cardizem) Amlodipine
(Norvasc) Hypotension, Dizziness, GI distress, Liver dysfunction, Jitteriness, Reduces
workload of left ventricle, Coronary vasodilator
Monitor blood pressure during dosage adjustments, assist patient with ambulation at start of
therapy. Nifedipine - high risk hypotension and constipation in older adults

Acute Hypertensive Crisis
Often occurs with noncompliance.
Nursing Actions
Thorough Assessment - Severe headache, Extremely high blood pressure
(generally, systolic blood pressure greater than 240 mm Hg, diastolic greater than 120
mm Hg), Blurred vision, dizziness, and disorientation, Epistaxis
Administer IV antihypertensive therapies, such as nitroprusside (Nipride),
nicardipine (Cardene IV), and labetalol (Normodyne).
Before, during, and after administration of IV antihypertensive, closely monitor blood
pressure every 5 to 15 min as prescribed.
Assess the client’s neurological status such as pupils, level of consciousness, and
muscle strength, frequently to monitor for cerebrovascular change.
Monitor the ECG to assess the client’s cardiac status.

A nurse is caring for a client who is admitted to the emergency department with a blood
pressure of 266/147 mm Hg. The client reports a headache and states that she is seeing
double. The client states that she ran out of her diltiazem (Cardizem) 3 days ago, and
she has not been able to purchase more. Which of the following nursing interventions
should the nurse expect to perform first?
A. Administer acetaminophen for headache.
B. Provide teaching in regard to the importance of not abruptly stopping an
antihypertensive.
C. Obtain IV access and prepare to administer an IV antihypertensive.
D. Call social services for a referral for financial assistance in obtaining
prescribed medication

A nurse is caring for a client who is admitted to the emergency department with a blood
pressure of 266/147 mm Hg. The client reports a headache and states that she is seeing
double. The client states that she ran out of her diltiazem (Cardizem) 3 days ago, and
she has not been able to purchase more. Which of the following nursing interventions
should the nurse expect to perform first?
A. Administer acetaminophen for headache.
B. Provide teaching in regard to the importance of not abruptly stopping an
antihypertensive.
X C. Obtain IV access and prepare to administer an IV antihypertensive.
D. Call social services for a referral for financial assistance in obtaining
prescribed medication
The greatest risk to the client is injury due to a blood pressure of 266/147 mm Hg, which
can be life-threatening. The highest priority is to decrease the client’s blood pressure as
quickly as possible. An IV should be started for IV access. Medications given by the IV
route will be absorbed and distributed much faster than by the oral route. Administering
acetaminophen for headache, providing teaching regarding medication administration,
and obtaining financial assistance is important, but not the priority at this time.

Cardiomyopathy
Impaired cardiac function leading to heart failure.
Blood circulation is impaired to the lungs or body when the cardiac pump is
compromised.
Of the three types (dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive
cardiomyopathy), dilated cardiomyopathy is the most common.
Dilated – decreased contractility and increased ventricular filling pressures. This can be a
result of:
Coronary artery disease
Infection or inflammation of the heart muscle
Various cancer treatments
Prolonged alcohol abuse
Activity intolerance may be a symptom of dilated cardiomyopathy related to worsening
failure

Heart Failure
Failure of the cardiac muscle to pump sufficient blood to meet the body’s metabolic needs
Class I: Client exhibits no symptoms with activity (chest pain, SOB).
Class II: Client has symptoms with ordinary exertion.
Class III: Client displays symptoms with minimal exertion.
Class IV: Client has symptoms at rest.

Conditions that predispose heart to gradual failure
Inflow of blood to the heart is reduced due to hemorrhage or dehydration
Inflow of blood to the heart is increased due to excessive IV fluids or sodium and
water retention
Outflow of blood from the heart is obstructed due to damaged valves and narrowed
arteries
The heart muscle is damaged from ischemia or inflammatory processes
The metabolic needs of the body are increased as a result of fever or pregnancy
Some disease processes that may lead to heart failure include: Hypertensive
disease, Arteriosclerosis, Valvular heart disease, Rheumatic heart disease, Ischemic
heart disease, Constrictive pericarditis, Circulatory overload, Pulmonary disease,
Tachydysrhythmias

Compensatory Mechanisms of a failing heart
Ventricular dilation - increase in the length of muscle fibers, creating an increase in the
volume of the heart chambers
1) Starling’s law - a stretched muscle contracts more forcefully; therefore, dilation
causes an increased systolic output within limits
2) This compensatory mechanism is limited because if stretched beyond a certain
point, muscle fibers cease to increase contractile power of the heart and because a
greatly dilated heart requires more oxygen to meet its metabolic needs, resulting, in time,
in hypoxia of the heart muscle
Ventricular hypertrophy - increase in diameter of muscle fibers creating a thickening of
the walls of the chambers and a corresponding increase in the weight of the heart
1) Generally follows persistent dilation, further increasing the contractile power of
muscle fibers

