exam 1 Flashcards
1
Q
People-first language
A
Conveys the person is of greater importance than the disability
-example: woman with a disability NOT disabled woman
2
Q
disability definition and examples
A
limitation in performance or function in everyday activities.
- talking, hearing, seeing, walking, climbing stairs, lifting or carrying objects, performing ADLs (feeding oneself, bathing, dressing, grooming, toileting, doing work)
3
Q
Americans with Disabilities Act definition of a person with a disability
A
-has physical or mental impairment that substantially limits one or more major life activities
-has a record of such an impairment
-regarded as having such an impairment
4
Q
Categories of disabilities
A
-physical
-cognitive
-developmental
-intellectual
-sensory
-psychiatric
-acquired
5
Q
Rehabilitation Act of 1973
A
Forbids organizations from excluding or denying people with disabilities equal access to program benefits and services. Prohibits discrimination related to availability, accessibility, and services.
6
Q
Americans with Disabilities Act 1990
A
Mandates that people with disabilities have access to job opportunities and to the community without discrimination.
7
Q
Reasonable accommodations for people with disabilities
A
-mandated by law in healthcare, the workplace, or with housing
-financial responsibility of the healthcare provider or facility
-people with disabilities should not be expected to provide their own accommodations, with the exception of undue financial burden
-right to modify housing at own expense
-family members should not be expected to serve as interpreters
8
Q
Medicare
A
-federal assistance programs
-health insurance program for people aged 65+ and under 65 with disabilities (hospital care, medical services, prescription drugs)
9
Q
Medicaid
A
-federal assistance programs
-A joint federal and state program that provides health coverage to low-income individuals, including those with disabilities (services not provided by Medicare, such as long term care)
10
Q
Social Security Disability Insurance=SSDI
A
A program that provides monthly benefits to people who have worked and paid social security taxes but are now unable to work due to a disability. eligibility= significant work history and a severe disability that is expected to last at least one year or result in death.
11
Q
Supplemental Security Income=SSI
A
A need-based income program that provides cash assistance to individuals with disabilities with limited income and resources, regardless of their work history. also available to children with disabilities.
12
Q
To understand the impact disabilities have on daily activities and healthcare needs, provide patient centered care and enhance quality of life by promoting independence and safety while maintaining respect and dignity through-
A
-communicating effectively
-safe mobility and transfers
-adapt to perform ADLs
-create a supportive environment
-collaborate with patient, family, interprofessional team
-remove accessibility barriers
-advocate for patient needs
-provide needed education
-familiarize with assistive communication devices
13
Q
Mobility and transfers
A
-assess patient mobility and choose appropriate assistive devices
-practice proper body mechanics during transfers
-involve patients in their mobility to promote independence
14
Q
Personal hygiene and dressing assistance
A
-adapt hygiene practices to patient abilities
-utilize adaptive equipment for grooming and dressing
-always respect patient privacy and dignity
15
Q
Emotional support and advocacy
A
-offer reassurance and address patient concerns
-advocate for patient rights within the healthcare system
-involve support groups for additional emotional support
16
Q
Education and empowerment
A
-educate patients and families about conditions and resources
-encourage informed decision-making
-provide information in accessible formats
17
Q
Risk for secondary health conditions
A
-pressure injuries
-urinary tract infections
-injury related to falls
-depression
-social isolation
18
Q
healthcare access for patients with disabilities
A
-evaluate the patient’s ability to obtain required health care and recommended health screening
-ensure that appropriate modifications have been made so that people with disabilities can receive health care equal to that of people without disabilities
-examine facilities and procedures to ensure that the needs of people with various disabilities can be adequately addressed
-consider the effects of aging on a pre-existing disability and in turn the effects of disability on aging
19
Q
Chronic disease and disability
A
Some degree of disability is often present in severe or advanced chronic illness (>3 months), such as:
-stroke
-diabetes
-obesity
20
Q
Disabilities may be due to:
A
-genetics
-injury
-medical procedures
-accidents
-chronic conditions
21
Q
Perfusion circulation
A
Blood pumped from the heart through a network of arteries, which branch into smaller arterioles and then into even smaller capillaries. the capillaries are where the actual exchange of oxygen, nutrients, and waste occurs.
22
Q
Perfusion exchange
A
In the capillaries, oxygen and nutrients diffuse from the blood into the tissues, while waste products like carbon dioxide move from the tissues into the blood.
23
Q
Perfusion return
A
After passing through the capillaries, the now-deoxygenated blood is collected by venules and veins, which return it to the heart. from there, it is pumped to the lungs for oxygenation before being sent out to the rest of the body again.
