deep vein thrombosis (DVT)

risk factors for DVT (age >60, being hospitalized and in bed for 3 days
neurovascular assessment of the extremities, including presence and quality of dorsalis
pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary
refill, and circumference measurements of both calves and thighs. Both extremities
should be assessed for comparison
clinical manifestations: unilateral edema, calf pain or tenderness to
touch, warmth and erythema, and low-grade temperature.
Discharge teaching for a client who has had DVT emphasizes

 Drink plenty of fluids and limit caffeine and alcohol intake to avoid dehydration,
which predisposes to blood hypercoagulability and venous thromboembolism
 Elevate legs on a footstool when sitting and dorsiflex the feet often to reduce
venous hypertension, edema, and promote venous return
 Resume walking/swimming exercise program as soon as possible after getting
home to promote venous return through contraction of calf and thigh muscles
 Change position frequently to promote venous return, circulation, and prevent
venous stasis.
 Stop smoking to prevent endothelial damage and vasoconstriction as this
promotes clotting.
 Avoid restrictive clothing (eg, Spanx, tight jeans) that interferes with circulation
and promotes clotting.

Cardiogenic shock
Cardiomyopathy is a group of diseases in which the heart muscle (myocardium) has a
reduced ability to pump blood effectively, placing clients at risk for cardiogenic shock.
Cardiogenic Shock is manifested by reduced cardiac output (hypotension, narrow pulse
pressure), which can lead to pulmonary edema (tachypnea, bibasilar crackles, decreased
oxygen saturation)
decreased perfusion and oxygenation of tissues as well as death
Treatment of cardiogenic shock includes supplemental oxygen, an ECG, cardiac enzyme
testing, and interventions to reduce cardiac workload.

Failure to capture from the permanent pacemaker

Failure to capture appears on the cardiac monitor as pacemaker spikes that are not
followed by QRS complexes.
symptomatic (hypotension, dizziness) from insufficient perfusion. The nurse's priority is
to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood
pressure, and adequately perfuse organs until the permanent pacemaker is repaired or
replaced
Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very
uncomfortable for the client.
Endovascular abdominal aortic aneurysm repair
minimally invasive procedure that involves the placement of a suture less aortic graft
inside the aortic aneurysm via the femoral artery.
It does not require an abdominal incision. The nurse will need to monitor the puncture
sites in the groin area for bleeding or hematoma formation
Peripheral pulses should be palpated and monitored frequently in the early post-op
period and routinely afterward
Renal artery occlusion can occur due to graft migration or thrombosis so careful
monitoring of urine output and kidney function should be part of nursing care
*Signs of graft leakage that are important to monitor after repair of an abdominal aortic
aneurysm include pain in the back, pelvis, or groin; ecchymosis of the groin, scrotum, or
penis; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and
hemoglobin; increased abdominal girth; and decreased urinary output.

An aneurysm is an outpouching or dilation of a vessel wall. An abdominal aneurysm

occurs on the aorta. A bruit, a swishing or buzzing sound that indicates turbulent blood
flow in the aneurysm, is best heard with the bell of the stethoscope. It may be
auscultated over the aortic aneurysm in the periumbilical or epigastric area slightly left
of the midline.
Educational objective:
The nurse should listen for a bruit with the bell of the stethoscope over the periumbilical
or epigastric area.
Acute pericarditis
The most common cause is a recent viral infection. It is an inflammation of the visceral
and/or parietal pericardium. Pericarditis is characterized by typical pleuritic chest
pain that is sharp. It is aggravated during inspiration and coughing. Pain is
typically relieved by sitting up and leaning forward. This position reduces pressure on
the inflamed parietal pericardium, especially during lung inflation. The pain is different
than that experienced during myocardial infarction. Assessment shows a
pericardial friction rub (scratchy or squeaking sound). Treatment includes a
combination of nonsteroidal anti-inflammatory drugs (NSAIDS) or aspirin plus colchicine.

Atrial fibrillation (AF)

common dysrhythmia after cardiac surgery. It is characterized by a
total disorganization of atrial electrical activity that results in the loss of effective atrial
contraction.
P waves are not visible; they are replaced by fibrillatory waves
ventricular rate varies, but the rhythm is typically irregular
increased risk for stroke
Treatment goals include a decrease in ventricular rate to <100/min and
adequate anticoagulation to prevent thromboembolic complications. Medications used
for rate control include calcium channel blockers (diltiazem, verapamil), beta blockers
(metoprolol), and digoxin. Medications that convert to and maintain sinus rhythm
include amiodarone, flecainide, and sotalol. Electrical cardioversion may also be
considered in hemodynamically unstable clients.