2) Limited compensatory mechanism because in time increased muscle mass of
heart outgrows coronary blood supply and becomes hypoxic
Tachycardia - least effective compensatory mechanism because when heart rate
becomes too rapid, the ventricles are unable to fill adequately, with resultant hypotension
and shock
Cardiac decompensation occurs when the heart is unable to cope with the work demands
placed upon it and thus expends most of its reserve

Assessment
Presence of characteristic symptoms of left or
right heart failure
Muffled heart sounds
Abnormal heart sounds (S3)
Rales (crackles) at the base of the lungs
Hazy lung fields and prominent, distended
pulmonary veins on x-ray
Elevated venous pressure
Distended neck veins
Prolonged circulation time
Reduction in cardiac output
Presence of albuminuria
Elevated BUN
Gerontologic considerations - may see
change in grooming habits, change in
personality, dizziness or
lightheadedness, decreased appetite,
gait and balance alterations, malaise,
chronic cough, nocturia; manifestations
are worse during exacerbation of heart
failure

Human B-type natriuretic peptides (hBNP): Elevated in heart failure. Used
to differentiate dyspnea related to heart failure versus respiratory problem
and to monitor the need for and the effectiveness of aggressive heart failure
intervention.
A level below 100 pg/mL indicates no heart failure.
Levels between 100 to 300 pg/mL suggest heart failure is present.
A level above 300 pg/mL indicates mild heart failure.
A level above 600 pg/mL indicates moderate heart failure.
A level above 900 pg/mL indicates severe heart failure.

Nursing Management
Medications - primarily Digitalis and diuretics
Diet
Restricted sodium diet
Normal intake: 6–15 g/d
No table salt: 1.6–2.8 g/d
No salt: 1.2–1.4 g/d
Strict low-sodium diet: 0.2–1 g/d
Low calorie, supplemented with vitamins - promotes weight loss, reducing the
workload of the heart
Bland, low residue—avoids discomfort from gastric distention and heartburn
Small, frequent feedings to avoid gastric distention, flatulence, and heartburn

Record intake and output
Weigh daily
Good skin care
Oxygen therapy
Encourage bedrest and energy conservation until stable
Place in high Fowler’s position to support breathing
Teaching about disease process and medications

A nurse is caring for a client who has a diagnosis of heart failure and asks how to limit
fluid intake to 2,000 mL/day. Which of the following responses should the nurse give to
the client?
A. “Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of
how much you drink.”
B. “Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can
have a total of 8 glasses or cups of fluid each day.”
C. “This is the same as 2 quarts, or about the same as two pots of coffee.”
D. “Take sips of water or ice chips so you will not take in too much fluid.”

A nurse is caring for a client who has a diagnosis of heart failure and asks how to limit
fluid intake to 2,000 mL/day. Which of the following responses should the nurse give to
the client?
X A. “Pour the amount of fluid you drink into an empty 2 liter bottle to keep track
of how much you drink.”
B. “Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can
have a total of 8 glasses or cups of fluid each day.”
C. “This is the same as 2 quarts, or about the same as two pots of coffee.”
D. “Take sips of water or ice chips so you will not take in too much fluid.”
Pouring the amount of fluid consumed into an empty 2 L bottle will give the client a visual
guide to how much fluid is consumed and how much is left. Glasses and cups vary in
size. Providing frames of reference for the amount of fluid in 2 L or suggesting that the
client take sips of water or ice chips are not concrete methods to determine intake.

Identify which of the following food selections are high in sodium (mark with an S) and
which are high in potassium (mark with a P).
Cheese (cheddar and cottage cheese)
Cantaloupe
Milk
Soy sauce
Cured meats (pork)
White potatoes
Avocado
Banana
Raisins
Meats (beef, pork, chicken, and veal)
Codfish, salmon, and tuna

Identify which of the following food selections are high in sodium (mark with an S) and
which are high in potassium (mark with a P).
S Cheese (cheddar and cottage cheese)
P Cantaloupe
S Milk
S Soy sauce
SP Cured meats (pork)
P White potatoes
P Avocado
P Banana
P Raisins
P Meats (beef, pork, chicken, and veal)
P Codfish, salmon, and tuna

Interdisciplinary Care
Cardiology and pulmonary services should be consulted to manage heart failure.
Respiratory services should be consulted for inhalers, breathing treatments, and
suctioning for airway management.
Cardiac rehabilitation services can be consulted if the client has prolonged weakness
and needs assistance with increasing level of activity.
Nutritional services can be consulted for diet modification to promote low sodium,
and low-saturated fat food choices.

Ventricular assist device (VAD)
A VAD is a mechanical pump that assists a heart that is too weak to pump blood through
the body. A VAD is used in clients who are eligible for heart transplants or who have
severe end-stage heart failure and are not candidates for heart transplants. Heart
transplantation is the treatment of choice for clients who have severe dilated
cardiomyopathy.
Nursing Actions
Prepare the client for the procedure (NPO status and informed consent).
Monitor postoperatively (vital signs, SaO2, incision drainage, and pain management).