24
Q
Importance of oxygen and nutrients in the body/perfusion
A
Adequate perfusion is crucial for delivering oxygen and nutrients to tissues and organs. without it, cells can suffer from hypoxia and nutrient deficiencies, which can lead to cell damage or death.
25
Assessment of perfusion
BP, HR, O2 sat, cap refill, skin assessment (color, temp, moisture), pulses, LOC, urine output
26
Cardiac biomarkers/labs
-troponin: sensitive and #1 test- protein released in blood with heart injury
-CK: muscle breakdown
27
Which coronary artery supplies blood to both ventricles?
Left anterior descending= LAD (interventricular artery)
28
Coronary artery disease= CAD
Ischemic heart disease; coronary arteries become narrowed or blocked due to atherosclerosis.
29
Symptoms of CAD
-may vary
-might not experience symptoms until advanced disease
-angina= chest pain or discomfort
-shortness of breath
-heart attack= a sudden, severe event where the blood flow to part of the heart muscle is blocked for a prolonged period, potentially leading to heart muscle damage.
-typical chest pain in men include heavy crushing, "elephant on chest", center or left side of the chest, radiating to left arm or jawline
-atypical chest pain in women includes sharp, burning, indigestion, discomfort to back, shoulders, abdomen, jaw pain
-N/V
-Pale skin
-Fatigue
-Dizzy, lightheaded
-Palpitations
30
Risk factors of CAD
High cholesterol, HTN, tobacco use, diabetes, obesity, physical inactivity, unhealthy diet (high in saturated and trans fats, cholesterol), stress, family history (genetics), increasing age, male gender, race, premature menopause, social determinants of health (lower socioeconomic status), air pollution.
31
Assessment of CAD
VS, pain, EKG and continuous cardiac monitoring/telemetry, perfusion, skin, GI, respiratory, patient hx (risk factors, angina pattern), recreational drug use (cocaine use/induced vasospasm leads to MI), lab values:
-cardiac biomarkers=troponin, CK, CK-MB
-Creatinine, BUN
-Glycosylated hgb (HgbA1c)
-lipid profiles=cholesterol, triglycerides, LDL, HDL
32
Health promotion for CAD
Goal=reduce risk for developing CAD
-reduce cholesterol level- diet, weight reduction, exercise, medications (statins)
-smoking cessation
-manage HTN
-good glycemic control for diabetics
-manage stress
-attend follow up appointments
33
Medications for CAD
-cholesterol-lowering drugs= statins
-antiplatelets- ASA, clopidogrel
-anticoagulants= warfarin, rivaroxaban, apixaban
-antihypertensives- BB, CCB, ACE, ARB
-nitrates to manage angina= nitroglycerin, isosorbide
34
Angioplasty and stenting
catheter with a balloon is used to open up narrowed arteries, and a stent is placed to keep the artery open= percutaneous coronary intervention
-indicated with high risk stable angina and unstable angina
35
coronary artery bypass grafting=CABG
surgery where a healthy artery or vein from another part of the body is used to bypass the blocked coronary artery
-indicated with high risk stable angina and unstable angina
-no heavy lifting 4-8 weeks afterward
-epicardial/pacing wires are temporary and can be atrial or ventricular. dressing changes every 24 hours. can be implanted or outside wires.
-chest tube: NEVER more than 100 mL/hr
36
Primary angioplasty MI= PAMI
procedure when vessel is occluded and need to open it up
37
cardiac catheterization
a thin flexible catheter is inserted into a blood vessel (femoral or radial artery=radial preferred) and guided to the heart using fluoroscopy to diagnose and treat heart conditions if necessary.
-purpose:
-diagnosis: angiography used to assess the function of the heart, measure pressures within the heart chambers, and evaluate the heart's blood supply
-treatment: PCI- interventions such as balloon angioplasty, stent placement, or biopsy of the heart tissue
-risks: infection at insertion site, bleeding or hematoma, allergic reaction to contrast dye, rarely heart attack or stroke
-VS q 15min for 1st hour after cath-lab
ASSESS FOR BLEEDING
38
cardiac/coronary angiography
-type of imaging done to visualize the inside of the coronary arteries and assess the presence and severity of blockages.
-purpose:
-diagnosis: to identify the location and extent of blockages or narrowing in the coronary arteries.
-guidance: to guide treatment decisions, such as the need for angioplasty, stenting, or bypass surgery.
