Page 752 - Cardiac Nursing

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728 PA R T I V / Pathophysiology and Management of Heart Disease
Nursing Management in important. Volume expanders and vasoactive medications may
Pericardial Disease both be needed to maintain CO. The nurse is responsible for
accurate hemodynamic measurements as this information is
The nurse is perfectly positioned to recognize the symptoms of used to guide many treatment decisions. The nurse provides
pericardial disease and the potential complications. The first pri- nursing care to prevent atelectasis and pneumonia, and moni-
ority of nursing management in pericardial disease is the recogni- tors the surgical incision for infection. The nurse also monitors
tion of the patient exhibiting hemodynamic compromise. It is the effects of any other pharmacological therapy, such as
critical that the patient maintain an adequate CO for organ per- NSAIDs, and is vigilant for side effects such as gastrointestinal
fusion. The nurse evaluates the patient’s hemodynamic state, eval- upset or bleeding. The physician is notified if the desired effects
uating vital signs, symptoms, presence of pulsus paradoxus, and of medical interventions are not seen or if side effects or com-
jugular venous distension. The nurse implements interventions plications arise.
that improve cardiac function, including oxygen, vasoactive med-
ications, fluid management, and decreasing anxiety and stress.
Nurses monitor for cardiac arrhythmias and evaluate their effects
on the patient’s condition. It is imperative that cardiac tamponade CARDIOMYOPATHIES
be diagnosed early, before hemodynamic collapse. Upon identifi-
cation of a patient at risk, the nurse has the equipment readily The World Health Organization (WHO) defines cardiomy-
available for an emergency pericardiocentesis. Close monitoring opathies as diseases of the myocardium associated with cardiac
of the patient’s condition during and after the procedure reveals dysfunction. The WHO classification of cardiomyopathies in-
any other complications. cludes dilated, hypertrophic, restrictive, and arrhythmogenic right
41
The nurse who is knowledgeable of pericardial disease is able ventricular cardiomyopathies. The mortality rate in the United
to identify the patients most at risk, such as those with renal fail- States due to cardiomyopathy is greater than 10,000 per year, with
ure or recent MI. Evaluation of history, physical exam, labora- dilated cardiomyopathy (DCM) being the greatest contributor.
tory results, ECGs, and vital signs are key nursing interventions The total cost of health care in the United States focused on car-
that have an enormous impact on the patient’s outcome. A care- diomyopathies is in the billions of dollars and limited success has
42
ful and skilled assessment is pivotal and points to the medical di- been realized. Left ventricular noncompaction is another type of
agnosis of pericardial disease. To ensure appropriate treatment, cardiomyopathy that has recently gained attention. It may be-
42
the nurse needs to be aware of the subtle differences between come a distinct classification in the future. Noncompaction of
symptoms of pericarditis and other conditions that cause chest the left ventricle is theorized to be due to myocardium embryoge-
43
pain, such as MI and pulmonary embolus. The characteristics of nesis of the endocardium and myocardium.
pericardial pain, including intermittent presence, location, qual-
ity, and the effect of position changes, are aspects of the patient’s Dilated Cardiomyopathy
condition that nurses are best suited to assess. Because a pericar-
dial friction rub is likely to come and go, and change in quality, DCM is characterized by dilation and impaired contraction of the
41
the nurse is most likely to find the sound as the member of the left or both ventricles. The diagnosis of DCM is made after ex-
health care team who is consistently and frequently evaluating clusion of known, specific causes of heart failure. 44 DCM causes
the patient. considerable morbidity and mortality, and it is one of the major
Anxiety is common among cardiac patients, has potentially se- causes of sudden cardiac death. DCM is the most common car-
rious consequences if untreated, and yet it is often not assessed or diomyopathy at 60% of the total cases. 45 Idiopathic DCM is the
managed appropriately. 39 Emotional support and education can most common cause of congestive heart failure in the young with
serve to decrease patient anxiety. Consistent care and a caring ap- an estimated prevalence of at least 36.5 per 100,000 persons in the
46
proach can encourage both the patient and family members to United States for adults. The annual incidence of DCM in chil-
verbalize their fears. Nursing interventions to decrease anxiety of dren younger than 18 years was 0.57 cases per 100,000 per year.
cardiac patients are the focus of research. 39 DCM is the most common reason for cardiac transplantation in
Listening to concerns and questions and providing informa- adults and children. 47
tion bolsters coping of patients and their family. Teaching about
diagnostic tests can allay fears. The nurse intervenes with many Etiology
measures that promote patient comfort and pain relief, including DCM may be idiopathic, familial/genetic, viral, and/or immune,
narcotics and NSAIDs, positioning, diversion, and bed rest or alcoholic, toxic, or associated with recognized cardiovascular dis-
limitation of activities. Effective teaching by nurses includes in- ease in which the degree of myocardial dysfunction is not ex-
formation on potential complications, and expected course of the plained by the abnormal loading conditions or the extent of is-
disease. If being treated as an outpatient, those with pericarditis chemic damage. 41 It is estimated that 30% to 50% of cases of
should be instructed to return if symptoms do not improve in 48 idiopathic DCM have a genetic origin. 45 Recently, multiple
hours, or worsen. 40 genes have been identified to be associated with DCM. These
If the patient with pericardial disease is uremic, then he or she genes appear to encode two major subgroups of proteins; cy-
is prepared for dialysis. If a patient is to have surgery, preoperative toskeletal and sarcomeric proteins. 42 The diagnosis of familial
teaching and preparation are key nursing interventions. Inform- DCM is made when DCM is present in the setting of positive
ing the patient and family of what to expect can help them cope family history (at least two family members are affected). 48 In a
with this potentially frightening event. If a patient has a peri- study of patients with idiopathic DCM, a large number of pa-
cardiectomy, pericardial window, or other cardiac surgery, close tients were found to have had viral infections. These data suggest
monitoring of hemodynamics after the surgical procedure is very that myocardial persistence of various viruses, often presenting as