Heart Transplantation
A possible option for clients who have end-stage heart failure. Lifelong
immunosuppressant therapy is required posttransplantation to prevent rejection.
Nursing Actions
Prepare the client for the procedure (NPO status and informed consent).
Monitor postoperatively (vital signs, SaO2, incision drainage, and pain
management).

Left-Sided Heart Failure
develops as a result of left ventricular dysfunction, which causes blood to back up
through the left atrium and into the pulmonary veins
Dyspnea - results from pulmonary congestion due to pulmonary engorgement; poor gas
exchange because of fluid in the alveoli
Orthopnea - shortness of breath occurring when the patient is in a recumbent position
Paroxysmal nocturnal dyspnea
Cheyne-Stokes respirations - exact cause in HF unknown; believed that they occur as a
result of prolonged circulation time between the pulmonary circulation and the central
nervous system, which in turn affects the respiratory center
Pleural effusion and pulmonary edema - from severe pulmonary congestion, causing
distended capillaries, which leak fluid into the interstitial and alveolar spaces of the lungs
Cough and cardiac asthma - cough productive of large amounts of frothy, blood-tinged
sputum results from edema fluid trapped within the pulmonary tree, irritating the delicate
mucosa of the lungs

Cerebral anoxia - develops because of the decrease in cardiac output to the brain, which
causes irritability, restlessness, and a shortened attention span
Fatigue and muscular weakness - decreased cardiac output diminishes oxygen to tissues
and decreases the speed with which metabolic wastes are swept up into the circulation
for excretion, thereby creating profound exhaustion
S3 gallop
B -type natriuretic peptide levels increased
Microalbuminuria
CVP/right atrial pressure (normal = 1 to 8 mm Hg): Normal or elevated
PAP (normal = 15 to 26 mm Hg/5 to 15 mm Hg): Elevated
PAWP (normal = 4 to 12 mm Hg): Elevated
CO (normal = 4 to 7 L/min): Decreased
The elderly may have atypical manifestations like falls, delirium, chronic cough, or weight
loss

Decreased renal function, edema, and weight gain - kidney function is adversely affected
by the development of HF, resulting in sodium and water retention
1) Decreased cardiac output results in decreased arterial pressure in the kidneys,
reducing glomerular filtration and output of sodium chloride and water
2) Reduced circulating blood volume triggers an increase in aldosterone secretion
by the adrenal cortex, thereby increasing the rate of reabsorption of sodium by renal
tubules
3) Increased sodium reabsorption results in increased concentration of extracellular
fluid
4) Increased osmotic pressure causes an increase in the release of antidiuretic
hormone (ADH) from the neurosecretory cells of the hypothalamus, resulting in
increased tubular reabsorption of water

Right Sided Heart Failure
Develops from a diseased right ventricle that causes backward flow to right atrium and
venous circulation; usually caused by left-sided failure
Liver enlargement and abdominal pain - as the liver becomes congested with venous
blood, it enlarges; stretching of the capsule surrounding the liver causes severe
discomfort in the right upper quadrant
Anorexia, nausea, and bloating - secondary to venous congestion of the gastrointestinal
tract (anorexia and nausea may also result from digitalis toxicity, a common problem
because digitalis is a major drug in treating heart failure)
Dependent edema - early signs of right-sided heart failure include edema of ankles and
lower extremities, resulting from venous congestion of kidneys producing compensatory
vasoconstriction that decreases renal blood flow, impairing sodium excretion
Coolness of extremities - venous congestion throughout the body reduces peripheral
blood flow, often causing coolness of extremities and cyanosis of nail beds
Weight gain
CVP/right atrial pressure (normal = 1 to 8 mm Hg): Elevated

Advanced Heart Failure
Weight loss and cachexia—low cardiac output and venous congestion create
malnutrition of tissues, although patient may appear puffy and bloated due to
edema
Shock syndrome—typical clinical picture of shock usually appears during
terminal stages of HF
Stupor
Pallor
Rapid, thready pulse
Cold sweats
Restlessness
Profound hypotension

Medications for Heart Failure
Cardiac Glycosides
Digoxin (Lanoxin) Anorexia, Nausea, Bradycardia, Visual disturbances, Confusion,
Abdominal pain
Take apical pulse for 1 full minute before administering, Notify physician if apical pulse is
less than 60 (adult), less than 90-110 (infants and young children), less than 70 (older
children) . Loading dose 0.5-1 mg IV or PO in divided doses over 24 h, Maintenance
dose 0.125-0.5 mg IV or PO (average is 0.25 mg). Teach patient to check pulse rate and
discuss side effects. Low K+ increases risk of digitalis toxicity. Take at the same time
each day. Take 2 hours apart from antacids.
If toxicity occurs (>2.0 nanograms/mL) - Discontinue the drug and potassium-wasting
diuretics. Monitor serum potassium. Administer antidysrhythmic drug as needed. For
severe toxicity: Fab body fragments (Digibind) administered, Cholestyramine and
activated charcoal orally to suppress absorption.