Holter monitor
continuously records a client's electrocardiogram rhythm for 24-48 hours.
Client instructions include the following:
1. Keep a diary of activities and any symptoms experienced while wearing the
monitor so that these may later be correlated with any recorded rhythm
disturbances
2. Do not bathe or shower during the test period
3. Engage in normal activities to simulate conditions that may produce symptoms
that the monitor can record
Procedure for measurement of orthostatic BP
1. Have the client lie down for at least 5 minutes
2. Measure BP and HR
3. Have the client stand
4. Repeat BP and HR measurements after standing at 1- and 3-minute intervals
A drop in systolic BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg, or experiencing
lightheadedness or dizziness is considered abnormal
The DASH diet is often suggested for clients to reduce hypertension as this diet:
 Emphasizes intake of vegetables, fruits, and fat-free or low-fat dairy products
 Includes whole grains, fish, poultry, beans, seeds, nuts, and vegetable oils
 Limits ingestion of sodium, sweets, sugary beverages, and red meat
Nutritionally, the DASH diet is low in saturated and trans fats and rich in potassium,
calcium, magnesium, fiber, and protein.
The Dietary Approaches to Stop Hypertension (DASH) diet is widely used for clients with
heart failure. All foods high in sodium (>400 mg/serving) should be avoided.
General principles of a low-sodium diet are as follows:
 Do not add salt or seasonings containing sodium when preparing meals
 Do not use salt at the table
 Avoid high-sodium foods (canned soups, processed meats, cheese, frozen meals)
 Limit milk products to 2 cups daily

Peripheral Artery Disease (PAD

reduces tissue perfusion and can cause ischemic pain of the lower extremities
Factors that increase risk for PAD include:
 Hypertension: Vessel damage from chronically elevated vascular resistance
 Diabetes mellitus: Inflammatory vascular changes from hyperglycemia
 Hyperlipidemia: Increased plaque formation (atherosclerosis)
 Smoking: Chronic vasoconstriction from nicotine inhalation
Decreased sensations from nerve ischemia or coexisting diabetes mellitus. They
should never apply direct heat to the extremity due to the risk for a burn
wound. Wound healing is impaired in these clients.
Swelling in the extremities (edema) could result from venous stasis (venous valve
incompetence or varicose veins); these clients are asked to elevate their extremities
during rest. However, clients with PAD usually do not have swelling, but rather have
decreased blood supply. The extremities should not be elevated above the level of the
heart because extreme elevation further impedes arterial blood flow to the feet.
Additional teaching for the client with PAD includes the following:
 Smoking cessation  Tight blood pressure control
 Regular exercise  Use of lipid management
 Achieving or maintaining ideal medications
body weight  Use of antiplatelet medications
 Low-sodium diet  Proper limb and foot care
 Tight glucose control in diabetics

Pericardial Effusion
signs and symptoms (narrowed pulse pressure, hypotension, and jugular venous
distension) risk of developing cardiac tamponade, a life-threatening complication of
pericardial effusion in which fluid builds up in the pericardial sac and compresses the
heart. The heart is unable to contract effectively against the fluid, and cardiac output
can drop drastically. Emergency pericardiocentesis is needed. Other important
manifestations of tamponade include muffled or distant heart tones, paradoxical pulse
(abnormally large decrease in stroke volume), dyspnea, tachypnea, and tachycardia.
The nurse should report these findings to the health care provider immediately and
prepare for a pericardiocentesis

Aortic Stenosis
narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the
aorta. As stenosis progresses, the heart cannot overcome the worsening obstruction,
and ejects a smaller fraction of blood volume from the left ventricle during
systole. This decreased ejection fraction results in a narrowed pulse pressure (the
difference between systolic and diastolic blood pressures) and weak, thready peripheral
pulses. With exertion, the volume of blood that is pumped to the brain and other parts
of the body is insufficient to meet metabolic demands, resulting in exertional dyspnea,
anginal chest pain, and syncope. A systolic ejection murmur over the aortic area, soft or
absent second heart sounds, and weak peripheral pulses are characteristic.

