Sunday, February 24, 2019

MANAGE NURSING CARE AT HOME, "Ch. 12 Cardiovascular System"

How to Manage Nursing Care at Home

Some classifications separate this system into two distinct systems:  the cardiac system and the vascular system.  However, they are so interconnected that they are more frequently studied and assessed at the same time.  The cardiovascular system is comprised of the heart and all vessels within the body called arteries and veins to the smallest units called arterioles and capillaries, respectively, where oxygen transfer occurs. 

The heart is a two-sided, four-chambered muscular organ.  The left side of the heart pumps the oxygen-rich blood it receives from the lungs to all parts of the body.  The right side receives oxygen-depleted blood back from the body and returns it to the lungs where it can be re-oxygenated. 

The vessels that distribute oxygenated blood from the left side of the heart are arteries.  Veins return deoxygenated blood to the right side of the heart, which sends it to the lungs for oxygen replenishment.  This system allows for a constant cycling and replenishing of oxygen to the blood which is vital for cellular life.

Some of the various cardiac and vasculature system conditions and care considerations appear below:

Heart Disease (also called Cardiovascular Disease):  is a general descriptive term used to indicate an illness or condition that affects any part of the heart and its normal functioning.  It may include the coronary arteries (the arteries that provide oxygen solely to the heart), the electrical conduction system which effects and regulates the heart rhythm, the valves of the heart chambers which regulate blood flow, or the actual muscle of the heart (myocardium). 

Commonly, heart disease is diagnosed after a heart attack (myocardial infarction or “MI”), which occurs when blood flow to coronary arteries is blocked.  MIs usually result from coronary artery disease (CAD), the most common form of heart disease.  Narrowing of the coronary arteries’ lumens is caused by a build-up of plaque (atherosclerosis).  The narrowing of these vessels decreases blood flow to the heart tissue (myocardium).  As the openings, lumens, of the cardiac arteries become blocked, the supply of oxygen to the heart decreases.  Ultimately, the heart itself doesn’t have enough oxygen to continue its function.  Heart attacks (MIs) usually result from these blockages, causing ischemia, injury and death of cardiac muscle. 

This disease could also include angina, which often presents as a heart attack with the associated symptoms of burning, crushing pressure, or squeezing tightness.  Often these symptoms exacerbate with exertion, emotions, increased food consumption, and cold air, and could be preemptive signs of potential heart attacks.

     Defects of any of the four heart valves (which act as two-way toggle switches) can also be included in this category.  Heart valves regulate the amount of blood flow into and out of the heart.  They open and close based upon pressures of the fluid within each heart chamber, as well as working with other anatomical structures.  Like any pump, the heart requires intake and output values that regulate the pressures in the chambers of the heart to direct flow from one chamber to the next. Once the pressure on one side is maximized, fluid is released and allowed to enter the next chamber. 

When the valves no longer hold complete seals, blood can leak in or seep out of the chamber, making it difficult to pump blood effectively and completely.  Sometimes, valve malfunctions can be detected during regular medical check-ups, due to the sounds picked up using a stethoscope, “heart murmurs.” Deficits due to heart valve dysfunction diminish the effectiveness of the heart because blood is not contained and regulated completely causing a decrease in blood that is pumped to the body.

Arrhythmias (irregular and abnormal heart beatings and rhythms), and other cardiac conduction issues may also contribute to heart disease but rarely cause the disease itself.  Arrhythmias can result from myocardial infarctions, stress, increased caffeine consumption, and various other factors.  Over time, they can cause cardiomyopathy (enlarged heart tissue growth), eventually leading to heart failure.
Care Considerations for Cardiovascular Disease:  
1) Weight loss and dietary changes prove most effective.    Decreasing salt decreases potential water weight retention and edema and possible hypertension, thus lessening stress on the heart. Weight loss decreases risk for diabetes, paramount in ensuring small blood vessels can provide oxygenated blood to small capillaries that supply the eyes, feet, heart, etc.   Extra fluid retention causes exertion by the heart muscle, which increases oxygen demand and increases edema into tissues.  Dietary changes, such as minimizing fats and cholesterol, as well as eating vegetables, fruits, and whole grains, provide additional benefits beside weight loss.  These include the decrease or elimination of the need for anti-cholesterol medication (statins) when dietary cholesterol is decreased.  With increased fiber, cholesterol is eliminated in the stool.  Decreases of sugar and processed sodium allow decreases in hypertensive medication and improved diabetes management.
2)  Smoking cessation is key, and various aids are available on the market to assist in this endeavor.  Even if full elimination is not achieved, decreasing the daily intake of tobacco products is worthwhile. 
3) Regular exercise and decreasing stress often work together.  Exercise increases effort by your heart and blood vessels and directly increases blood flow to all parts of your body, strengthening the heart muscle and increasing oxygenation of the body even during rest.  Exercise also decreases stress because you increase endorphins, which are “brain hormones” that provide feelings of well-being.  With exercise, the signs and symptoms of diabetes and excessive fats or lipids in the blood (hyperlipidemia) can be lessened.
4)  Medication is often prescribed and may alleviate and postpone the adverse symptoms and progression of the disease.   Medications that may be prescribed include anti-hypertensives (to decrease high blood pressure), diuretics (water pills), statins (to decrease cholesterol), beta blockers (to regulate heart rate and rhythms), sublingual nitroglycerin (for angina pain and symptoms), and aspirin (to decrease platelet aggregation).  
5) In severe cases, surgical intervention may be required.  This includes coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) during a cardiac catheterization.  Pacemakers may be surgically implanted to regulate dysrhythmias