A nurse is caring for four clients, each taking digoxin (Lanoxin). Which of the following
clients is at risk for digoxin toxicity? A client who is taking
A. procainamide (Pronestyl) for premature ventricular contractions.
B. ranitidine (Zantac) for peptic ulcer disease.
C. phenytoin (Dilantin) for a seizure disorder.
D. furosemide (Lasix) for congestive heart failure.

A nurse is caring for four clients, each taking digoxin (Lanoxin). Which of the following
clients is at risk for digoxin toxicity? A client who is taking
A. procainamide (Pronestyl) for premature ventricular contractions.
B. ranitidine (Zantac) for peptic ulcer disease.
C. phenytoin (Dilantin) for a seizure disorder.
D. furosemide (Lasix) for congestive heart failure.
Loop diuretics cause potassium to be excreted from the kidneys. Hypokalemia increases
the risk for digoxin toxicity. Concurrent use with Procainamide, ranitidine or phenytoin
does not increase the risk of digoxin toxicity.

Which of the following client findings suggests digitalis toxicity or a risk for developing
digitalis toxicity? (Select all that apply.)
Serum potassium level of 3.2 mEq/L
Apical heart rate of 54/min
Blurred vision
Dysrhythmia
Weight gain of 2 lb in 1 day
Leg cramps
Slurred speech
Shortness of breath
Anorexia
Altered mental status

Which of the following client findings suggests digitalis toxicity or a risk for developing
digitalis toxicity? (Select all that apply.)
X Serum potassium level of 3.2 mEq/L
X Apical heart rate of 54/min
X Blurred vision
X Dysrhythmia
Weight gain of 2 lb in 1 day
X Leg cramps
Slurred speech
Shortness of breath
X Anorexia
X Altered mental status
Hypokalemia increases the risk of
digitalis toxicity. Leg cramps are a
possible sign of hypokalemia. Slowed
pulse, blurred vision, dysrhythmias,
anorexia, and altered mental status are
signs of digitalis toxicity. Weight gain
and shortness of breath are signs of
heart failure. Slurred speech could be a
sign of a cerebrovascular accident.

Thiazide diuretics Inhibits reabsorption of sodium and chloride in distal renal tubule
Hydrochlorothiazide (Hydrodiuril) Chlorothiazide (Diuril) Hypokalemia,
Hyperglycemia, Blurred vision, Loss of Sodium, Dry mouth, Hypotension
Monitor electrolytes, especially potassium. I and O. Monitor BUN and creatinine. Don’t
give at night. Weigh patient daily. Encourage potassium-containing foods
Potassium sparing blocks effect of aldosterone on renal tubules, causing loss of sodium
and water and retention of potassium.
Spironolactone (Aldactone) Hyperkalemia, Hyponatremia, Hepatic and renal damage,
Tinnitus, Rash
Give with meals. Avoid salt substitutes, containing potassium. Monitor I and O.
Human B-type natriuretic peptides (hBNP)
Nesiritide (Natrecor) Hypotension, dysrhythmias like ventricular tachycardia and
bradycardia. Causes natriuresis (loss of sodium and vasodilation)
BNP levels will increase while on this medication. ECG, blood pressure, and other
parameters must be closely monitored. Change position slowly.

Loop diuretics Inhibits reabsorption of sodium and chloride in loop of Henle and distal
renal tubules
Furosemide (Lasix) Ethacrynic acid (Edecrin) Hypotension, Hypokalemia,
Hyperglycemia, GI upset, Weakness
Monitor BP, pulse rate, I and O. Monitor potassium. Give IV dose over 1-2 minutes →
diuresis in 5-10 min. After the PO dose diuresis is in about 30 minutes. Weigh the patient
daily. Don’t give at night. Encourage potassium-containing foods.
Bumetanide (Bumex) Potassium depletion, Electrolyte imbalance, Hypovolemia,
Ototoxicity
Supervise ambulation. Monitor blood pressure and pulse. Observe for signs of electrolyte
imbalance.

Osmotic diuretic Pulls fluid from tissues due to hypertonic effect
Mannitol Dry mouth, Thirst
I and O must be measured. Monitor vital signs. Monitor for electrolyte imbalance.
Other diuretics
Chlorthalidone (Hygroton, Thalitone) Dizziness, Aplastic anemia, Orthostatic
hypotension, Acts like a thiazide diuretic, Acts in 2-3 h, peak 2-6 h, lasts 2-3 days.
Administer in morning, Monitor output, weight, BP, electrolytes. Increase K+ in diet.
Monitor glucose levels in diabetic patients. Change position slowly.

