Chapter 35 continued: Respiratory

Related Nursing Diagnoses

Pain
• Commonly accompanies ↓ in circulation-compensatory mechanisms body tissues
switch from aerobic to anaerobic metabolism (inadequate circulation fail)
• By product of anaerobic is lactic acid
• Lactic avid irritates nerve endings and produces pain
• Restoration of circulation is priority to prevent damage to tissues and nerves

Anxiety
• ↓ circulation
• Pain
• Cerebral hypoxia
• Brain needs constant O2 to function

Risk for impaired skin integrity

• Bad circulation
• Blood is shunted from nonessential organs (skin) to vital organs
• Vasoconstriction accompanies blood shunting, produces clod, clammy, mottled
skin
• Arterial/venous insufficiency likely to develop ulcers/ necrotic areas

Ineffective Health Maintenance

• Change life style
• Assess lifestyle, knowledge, motivation

Activity Intolerance
• Assess tolerance level
• muscles with ↓ O2 supply fatigue quickly

Planning
Outcomes depend on chronic/acute cardio problems

Acute cardiovascular problems

• Interventions: assess, monitor changes in circulatory status
• Support of circulation, implement medical therapies
• Early recognition crucial for successful outcomes
• Unique aspects: living arrangements, transportation, fiancés, support systems,
culture
Outcomes for Ineffective Tissue Perfusion
• Prevent permanent tissue damage
• Prevent death
• Rapid assessment (essential)
For Chronic profusion
• Improvement of circulation/adaptation
• Nurses role (detect subtle signs, teach, foster compliance, emotional support)

Outcomes (adequate tissue perfusion)

• B/P WNL for client
• Peripheral pulses equal strength/quality
• Skin warm dry
• Cap, refill < 3sec
• 0/10 pain
• LOC WNL for client
• Output at least 30mL/hr
*pay close attention to affected body system

Outcomes (decreased cardiac output)

• Reduce cardiac workload
• Use meds effectively
• Control salt/water retention
*short-term/intermediate goals used to measure progress

Adequate cardiac output

• B/P WNL
• Absence of abnormal heart sounds
• Lungs clear
• Absence of edema
• LOC WNL
• Output at least 30mL/ hr
• Ǿ fatigue/weakness

Outcomes (risk for Peripheral Neurovascular Dysfunction)

*addresses impaired circulation to extremity
• Palpable peripheral pulses
• Skin warm/pink
• Cap refill < 3 sec
• Ǿ pallor, pain, paresthesia, paralysis

Outcomes for shock

• Adequate tissue perfusion: A/o, skin warm/dry, VS stable, urine output at least 50
mL/hr
 • BP, pulse, resp. WN parameters (systolic > 100, pulse < 100, resp. < 30/min.)
• Ǿ S/S of neuro, renal, GI, peripheral vascular, resp. ischemia/ dysfunction

Interventions (Tissue perfusion)

• Open blood vessels and dynamic blood flow maximize circulation

Modifying risk factors:

PREVENTION PRIMARY NURSING GOAL
TEACHING

DIET
LOW CHOLESTEROL/ FAT DECREASES FATS AVAILBLE TO
FORM ATHEROSCLEROTIC DEPOSITS
O AVOID FATS ESPECIALLY COCNUT OIL
O REMOVE SKIN BEFORE COOKING
FATS PROVIDE 9KCAL/G – CARBS AND PROTEIN 4KCAL/G

EXERCISE
o INCREASES PROPORTION OF HDL’S IN BLOOD
o HDL’S PROTECT BLOOD VESSELS
o STIMULATES DEVELOPMENT OF COLLATERAL CIRCULATION
AND NEW BLOOD VESSELS
o EXERCISE REGULALY/ENERGETICALY
o RYTHMIC CONTRATIONS OF LARGE MUCSLES
o 3-5 TIMES/WEEK 20-30- MIN/SESSION
o CHECK PULSE MAINTAIN TARGET RATE FOR 20 MINUTES

CONCURRENT HEALTH PRBLEMS

o HYPERTENTION, DIABETES MELLITUS, ACCELERATE
ATHEROSCEROSIS
o CAREFUL MANAGEMENT AND CONSISTENT FOLLOW-UP KEEP
PROBLEMS UNDR CONTROL

PREVENTING VASOCONTRICTION
Causes of vasoconstriction
IMPROPER POSITION COLD TEMP, NICOTINE, EMOTIONAL
STRESS

