Altered Cardiac Function: Valvular Impairment

Clients in all age groups may have changes in cardiovascular and cardiopulmonary
status. Older adults are more prone to these changes due to the accumulation of plaque
in veins and arteries. Older adults' heart valves are thicker and more fibrotic.
Valvular impairment: Impairment of the heart valves causes obstruction or regurgitation
of blood flow in the heart chambers. A stenotic heart valve obstructs blood flow. When
the aortic or pulmonic heart valves become stenosed, the ventricles of the heart are
forced to work harder, leading to heart enlargement and the development of left- or rightsided heart failure.
Altered Cardiac Function: Altered Conduction
Altered conduction: A disturbance in the heart's conduction occurs when an impulse
originates from somewhere in the heart other than the sinoatrial node. When this occurs,
the heart rhythm becomes dysrhythmic. A dysrhythmia occurs from a primary conduction
disturbance such as anxiety, increased serum drug levels, diminished blood flow to the
heart, or an abnormality of the heart valve. Caffeine, alcohol, and tobacco can also
cause an impulse to originate away from the sinoatrial node.
Types of Dysrhythmias:

Bradydysrhythmia: Decreased heart rate and lower cardiac output.

Tachydysrhythmia: Increased heart rate and lower cardiac output.

Ventricular dysrhythmia: The site of the ectopic impulse is within the ventricles.
The QRS interval is widened, and the P wave is not present.

Ventricular tachycardia: Life-threatening rhythm with decreased cardiac output

that requires immediate attention.

Ventricular fibrillation: Life-threatening rhythm with a rapid disorganized

ventricular rhythm with quivering of the ventricles. There is no atrial activity noted
on theelectrocardiogram.

Atrial fibrillation: The atrial impulse in the atria originates in different parts of the
atria at multiple times. This dysrhythmia is common in older adults and places the
client at risk for the development of clots.

Altered Cardiac Function: Altered Cardiac Output

Alteration in cardiac output results in the inability of the heart to eject a sufficient amount
of blood to be circulated through the systemic and pulmonary circulation. The client is
then at risk for the development of right- or left-sided heart failure. Causes of altered
cardiac output include:

Pulmonary disease

Valvular disorders

Cardiomyopathy

Right-sided heart failure: Right-sided heart failure occurs from impaired function of the
right ventricle and results from pulmonary disease or long-term left-sided heart failure. In
right-sided heart failure, the pulmonary vascular resistance (PVR) is elevated and the
oxygen demand of the heart is increased. Blood backs up in the systemic circulation
because it cannot be ejected from the right ventricle. The client becomes edematous,
the neck veins become distended, and hepatomegaly and splenomegaly develop.
Left-sided heart failure: In left-sided heart failure, there is deceased functioning of the left
ventricle. As the volume of blood ejected by the left ventricle decreases, so does the
cardiac output. The client becomes confused, fatigued, dyspneic, and dizzy. As the heart
failure worsens and the left ventricle fails, blood pools in the pulmonary circulation,
resulting in pulmonary congestion. When you assess this client, you will note lung
cracklesper auscultation, dyspnea, hypoxia, and paroxysmal nocturnal dyspnea (PND).
Altered Cardiac Function: Angina
Myocardial ischemia is a diminished amount of oxygenated blood delivered to the
cardiac muscle. A diminished flow of blood to the myocardium results in angina or
myocardial infarction.
Angina: A client who experiences transient chest pain suffers from a condition called
angina or angina pectoris. The pain usually occurs following strenuous activity, stressful
conditions, or a heavy meal.
The client describes the following clinical manifestations of angina:

Left-sided chest pain that is crushing, stabbing, or squeezing

Pain may be in back, jaw, teeth, or epigastric region

Pain may radiate down the left arm

With regards to treatment, the client is encouraged to rest and administer nitroglycerine
preparations.
Altered Cardiac Function: Myocardial Infarction
When you are providing care to a client who complains of chest pain, you should always
take the complaint seriously and assess the client's cardiac, pulmonary, and vascular
status. The client who complains of chest pain could be suffering from a myocardial
infarction, commonly referred to as a heart attack.

