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10: CARDIOVASCULAR GUIDELINES
H. Emotions such as fear.
I. Exertion.
J. Diabetes mellitus and insulin reaction.
COMMON COMPLAINTS
A. Palpitations are often described as a turning over or op-
ping sensation in the chest, but symptoms vary enormously.
B. Most clients are free of palpitations at the time of the
examination.
OTHER SIGNS AND SYMPTOMS
A. Fluttering in the chest.
B. Shortness of breath (SOB).
C. Pounding in the chest and neck.
D. Diaphoresis.
E. Light-headedness.
F. Anxiety or fear.
SUBJECTIVE DATA
A. Ask the client when symptoms rst presented, including
age, and how they have changed.
B. Have the client describe the characteristics of the palpita-
tions, such as rapid, regular, irregular, or slow.
C. Ask the client what precipitates the palpitations. Does
anything terminate them, or do they go away on their own?
D. Inquire whether symptoms occur or change with position
(standing, bending over, lying down, left lateral decubitus
position) and/or exercise.
E. Ask the client about other symptoms associated with the
palpitations, such as dizziness or syncope.
F. Ask how often the episodes occur and how long each lasts.
G. Discuss any previous treatments for this condition and the
results.
H. Ask the client about risk factors for and prior cardiac history.
I. Question the client’s use of over-the-counter deconges-
tants and diet pills. Are there any new medications or change
in routine medications? Obtain a complete list of medications
the client is currently taking.
PHYSICAL EXAMINATION
A. Check pulse (count the pulse for 1 full minute) and
respirations.
B. Inspect:
1. Overall appearance.
2. Skin for diaphoresis and pallor.
3. Neck for thyromegaly or jugular vein distention.
4. Legs for edema.
C. Palpate:
1. Skin for temperature and dryness.
2. Lower extremities for edema and calf tenderness.
3. Neck for thyroid enlargement.
D. Auscultate:
1. Heart for abnormal rhythms. Auscultate the heart with
the client in the sitting, standing, and left lateral decubitus
positions. Ask the client to walk quickly down the hallway
and back, and then auscultate the heart in all positions again.
2. Lungs.
3. Neck and carotid arteries for bruits.
E. Mental status:
1. Does the client appear light-headed, anxious, or fearful?
DIAGNOSTIC TESTS
A. Diagnostic testing is highly recommended for clients who
have an arrhythmia or who are at risk of an arrhythmia, and
clients who are anxious and want to explore the causes of their
symptoms. The following are the recommended tests:
1. Hemoglobin to rule out anemia if suggestive on
examination.
2. Thyroid-stimulating hormone (TSH) to rule out hyper-
thyroidism if suggestive on examination.
3. EKG during episode if possible.
4. Ambulatory monitoring if symptoms continue, either
24-hour Holter monitoring or client-activated transtelephonic monitoring.
5. Treadmill test if palpitations are provoked by exercise.
DIFFERENTIAL DIAGNOSES
A. Palpitations are secondary to the underlying problem,
such as anxiety, medications, or cardiac or pulmonary origin.
PLAN
A. General interventions:
1. Provide reassurance if the palpitations result from a
neurotic concern.
B. Client teaching:
1. Caution the client to avoid any factors that trigger epi-
sodes. Factors may include stress, exercise, foods, and
medications.
2. Teach the client a vagal maneuver, which is effective in
halting palpitations.
C. Medical and surgical management:
1. Correct any underlying problem (e.g., cardiac or pulmo-
nary). Treat medical conditions accordingly. Management
of arrhythmias should be monitored by a cardiologist.
D. Pharmaceutical therapy:
1. Discontinue all nonessential medications that could
cause palpitations.
FOLLOW-UP
A. Depending on the etiology of palpitations and the exis-
tence of comorbid conditions, the prognosis in clients with no
underlying cardiac disease is generally favorable.
CONSULTATION/REFERRAL
A. Consult a physician if the client has a history of palpita-
tions leading to syncope or near syncope, angina-like chest
pain, or dyspnea. These clients are candidates for referral to
a cardiologist and/or inpatient evaluation. Refer any client
with an arrhythmia to a cardiologist.
B. Hemodynamically compromised clients need prompt hos-
pital admission.
INDIVIDUAL CONSIDERATIONS
A. Geriatrics:
1. Elderly clients are at increased risk of adverse effects
from antiarrhythmic medications.
2. If drug treatment is necessary, lower doses should be
used. Use the rule of thumb: “start low and go slow.”
3. Polypharmacy (variously dened as the use of
more than ve to nine medications) may be involved in
heart-related symptoms.
4. Use caution when prescribing aspirin therapy in older
adults. Refer to the “Atrial Fibrillation” section of this
chapter under Pharmaceutical Therapy for details found
in the Beers criteria.
BIBLIOGRAPHY
Weinstock, C., Wagner, H., Snuckel, M., & Katz, M. (2021, January).
Evidence-based approach to palpitations. Medical Clinics of North
America, 105(1), 93–106. https://doi.org/10.1016/j.mcna.2020.09.004
PMID: 33246525
PERIPHERAL ARTERIAL DISEASE
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309
Wexler, R., & Pleister, A. (2017). Palpitations: Evaluation in the primary
care setting. American Family Physician, 96(12), 784–789. https://www.
aafp.org/afp/2017/1215/p784.html
Zimetbaum, P. (2021). Evaluation of Palpitations in Adults. UpToDate. htt
ps://www.uptodate.com/contents/evaluation-of-palpitations-in-ad
ults/print#!
PERIPHERAL ARTERIAL DISEASE
DEFINITION
A. Peripheral arterial disease (PAD) is a circulatory disorder
characterized by the buildup of plaques on the interior surface
of arteries. These plaques harden and narrow the diameter of
the arteries, which reduces the volume of blood circulating
to the internal organs and extremities. The arteries affected
by PAD include all arteries in the body with the exception of
the cerebral and coronary arteries. The decreased circulation
seen in PAD can also be caused by nonatherosclerotic conditions. Some of these conditions are arteritis, trauma, radiation
damage, and bromuscular dysplasia. Symptoms of PAD can
occur in the upper or lower extremities (Figure 10.5).