Central Venous Pressure (CVP)

CVP is a measurement of right ventricular preload (volume within the ventricle at the
end of diastole) and reflects fluid volume problems. The normal CVP is 2-8 mm
Hg. An elevated CVP can indicate right ventricular failure or fluid volume overload.
Clinical signs of fluid volume overload include the following:
 Peripheral edema
 Increased urine output that is dilute
 Acute, rapid weight gain
 Jugular venous distension
 S3 heart sound in adults
 Tachypnea, dyspnea, crackles in lungs
 Bounding peripheral pulses

Hypertensive Crisis
Life-threatening emergency due to the possibility of severe organ damage.
Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is
important to lower the blood pressure slowly, as too rapid a drop may cause decreased
perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or
MI. The initial goal is usually to decrease the MAP by no more than 25% or to
maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a
period of 24 hours. MAP = (2 x DBP + SBP) / 3

Myocardial Infarctions
Women, the elderly, and clients with a history of diabetes may not have the classic
heart attack symptoms of dull chest pain with radiation down the left arm. Instead,
they can present with "atypical" symptoms such as nausea, vomiting, belching,
indigestion, diaphoresis, dizziness, and fatigue.
Mitral Valve Regurgitation
Chronic mitral valve regurgitation is often asymptomatic, but many clients eventually
develop heart failure; therefore, early recognition of symptoms is a priority. Mitral
regurgitation causes a backflow of blood from the left ventricle to the left atrium,
resulting in pulmonary edema (dyspnea, orthopnea) and decreased cardiac output
(fatigue). Left atrial enlargement can also result in atrial fibrillation (palpitations).

Cardiac catheterization
Cardiac catheterization uses IV contrast to assess for artery obstruction. Complications
include allergic reactions, lactic acidosis, and kidney injury. Contrast is avoided in clients
who had a previous allergic reaction to contrast agents, took metformin in the last 24
hours, or have renal impairment.
Metformin (Glucophage) with IV iodine contrast increases the risk for lactic acidosis
usually discontinued 24-48 hours before exposure and restarted after 48 hours

jugular venous distension (JVD)

performed with the client sitting with the head of the bed at a 30- to 45-degree
angle. The nurse will observe for distension and prominent pulsation of the neck
veins. The presence of JVD in the client with heart failure may indicate an exacerbation
and possible fluid overload.

Angina Pectoris
Chest pain brought on by myocardial ischemia (decreased blood flow to the heart
muscle). Any factor that increases oxygen demand or decreases oxygen supply to
cardiac muscle may cause angina, including the following:
 Physical exertion (exercise, sexual activity): Increases heart rate and reduces
diastole (time of maximum blood flow to the myocardium)
 Intense emotion (anxiety, fear): Initiates the sympathetic nervous system and
increases cardiac workload
 Temperature extremes: Usually cold exposure and hypothermia
(vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling)
 Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon
monoxide; nicotine causes vasoconstriction and catecholamine release
 Stimulants (cocaine, amphetamines): Increase heart rate and cause
vasoconstriction
 Coronary artery narrowing (atherosclerosis, coronary artery spasm): Decreases
blood flow to myocardium
Coronary Arteriogram
Client have nothing by mouth for 6-12 hours prior to the procedure and have an IV line
started for sedation medications. The client may feel warm and flushed while the dye is
being injected. The client is required to lie flat for several hours following the
procedure to achieve hemostasis at the access site (femoral access). The client typically
goes home the same day unless other interventions have been performed.
Chronic Congestive Heart Failure
clinical manifestations of both right-sided (systemic venous congestion) and left-sided
(pulmonary congestion) failure.
Crackles usually heard on inspiration and indicate the presence of pulmonary
congestion (left-sided failure)
Increased jugular venous distention reflects an increase in pressure and volume in the
systemic circulation, resulting in elevated central venous pressure (CVP) (right-sided
failure)
dependent pitting edema of the extremities is related to sodium and fluid retention
(right-sided failure)
Pharmacologic Nuclear Stress Test
utilizes vasodilators (adenosine, dipyridamole) to simulate exercise when clients are
unable to tolerate continuous physical activity or when their target heart rate is not
achieved through exercise alone.
A radioactive dye is injected so that a special camera can produce images of the
heart. Based on these images, the health care provider (HCP) can visualize if there is
adequate coronary perfusion.
Pre-procedure client instructions include the following:

 Do not eat, drink, or smoke on the day of the test (NPO for at least 4
hours). Small sips of water may be taken with medications.
 Avoid caffeine products 24 hours before the test.
 Avoid decaffeinated products 24 hours before the test as these contain trace
amounts of caffeine.
 Do not take theophylline 24-48 hours prior to the test (if tolerated).
 If insulin/pills are prescribed for diabetes, consult the HCP about appropriate
dosage on the day of the test. Hypoglycemia can result if the medicine is taken
without food.
 Some medications can interfere with the test results by masking angina. Do not
take the following cardiac medications unless the HCP directs otherwise, or
unless needed to treat chest discomfort on the day of the test:
o Nitrates (nitroglycerine or isosorbide)
o Dipyridamole
o Beta blockers

Murmurs
indicate turbulent blood flow across diseased or malformed cardiac valves. They
are often described as musical, blowing, or swooshing sounds that occur
between normal heart sounds. They may be auscultated at the aortic, pulmonic,
tricuspid, or mitral areas.