Myocardial infarction: When the myocardium has a sudden decrease in coronary blood
flow and there is a lack of coronary perfusion a myocardial infarction results. In a
myocardial infarction, the heart muscle becomes ischemic due to lack of oxygenated
blood. This ischemia can result in myocardial necrosis.
The client may describe the following clinical manifestations of myocardial infarction:

Chest pain at rest or with exertion

Pain that lasts more than 30 min

Left-sided chest pain that is crushing, stabbing, or squeezing

Pain that may be in the back, jaw, teeth, or epigastric region

Pain that may radiate down the left arm

Women's symptoms may differ; they often experience fatigue, indigestion, jaw or
back pain, dyspnea, or vasospasms

Altered Respiratory Function: Hyperventilation and Hypoventilation

Many illnesses and conditions alter respiratory function and interrupt oxygen transport to
body tissues. Adequate ventilation produces an arterial carbon dioxide level of 35 to 45
mmHg and an arterial oxygen level between 95 and 100 mmHg.1 Hyperventilation,
hypoventilation, and hypoxia affect normal arterial blood carbon dioxide and oxygen
levels.
Hyperventilation

Hyperventilation is the increased movement of air in and out of the

lungs. Kussmaul breathing is hyperventilation caused by metabolic acidosis.
Stress also contributes to the development of hyperventilation.

Signs and symptoms: Increased rate and depth of respirations decrease arterial
carbon dioxide.

Hypoventilation

Hypoventilation is alveolar ventilation that is inadequate to meet the body's

demand for oxygen and elimination of carbon dioxide.

Causes:
o

Alveolar collapse

Airway obstruction

Adverse effects of medications

Signs and symptoms: Increased arterial carbon dioxide that leads to hypoxia.

Altered Respiratory Function: Hypoxia

A client experiences hypoxia when an inadequate amount of oxygen is transported to the
tissues. The causes of hypoxia include anemia, pulmonary edema, heart failure, and
anesthetic agents.
Hypoxia Signs and Symptoms

Tachycardia

Rapid, shallow respirations

Dyspnea

Flaring of the nostrils

Restlessness

Substernal and intercostal retractions

Cyanosis

Chronic Hypoxia Signs and Symptoms

Fatigue

Lethargy

Clubbing of the fingers and toes (changes in the angle between the nail beds and
nails to 180 or greater)

Hypoxia can cause cellular injury or death. Treatment for hypoxia includes the
administration of oxygen via a nasal cannula or mask.
Altered Respiratory Function: Orthopnea and Wheezing
Orthopnea

Orthopnea is the inability to breathe in a supine position. Orthopnea is caused by

respiratory and cardiac diseases or airway obstruction.

Signs and symptoms:

o

Inability to breathe except when sitting or upright

Dyspnea or air hunger in a reclining position

Wheezing

The sound of wheezing is caused by narrowing of the bronchus.

Signs and symptoms:

o

High-pitched, continuous musical, rasping, or whistling sounds heard

during inspiration or expiration

Sounds do not clear with coughing

Altered Respiratory Function: Cyanosis

Cyanosis is a dark blue or purple discoloration of the skin, nail beds, lips, or mucous
membranes related to decreased hemoglobin-oxygen saturation. Cyanosis is a late
indicator of hypoxia.
Causes of cyanosis include:

Severe anemia

Respiratory tract obstruction

Heart disease

A cold environment

Altered Respiratory Function: Tension Pneumothorax and Hemothorax

Pneumothorax: The collapse of the lung causes the collection of air in the pleural space.
Hemothorax: A hemothorax is the accumulation of blood in the pleural space.
Pleural effusion: Pleural effusion is excess fluid in the pleural space.
All three conditions interfere with lung expansion. A chest tube may be inserted in the
pleural cavity to restore negative pressure and drain blood or fluid. A chest tube used to
treat a pneumothorax is inserted in the upper anterior thorax. A chest tube to treat a

hemothorax and a pleural effusion is inserted in the lower lateral chest wall to allow for
the drainage of blood and fluid.
Closed Drainage System

The chest tube is connected to a sealed drainage system or a one-way valve

allowing air and fluid to be removed from the chest cavity and preventing air from
entering from outside.

The system has a suction control chamber, a water seal chamber, and a closed
collection chamber.

Water seal system: The client inhales, and the water prevents air from entering
the system from the outside.

When the client exhales, air can exit the chest cavity, bubbling up through the
water.

Suction can be added to the system to facilitate the removal of air or secretions.

A Heimlich valve is applied for ambulatory clients to allow air to escape from the
chest cavity and to prevent air from re-entering.

Factors Affecting Oxygenation: Age and Development

Different factors may influence a clients ability to oxygenate all areas of the body at
different ages:
Premature Infants

Inadequate ventilatory function results from immature lung development in utero.

The respiratory center of the brain is immature, as is the gag and cough reflex.

Infants and Toddlers

Both infants and toddlers have small airways, placing them at risk for aspiration
of small food items and foreign objects.

Exposure to secondhand smoke puts them at risk for bronchoconstriction and the
development of asthma.

The process of teething increases nasal congestion and respiratory infection.

School-Age Children

School-age children are exposed to respiratory infections, which can in turn lead
to them developing upper respiratory infections.

