Current Employee Test #1: Cardiac Disease

Many clients that we serve have chronic cardiac conditions that need your attention. This in-service will address some of those conditions and what interventions you can take to help your client. Your client can also experience an acute cardiac crisis and you will need to act quickly and appropriately in those cases.

Heart Attack (myocardial infarction) –
Signs and symptoms
1. chest pain – crushing or squeezing
2. pain not relieved by nitro glycerin in angina patients
3. pain not relieved by rest
4. pain radiating down the arm most commonly the left arm
5. pain that radiates to the back, shoulder, neck or jaw
6. may have an increased or decreased heart rate, blood pressure and respiratory rate.
7. sweating, clammy skin, pale color
8. shortness of breath
9. anxiety, confusion, restlessness
10. fainting
11. weakness – extreme tiredness
12. heart burn or upset stomach

Silent heart attacks – Women will often have vague complaints such as gas or feeling very tired – The elderly may have low blood pressure, low body temperature, vague discomfort, perspiration and dizziness.

Heart Attack is a true emergency if you feel your client is having the signs and symptoms of a heart attack you must act quickly:
1. call 911 and get help – unless the patient is hospice patient, then call the hospice
2. sit the client up or prop them up with pillows
3. if they have oxygen in the house administer oxygen
4. be prepared to begin CPR as you have been trained if the client ‘s heart stops
5. if they are hot and sweaty sponge with cool water
6. remain calm and try and keep the client calm until help arrives
7. follow instructions given by the EMS operator until help arrives
8. after the ambulance crew attends to the client call the office and report

It is important to know the exact address and phone number of the clients home when calling for help, be sure you are always aware of the exact address when on a case.

Chronic cardiac conditions-

CHF- congestive heart failure Congestive heart failure results from the hearts inability to pump the needed oxygenated blood to the body. CHF often causes congestion in the lungs from hearts inability to keep blood pumping normally. Signs and symptoms-
1. swelling or edema of the feet and ankles
2. loss of appetite and nausea
3. prominent neck veins
4. frequent urination at night
5. cough
6. shortness of breath – being able to breathe only when sitting up
7. inability to sleep
8. restlessness
9. rapid pulse
10. tiredness – weakness

Treatment includes, oxygen therapy, elevating the head, elevating feet whenever possible, low salt (sodium) diet and sometimes restricted fluids. Heart medications and diuretics or water pills are often prescribed.

What you can do-
1. if possible weigh the client frequently and report weight gains of 2-3 pounds which may be excess fluid
2. be aware of restricted fluids if the clients doctor has ordered them
3. the client should be on a low salt diet,
4. do not use added salt while cooking. While shopping look for low salt or salt free foods
5. if the client is short of breath elevate the head with pillows or sit them in a recliner with feet elevated. If there is a hospital bed elevate to head of the bed.
6. supporting the arms on pillows can improve breathing
7. check feet and ankles and report increased swelling – swelling increases the probability of bedsores
8. understand the client urgent need to urinate when taking water pills
9. keep a night light and be sure the path to the bathroom is free of clutter and well lit to prevent falls
10. give good foot care and report open areas
11. monitor ambulation and showers as the client may be very weak
12. request a bedside commode if the client is having trouble getting to the bathroom on time or is too weak to walk
13. provide incontinence care if needed – be aware that the client may be embarrassed by incontinence
14. request a shower chair if the client is getting weaker and unable to tolerate standing in the shower
15. if the client has an oxygen concentrator, clean the filter daily and maintain the humidifier bottle.
16. be sure clients positions is changing every 2 hours to prevent pneumonia
17. report noisy or congested breathing
18. if you are monitoring vital signs record them for the nurse and doctor to review – report significant changes
19. report changes of appetite and sudden nausea and stomach distress or pain or swelling of the abdomen

ACUTE pulmonary edema –
Acute pulmonary edema means that there is an excess of fluid in the lungs. The client is not able to circulate enough oxygenated blood to his body and CHF will worsen and can cause death if not treated.
Signs and symptoms-
1. extreme shortness of breath
2. noisy congested breathing
3. cough
4. can only breath sitting up
5. anxiety and panic
6. rapid pulse
7. neck veins will stand out on neck ( JVD)
8. Cyanosis or blue color
9. profuse sweating
10. inability to sleep

What you should do:
1. Report condition ASAP
2. If extreme distress is present call 911 unless the client is a hospice patient, then call the hospice
3. be sure head is elevated
4. sponge with cool cloths while waiting for assistance