B. Classication of PAD:
1. Asymptomatic PAD: no symptoms but the presence
of risk factors or a new diagnosis of a common coexisting
disease (coronary artery disease [CAD] or cerebrovascular
disease) should prompt further evaluation.
2. Intermittent claudication (IC): discomfort including
cramping or pain with physical exertion that remits within
10 minutes of rest.
3. Chronic limb ischemia (CLI):
a. Pain at rest with a nonhealing wound, skin ulcer-
ation, or gangrene.
b. Onset is dened as chronic (i.e., ≥2 weeks).
4. Acute limb ischemia (ALI):
a. Pain at rest in a pale, pulseless extremity that is usu-
ally cold (poikilothermia) and has paresthesias and/or
paralysis.
b. Onset is dened as acute (i.e., <2 weeks).
C. Other conditions contained within PAD:
1. Buerger disease (thromboangiitis obliterans): a dis-
ease manifested by inammation, peripheral edema, and
microthrombi leading to gangrene of the hands and feet;
usually caused by tobacco abuse; clients are thought to
have a genetic predisposition to develop this condition.
2. Raynaud disease/phenomenon: a vasospastic disorder
manifested by a response in the extremities to cold temperatures or stress during which pallor, cyanosis, numbness,
and/or pain are experienced.
3. Leriche syndrome: the triad of claudication, absent or
diminished femoral pulses, and erectile dysfunction.
INCIDENCE
A. Approximately 8 million adults in the United States have
PAD. This correlates to 20% of Americans older than 80 years
of age.
B. PAD is more common in males than in females.
C. People of African and Hispanic descent have a higher rate
of PAD compared with the non-Hispanic white population.
PATHOGENESIS
A. PAD is most commonly precipitated by atherosclerosis.
An atherosclerotic plaque develops in response to turbulent
blood ow on the endothelial cells of the vessel wall. The
plaque contains inammatory cells and a thrombogenic lipid
core that is covered by a brous cap. When the brous cap is
disturbed, the lipid core can precipitate the development of a
thrombus and lead to occlusion of the vessel.
PREDISPOSING FACTORS
A. Smoking.
B. Diabetes.
C. Dyslipidemia.
D. Hypertension (HTN).
E. Obesity.
F. Atherosclerotic disease in another vascular bed (e.g., coro-
nary, carotid, subclavian, renal, mesenteric artery stenosis, or
abdominal aortic aneurysm).
G. Age:
1. Age ≥65 years: increased occurrence.
2. Age 50 to 64 years: with family history of PAD or risk
factors for atherosclerosis (e.g., diabetes, smoking history,
hyperlipidemia, and/or HTN).
3. Age <50 years: with diabetes and one additional risk
factor for atherosclerosis (e.g., coronary, carotid, subclavian, renal, mesenteric artery stenosis, and abdominal aortic aneurysm).
COMMON COMPLAINTS
A. Pain with activity is commonly characterized as cramping
and/or aching:
1. Upper extremity pain in the forearm, hand, and digits.
2. Lower extremity pain in the foot, calf, hip, thigh, and/
or buttocks:
a. Foot pain is most common in tibial or peroneal
artery stenosis.
b. Calf pain is most common with supercial femoral
or popliteal artery stenosis.
c. Thigh pain is most common in aortoiliac and com-
mon femoral artery stenosis.
d. Hip and buttock pain are most common with aor-
toiliac arterial stenosis.
B. Pain at rest.
C. Calf weakness or fatigue.
D. Numbness or tingling.
E. Dizziness with upper extremity exertion.
F. Syncope with upper extremity exertion.
G. Extremity ulceration.
OTHER SIGNS AND SYMPTOMS
A. Decreased peripheral pulses.
B. Blanching of the affected limb with elevation.
C. Ulcerations or infection on distal aspects of extremities.
D. Erectile dysfunction.
POTENTIAL COMPLICATIONS
A. Nonhealing lower extremity ulcerations.
B. Infection.
C. Amputation.
D. Common coexisting diseases:
1. CAD; also known as coronary heart disease (CHD).
2. Cerebrovascular disease.
3. Subclavian artery stenosis.
SUBJECTIVE DATA
A. Ask the client what activity brought about or preceded the
episode or whether it occurs at rest. If ambulation was the precipitating factor, how far was the client able to walk?
B. Have the client describe the duration of pain and what
time of day symptoms began.
C. Ask the client what alleviates their pain.
Normal
Narrowed
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artery
10: CARDIOVASCULAR GUIDELINES
atherosclerotic
artery
Plaque
FIGURE 10.5 Peripheral artery disease.
D. Ask the client whether any previous episodes have
occurred.
E. Ask the client to list all medications, including over-the-
counter (OTC) and herbal products currently being taken or
recently stopped.
F. Ask the client to quantify their smoking history.
G. Ask the client if they have a medical history of myocardial
infarction (MI) or cerebrovascular accident (CVA).
H. Ask if client has any history of impotence or erectile
dysfunction.
PHYSICAL EXAMINATION
A. Clients presenting with ALI should be quickly assessed for
the need to call emergency services/911 for immediate transport to the hospital.
1. Symptoms of ALI as evidenced by the six Ps: pain, pal-
lor, paresthesia, paralysis, pulselessness, and poikilothermia (the inability to maintain a constant core temperature).
B. Check vital signs:
1. Check blood pressure (BP) in both upper extremities.
a. A difference in systolic blood pressure (SBP) of 10
mmHg or greater in the upper extremities is associated
with upper extremity PAD and cerebrovascular disease.
b. A difference in SBP of 15 mmHg or greater in the upper
extremities is associated with lower extremity PAD.
c. A difference in SBP of 15 to 20 mmHg is suggestive
of subclavian artery stenosis.
2. Check BP in both lower extremities.
3. Document resting heart rate, respirations, height, and
weight.
C. Inspect:
1. Perform a funduscopic examination: Check for retinal
vascular changes that indicate a retinal vascular occlusion,
such as macular edema and neovascularization.
a. Macular edema is the swelling of the central part of
the retina.
b. Neovascularization is the growth of abnormal ves-
sels secondary to decreased perfusion of the retina.