Which of the following actions should a nurse include when planning discharge teaching
for a client who has heart failure? (Select all that apply.)
Conserve energy; the client should schedule rest periods between activities.
Adhere to medication regimen.
Weigh self weekly and notify the provider if there is a weight gain of 5 lb in 2
weeks.
Get influenza vaccine yearly
If prescribed digoxin (Lanoxin), take pulse for 1 min, and notify the provider if
the pulse is below the set limit.
Take diuretics in the early morning and early afternoon (if prescribed twice
daily) to allow for uninterrupted sleep.
Notify the provider of increased dyspnea, orthopnea, and inability to wear rings
or shoes.

Which of the following actions should a nurse include when planning discharge teaching for a client who has
heart failure? (Select all that apply.)
X Conserve energy; the client should schedule rest periods between activities.
X Adhere to medication regimen.
Weigh self weekly and notify the provider if there is a weight gain of 5 lb in 2 weeks.
X Get influenza vaccine yearly
X If prescribed digoxin (Lanoxin), take pulse for 1 min, and notify the provider if the pulse is below the
set limit.
X Take diuretics in the early morning and early afternoon (if prescribed twice daily) to allow for
uninterrupted sleep.
X Notify the provider of increased dyspnea, orthopnea, and inability to wear rings or shoes.
The client who has heart failure should take medications as prescribed. If prescribed digoxin, the client should
take her pulse for 1 min, and notify the provider if her pulse rate is below the set limit. The client should take
diuretics early in the morning and early in the afternoon to prevent interruptions in sleep. The client should also
get vaccinations (pneumococcal and yearly influenza vaccines), maintain fluid and sodium restrictions (dietary
consult can be useful), weigh herself at the same time daily, and notify the provider of a weight gain of 2 lb in
24 hr or 5 lb in 1 week

Acute Pulmonary Edema
A life-threatening medical emergency.
Symptoms include anxiety, tachycardia, acute respiratory distress, dyspnea at rest,
change in level of consciousness, and an ascending fluid level within the lungs
(crackles, cough productive of frothy, blood-tinged sputum).
Nursing Actions
Administer prescribed medications to improve cardiac output.
Teach the client about measures to improve tolerance to activity, such as
alternating periods of activity with periods of rest.

Prompt response for pulmonary edema includes:
Positioning the client in high-Fowler’s position.
Administration of oxygen, positive airway pressure, and/or intubation and
mechanical ventilation.
IV morphine (to decrease anxiety, respiratory distress, and decrease venous return).
IV administration of rapid-acting loop diuretics, such as furosemide (Lasix).
Effective intervention should result in diuresis (carefully monitor output), reduction in
respiratory distress, improved lung sounds, and adequate oxygenation.

Cardiac Tamponade
Can result from fluid accumulation in the pericardial sac. Signs include hypotension, jugular
venous distention, muffled heart sounds, and paradoxical pulse (variance of 10 mm Hg or more
in systolic blood pressure between expiration and inspiration). Hemodynamic monitoring will
reveal intracardiac and pulmonary artery pressures similar and elevated (plateau pressures).
Nursing Actions:
Notify the provider immediately.
Administer IV fluids to combat hypotension as prescribed.
Obtain a chest x-ray or echocardiogram to confirm diagnosis.
Prepare the client for pericardiocentesis (informed consent, gather materials, administer
medications as appropriate).
Monitor hemodynamic pressures as they normalize. Monitor heart rhythm; changes indicate
improper positioning of the needle. Monitor for recurrence of signs after the procedure.

Coronary Artery Disease
Caused by an imbalance between myocardial oxygen supply and demand.
An increased risk of coronary artery disease exists for older adult clients who are
physically inactive, have one or more chronic diseases (hypertension, heart failure,
and diabetes mellitus), or have lifestyle (smoking and diet) habits that contribute to
atherosclerosis.
The incidence of cardiac disease increases with age, especially in the presence of
hypertension, diabetes mellitus, hypercholesterolemia, elevated homocysteine, and
highly sensitive C-reactive protein (HS-CRP).
Atherosclerotic changes related to aging predispose the heart to poor blood perfusion
and oxygen delivery.