Heart Failure (also called Congestive Heart Failure):  is a disease that affects the pumping action of one side of the heart, the left or right ventricle, such that it no longer meets the body’s demand for oxygen.  It typically is caused from coronary artery disease or myocardial infarctions that weaken the heart muscle. 

The left ventricle of the heart pumps oxygenated blood received from the lungs to the entire body, via the arteries.  When that side of the heart does not pump effectively, fluid is retained in the left ventricle, backs up and returns to the lungs.  Pulmonary dysfunction ultimately resulting in loss of oxygen to the body occurs.  With diminished oxygenation and pulmonary congestion, the patient may exhibit shortness of breath, diminished and adventitious lung sounds as fluid is retained in the lungs, activity intolerance, high heart rate (tachycardia) due to increased oxygen demand, faintness and light headedness.   Blood oxygen is not available to meet the needs of the individual.

        The right side of the heart and venous system receives deoxygenated blood back from the body sending it to the lungs for oxygen recovery.  If this side of the heart fails, because the right ventricle cannot eliminate all the liquid, systemic edema results.  In this case, fluid cannot be eliminated, so it eventually flows back to where it was received, from the body, primarily notable by swelling in the extremities.  The patient exhibits edema in the extremities and tissues, unexplained weight gain, abdominal distention, and bloating in organs such as the liver and spleen.  Fluid is trapped.  It cannot be eliminated because the right side of the heart cannot effectively pump the fluid received from body tissues.  Right-sided heart failure is often secondary to left-sided heart failure.

Care Considerations for Heart Failure:
1)  Patients are usually on fluid restrictions to decrease the accumulation of fluid that the heart must pump.  Strict attention to fluid volume is required and must be measured.  In addition, low-sodium diets are also key because excess sodium causes the body to hold water.
2) Medication to improve heart function and to aid the body is often prescribed.  These include diuretics (water-pills) to promote elimination of water via the renal system and cardiac drugs to increase the heart’s pumping action.  Other medications may include potassium supplements, if diuretics are used.
3)  Because of pulmonary congestion, numerous actions should be taken.  Supplemental oxygenation may be prescribed due to the patient’s shortness of breath and may be used especially during exertion.  Ambulation and activities should be increased as much as can be tolerated.  Utilize a pulse oximeter (giving blood oxygen level as well as pulse rate) to ensure adequate oxygen is obtained.  In addition, coughing and deep breathing exercises should be practiced promoting full expansion of the lungs.  Listen to lung sounds.  Often fluid backs up into these organs and is heard as “crackles”.  These sounds are typically heard in the lung bases first.  Position head of bed to a sitting position to promote oxygenation
4)  Due to systemic and portal congestion, measures are taken to decrease problems associated with edema.  Fluid is retained in the lower extremities first, due to gravity.  Pedal pulses should be checked to ensure continued blood flow.  Likewise, check skin color for pallor, cyanosis, and signs of venous stasis which can lead to skin breakdown.  Elevate legs, perform range of motion exercises, and promote ambulation as tolerated to promote fluid return.
5) If fluid accumulates in the organs, anorexia and nausea may be present.  Promote frequent small meals rather than large ones.  Ensure fluid restrictions are maintained.