2. Inspect the abdomen for a pulsating abdominal mass.
3. Inspect the extremities. Note edema, pallor, and cyano-
sis. Note the color of the extremities in dependent and elevated positions (e.g., elevation pallor and dependent rubor).
4. Inspect the distal skin, hair, and nails. Note any tem-
perature discrepancies or trophic changes that are indicative of ischemia.
5. Assess the lower extremities for any ulcerations or dif-
fuse erythema.
6. Assess for Homans sign (i.e., calf pain with forced
dorsiexion).
7. Assess whether pain occurs when affected limb is
elevated.
D. Auscultate:
1. Heart: Assess the rate, rhythm, heart sounds, murmur,
and gallops.
2. Carotids, abdomen, and bilateral groin for bruits.
3. Lungs: Assess lung sounds, noting any sign of heart
failure (HF).
E. Palpate:
1. Palpate pulses, noting symmetry.
a. Bilateral upper extremities (brachial and radial).
b. Abdominal (aorta).
c. Bilateral groin (femoral).
d. Bilateral lower extremity pulses (popliteal, dorsalis
pedis, and posterior tibialis).
2. Palpate capillary rell.
3. Perform an Allen test: Occlude the radial and ulnar
arteries with the st closed. Open the hand and then release
one of the occluded arteries. Repeat but release the other
artery. Each time, prompt capillary rell should occur.
4. Palpate neck for carotid bruits.
5. Palpate the abdominal aorta, noting any lateral pulsa-
tion, indicative of an aortic aneurysm.
DIAGNOSTIC TESTS
A. Doppler ankle-brachial index (ABI).
1. Interpretation of ABI ratios:
a. 1.00 to 1.40: normal.
b. 0.91 to 0.99: borderline PAD.
c. 0.41 to 0.90: mild to moderate PAD.
d. 0.00 to 0.40: severe PAD.
B. Basic metabolic panel (including blood urea nitrogen, cre-
atinine, sodium, and potassium).
C. Lipid prole.
D. C-reactive protein, homocysteine, and D-dimer.
E. EKG (12-lead).
F. Doppler ultrasound.
G. Abdominal ultrasound.
H. Treadmill testing.
I. CT angiography (CTA).
J. Magnetic resonance angiography (MRA).
K. Angiography, ordered and performed by a surgeon.
DIFFERENTIAL DIAGNOSES
A. PAD.
B. Venous stasis.
C. Venous obstruction/claudication.
D. Spinal stenosis.
E. Nerve root compression.
F. Arthritis of the hip.
G. Peripheral neuropathy.
H. Arteritis.
PLAN
A. General interventions:
1. The goal of therapy is to improve the client’s quality of
life by reducing morbidity and prolonging survival.
2. Encourage preventive measures such as controlling
other chronic medical conditions, such as diabetes, dyslipidemia, HTN, and obesity.
PERIPHERAL ARTERIAL DISEASE
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B. Client teaching: See Client Teaching Guide for this chapter,
“Peripheral Arterial Disease.”
1. Encourage smoking cessation, weight loss, and exer-
cise if applicable.
2. Encourage strategies to better manage other chronic
medical conditions that directly affect the progression of
PAD—that is, diabetes, dyslipidemia, obesity, and HTN.
3. Proper foot care:
a. Instruct the client to wear proper-tting shoes that
protect the feet.
b. Inspect the inside of the shoes before donning them.
c. Encourage the client to inspect the feet daily for
signs of trauma or infection.
d. Instruct the client to dry the feet well, including
between the toes, after bathing.
C. Pharmaceutical therapy:
1. Goal of therapy: prevention of thromboembolism:
a. Pentoxifylline (Trental):
i. 400mg tablet.
ii. Dosage indications based on creatinine clear-
ance (CrCl):
1) CrCl <10mL/min: 400mg, taken once a day.
2) CrCl = 10 to 50mL/min: 400mg, taken BID.
3) CrCl >50mg/min: 400mg, taken TID.
b. Cilostazol (Pletal):
i. 50mg and 100mg tablets:
1) Warning: The metabolites of Pletal are inhib-
itors of phosphodiesterase III and are contraindicated in clients with congestive heart failure
of any severity.
2) Dosage indications:
a) 50mg, taken BID when coadministered
with ketoconazole, itraconazole, erythromycin, and diltiazem.
b) 100mg, taken BID at least half an hour
before or 2 hours after breakfast and dinner.
c. Aspirin (acetylsalicylic acid; Ecotrin):
i. 81mg, 325mg tablets, taken once daily.
d. Rivaroxaban (Xarelto): Low-dose prescription in
combination with aspirin has shown improved outcomes when compared with aspirin monotherapy.
Consultation with cardiology is strongly suggested.
e. Clopidogrel bisulfate (Plavix):
i. 75mg, taken once daily.
2. Risk factor reduction:
a. Manage dyslipidemia:
i. Low-density lipoprotein cholesterol (LDL-C)
goal: less than 100mg/dL.
ii. LDL-C goal in clients at high risk of CAD: less
than 70mg/dL.
b. Manage HTN:
i. BP goal in clients without diabetes: less than
140/90 mmHg.
ii. BP goal in clients with diabetes or chronic kid-
ney disease: less than 130/80 mmHg.
c. Manage diabetes:
i. Hemoglobin A1C goal: less than 7.0%.
D. Dietary management:
1. To manage dyslipidemia and HTN, counsel the client on
nutrition and low-fat, low-cholesterol, low-sodium diet.
2. To manage diabetes, counsel the client on diabetic diet
and carbohydrate counting.
3. To manage infection related to PAD, counsel the client
on high-calorie, high-protein diet. Consider the addition of
vitamins and minerals to promote wound healing, specically, zinc, vitamin A, and vitamin C.
4. Give diet handouts and/or refer to a registered dietitian.
E. Surgical therapies:
1. Surgical therapies are considered in clients with pain
at rest, tissue loss, or signicant physical limitations that
prevent exercise.
a. Bypass.
b. Stenting.
c. Angioplasty/percutaneous transluminal angioplasty.