Blood Clotting Disorders-
Many cardiac patients have blood clotting disorders which require blood thinners or anti-coagulants. These clients will need frequent blood tests to determine that their clotting time remains adequate.
Common blood thinners- Heparin, Coumadin, Warfarin, Lovenox. These medications are taken orally or injected. If the client or his family is injecting medications be sure needles are properly disposed of. Under no circumstance should you recap needles or handle needles, the client or family member should dispose of needles in a proper container. If needles are thrown in the trash or otherwise disposed of call the office to report. DO NOT HANLDE TRASH THAT HAS NEEDLES IN IT.
People taking blood thinners should not take herbs, supplements or any over the counter medications especially aspirin or ibuprofen, without the knowledge of their doctor due to possible interactions that may increase or decease bleeding time- Also they should avoid spinach or other dark green leafy vegetables, tomatoes, fish, liver and green tea

Monitor your client for bleeding while on blood thinners. Signs and symptoms of problems that require reporting include:
1. blood in the urine
2. blood in the stool or dark tarry or black stools
3. unusual bruising
4. bad nose bleeds
5. bleeding gums especially while brushing teeth
6. vomiting blood or severe stomach pain
7. coughing up blood

What you can do while your client is on blood thinning medications
1. monitor for bleeding – refer to the signs and symptoms above
2. use caution while turning and transferring- even touching can cause bruising- call the office right away if you notice bruises. This is not caused by something you did wrong it is a sign that the client needs their medication adjusted It is important to recognize signs early for quick intervention.
3. check skin for bleeding and bruising while bathing and providing personal care. When applying lotion do not rub briskly or hard as it will cause bruising, use a gentle slow motion
4. have the client wear slippers or shoes when out of bed to protect their feet
5. Be sure the dentist knows that the client is taking blood thinners if he goes for dental work
6. be sure any doctor, ambulance crew or hospital emergency dept is aware of the blood thinners if treatment is needed
7. limit the consumption of alcohol while on blood thinners
8. avoid dark green leafy vegetables, tomatoes, liver, fish or green tea as part of the diet for the client
9. remind client not to take over the counter remedies, herbs, supplements etc without the knowledge of their doctor and report such use to the office
10. report unusual weakness, dizziness or fainting
11. avoid activities that can cause injury
12. if a dose of blood thinning medications is missed do not “make up the dose” or let the client take extra pills to make up the dose

Phlebitis and DVT deep vein thrombosis –
Phlebitis is an inflammation of a vein. DVT or deep vein thrombosis is where a clot forms secondary to phlebitis or because of occlusions of the vein. His condition is treated with blood thinning medications, see precautions above. Signs and symptoms of venous obstruction-
1. blue or red color
2. skin over area is warm, hot and or hard to touch
3. swelling or edema at the site – hard stretched skin
4. most commonly in the legs – usually from the calf to the foot
5. pulse may be normal
6. elevation of the affected leg can help
7. may have calf pain
8. one calf greater in size than the other
1. venous stasis- from remaining on bed rest for a long time
2. pronged sitting
3. injury to vein – or fracture of the leg, hip fracture
4. after surgery
5. pressure from a tumor, aneurysm or excessive weight
6. sedentary life style
7. persons with cancer
8. obesity
9. smoking

If you suspect Phlebitis or deep vein thrombosis (DVT) report it immediately. The client needs immediate medical intervention to prevent complications or death. Do not try and treat this condition yourself.

What you can do to prevent DVT in your client
1. support legs when they are elevated in bed
2. prevent pressure ulcers
3. turn and position client frequently
4. keep pillows between knees if positioning on the side
5. Range of motion exercise for immobile clients
6. chair exercise may be planned for immobile clients that can participate
7. walking is encouraged for clients who can participate
8. avoid “HYPERFLEXION” head up, knees up, pelvis down
9. encourage fluids
10. encourage deep breathing and or coughing
11. discourage leg crossing if sitting for long periods
12. assist with application of elastic stockings (see below) if they have been ordered by the doctor

TEDS or Elastic stockings may be prescribed for your client- Teds or elastic hose should be put on early in the day before swelling occurs-
1. elastic hose should be turned inside out
2. place hose over the foot starting at the toes turning the hose right side out as you go
3. pull hose over the heels
4. pull hose up over the ankles and be sure heel is in place
5. always pull hose from the sides never on the seams
6. straighten the hose over the foot and cover the toes be sure hose are smooth and not bunched up
7. use quick pulls to get hose up the leg a little at a time
8. be sure the top is not rolling down and do not turn the edges down
9. smooth hose so there are no wrinkles and hose lay flat on skin

Chronic Venous Insufficiency-

Chronic venous insufficiency results from chronic occlusion of the veins.