Raynaud phenomenon
Raynaud phenomenon is a vasospastic disorder triggered by exposure to cold or
stress. Key elements of client teaching include management of acute attacks,
avoidance of vasoconstrictive substances (tobacco, cocaine, caffeine), stress
reduction, and appropriate clothing (gloves, warm layers).
Right-sided Heart Failure
results from pulmonary hypertension, right ventricular myocardial infarction, or left-
sided heart failure.
Clinical manifestations result from systemic venous congestion and include peripheral
edema, jugular venous distension, increased abdominal girth (hepatomegaly,
splenomegaly), and ascites.

Left-sided Heart Failure

Dyspnea, orthopnea, crackles, paroxysmal nocturnal dyspnea, displaced PMI, S3 sound
Chronic heart failure involves the inability of the heart to fill and pump blood effectively
to meet the body's oxygen demands. As a result, clients can develop dilutional
hyponatremia (serum sodium <135 mEq/L [135 mmol/L]), an electrolyte disturbance
caused by an excess of total body water in relation to total sodium content.
An infusion of an isotonic solution of 0.9% normal saline at 85 mL/h is contraindicated in
this client as it would increase the circulating extracellular fluid volume, worsen the
symptoms, and exceed the <2 L/day fluid restriction (85 mL × 24 hours = 2040
mL). Converting the running IV line to a lock for medication administration would be
appropriate.

Hypovolemic Shock
Clinical manifestations of hypovolemic shock are associated with inadequate tissue
perfusion and include change in mental status; tachypnea; tachycardia with thready
pulse; cool, clammy skin; and oliguria.
A mean arterial blood pressure of 70-105 mm Hg is considered normal, and >60 mm Hg
is needed for adequate tissue perfusion to vital organs (brain, coronary artery).

Buerger's Disease
a nonatherosclerotic vasculitis involving small to medium arteries and veins of the upper
and lower extremities. Young male smokers are typically affected. Clients should avoid
exposure to cold weather and cease using tobacco and marijuana in all forms. Smoking
cessation can be achieved with bupropion or varenicline but not with nicotine
replacement products.

Peripheral artery disease

arteries that have thickened, have lost elasticity due to calcification of the artery walls,
and are narrowed by atherosclerotic plaques
pain is arterial in nature and results from decreased blood flow to the legs. It is made
worse with leg elevation. Arterial ulcers are formed at the most distal end of the
body. Venous ulcers form over the medial malleolus, and compression bandaging is
needed to reduce the pressure.
Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen).
progressive walking program will aid the development of collateral circulation.

Thrombolytic therapy
aimed at stopping the infarction process, dissolving the thrombus in the coronary artery,
and reperfusion of the myocardium.
Minor or major bleeding can be a complication of therapy.
Inclusion criteria for thrombolytic therapy are chest pain typical of acute MI 6 hours or
less in duration, 12-lead electrocardiogram findings consistent with acute MI, and no
absolute contraindications.
BNP
a peptide that causes natriuresis
Elevation of BNP to >100 pg/mL is seen in heart failure. It aids in the assessment of the
severity of heart failure and helps distinguish cardiac from respiratory causes of
dyspnea.

Torsades de Pointes
a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is
a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop
quickly into ventricular fibrillation. The American Heart Association recommends
treatment with IV magnesium sulfate.
In a client with hypomagnesemia, it is important to assess the QT interval.
normal Mg: 1.5-2.5 mEq/L

Hypokalemia
The nurse should recognize muscle cramps in the legs as a possible sign of hypokalemia
in the client taking diuretics. Muscle cramps should be reported to the health care
provider in anticipation of checking a potassium level, adding a potassium supplement,
and instructing the client to eat potassium-rich foods.
Hypokalemia may manifest as muscle cramps, weakness, or paralysis and typically starts
with the leg muscles

Permanent Pacemaker
Clients with a pacemaker should avoid heavy lifting and above-the-shoulder exercises until the
HCP approves. They should carry a pacemaker ID card, wear a medic alert bracelet, avoid MRI
scans, never place a cell phone over the pacemaker, and inform airline security personnel.
Microwave ovens are safe. Report fever or any signs of redness, swelling, or drainage at the
incision site.
client is sedated with propofol, on a mechanical ventilator, and is
receiving enteral feeding via nasogastric tube.
Assessing gastric residual volumes and level of sedation at regular intervals, checking
enteral feeding tube placement, and administering continual rather than bolus tube
feeding are interventions that help prevent aspiration in critically ill high-risk clients.