F. Nonsurgical therapies:
1. Smoking-cessation program.
2. Daily walking program.
a. Instruct client to walk to the point of pain, then stop
and resume walking when pain remits.
b. May need to obtain medical clearance for the client
to exercise.
FOLLOW-UP
A. When PAD manifests with persistent symptoms, the client
should be followed by a cardiologist.
B. Follow-up is determined by the client’s needs, the fre-
quency and intensity of symptoms, and the presence of other
medical conditions.
CONSULTATION/REFERRAL
A. When ALI is suspected, refer the client for immediate hospi-
talization to obtain diagnostic testing to determine the presence
of a thrombus and restore circulation to the affected extremity.
B. If CLI has led to ulceration and/or superimposed infec-
tion, then hospitalization is indicated to initiate a wound care
consultation and diagnostic testing to determine the degree of
arterial occlusion.
C. Refer to a cardiologist in the presence of persistent PAD
symptoms.
D. Refer to a vascular surgeon for further evaluation of angio-
plasty, stenting, or bypass surgery.
E. Refer to a podiatrist to trim toenails and assess the client
for proper-tting shoes.
F. Refer to pain management if pain is resistant to treatment.
G. Refer to a registered dietitian as indicated by the client’s
understanding of the dietary modications necessary to
improve status of risk factors.
INDIVIDUAL CONSIDERATIONS
A. Nonambulatory clients:
1. Using rocking chairs is a possible substitute for per-
sons unable to participate in a walking program.
B. Geriatrics:
1. Be alert to signs and symptoms of depression related to
immobility and pain.
BIBLIOGRAPHY
Barshes, N.R. (2019, June 4). Overview of upper extremity peripheral artery dis-
ease. UpToDate. https://www.uptodate.com/contents/overview-of
-upper-extremity-peripheral-artery-disease
Gerhard-Herman, M. D ., Gornik, H.L., Barrett, C., Barshes, N.R., Corriere,
M. A., Drachman, D. E., Fleisher, L. A., Fowkes, F. G. R., Hamburg,
N. M., Kinlay, S., Lookstein, R., Misra, S., Mureebe, L., Olin, J. W.,
Patel, R. A. G., Regensteiner, J. G., Schanzer, A., Shishehbor, M. H.,
Stewart, K. J.,. . . Walsh, M. E. (2017, March). 2016). AHA/ACC guideline on the management of patients with lower extremity peripheral
artery disease: Executive summary: A report of the American College
of Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines. Journal of the American College of Cardiology, 69(11),
e71–e126. https://www.jacc.org/doi/10.1016/j.jacc.2016.11.007?_ga=
2.184741741.552313306.1636333353-2106124792.1636333353
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10: CARDIOVASCULAR GUIDELINES
Harris, L., & Dryjski, M. (2021, Oct 21). Epidemiology, risk factors, and nat-
ural history of peripheral artery disease. UpToDate. https://www.upto
date.com/contents/epidemiology-risk-factors-and-natural-historyof-peripheral-artery-disease
Kohlman-Trigoboff, D. (2019, January 1). Update: Diagnosis and manage-
ment of peripheral arterial disease. The Journal for Nurse Practitioners,
15(1), 87–95. https://doi.org/10.1016/j.nurpra.2018.09.008
Kotalczyk, A., Vallabhaneri, S.R., & Lip, G.Y.H. (2021, November 1).
Review new concepts in pharmacotherapy for peripheral arterial disease. Current Opinions in Cardiology, 36(6), 720–726. https://doi.org/ 1
0.1097/HCO.0000000000000883
Morcos, R., Louka, B., Tseng, A., Misra, S., McBane, R., Esser, H., &
Shamoun, F. (2018, January 9). The evolving treatment of peripheral
arterial disease through guideline-directed recommendations. Journal
of Clinical Medicine, 7(1), 9. https://doi.org/10.3390/jcm7010009
SUPERFICIAL THROMBOPHLEBITIS
DEFINITION
A. Supercial thrombophlebitis occurs when venous turbu-
lence, statis, or coagulability allow microthrombi to form in
the presence of vessel wall (endothelial) injury, which triggers
an inammatory response in a supercial vein.
B. Most supercial thrombophlebitis occurs in the lower extrem-
ity but may also occur in the breast and penis (Mondor disease).
C. Supercial thrombophlebitis may also occur in the upper
extremities and neck after invasive intravenous (IV) catheters
are used in medical procedures and medication administration.
D. Generally, supercial thrombophlebitis is usually benign
and self-limiting but may persist for a period of time (3–4
weeks or longer) before resolution.
E. Supercial thrombophlebitis with an infection is referred
to as septic thrombophlebitis.
INCIDENCE
A. Pregnancy carries an increased risk of phlebitis. Of throm-
boembolic events in pregnancy, 80% are venous.
B. The prevalence of supercial thrombophlebitis ranges
from 4% to 7% in clients with an indwelling IV catheter.
C. Supercial phlebitis is common after a vein radiofre-
quency or laser ablation.
PATHOGENESIS
A. Supercial thrombosis is caused by infection, abuse of
IV drugs, chemical irritation from overuse of an IV route for
diagnostic tests and drugs, and/or trauma. Several episodes
of supercial thrombosis can signal an underlying problem,
such as carcinoma of the pancreas and hemoglobinopathies.
B. Thrombi in the upper extremities commonly have iatro-
genic causes, such as IV catheters.
C. Supercial thrombophlebitis during pregnancy through
the rst 6 weeks postpartum is linked to a reduced brinolytic
state.
PREDISPOSING FACTORS
A. Previous thrombophlebitis is the highest risk factor for
recurrence.
B. Hypercoagulability states such as pregnancy (50% of
events) through 6 weeks postpartum (50% of events).
C. History of polyarteritis nodosa, thromboangiitis obliterans
(Buerger disease), or Behçet disease.
D. Hemoglobinopathies:
1. Factor V Leiden mutation.
2. Protein C deciency.
3. Protein S deciency.
4. Prothrombin gene mutation.
5. Antithrombin III deciency.
6. Factor XII deciency.
E. Estrogen therapy, especially high-dose hormone replace-
ment therapy (HRT).