Adolescents

The heart and lungs of the adolescent increase in size, and the heart rate
decreases.

The adolescent should be taught the risks of smoking, and smoking cessation
should be provided for those who do smoke.

Young and Middle Age Adults

Aerobic activity and cardiac output show age-related changes due to unhealthy
diet, lack of exercise, stress, and smoking.

Loss of blood vessel elasticity may contribute to hypertension.

Older Adult

The lungs diminish in elasticity, and the chest wall becomes thickened due to
age-related changes.

The number of functional cilia in the lungs is decreased, resulting in a decreased

cough reflex and an increased risk of respiratory infection.

The arterial system has atherosclerotic changes due to the formation of plaque.
The client may also have calcification of the heart valves, sinoatrial node, and
costal cartilage.

Health Status
Oxygenation can be affected by disorders that affect other body systems:

Impaired cardiac or renal function: Clients with conditions that lead to cardiac or
renal insufficiency suffer from pulmonary insufficiency and disease. These
disorders place the client at risk for fluid overload and tissue perfusion
impairment.

Impaired muscle strength: Decreased muscle strength impairs cardiac output and
respiratory function, both of which also diminish tissue perfusion.

Impaired hematologic status: Anemia lowers the oxygen-carrying capacity of the

blood, preventing oxygenated blood from being distributed efficiently to body
tissues.

Impaired musculature: Scoliosis and kyphosis diminish lung capacity.

Factors Affecting Oxygenation: Medications and Psychological Health

Medications
Medications that depress the central nervous system (CNS) decrease respiratory
function and rate, placing clients at risk for the development of pneumonia and altered
tissue perfusion. The most common medications that decrease respiratory function
are benzodiazepines, opioids, and anxiolytics.
Psychological Health
High levels of anxiety can cause bronchospasms and the onset of bronchial asthma.
Some clients hyperventilate in response to stress. The client's arterial oxygen levels rise,
and the arterial carbon dioxide levels decline. The client experiences lightheadedness
along with numbness and tingling of the fingers, the toes, and around the mouth. Stress
reactions that stimulate the sympathetic nervous system to release epinephrine increase
the client's risk for developing cardiovascular disease.
Factors Affecting Oxygenation: Lifestyle and Environment
Lifestyle

Individuals who live a sedentary lifestyle have diminished alveolar expansion,

placing them at risk for altered respiratory function.

Clients with occupations that cause them to inhale chemicals and dust are at
increased risk for developing lung disease.

Clients who smoke are at risk for pulmonary and cardiac disease.

The intake of a diet high in fat predisposes clients to cardiovascular disease.

Environment

High altitudes, excessive heat and cold, as well as air pollution place clients at
risk for cardiopulmonary insufficiency.

Nursing Process: Assessment

When you are assessing the client's cardiac, vascular, and pulmonary status, begin by
gathering information on the client's health history.
Pulmonary health history: Begin the pulmonary or respiratory assessment by asking the
client the following questions:

Do you have a history of cough, dyspnea, wheezing, or pain?

Have you been exposed to environmental hazards such as asbestos, bacterial or

viral respiratory infections, or smoke?

Have you ever been diagnosed with a respiratory disease such as asthma,
chronic obstructive pulmonary disease, or lung cancer?

What medications are you taking?

Cardiac and vascular health history: During the cardiac assessment, gather information
on the following:

Cardiac risk factors such as high-fat diet, sedentary lifestyle, and stress

Whether the client has experienced (or is experiencing) chest pain, fatigue,
dyspnea, or cardiac symptoms

Any past or present cardiovascular disease

Physical assessment: When performing a physical assessment to help determine

cardiac, pulmonary, and vascular status, begin with inspection, followed by palpation,
percussion, and auscultation.

Nursing Process: Inspection, Palpation, Percussion, Auscultation

Inspection: Assess the client from head to toe, inspecting the color of his/her skin and
mucous membranes, level of consciousness and orientation, breathing patterns, and
chest wall movement. Assess the client's pulse oximetry.
Palpation: Palpate the chest for tenderness, lesions, tactile fremitus, and the point of
maximal impulse (PMI). You should locate the angle of Louis and slide your fingers down
each side of the angle, locating the intercostal spaces and counting down to the fifth
intercostal space. Then slide your finger to the midline of the left side of the chest. This is
the site of the point of maximal impulse. Palpate for thrills or heaves at the PMI. Palpate
the pulses in all the extremities and neck to determine if they are regular and their rate.
Note variations in skin temperature in all areas. Palpate for edema in the lower
extremities.
Percuss: Percuss the lung fields and heart for the presence of fluid. Percuss the lung
fields for air.
Auscultate: Auscultate the heart valve sites for S1 and S2 sounds. The presence of S3
or S4 is abnormal and could indicate heart failure or a gallop, murmur, or rub. Auscultate
the carotid, abdominal aortic, and femoral arteries for a bruit. Auscultate for absent or
adventitious breath sounds.
Also auscultate heart rate and rhythm.