Nonmodifiable Risk Factors for Coronary Artery Disease
Increasing age
Family history of coronary artery disease
Men are more likely to develop heart disease than are premenopausal women even
if they are the same age
Race (higher incidence in African Americans than whites)

Modifiable Risk Factors for Coronary Artery DIsease
Elevated serum cholesterol
Cigarette smoking
Hypertension
Diabetes mellitus
Physical inactivity
Obesity
Stress
Oral contraceptive use or hormone replacement therapy
Hyperthyroidism
Methamphetamine or Cocaine Use

Nursing management for Coronary Artery Disease
Health Promotion
Do not smoke
Follow balanced diet that limits intake of fat and sodium
Check blood pressure and cholesterol regularly
Engage in regular physical activity - the goal is reduction of blood pressure and
pulse rate upon exertion

A client who has angina reports that he is not able to make all of the lifestyle changes
recommended. Which of the following changes should the nurse suggest that the client
work on first?
A. Diet modification
B. Relaxation exercises
C. Smoking cessation
D. Taking omega-3 capsules

A client who has angina reports that he is not able to make all of the lifestyle changes
recommended. Which of the following changes should the nurse suggest that the client
work on first?
A. Diet modification
B. Relaxation exercises
C. Smoking cessation
D. Taking omega-3 capsules
According to the airway, breathing, and circulation (ABC) priority setting framework,
ensuring that the client has adequate oxygen should be the nurse’s first priority. Nicotine
causes vasoconstriction, elevates blood pressure, and narrows coronary arteries;
therefore, the nurse should suggest that the client first work on a smoking cessation
program.

Angina
Angina pectoris is a warning sign of an impending acute MI. Relieved by rest or
nitroglycerin. Precipitated by exertion or stress. Symptoms last less than 15 minutes. Not
associated with nausea, epigastric distress, dyspnea, anxiety, or diaphoresis.
Stable angina (exertional angina) occurs with exercise or emotional stress and is
relieved by rest or nitroglycerin (Nitrostat).
Unstable angina (preinfarction angina) occurs with exercise or emotional stress, but
it increases in occurrence, severity, and duration over time.
Variant angina (Prinzmetal’s angina) is due to a coronary artery spasm, often
occurring during periods of rest.
Pain unrelieved by rest or nitroglycerin and lasting for more than 15 min differentiates an
MI from angina.

Assessment for Angina
Pallor and cool, clammy skin
Tachycardia
Heart palpitations
Diaphoresis
Vomiting
Decreased level of consciousness

Antianginal Medications
Vasodilators
Nitroglycerin (Nitro-Bid, Nitrostat, Transderm-Nitro) Flushing, Hypotension,
Headache, Tachycardia, Dizziness, Blurred vision
Prevents coronary artery vasospasm and reduces preload and afterload, decreasing
myocardial oxygen demand.
Avoid alcoholic beverages. Sublingual dose may be repeated every 5 min for 3 doses, If
pain is unrelieved, then seek immediate further medical care. Protect drug from light.
Should wet tablet with saliva and place under tongue. Lie down when taking sublingual
nitroglycerin. Headache most common side effect.
Isosorbide (Isordil, Sorbitrate) Headache, Orthostatic hypotension
Change position slowly. Take between meals. Don’t discontinue abruptly.

Calcium channel blockers
Amlodipine (Norvasc) Diltiazem (Cardizem) Verapamil (Calan) Hypotension
Contraindicated in second- or third-degree heart block, cardiogenic shock, severe bradycardia,
heart failure, or hypotension. Use cautiously with renal or hepatic impairment. Can potentiate
the action of digoxin.
Angiotensin converting enzyme inhibitors
Captopril (Capoten) Dry annoying cough, Hypotension, Hyperkalemia
Diuretics increase effect. Avoid high-potassium foods.
Beta blockers
Propranolol (Inderal) Metoprolol (Lopressor) Atenolol (Tenormin) Carvedilol (Coreg)
Bradycardia, Hypotension, Bronchoconstriction
Should not be given to clients with known or suspected coronary artery spasms. Clients who
continue to smoke have reduced effectiveness of therapy. Clients with asthma may experience
bronchospasms. Should be used with caution in clients with diabetes mellitus (may mask signs
of hypoglycemia). Should be discontinued gradually to prevent rebound angina. Hold the
medication if the client’s apical pulse is less than 60/min and notify the provider.

Aspirin (Ecotrin) and Clopidogrel (Plavix) GI Bleeds, Tinnitus can be a sign of aspirin
toxicity. Prevents platelets from forming together, which can produce arterial clotting.■
Remind the client of the risk for bruising and bleeding while on this medication.
Encourage the client to use aspirin tablets with enteric coating and to take with food. Ask
the client if she is experiencing ringing in the ears.
Glycoprotein IIB/IIIA inhibitors
Eptifibatide (Integrilin) Bleeding. Used to prevent the binding of fibrogen, in turn blocking
platelet aggregation. In combination with aspirin therapy, IIB/IIA inhibitors are standard
therapy.
Instruct the client to report signs of bleeding during medication therapy.

A client asks a nurse why her provider prescribed 1 aspirin per day. Which of the
following responses should the nurse give?
A. “Aspirin reduces the formation of blood clots that could cause a heart
attack.”
B. “Aspirin decreases any pain due to myocardial ischemia.”
C. “Aspirin dissolves any clots that are forming in your coronary arteries.”
D. “Aspirin relieves any headaches that are caused by other medications.”