F. Malignancy (especially in the tail of the pancreas).
G. Systemic lupus erythematosus with a positive anticardio-
lipin antibody.
H. Sepsis.
I. Recent surgery.
J. Long bone trauma.
K. Recent IV catheter access.
L. Prolonged immobilization.
M. Obesity, specically with a body mass index exceeding
25kg/m2.
N. Varicose veins or venous stasis.
O. Age older than 60 years.
P. Stroke.
Q. Myocardial infarction (MI).
R. Family history of deep vein thrombosis (DVT).
S. Smoking.
T. Hypertension (HTN).
U. Infection.
V. IV drug abuse.
COMMON COMPLAINTS
A. Warm, tender, inamed vessel with palpable cord.
B. Discoloration: redness along the course of the supercial
vein in the acute phase with progression to a brown pigmentation in the chronic phase.
C. Tenderness or pain localized to the affected vein.
OTHER SIGNS AND SYMPTOMS
A. Fever/no fever.
B. Localized edema.
POTENTIAL COMPLICATIONS
A. Supercial thrombophlebitis extending into the deep
venous system.
B. Conversion to suppurative thrombophlebitis:
1. Metastatic abscess formation.
2. Septicemia.
3. Septic emboli.
SUBJECTIVE DATA
A. Query the client regarding the onset, duration, and inten-
sity of symptoms.
B. Ask the client about fever or other related symptoms.
C. Obtain a thorough medical history and account of recent
physical activity.
D. Ask the client about any recent experience of any type of
injury.
E. Inquire whether the client has ever had similar symptoms
or history of thrombophlebitis. If so, discuss previous treatment and therapy used and the results.
F. Review current medications: prescription, over-the-coun-
ter, and herbal products. Ask specically about oral contraceptives and hormone therapy.
G. Review the client’s occupation for sedentary lifestyle.
H. Review any recent plane travel.
I. Review history for recent invasive procedures.
SUPERFICIAL THROMBOPHLEBITIS
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PHYSICAL EXAMINATION
A. Check temperature (if indicated with inammation),
pulse, andrespirations.
B. Inspect:
1. Assess overall appearance. Evaluate for the presence of
respiratory distress.
2. Inspect extremities, noting erythema and edema.
3. Assess for increased warmth over the affected vein.
C. Auscultate:
1. Heart, noting rate, rhythm, heart sounds, murmurs,
and gallops.
2. Lungs for lung sounds in all elds.
D. Palpate:
1. Palpate extremities; check all pulses, including femo-
ral, posttibial, pedal, and radial.
2. Palpate extremities for tenderness and palpable cord.
3. Palpate lymph nodes distal and proximal to the site.
4. Test for Homans sign in lower extremities bilaterally if
DVT is suspected.
DIAGNOSTIC TESTS
A. Duplex ultrasound, which identies the presence, loca-
tion, and extent of venous thrombosis.
B. Doppler ultrasound.
C. Magnetic resonance venography (MRV), which is
noninvasive and sensitive for diagnosis but may not be readily available.
D. Laboratory tests are ordered dependent on the clinical
situation:
1. Complete blood count (CBC) with differential.
2. Screening for hypercoagulability should not be consid-
ered for one episode of supercial thrombophlebitis.
3. Screening for hypercoagulability should be considered
for recurrent supercial thrombophlebitis.
4. Blood cultures.
forms of birth control recommended by the American
College of Obstetricians and Gynecologists (ACOG)
include:
a. Intrauterine devices (IUDs), including IUDs that
contain progestin.
b. Progestin-only oral contraceptives.
c. Progestin-only implants.
d. Barrier methods.
e. Surgical procedures: vasectomy and tubal ligation.
C. Pharmaceutical therapy:
1. Nonsteroidal anti-inammatory drugs (NSAIDs) are
used for treatment of pain. No NSAID has been identied
as superior for treatment.
2. The use of anticoagulation therapy for treatment of
lower extremity supercial thrombophlebitis is controversial. Unfractionated heparin and low-molecular-weight
heparin (LMWH) are both used for treatment to reduce
risk of DVT and/or recurrent phlebitis.
3. The American College of Chest Physicians recom-
mends anticoagulation for clients with lower extremity
supercial thrombophlebitis at increased risk of thromboembolism. This is dened as having an affected venous
segment greater than or equal to 5 cm in proximity (>5
cm) to the deep venous system and positive medical risk
factors. The American College of Chest Physicians’ full
evidence-based clinical practice guidelines on antithrombotic therapy are available at journal.chestnet.org/article/
S0012-3692(15)00335-9/pdf.
4. Antibiotics, if infection is suspected.
D. Surgery:
1. Biopsy.
2. Vein ablation, but only if symptoms are signicant and
persistent.
3. Vein ligation, but only if symptoms are signicant and
persistent.
DIFFERENTIAL DIAGNOSES
A. Thrombophlebitis.
B. Varicose veins.
C. Cellulitis.
D. Strained muscle.
E. Insect bites.
F. Erythema nodosum.
G. Cutaneous polyarteritis nodosa.
H. Kaposi sarcoma.
I. Hyperalgesic pseudothrombophlebitis.
PLAN
A. General interventions:
1. The goal is to offer comfort, time for healing, and pre-
vent an evolution into the deep venous system.
a. Prescribe supportive hose/compression stockings.
b. Prescribe bedrest for supercial thrombophlebitis.
c. DVT requires hospitalization.
B. Client teaching: See Client Teaching Guides for this chapter,
“Supercial Thrombophlebitis” and “Varicose Veins.”
1. Tell the client to avoid prolonged sitting or standing
and not to cross or massage theirlegs.
2. Advise the client to avoid constrictive clothing such as
knee-high hosiery.
3. Have the client apply heat and elevate the extremity
for varicose veins or supercial thrombophlebitis.
4. Advise clients with thrombophlebitis to discontinue
oral contraceptives and hormone replacement. Alternative
FOLLOW-UP
A. Schedule an appointment for clients with supercial
thrombophlebitis to return in 7 to 10 days, or earlier as needed.
Repeat physical examination as needed to evaluate resolution
or progression of the thrombophlebitis.
B. Periodic follow-up is needed to monitor clients on antico-
agulation therapy.