Signs and Symptoms-
1. lower leg is discolored red and purple in severe cases a blackish color
2. swelling of the legs and ankles – (edema)
3. severe varicose veins
1. stop smoking
2. elevate legs
3. elastic stockings
4. walking exercise
5. do not cross legs
6. lose weight if obese

1. cellulitis – inflammation of the tissue under the outer layer of skin caused by an infection
2. DVT’s
3. Stasis ulcers- open sore that is caused by inadequate oxygenation of the tissues due to swelling and poor circulation

What you can do
1. Assist with elastic stockings if used
2. remind client to keep legs elevated
3. remind client not to cross legs
4. use pillows between legs in bed
5. encourage walking or other exercises prescribed by the doctor or therapist
6. report ulcers or openings in the skin ASAP

High Blood Pressure or Hypertension –

People are diagnosed with high blood pressure when the blood pressure is over 140/90 with multiple readings confirming the readings. Untreated high blood pressure can lead to a stroke or cerebral vascular accident.

1. excessive salt intake
2. family history
3. diabetes
4. kidney disease
5. certain medications
6. heart disease
7. many underlying medical conditions
8. obesity
9. advanced age
10. sleep apnea

Treatment – lifestyle changes-
1. stop smoking
2. weight loss
3. decrease salt intake
4. limit alcohol consumption
5. exercise especially walking as tolerated
6. low saturated fat diet
7. decrease caffeine intake
8. drug therapy –
9. Follow a diet rich in fruit, veggies, low fat dairy, low cholesterol and fat, high in fiber and low salt

What you can do to assist the client with High Blood Pressure
1. Assist the client with blood pressure monitoring if needed. If a nurse has not checked you off on blood pressure monitoring ask for instruction. Many automatic cuffs are available but still must be used properly be sure you have instruction in use.
2. have the client sit at the side of the bed for a few minutes when getting up from a lying position as blood pressure may drop from sitting up quickly and make the client dizzy
3. encourage diet recommendations above
4. assist with the exercise program prescribed for the client
5. discourage smoking or family members smoking near the client
6. report unusual blood pressures to the office

Stroke or Cerebral Vascular Accident-

A stroke is caused by an interruption of the blood supply to the brain and results in neurological dysfunction.

Signs and symptoms-
1. severe headache
2. numbness or weakness on one side of the body
3. loss of motor ability on one side of the body
4. difficulty swallowing
5. inability to speak
6. loss of vision, double vision

If you suspect a stroke – ask the client to
1. raise both arms over his head
2. smile
3. speak a simple sentence

A stroke is an emergency call 911 for an acute stroke

Problems after a stroke-
1. paralysis or weakness on one side
2. inability to speak – aphasia
3. difficulty swallowing – can lead to pneumonia
4. inability to care for self- bathing dressing eating etc
5. depression
6. incontinence
7. inability to understand directions

What you can do for a client recovering from a stroke

1. be aware of dietary restrictions
2. be sure the client is not pocketing food or having difficulty swallowing
3. keep client sitting up, during and 30 minutes after meals, fluids and snacks to prevent aspiration
4. be patient with the client as they may have a hard time processing instructions .
5. participate in therapy sessions and learn the exercise program prescribed for your client.
6. do range of motion exercises on the affected limbs
7. understand that this condition is very stressful and frustrating to the client
8. find ways to communicate with the client , he may be able to write notes if he can not speak. Be aware that clients with right sided weakness usually have difficulty speaking and if the client is right handed he may have problems writing as well
9. encourage the client to participate in his care as much as possible
10. teach him about the dietary changes listed above

    *2 in-service credit hours

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    #1: When a client has high blood pressure, he should

    #2: Heart attack pain

    #3: Silent heart attack symptoms in the elderly commonly cause

    #4: Congestive heart failure or CHF causes

    #5: If your client is taking water pills or diuretics

    #6: The congestive heart failure client should be positioned

    #7: Signs and symptoms of Acute pulmonary edema

    #8: If you suspect your client is having a heart attack, the first call should be to:

    #9: If your client is on hospice and having distress your first call should be to

    #10: If your client is taking blood thinners be alert for

    #11: If your client is on blood thinners you should

    #12: It is important to let ________know if a client is on blood thinning medication

    #13: Signs and symptoms of DVT include

    #14: Causes of DVT include

    #15: DVT is most commonly found in the

    #16: When applying elastic stockings

    #17: To prevent DVT in your client you should

    #18: To prevent chronic venous insufficiency

    #19: High blood pressure is diagnosed when blood pressure is over

    #20: A person with high blood pressure should eat a diet rich in