A client asks a nurse why her provider prescribed 1 aspirin per day. Which of the
following responses should the nurse give?
X A. “Aspirin reduces the formation of blood clots that could cause a heart
attack.”
B. “Aspirin decreases any pain due to myocardial ischemia.”
C. “Aspirin dissolves any clots that are forming in your coronary arteries.”
D. “Aspirin relieves any headaches that are caused by other medications.”
Aspirin decreases platelet aggregation. One aspirin a day is not sufficient to alleviate
ischemic pain. Aspirin does not dissolve clots. Other medications can cause headaches,
but one aspirin per day is not administered as an analgesic

Heparin Can produce hemorrhage from any body site (10%) ,Tissue irritation/pain at
injection site, Anemia ,Thrombocytopenia, Fever
Monitor therapeutic PTT at 1.5–2.5 times the control without signs of hemorrhage. Lower
limit of normal 20–25 sec; upper limit of normal 32–39 sec. For IV administration: use
infusion pump, peak 5 minutes, duration 2–6 hours For injection: give deep SQ; never IM
(danger of hematoma), onset 20–60 minutes, duration 8–12 hours Antidote: protamine
sulfate within 30 minutes Can be allergenic
Enoxaparin low-molecular weight heparin (Lovenox) Same as heparin
Less allergenic than heparin, Must be given deep SQ, never IV or IM. Does not require
lab test monitoring
Warfarin (Coumadin) Hemorrhage, Diarrhea, Rash, Fever
Monitor therapeutic PT at 1.5–2.5 times the control, or monitor international normalized
ratio (INR) Normal PT 9.5–12 sec; normal INR 2.0–3.5. Onset: 12–24 hours, peak 1.5–3
days, duration: 3–5 days. Antidotes: vitamin K, whole blood, plasma. Teach measures to
avoid venous stasis. Emphasize importance of regular lab testing. Patient should avoid
foods high in vitamin K: many green vegetables, pork, rice, yogurt, cheeses, fish, milk.

Analgesics
Morphine sulfate respiratory depression,euphoria, sedation, and a decrease in GI motility.
Use cautiously with clients who have asthma or emphysema due to the risk of
respiratory depression.
For the client having chest pain, assess the client’s pain every 5 to 15 min. Watch the
client for signs of respiratory depression, especially older adults. If the respirations are
12/min or less, stop the medication and notify the provider immediately. Monitor the
client’s vital signs closely for signs of hypotension and decreased respirations. Observe
the client for nausea and vomiting.

Myocardial Infarction
Can occur without cause, often in the morning, after rest. Relieved only by opioids.
Symptoms last more than 30 minutes. Associated with nausea, epigastric distress,
dyspnea, anxiety, diaphoresis
Cardiac enzymes released with cardiac muscle injury
Myoglobin – Levels no longer evident after 24 hr
Creatine kinase-MB – Levels no longer evident after 3 days
Troponin I – Levels no longer evident after 7 days
Troponin T – Levels no longer evident after 14 to 21 days

A client who has a diagnosis of an MI reports that dyspnea began 2 weeks ago. Which of
the following cardiac enzymes should the nurse assess to determine if the infarction
occurred 14 days ago?
A. CK-MB
B. Troponin I
C. Troponin T
D. Myoglobin

A client who has a diagnosis of an MI reports that dyspnea began 2 weeks ago. Which of
the following cardiac enzymes should the nurse assess to determine if the infarction
occurred 14 days ago?
A. CK-MB
B. Troponin I
X C. Troponin T
D. Myoglobin
The Troponin T level will still be evident 14 to 21 days following an MI. Troponin I levels
are no longer evident after 7 days, myoglobin levels are no longer evident after 24 hr, and
creatine kinase-MB levels are no longer evident after 3 days.

Interdisciplinary Care for Myocardial Infarction
Pain management services can be consulted if pain persists and/or is uncontrolled.
Cardiac rehabilitation care can be consulted if the client has prolonged weakness and
needs assistance with increasing level of activity.
Nutritional services can be consulted for diet modification to promote low-sodium
and low-saturated fat food choices.

Medications for Myocardial Infarction
Thrombolytics
Reteplase (Retavase) Alteplase (Activase) Tissue plasminogen activator (t-PA) Bleeding t-PA is
a naturally occurring enzyme Low allergenic risk but high cost
Anistreplase (Eminase) Streptokinase (Streptase [SK]) Bleeding Because streptokinase is
made from a bacterium, patient can have an allergic reaction. Not used if patient had recent
Streptococcus infection or received Streptase in past year
Retavase and Activase break down plasminogen into plasmin, which dissolves the fibrin
network of a clot. Eminase and Streptase bind with plasminogen to form a complex that digests
fibrin.
Indications - MIs within the first 6 hours after symptoms, limited arterial thrombosis, thrombotic
strokes, occluded shunts
Nursing considerations - Check for signs of bleeding; minimize number of punctures for
inserting IVs; avoid IM injections; apply pressure at least twice as long as usual after any
puncture.