C. After an acute problem is resolved, consider laboratory
evaluation for hypercoagulation syndrome (e.g., protein C,
protein S, and antithrombin III).
D. Monitor bone loss with a dual-energy x-ray absorptiom-
etry (DEXA) scan with prolonged use of heparin.
E. Screening all females for thrombophilias before starting
oral contraceptives is not recommended by the ACOG.
F. Screening all females with a history of thrombosis who
have not had a complete evaluation should be tested for both
antiphospholipid antibodies and inherited thrombophilias.
CONSULTATION/REFERRAL
A. If septic thrombophlebitis or DVT is diagnosed, refer the
client to a physician.
B. Hospitalization is required to initiate heparin therapy.
C. Comanage pregnancy with an obstetrician.
INDIVIDUAL CONSIDERATIONS
A. Pregnancy:
1. Routine anticoagulation therapy for all pregnant cli-
ents is not recommended. Therapeutic anticoagulation
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is recommended for clients with acute thromboembolism during the current pregnancy or those at high risk of
thrombosis, such as females with mechanical heart valves.
2. Warfarin and NSAIDs are contraindicated.
3. Heparin is the preferred anticoagulant in pregnancy.
Neither unfractionated heparin nor LMWH crosses the
placenta.
4. Warfarin, LMWH, and unfractionated heparin do not
accumulate in breast milk and do not induce an anticoagulant effect in the infant; therefore, they are considered
compatible with breastfeeding.
B. Geriatrics:
1. NSAIDs should not be used chronically in older
adults. Short-term use should also be used with caution
or avoided in certain populations due to the risk of cardiovascular disease (CVD) and kidney injury.
2. The overall prognosis is poor for geriatric clients with
septic thrombophlebitis.
3. Static or seated exercise therapy or even the use of
a self-propelled wheelchair (using the feet to walk with
wheelchair forward) or a rocking chair is a possible substitute for persons unable to participate in a walking
program.
4. Be alert to signs and symptoms of depression related to
immobility and pain.
BIBLIOGRAPHY
Czysz, A., & Higbee, S. (2021, January 11). Supercial Thrombophlebitis.
StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK556017/
Di Nisio, M., Wickers, I., & Middeldorp, S. (2018, December 11). Treatment
of lower extremity supercial thrombophlebitis. Journal of the American
Medical Association, 320(22), 2367–2368. https://https://doi.org/10.10
01/jama.2018.16623
Nagarsheth, K.H. (2021, February 25). Supercial Thrombophlebitis. https:/
/emedicine.medscape.com/article/463256-overview/
Scovell, S. (2021, February 18). Supercial vein thrombosis and phlebitis of
the lower extremity veins. UpToDate. https://www.uptodate.com/
contents/superficial-vein-thrombosis-and-phlebitis-of-the-lowerextremity-veins/
SYNCOPE
DEFINITION
A. Syncope is a brief, sudden loss of consciousness and mus-
cle tone secondary to cerebral ischemia, or inadequate oxygen
or glucose delivery to brain tissue. Recovery is spontaneous.
INCIDENCE
A. Syncope is a common problem in all age groups. An esti-
mated 15% of children experience an episode by adulthood.
Between 12% and 48% of healthy young adults have lost consciousness (one-third following trauma), but most do not
seek medical attention. Adults older than 75 years of age in
long-term care facilities have a 6% annual incidence of syncope and 23% have had previous episodes. Syncopal episodes
account for approximately 1% to 6% of hospital admissions
and 3% of ED visits.
PATHOGENESIS
A. The most common cause of syncope is inadequate cerebral
perfusion caused by one of the following:
1. Vasomotor instability associated with a decrease in
systemic vascular resistance and/or venous return. The
following may cause syncope:
a. Vasovagal episodes.
b. Situational syncope, from coughing, micturition,
and defecation.
c. Medications:
i. Vasodilators.
ii. Antiarrhythmics.
iii. Diuretics.
iv. Neurologic agents.
v. Glucose-regulating drugs.
vi. Impotence therapy.
2. Decrease in cardiac output caused by blood-ow
obstruction within the heart or pulmonary circulation or
by arrhythmias. This may be caused by the following:
a. Aortic, pulmonic, and mitral stenosis.
b. Idiopathic hypertrophic subaortic stenosis (IHSS).
c. Pump failure.
d. Subclavian steal syndrome.
e. Seizures.
3. Focal or generalized decrease in cerebral perfusion, lead-
ing to transient ischemia due to cerebrovascular disease.
4. Metabolic abnormalities:
a. Hypoglycemia.
b. Hypocarbia and hypoxia usually do not result in
syncope unless they are profound, although consciousness may be altered.
5. Psychiatric illnesses associated with syncope include:
a. Generalized anxiety.
b. Panic attacks.
c. Major depressive disorders.
6. Unexplained cause.
PREDISPOSING FACTORS
A. Advanced age, caused by altered regulation of cerebral
blood ow and/or systemic arterial pressure due to aging
process and increased medication use.
B. Other factors, depending on etiology.
C. Medication use (noted earlier).
COMMON COMPLAINTS
A. Dizziness.
B. Light-headedness.
C. Fainting with no memory of events.
OTHER SIGNS AND SYMPTOMS
A. Neuroautonomic regulations:
1. Event triggered by changing position, turning head,
and wearing tight collars.
2. Nausea, warmth, diaphoresis, weakness 1 hour after eating.
B. Cardiac causes:
1. Exercise-induced palpitations, chest pain, and short-
ness of breath (SOB), with no warning before episode.
C. Neurologic causes:
1. Vertigo.
2. Diplopia.
3. Facial paresthesias.
4. Ataxia.
5. Auditory, visual, or vestibular disturbances.
D. Metabolic or endocrine causes:
1. Restlessness.
2. Anxiety.
3. Confusion.
4. No recent food intake, low glucose level.
E. Psychiatric:
1. Graceful fainting in presence of an audience.
SUBJECTIVE DATA
A. Inquire if the client ever experienced similar symptoms or
episodes before. If so, when and at what age did it begin?