Positioning
Frequent repositioning
Do not cross legs for prolonged time
Do not place pillows behind knees
 Do not use knee elevator on Gatch bed
Elevate legs for venous insufficiency uses gravity to improve
circulation
Stocking for external support/minimize venous pooling

Cold Temperatures
Dress warm to minimize vasoconstriction

Nicotine
Vasoconstriction
Gum/patches help
American Heart Association, American Cancer association sponsor
community programs

Emotional stress
Activates flight/fight response---vasoconstriction diverts blood to
essential organs
To reduce deep breathing, relaxation, imagery

Administering Medications
High risk clients anticoagulant therapy
Antiplatelet aggregates (acetylsalicylic acid-aspirin and
clopidogrel-Plavix) reduce stickiness
Anticoagulants
o Interrupt step in clotting cascade
o Warfarin ( Coumadin) and Heparin- risk for bleeding
o PT/ INR for Coumadin
o PTT for Heparin
o Report to MD before giving
o Assess for signs of bleeding
Vasodilating medications-enlarge lumens of blood vessels-
greater blood to tissues
o Nitrates: Nitroglycerin (Nitro-Bid, Transderm-Nitro)
Relaxes smooth muscle/decreases venous return
and preload
Dilates coronary vessels
Dilates systemic vessels/decreasing afterload

Side effects
o Headache
o Flushing
o Hypotension
Nursing Responsibilities
o Monitor B/P – *position change
o Report dizziness, headache
 o Avoid alcohol

Calcium Channel Blockers (Amlodipine besylate – Norvasc)

o Slows calcium into smooth muscle/ relaxation-
vasodilation

Side effects
o Hypotension
o Dizziness
o Constipation
o Peripheral edema

Nursing Responsibilities
o Monitor v/s
o Encourage intake- fluids/fiber
o Assess for edema
o Report all meds to MD-interaction (Digoxin, GI
meds)

Beta-Adrenergic Blockers
Carvedilol (Coreg)-Metoprolol (Lopressor, Toprol) Atenolol (Tenormin),
Labetalol (Normodyne)-

Competes for norepinephrine binding site-blocking beta-1/beta-2 adrenergic

action

Side effects
o Fatigue
o Hypotension
o Bradycardia
o Insomnia
o Depression
o Heart failure

Nursing Responsibilities
o Monitor B/P, pulse
o S/s heart failure
o Consult before exercise
o Never discontinue abruptly

Preventing surgical complications

○ All post op at risk for DVT
○ Frequent repositioning
○ Early ambulation
 ○ Some require removal/bypass of diseased vessels

Interventions To Improve Cardiac Output - primary nursing goal lessen need for
O2 at tissue level – ease heart’s workload
○ Promoting rest
○ conserves energy-decrease O2 demand
○ rest periods
○ assist with ADL’s
○ monitor v/s, skin color-before, during, after activity
○ place items in reach
○ quiet environment-darkened room-relaxing music

○ Positioning to Improve Cardiac output

○ Eases cardiac workload
○ Semi-fowler – high-fowlers decreases venous return and preload by
pooling blood- lowering preload decreases risk for heart congestion and
heart failure
○ Optimizes chest expansion and O2 intake
○ Reduces dyspnea and SOB

• Avoiding valsalva Maneuver

○ Do not hold breath while moving or turning
○ Assist by lowering HOB before turning
○ Do not bear down during BM
○ Assess consistency/frequency of BM
○ Encourage fluid intake
○ Increase GI motility – fruit, juices
○ Administer stool softeners
• Avoiding stimulants
○ Increase HR an O2 demand
○ OTC’s- appetite suppressants, cold meds
○ Dietary stimulants-coffee, tea, chocolate
○ Offer substitutions-decaffeinated beverages, fruits
• Maintaining Fluid Balance
○ Monitor I & O’s, weight, breath sounds, jugular vein distention, ankles for
edema
○ Monitor sudden onset of dyspnea, suffocation cyanosis, gurgling
respiration, frothy sputum-elevate HOB, call MD
○ Report immediately
○ Fluid and NA+ restriction to correct fluid overload
○ Diuretics-furosemide ( lasix), increase urine output/remove excess fluid
from body
○ Monitor electrolytes (potassium)
 • Medication Management