Which of the following findings will help a nurse distinguish angina from an MI?
A. Angina can be relieved with rest and nitroglycerin.
B. An MI will be relieved with nitroglycerin.
C. An MI will have cardiac enzyme levels within the expected reference range.
D. Angina can occur for longer than 30 min.

Which of the following findings will help a nurse distinguish angina from an MI?
X A. Angina can be relieved with rest and nitroglycerin.
B. An MI will be relieved with nitroglycerin.
C. An MI will have cardiac enzyme levels within the expected reference range.
D. Angina can occur for longer than 30 min.
Angina can be relieved with rest and nitroglycerin. An MI will need to be relieved using
opioids. Cardiac enzymes are abnormal with an MI. Angina usually occurs for 15 min or
less

Cardiogenic Shock
Injury to the left ventricle can lead to decreased cardiac output and heart failure. A
serious complication of pump failure, commonly following an MI of 40% blockage.
Assessment - Tachycardia, hypotension, inadequate urinary output, decreased level of
consciousness, respiratory distress, cool, clammy skin, decreased peripheral pulses, and
chest pain.
Nursing Actions
Administration of oxygen; possible intubation and ventilation may be required.
IV administration of morphine, diuretics, and/or nitroglycerin to decrease preload;
and IV administration of vasopressors and/or positive inotropes to increase cardiac
output and to maintain organ perfusion.
Maintain continuous hemodynamic monitoring.

Ischemic mitral regurgitation
Ischemia can be evidenced by the development of a new cardiac murmur.
Nursing Actions
Administer oxygen to the client.

Ventricular aneurysms/rupture
Necrosis due to an MI
Chest pain, dysrhythmias, and severe hypotension.
Nursing Actions
Administer oxygen to the client.

Dysrhythmias
An inferior wall MI may lead to an injury to the AV node resulting in bradycardia and
second-degree AV heart block. An anterior wall MI may lead to an injury to the ventricle
resulting in premature ventricular contractions, bundle branch, or a complete heart block.
Nursing Actions
Monitor ECG and vital signs.
Administer oxygen.
Administer antidysrhythmic medications as indicated.
Prepare for cardiac pacemaker if needed.

Atrial Fibrillation
The atria fibrillate, or quiver, due to diseased heart tissue of the sinus electrical
conduction system. Frequently accompanied by a rapid ventricular response.
Treated with calcium channel blockers depress depolarization and decrease oxygen
demand of the heart.
Verapamil (Calan) Diltiazem (Cardizem) Decrease force of contraction, Decrease
heart rate, Slow rate of conduction through the AV node. Can cause Bradycardia and
hypotension. Severe hypotension may be reversed with calcium chloride.

A client presents to the emergency room with severe hypotension. The family states the
client is taking verapamil (Calan) for atrial fibrillation. The emergency room nurse should
prepare to give which of the following?
A. Calcium chloride
B. Epinephrine sodium chloride
C. Potassium chloride
D. Magnesium sulfate

A client presents to the emergency room with severe hypotension. The family states the
client is taking verapamil (Calan) for atrial fibrillation. The emergency room nurse should
prepare to give which of the following?
X A. Calcium chloride
B. Epinephrine sodium chloride
C. Potassium chloride
D. Magnesium sulfate
Verapamil is a calcium channel blocker used to treat atrial fibrillation, atrial flutter
and paroxysmal ventricular tachycardia. Severe hypotension may be reversed with
calcium chloride given slowly, IV. The other medications will not reverse the
hypotension

Which of the following clients are at risk for the development of dysrhythmias? (Select all
that apply.)
Metabolic alkalosis
A client who has a serum potassium level of 4.3 mEq/L
A client who has an SaO2 of 96%
A client who has COPD
A client who is 3 hr post MI

Which of the following clients are at risk for the development of dysrhythmias? (Select all
that apply.)
X Metabolic alkalosis
A client who has a serum potassium level of 4.3 mEq/L
A client who has an SaO2 of 96%
X A client who has COPD
X A client who is 3 hr post MI
These ABG results, COPD, and a recent MI are risk factors for developing a dysrhythmia.
A potassium level of 4.3 mEq/L (expected reference range) and an oxygen saturation of
96% (expected reference range) do not increase the risk for developing dysrhythmias.

Endocarditis
Bacterial endocarditis or subacute bacterial endocarditis - infection of the valves or lining
of the heart.
Bacterial endocarditis prophylaxis
Receiving prophylactic antibiotic therapy prior to dental and surgical
procedures (dental extractions, endodontic surgery, surgical procedures that involve
the respiratory or gastrointestinal mucosa).
Causative organisms include Streptococcus viridans and Staphylococcus aureus.
Nursing Actions
Administer antibiotics parenterally for approximately 8 weeks.

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