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B. Ask the client or witness of the episode to give a detailed
description of the loss of consciousness. Was loss of consciousness complete, and if so for how long? What was the posture
of the client before, during, and after the event? Did it occur
abruptly, or were there symptoms leading up to the event?
C. Question the client regarding events leading up to the epi-
sode, noting prodromal symptoms such as headache, aura, nausea/vomiting, light-headedness, diaphoresis, feeling of warmth.
D. Obtain a detailed account of symptoms during and after
the episode, noting mental status. Did the client recover on
their own or did the client require assistance? Were there any
associated symptoms that occurred during the event—SOB,
chest pain, loss of bowel, or bladder control?
E. If syncope has occurred in the past, are there any events
that precipitate an episode? Exertion, exercise, coughing,
standing quickly?
F. Obtain a detailed medication history, addressing prescribed
and over-the-counter drugs, alcohol, and illicit preparations.
G. Review the client’s medical history.
PHYSICAL EXAMINATION
A. Check temperature, if indicated, pulse, respirations, and
blood pressure (BP).
1. Measure BP and pulse in both arms and legs. Note BP
differences between the arms.
2. Measure BP several times during a 2-minute period
with the client standing.
3. Check for orthostatic hypotension, which is dened as
a drop of 20 mmHg or more in systolic blood pressure on
standing:
a. First, measure BP after the client lies supine for 5 to
10 minutes.
b. Then have the client stand and measure BP several
times during a 2-minute period.
B. Inspect:
1. Assess overall appearance of the client, includingskin
color.
2. Note the range of motion in the neck.
C. Auscultate:
1. Heart with position changes. Note murmurs or extra
heart sounds to rule out structural disease.
2. Carotid arteries.
3. Abdomen for bruits.
D. Palpate:
1. Abdomen, noting pulsatile expansion.
E. Perform neurologic examination:
1. Perform a complete examination, if indicated, includ-
ing assessing cranial nerves II to XII, Babinski reflex,
and gait.
F. Mental status:
1. Assess mental health if indicated.
DIAGNOSTIC TESTS
A. The following tests are performed depending on history
and physical examination results. The European Society of
Cardiology (ESC) published new guidelines and the ESC
guidelines of 2018 recommend the following workup:
1. Carotid sinus massage in clients older than 40 years
of age. Avoid if the clients has a history of transient ischemic attack (TIA) or stroke in the past 3 months and in
the client with carotid bruits. Recommend physician or
cardiology specialist assistance when performing carotid
massage. Use caution when performing carotid sinus massage. Consider contraindications, complications, and protocol for performing this procedure.
2. Echocardiogram for clients with a history of heart dis-
ease, structural heart disease, or syncope secondary to cardiovascular cause (known heart disease, family history
of unexplained sudden death, syncope with exertion or
supine, abnormal EKG, sudden onset of palpitation before
syncope, or arrhythmia on EKG).
3. EKG for clients with suspected arrhythmia or cardiac
disease. Identify acute and old EKG changes to rule out
pathologic Q waves, ST-segment elevation, and left ventricular hypertrophy.
4. Orthostatic challenge test if syncope is related to posi-
tion change or a suspected reex mechanism.
5. Neurologic/serum laboratory testing for other con-
cerns of nonsyncopal loss of consciousness. Laboratory
testing includes chemistry prole, thyroid-stimulating
hormone, and free T4. Consider a glucose tolerance test if
diabetes is suspected. It may be useful to evaluate cardiac
versus noncardiac causes of syncope.
6. Chest radiography, for essential baseline data. Wide
mediastinum signals aortic dissection.
7. In-hospital monitoring recommended for unstable,
life-threatened clients.
8. Holter monitoring for 24 to 48 hours.
9. External event monitoring.
10. Exercise testing is recommended for clients with syn-
cope that occurs during, or quickly after, cessation of exercise. Echocardiogram is recommended before this testing.
11. Cardiac catheterization.
12. Lung scan.
13. Treadmill test.
14. Electrophysiologic studies are recommended for cli-
ents with unexplained syncope.
DIFFERENTIAL DIAGNOSES
A. Irregular neuroautonomic regulations:
1. Neurocardiogenic causes.
2. Situational causes, such as coughing, defecation, div-
ing, micturition, sneezing, swallowing, trumpet playing,
vagal stimulation, weightlifting, postprandial state.
3. Orthostatic causes:
a. Hyperadrenergic state.
b. Hypoadrenergic state, primary or secondary auto-
nomic insufciency.
c. Carotid sinus syncope.
d. Cardioinhibitory state.
e. Vasodepressor stimulation.
f. Mixed.
B. Cardiac causes:
1. Mechanical causes such as aortic dissection, aortic ste-
nosis, atrial myxoma, cardiac tamponade, global myocardial ischemia, hypertrophic cardiomyopathy, mitral
stenosis, myocardial infarction, prosthetic valve dysfunction, pulmonary embolism, pulmonary hypertension, pulmonary stenosis, and Takayasu arteritis.
2. Electrical causes, such as atrioventricular block, long QT
syndrome, pacemaker, sick sinus syndrome, supraventricular tachyarrhythmias, and ventricular tachyarrhythmias.
C. Neurologic causes:
1. Neuralgias: glossopharyngeal, trigeminal.
2. Normal-pressure hydrocephalus.
3. Subclavian steal.
4. Vertebrobasilar artery disease: compression, migraine,
and TIA.
D. Metabolic or endocrine causes: hypoadrenalism, hypogly-
cemia, hyponatremia, hypothyroidism, and hypoxia.
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E. Psychiatric causes: anxiety, hysteria, major depression,
panic disorder, somatization, and hyperventilation syndrome.
PLAN
A. General interventions:
1. Management is directed at the primary cause of the
episode.
B. Client teaching:
1. If the client has orthostatic hypotension, suggest that
they wear elastic stockings, change positions slowly, sleep
with the head of the bed elevated, and exercise theirlegs
before standing.
2. If syncope is induced by situations, warn the client to
avoid or alter their approach to such precipitating events.
3. If the client has prodromal symptoms, such as nausea,
light-headedness, pallor, sweating, or palpitations, advise
them to lie down when they occur.
4. If the client has hypersensitive carotid sinus reex, rec-
ommend that they loosen their collar.