Nursing Process: Diagnosis and Planning

Diagnosis: When establishing nursing diagnoses, keep in mind the following factors:

Tissue perfusion

Oxygenation

Gas exchange

Patterns of breathing and heart rate

Fluid volume

Fatigue

Planning: In planning care, ensure the client attains his/her goals regarding pulmonary,
cardiac, and vascular functioning. Appropriate goals include the following:

The client will ambulate without shortness of breath.

The client will have a regular heart rate and rhythm.

The client's oxygen saturation will be 95 to 100%.

The client's peripheral pulses will be palpable and strong.

Nursing Process: Implementation

Implementation: As the nurse, you will implement nursing interventions that promote and
maintain adequate pulmonary, cardiac, and vascular function.

According to CDC guidelines, maintain up-to-date immunizations for all ages

including influenza, and pneumonia for older adults.

Educate the client regarding the following topics:

Eating a high-fiber, low-fat diet

Restricting exposure to inhalants

Maintaining a regular exercise routine

Preventing exposure to infections

Assess serum cholesterol and triglycerides.

Assess heart sounds, lung sounds, and peripheral pulses.

Auscultate the heart sounds at the point of maximal impulse (PMI), count the
rate, assess the rhythm, and simultaneously compare the rate to the rate of the
radial pulse.

Administer medications to reduce asthma and chronic obstructive pulmonary

disease (COPD) symptoms, for example, bronchodilators, anti-infectives,
and steroidsas ordered.

Apply oxygen as ordered.

Chest physiotherapy is also known as postural drainage and involves striking all
the lung fields on the client's back with a cupped hand followed by vibration with
the fingertips.

Suction the client as ordered and as needed.

For clients who have a tracheostomy, provide tracheostomy care.

Nursing Process: Implementation: Chest Tube

When providing care to a client with a chest tube and drainage system, adhere to the
following nursing interventions:

Maintain a patent and functioning system.

Assess vital signs, oxygen saturation, and cardiovascular and pulmonary status.

Assess breath sounds bilaterally for symmetry.

Observe the dressing for drainage (colour and amount) and odour.

Palpate around the dressing for crackles (subcutaneous emphysema).

Assess the client's level of pain or discomfort.

Encourage coughing and deep breathing exercises every 2 hr.

Have the client sit upright and splint the site when coughing and deep breathing.

Perform range-of-motion exercises to the shoulder on the affected side.

Encourage the client to change positions every 2 hr.

Encourage the client to ambulate whenever possible and provide assistance

managing the drainage system when doing so.

Tape all connections of the system and maintain it below the client's chest level.

Do not milk the tubing.

Avoid clamping the tube as this increases the risk of a tension pneumothorax.
Clamp only for a moment if necessary to replace the unit or locate the source of
an air leak.

If the tubing becomes disconnected from the collecting system, submerge the
end in 2.6 cm. of sterile water to maintain the seal.

If the tubing is pulled out, cover the wound with a dry sterile dressing (be sure
that no air is leaking).

When transporting the client, keep the system below chest level, disconnect the
suction, and make sure the air vent is open.

Use good hand hygiene, standard precautions, and personal protective

equipment.

Medicate the client for pain prior to removal of the chest tube.

Nursing Process: Evaluation

In the evaluation phase of the nursing process, you will need to determine if the client's
goals have been attained related to adequate pulmonary, cardiac, and vascular function.

Assess the client's pulmonary status, including lung sounds, and degree of
breathlessness.

Ask the client if the interventions have assisted in relieving dyspnea or other
symptoms.

Notify the health care provider of any changes in pulmonary, cardiac, or vascular
function.

Expected outcomes include the following:

Respiratory rate, depth, and pattern within normal limits

Pulse rate, pattern, and amplitude within normal limits

Oxygen saturation greater than 95% (or at the level of the client's baseline)

Mucus thin and clear

Lung sounds clear to auscultation

Heart rate and rhythm normal

Skin colour pink

Unexpected outcomes include the following:

Restlessness

Cyanosis of lips and nail beds

Adventitious lung sounds

Productive cough

Abnormal heart rate and rhythm

Abnormal pulse rate, rhythm, and amplitude

Complaint of dyspnea and/or chest pain

Thick and/or coloured sputum

Dried mucous membranes

Oxygen saturation less than 95% (or at the rate and rhythm of the client's
baseline)

Complaints of fatigue