Acute Hemolytic Transfusion Reaction

life-threatening reaction caused primarily by blood incompatibility. If it occurs, the
transfusion should be stopped, and a fresh urine specimen should be collected and sent
to the laboratory to analyze for hemolyzed RBCs. Asking the client to void prior to
starting the transfusion helps ensure that any urine specimen collected after a reaction
is reflective of the body's physiological processes after the blood transfusion.

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can

cause cardiovascular side effects, including heart attack, stroke, high blood pressure,
and heart failure from fluid retention. These drugs also decrease the effectiveness of
diuretics and other blood pressure medications. The risks can be even higher in the
client who already has cardiovascular disease or takes NSAIDs routinely or for a long
time. In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic
kidney disease. These clients should use NSAIDs cautiously, at the lowest dose
necessary and for a short time. The nurse should notify the health care provider that
this client is routinely taking ibuprofen

Supraventricular tachycardia (SVT) is a dysrhythmia that originates from an ectopic

focus above the bifurcation of the bundle of His. The heart rate can be 150-220/min.
The rhythm is usually regular. P waves are often hidden. If visible, they may have an
abnormal shape and the PR interval may be shortened. The QRS complex is usually
narrow (<0.12 second).
Stimulants (nicotine, caffeine, cocaine) and organic heart disease can cause SVT. Clinical
significance depends on the client's symptoms. A prolonged episode of SVT with a heart
rate >180/min will cause decreased cardiac output and hypotension. The client may
also experience palpitations, dyspnea, and angina.
Treatment includes vagal stimulation and drug therapy. Common vagal maneuvers
include Valsalva, coughing, and carotid massage. IV adenosine is the drug of choice to
convert SVT to a sinus rhythm. If vagal stimulation and drug therapy are ineffective and
the client becomes hemodynamically unstable, synchronized cardioversion is used.
Recurrent SVT may require radiofrequency catheter ablation.
Radiofrequency Catheter Ablation
Radiofrequency ablation is performed through transvenous cardiac catheterization to
ablate (burn) electrical pathways causing supraventricular or ventricular
tachydysrhythmias. Ablation performed near the atrioventricular (AV) node can
damage conduction, causing varying degrees of AV block. Third-degree AV block, or
complete heart block, occurs when electrical conduction from the atria to the ventricles
is blocked, causing decreased cardiac output (dizziness, syncope, mental status changes,
heart failure, hypotension, bradycardia). On ECG, third-degree AV block presents as a
regular rate and rhythm with disassociated P waves and QRS complexes. This type of AV
block requires temporary or permanent pacing to restore electrical conduction and
hemodynamic stability.
(assessment that requires notifying the cardiologist and preparing for temporary pacing.
The nurse notes that the P waves are not associated with the QRS complexes on the
cardiac monitor)

Occasional premature ventricular contractions (PVCs) are common dysrhythmias that

may be precipitated by several factors, including electrolyte imbalances (potassium),
stimulants (caffeine, nicotine), and stress. Occasional PVCs typically do not cause
hemodynamic instability.
NTG is a vasodilator used to treat stable angina. It is a sublingual tablet or spray that is
placed under the client's tongue. It usually relieves pain in about 3 minutes and lasts 30-
40 minutes. The recommended dose is 1 tablet, or 1 spray taken sublingually for angina
every 5 minutes for a maximum of 3 doses. If symptoms are unchanged or worse 5
minutes after the first dose, emergency medical services (EMS) should be contacted
The NTG should be easily accessible at all times. Tablets are packaged in a light-
resistant bottle with a metal cap. They should be stored away from light and heat
sources, including body heat, to protect from degradation. Clients should be instructed
to keep the tablets in the original container. Once opened, the tablets lose potency and
should be replaced every 6 months
Waking up at night with chest pain can signify that angina is occurring at rest and is no
longer considered stable angina. This should be reported to the health care provider.
Hydrochlorothiazide and chlorthalidone are the most commonly used thiazide diuretics
for treating hypertension.
The major side effects of thiazide diuretics include:

 Hypokalemia (manifests as muscle cramps)

 Hyponatremia (manifests as altered mental status and seizures)
 Hyperuricemia (may worsen gout attacks)
 Hyperglycemia (requires adjustment of diabetic medications)
Of the above side effects, hypokalemia is the most serious as it can lead to life-
threatening cardiac arrhythmias.

Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the

patch) can result in serious rebound hypertension due to the rapid surge of
catecholamine secretion that was suppressed during therapy. Clonidine should be
tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound
hypertension and in precipitation of angina, myocardial infarction, or sudden death.