Peripheral Vascular Disease (PVD):  is a condition that is caused by partial or complete blood flow blockage, typically occurring in the lower extremities.  It may affect both venous and arterial flow, causing pain and often evidenced by changes to the skin and decreases in pulses in the feet (pedal pulses).  Because blood flow is obstructed by atherosclerosis (plaque build-up), a loss of elasticity of the vein walls (arteriosclerosis), clot formation (deep vein thrombosis), or other disease processes, such as diabetes, for example, there is a decrease in oxygen to the extremities if arterial blood flow is obstructed or stasis of blood when pooling of fluid occurs if venous return is compromised.  This condition often results secondary to hypertension (high blood pressure), stroke, diabetes, and hyperlipidemia (high blood cholesterol).  It is a major cause of amputation. Pain is the hallmark of the disease and when the pain occurs identifies the origin of the disease. 

Rest pain (pain during inactivity) occurs with arterial insufficiency because there is a decrease in the pumping of the blood by the arteries to the lower extremities.  When the body moves, blood is artificially pumped by activity, thus increasing circulatory flow.   Reduced blood flow occurs during rest without the movement that pushes blood to the legs and feet.  This leads to decreased oxygen to the tissues which results in pain and potential skin breakdown, because tissues die without enough oxygen.  Typically, it’s felt as a burning pain that increases when the legs are elevated, because gravity doesn’t aid in the transport of oxygenated blood to these far tissues. Blood flow to the legs increases when the legs are lowered (dependent), and pain decreases because the tissues receive oxygen.  This pain has been described as cold and numbing because tissues lack oxygen.  Skin is pale when elevated, due to lack of arterial (oxygenated) blood circulation.  With gravity and movement, the skin color becomes red, circulation increases, and pain decreases.

Claudication (derived from Latin meaning lameness) is a pain that occurs during activity and is caused by the inability of the vessels to return venous blood back to the heart.  This is the opposite of “resting pain.”  As activity pumps blood to the extremities, because of the insufficiency of valves in the vein or arteriosclerosis, for example, the fluid is trapped in the vessels, seeps into the tissues and does not transport back to the heart.  The stasis of the deoxygenated blood and consequential edema causes pain.  As activity increases, so does the pooling of the fluid in the lower extremities.  When the legs are elevated, cramping and pain subside.  This is classic for this condition.  Skin can become shiny and swollen (extremely edematous); pedal pulses are not able to be felt; skin breakdown can occur rapidly. 

Signs and symptoms are quite similar for both conditions and related to oxygen compromise to the tissues, but they result from different causes.   As noted above, what distinguishes these diseases process is WHEN the pain occurs – at rest or during activity.  Both have signs that include hair loss in the lower extremities, shiny and taunt skin, cold feet and lack or diminished pedal pulses, feet and ankles that are discolored and duskier that other areas of the leg, thick toenails, potential skin breakdown that quickly leads to gangrene and other infectious processes that may lead to systemic involvement.
Care Considerations for Peripheral Vascular Disease (PVD):
1)  Medication is often prescribed to promote vasodilatation (to open vessels promoting fluid return) as well as low-dose aspirin to decrease blood clot formation. 
2)  Smoking cessation and weight reduction are pivotal in increasing function.  Decreases in smoking readily increase circulatory function as well as decreasing venous vasospasms.  Weight loss increases ambulatory efficiency in promoting arterial flow and reducing venous stasis.
3)  Assess pedal pulses, extremity and color changes from toes to legs.  Decreases in circulation can be noted in color changes going from toes to thighs.  Check perfusion to lower extremities bilaterally (both left and right) using pulse oximeter.  Effects of PVD are not bilateral.
4)  Position changes are effective to enhance circulation and positional shifts should be completed often to decrease skin breakdown.   Elevate legs that exhibit venous claudication.   Allow gravity to assist arterial flow by keeping legs low if they are exhibiting resting pain.  Avoid sitting crossed legged and the use of knee stockings that decrease blood flow.
5)  Warm colder tissues with light blankets to promote circulation.  Caution should be paramount in using electric or hearted blankets; loss of circulation often decreases feeling.  This can lead to burns and tissue damage.
     6)  Exercise promotes circulation.  It promotes collateral circulation to establish additional vessels to aid in decreasing edema.  If pain develops, rest is necessary to prevent fluid overload.  In addition, exercise promotes transport of oxygen and nutrients to the tissues. 
7)  Skin and foot care should be meticulous.  Wash and dry without rubbing, which may damage skin.  Pay special attention to the areas between the toes.  Use lotion and powder as appropriate.  Mirrors can be used to examine feet for breakdown, ulcers, and necrotic areas, common with arterial insufficiency or venous stasis.  Seek professional help.