5. Tell the client to avoid prolonged standing. If they can-
not avoid it, they should contract their calf muscles to
increase venous blood ow.
6. Some driving restrictions exist for clients at risk of
recurrent syncope. Driving restrictions are enforced by
state law. Review these restrictions with the client and
their family as indicated by diagnosis.
C. Dietary management:
1. If not contraindicated, instruct clients with orthostatic
hypotension to use salt liberally.
D. Pharmaceutic therapy for neurocardiogenic syncope:
1. Nonpharmacologic methods suggested: Avoid volume
depletion. Maintain adequate sodium levels by increasing
salt intake in the diet. Wear thigh-high elastic support hose
with 30- to 40-mmHg pressure. Orthostatic training is also
recommended two times a day.
2. The drug of choice is beta-blockers (propranolol
80–160mg/d, metoprolol 50–100mg/d).
3. Fludrocortisone acetate (Florinef Acetate), a corticoste-
roid, may be used alone or with beta-blockers. Initial dosage is 0.1 to 0.4 mg/d; this may be increased gradually to
1.0 to 2.0 mg/d.
4. Other drugs include anticholinergic agents (disopyra-
mide 100 to 200mg BID sustained-release) and selective
serotonin reuptake inhibitors (sertraline 50mg/d, uoxetine 20mg/d, paroxetine 20mg/d).
FOLLOW-UP
A. Scheduling of return visits depends on the etiology and
severity of syncope and whether the client has been placed on
medications.
CONSULTATION/REFERRAL
A. Consult with or refer the client to a physician when cardiac
or neurologic involvement is suspected.
B. Consult with or refer the client to a physician if medication
therapy is required.
INDIVIDUAL CONSIDERATIONS
A. Adults:
1. In young adult athletes, be aware of symptoms of
Marfan syndrome.
2. In older adults, coronary atherosclerosis may present
along with syncope.
B. Geriatrics:
1. Elderly clients may have multiple comorbid condi-
tions, such as decreased cerebral blood ow and acute
viral illness.
BIBLIOGRAPHY
Benditt, D. (2018, September 28). Syncope in adults: Clinical manifesta-
tions and diagnostic evaluation. UpToDate. https://www.uptodat
e.com/contents/syncope-in-adults-clinical-manifestations-anddiagnostic-evaluation
Shen, W., Sheldon, R., & Benditt, D. (2017). 2017 ACC/AHA/HRS guide-
line for the evaluation and management of patients with syncope:
A report of the American College of Cardiology/American Heart
Association Task Force on Clinical Practice Guidelines and the Heart
Rhythm Society. Circulation, 136(5), e60–e122. https://doi.org/10.116
1/CIR.0000000000000537. https://www.ahajournals.org/doi/10.1161
/CIR.0000000000000499
Thiruganasambandamoorthy, V., Sivilotti, M. L. A., Le Sage, N., Yan, J.
W., Huang, P., Hegdekar, M., Mercier, E., Mukarram, M., Nemnom,
M. J., McRae, A. D., Rowe, B. H., Stiell, I. G., Wells, G. A., Krahn, A.
D., & Taljaard, M. (2020, May 1). Multicenter emergency department
validation of the canadian syncope risk score. JAMA Internal Medicine,
180(5), 737–744. https://doi.org/ 10.1001/jamainternmed.2020.0288
PMID: 32202605; PMCID: PMC7091474
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CLIENT TEACHING GUIDE
ATRIAL FIBRILLATION
PROBLEM Atrial brillation is the condition that causes the upper chambers of the heart (the atria) to beat faster and irregularly
(also called brillation). The upper chambers of the heart do not beat at the same time as the lower chambers (the ventricles). When
atrial brillation occurs, blood clots can form in the heart and then travel to the brain, causing a stroke.
CAUSE Atrial brillation is caused by a malfunction of the heart’s pacemaker. Many things can cause the heart’s pacemaker to
malfunction, including excessive alcohol intake, emotional stress, physical stress, recent heart surgery, medication side effects,
and a long list of medical conditions. These medical conditions include coronary artery disease, leaky heart valves, high blood
pressure, heart failure, heart attack, thyroid disease, infections, inammation around the heart, sleep apnea, obesity, and lung diseases such as chronic obstructive pulmonary disease, bronchitis, asthma, and emphysema.
PREVENTION/CARE
A. Stop smoking. Discuss smoking cessation with your healthcare provider.
B. Reduce or eliminate intake of alcohol and caffeine.
C. Lose weight. Discuss losing weight with your healthcare provider.
D. Make a list of your current medical conditions and current medications. Keep an updated copy in your wallet.
E. When traveling:
1. Always travel with enough of your medication to last through your vacation plus an additional 3 days.
TREATMENT PLAN
A. Effectively manage all other medical conditions, paying special attention to cholesterol, blood pressure, thyroid disease, sleep
apnea, and any lung diseases.
B. Follow up with your primary healthcare provider and/or cardiologist on a regularly scheduled basis.
Activity:
A. Get regular exercise, after discussing the type and frequency of exercise that is safe for you with your healthcare provider.
Diet:
A. Eat a balanced, low-fat, and low-salt diet in addition to dietary guidelines suggested by your healthcare provider.
B. If you are taking the blood thinner Coumadin, you will be given a list of foods that are high in vitamin K. These foods can inter-
fere with how the blood thinner works. Please discuss these foods further with your healthcare provider.
Medications:
You Have Been Prescribed:
You Need to Take:
You Need to Notify the Office If You Have Any of the Following:
A. Chest pain, shortness of breath at rest or activity, heart palpitations or uttering in your chest.
B. Weakness or extreme tiredness.
C. Dizziness, disorientation, confusion.
D. Passing out or losing consciousness.
E. Severe headache.
F. Frequent urination or a compelling urge to urinate.
G. Anxiety or panic symptoms.
H. Vomiting or other illness causes you to miss more than one dose of your medications.
I. Other:
Phone:
RESOURCES
American Heart Association: https://www.heart.org/en/health-topics/atrial-brillation
National Heart, Lung, and Blood Institute: https://www.nhlbi.nih.gov/health-topics/atrial-brillation
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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