Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.
The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief. The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It often is precipitated by exertion or stress, is accompanied by few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI also may radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and frequently is accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety).
The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often, thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication.
Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, and leg is very swollen.
The client with DVT may require bedrest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bedrest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT, because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism.
Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.