Deep Venous Thrombosis (DVT):  is a condition caused by a clot (thrombus) that is usually lodged in a deep tissue of one of the lower extremities.  The clot can result in partial or complete obstruction of the vein’s flow.  The obstruction’s ensuing stasis (stopping of normal flow) of blood can lead to severe edema, loss of pulses and loss of oxygenation below the clot.  This can eventually lead to tissue death, necrosis, and amputation if prolonged.  However, this is not the major and most life-threatening result of a DVT. 

   The venous system returns blood from the body back to the heart and eventually to the lungs for reoxygenation.  A thrombosis can dislodge, travel anywhere in the venous system, and then settle in a new place where it again halts blood flow to that tissue.  This traveling thrombosis is called an embolus.  Emboli may lodge in the heart arteries (causing MIs) or the brain (causing stokes).  But more often they terminate in the lungs, termed a pulmonary embolus, causing respiratory failure and potentially death. 

   This condition often occurs during a post-operative phase, due to prolonged sitting and inactivity, and any illness that prohibits blood flow and return to the lower extremities, such as diabetes, right-sided heart failure, and prolonged episodes of bed rest, as well as use of oral contraceptives and estrogen therapy.

Care Considerations for Deep Venous Thrombosis (DVT):
1)  The goal is to reduce and eliminate the thrombus and prevent it from traveling, especially to the lungs.  This is achieved by increasing tissue perfusion, minimizing risks, and administration of anti-coagulants.
2)  Check both extremities for skin color, temperature, and edema.  The affected appendage may show pallor (paleness), warmth, and puffiness which may range from mild to severe.  Check pulses by applying pulse oximeter to one of the toes on both feet.  Perform all tasks to both sides (bilaterally) and note differences (asymmetry) from one side compared to the other.  Ideally, without compromise to the venous flow, both sides should be equal. 
3) Using a tape measure, measure and record the circumferences of extremities at their widest point below the thrombus.  Then continue to measure daily.  To ensure consistent placement of the tape, initially mark tape position on both extremities to provide accurate placement of the tape measure.  This provides a baseline and subsequent gauge of blood flow increases or further obstruction. 
4) Anti-coagulant therapy is often prescribed.  These drugs do not dissolve clots.  Rather, they act in preventing additional clot formations as well as maintaining the size of existing clots, so they do not increase. These drugs can be taken orally or injected into the tissues.   This class of drug is also used for a heart arrhythmia problem called “atrial fibrillation,” to help prevent clots from traveling to the brain causing stokes.   These drugs cause decreased coagulation and stop clots from forming.  Therefore, they increase risks for bleeding and steps must be taken to minimize these bleeding risks.  Simple steps and tender care are required such as using a soft toothbrush to prevent gum bleeding, shaving with an electric razor to minimize nicks and cuts, refraining from going barefoot, to decrease feet and toe injuries, wearing gloves to protect hands during home or outside activities, and keeping nasal passages moist with humidification to eliminate dryness and forceful nose blowing.  Additionally, contact sports should be excluded, and use of sharp instruments such as cooking or gardening tools must be monitored. In general, decrease ANY and ALL risks for bleeding while using these drugs.  Lastly, avoid any kinds of OTC medications that may potentiate bleeding which include aspirin, NSAIDS, ibuprofen, Vitamin E, gingko biloba, and any other drug that minimizes blood clot formation.
5) At-home therapies to the affected area may also increase perfusion to tissues.  These include warm compresses, compression stockings, avoiding crossing one’s legs, as continued pressure behind the knees obstructs blood flow. Do not perform rubbing massages to the affected extremity, as this may disrupt and move the blood clot. 
6)  Pain is often exhibited.  Administer analgesics, such as Tylenol or other prescribed medication as needed.   Due to a swollen and painful appendage, provide pain relief before any physical therapy.
7)  It is important to promote deep breathing to ensure complete lung expansion.  This also assists in utilizing other pulmonary muscles in eliminating fluids.  This is especially vital if the patient is on bed rest due to the injury. 
8)  As appropriate, increase fluid intake. Fluids are necessary to prevent dehydration.  In addition, lack of fluid can increase blood thickness (viscosity) and cause additional risk for clots due to blood pooling (venous stasis).
9)  Some common signs of pulmonary distress, if the DVT dislodges and migrates to the lungs, include impending doom verbalized by the patient (classic sign), trouble breathing (dyspnea) with low pulse oximeter reading, high heart rate (tachycardia), low blood pressure (hypotension), chest pain, and loss of consciousness.  Call 911 immediately!


Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549

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