HISTORY. Patients are usually without symptoms until late in the disease. Up to 50% of the pulmonary circulation may be impaired before significant hypertension is produced. Determine the presence of risk factors. Ask if the patient has experienced chest pain, labored and painful breathing (dyspnea), or syncope. Occasionally, the enlarged pulmonary artery compresses the left recurrent laryngeal nerve, producing hoarseness. Some patients may describe periods of heart palpitations.

PHYSICAL EXAMINATION. Signs of right ventricular failure are common, such as jugular venous distension, increased central venous pressure, and peripheral edema. Low cardiac output may produce central cyanosis, syncope, or chest pain. Auscultation of the heart may therefore reveal atrial gallop at the lower left sternal border, narrow splitting of S2 or increased S2 intensity, or ejection click at the second intercostal space, left sternal border. When palpating the pre-cordium, you may detect a heave over the right ventricle or an impulse from the pulmonary artery itself. Signs of left ventricular failure, such as systemic hypotension (low blood pressure) and low urinary output, may coexist. Presentation may include hyperventilation, coughing, and eventually rapid breathing (tachypnea) or dyspnea. Initially, breath sounds may be clear or decreased, but you may hear crackles or wheezing.

PSYCHOSOCIAL. The patient is experiencing a potentially life-threatening condition that requires the use of complex medical technology. Assess the anxiety level of the patient, and plan interventions to place a minimum demand on the patient's energy. Support of the patient is

798 Pulmonary Hypertension essential throughout hospitalization, from routine care such as placement and maintenance of the pulmonary artery catheter to attempts at averting a cardiac arrest.

Diagnostic Highlights


Normal Result

Abnormality with Condition


Pulmonary artery pressure and pulmonary vascular resistance (PVR) (measurements made with a pulmonary artery pressure)

Systolic: 15-20 mm Hg; diastolic: 8-15 mm Hg; PVR: 180-285 dynes/sec

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