• Meds: Cornerstone of cardiovascular problems, enhance cardiac output, manage

complications associated with Decreased cardiac output

• Inotropic Meds
○ Increase contractility of heart muscle, thereby increasing cardiac output
○ Digoxin (Lanoxin) common inotropic med
○ Apical pulse 1 min before giving
○ Report AP < 60 and >110
○ Check potassium low K+ predisposes to digitalis toxicity
○ Digoxin level (0.5 to 2.0 mg/mL)
• Antidysrhythmic meds (?)
• Antihypertnsive meds
○ ACE inhibitors to treat left ventricle systolic dysfunction
○ Superior to digitalis in reducing mortality rate
○ Meds that lower B/P-nitrates (nitroglycerin), captopril (Capoten, Nifedipine
( Procardia)
○ Ease workload and improve cardiac output
○ Dilation decreases afterload, enables heart to eject blood with less effort
○ Monitor B/P
○ Check for orthostatic hypotension=decreases B/P when position changes
from lying to sitting to standing
○ Check for dizziness, lightheadedness
○ Prevent falls-call for help, sit on side o bed before standing

Increasing O2 supply: clients with impaired cardiac output deliver less O2-rich blood to
tissues

• Administering O2
○ Need carful balance between O2 demand a and supply
○ See chapter 34
• Avoiding Smoking
• Positioning to facilitate breathing
○ Elevating HOB facilitates respiration by shifting abdominal organs
downward and providing maximum space for expansion
Interventions to prevent peripheral neurovascular dysfunction
• Largely preventable
• Identify at risk clients
• Detect early S/S
 • Carful assessment cornerstone
• Follow protocol for casts and angiography
• Assess involved extremities for color, temperature, pulses, numbness, tingling,
pain
• Objective symptons:Pale , cold skin, decreased or absent pulses require
immediate attention
• Subjective symptoms: numbness, tingling, pain- instruct client to report
• Elevate to reduce edema
• Encourage movement of extremity to enhance venous return
• Notify MD of abnormal findings
• Immediately report-absence of pulse, pallor, pain, paralysis
Intervention to manage shock
Client usually In ICU,
Manifestations of shock
• Rapid, weak, thready pulse
• Rapid shallow respirations
• Systolic B/P <90
• LOC restlessness progressing to lethargy
• Skin pale, cool, clammy
• Urine output <20mL/hr
• Increase thirst
Maintaining O2

• O2 of tissue essential for survival

• Nassal canula
• Endotarcheal tube and mechanical ventilation ( can not breath on own)
Positioning for shock

• Depends on cause
• Hypovolemic shock elevate feet 15 to 20 inches above heart level-uses gravity to
increase venous return helping to maintain stroke volume
• Cardiogenic shock can not expel blood effectively from heart- position for
decrease venous return- semi-fowlers to high-fowler-position not always straight
forward check MD orders and s/s
Maintaining circulating Blood Volume

• Fluid replacement depends on cause

• Hypovolemic shock use blood, packed red blood cells, volume expanders
(dextran, plasma), IV solutions (NS or Lacted Ringers)
 ○ Monitor for transfusion reaction-chills, rash, dyspnea, chest pain, itching,
change in VS-stop transfusion immediately, stay with client, maintain IV
line, call MD
• Cardiogenic shock
○ Requires very cautious fluid replacement
○ Hemodynamic devices to evaluate tolerance and overload
○ Hemodynamic monitoring refers to type of catheters into pulmonary artery
to monitor pressures in vascular system
• Preventing complications
○ Continuously monitor circulatory status and tissue perfusion
○ Quickly recognize progression of shock and deteriorating organ function
○ Report change in VS, skin color, mental status, respiratory function, urine
output
Interventions For Cardiac or Respiratory Arrest
• Client suddenly stops breathing or heart stops
○ Act quickly
○ Simple action
○ Intense (CPR)
○ see p. 968
○ CPR synonymous with basic life support (BLS)
 Noninvasive assessments and interventions used to treats
respiratory or cardiovascular emergencies and stroke
 Can include automated external defibrillation
○ advanced cardiovascular life support (ACLS)
 To treat respiratory or cardiac emergencies and stroke
 Includes invasive techniques
 Intubation
 Drugs
○ CPR initiated by staff who finds victim first
○ Plan includes
 Call for help-cardiac response team
 Know code-give code and location
 Response team includes respiratory therapist, ICU nurse, general
duty nurse, MD
 Someone to draw to blood and x-ray tech may also respond
 As many as 8 people respond with specific task;
• Inserting end tracheal tube using Ambo bag
• Chest compression
• Starting IV
• IV fluids
• Preparing/ administering meds
• Attaching heart monitor, pulse oximeter
• Recording procedure (legal documentation
• Caring for family
• Making contact with MD, lab, radiology tech, ECG tech