-procedure: injection of contrast dye into the coronary arteries through a cardiac catheter, x-ray images taken as the dye flows through the coronary arteries, providing a detailed view of the blood vessels and any blockages or abnormalities.
-risks: allergic reaction to dye, kidney damage due to contrast dye, discomfort or bruising at the catheter insertion site, rarely heart attack or stroke.
39
PCI= percutaneous coronary intervention/balloon angioplasty with a stent
treatment for narrowed or blocked coronary arteries discovered during cardiac catheterization. restores blood flow and perfusion to cardiac muscle.
-procedure: cardiac insertion, balloon inflation at area of blockage, stent placement in area where blockage was to prevent restenosis
-no metformin 48 hours before, need distal pulses afterward, no bending leg 4-6 hours post if femoral
-patient medication education: low dose ASA indefinitely, clopidogrel/plavix for 6-12 months
40
Angina
episodes of chest pain caused by decreased perfusion of the heart muscle- increased oxygen demand, decreased oxygen supply to heart muscle.
-three types: stable, unstable, variant (prinzmetal's)
-stable and unstable: symptoms of CAD, precursor to MI
-variant: caused by vasospasm NOT atherosclerosis
41
Angina pectoris- stable angina
episodic chest pain because of inadequate oxygen supply to the heart, most often due to obstruction in the coronary arteries
-most common type of angina
-pain often presents as pressure, fullness, squeezing pain in the center of the chest
-angina= ischemia in the subendocardium- triggers release of adenosine and bradykinin-pain
42
Angina pectoris- unstable angina
episodic chest pain that either:
-is new in onset
-occurs at rest unpredictability
-rapidly worsens over time
-occurs within 48 hours after acute MI
usually caused by ruptured atherosclerotic plaque-formation of thrombosis on top of plaque- almost complete blockage in blood vessel-ischemia-pain
-medical emergency!!! high risk of progression to MI
(angina has myocytes still alive, myocardial infarction has death of myocytes)
43
Assessment of angina
-stable: predictable pattern, occurs with activity, subsides with rest and/or administration of nitro
-unstable: attacks that increase in frequency and severity, occur at rest with no pattern (prolonged episodes, not relieved by rest, require medical intervention like PCI or CABG, treat as emergency)
44
Symptoms of angina
chest pain, apprehension, anxiety, feeling of impending death/doom, SOB, pallor, diaphoresis, hypotension, dizziness or lightheadedness, N/V
-diabetics commonly have no symptoms!
45
Angina solutions
decrease oxygen demand of myocardium and increase oxygen supply
-stable: pharmacologic therapy, control of risk factors
-unstable: PCI, CABG
ABCDE: Aspirin and antianginal therapy, Beta blockers and blood pressure, Cigarette smoking and cholesterol, Diet and diabetes, education and exercise
46
Taking action for angina
-stop activity
-place in semi-fowler's position
-EKG WITHIN 10 MINUTES OF ARRIVAL TO ED
-VS
-NTG SL q5 minutes up to 3 doses- assess BP, HR, ST segment before each dose
-2 large bore IVs
-draw cardiac biomarkers: troponin, CK, CK-MB
-administer o2
-telemetry
-prep for cardiac cath WITHIN 90 MINUTES OF ARRIVAL TO ED
-reduce anxiety
47
Acute coronary syndrome= ACS
umbrella term for group of conditions:
1. unstable angina
2. non-ST elevation MI=NSTEMI
3. ST elevation MI= STEMI
-MEDICAL EMERGENCY- URGENT DIAGNOSIS AND CARE
-Treatment goals: improve/restore coronary blood flow, treat complications, prevent MI and complications
48
Assessment of unstable angina
manifestations of coronary ischemia, but ECG and cardiac biomarkers show no evidence of acute MI
-ST depression, T wave inversion- transient and reversed with relief/tx of angina
-normal cardiac biomarkers (troponin)
-no necrois, minimal occlusion
49
Assessment of NSTEMI
elevated cardiac biomarkers (troponin), no definite ECG evidence of acute MI, may be less damage to the myocardium
-ST depression, T wave inversion
-Elevated cardiac biomarkers (troponin)
-necrosis, severe occlusion
-MI
50
Assessment of STEMI
elevated cardiac biomarkers, ECG evidence of acute MI with characteristic changes in two contiguous leads on a 12-lead ECG, significant myocardial damage.
-ST elevation
-Elevated cardiac biomarkers (troponin)
-transmural necrosis, complete occlusion
-fireman's hat!
-MI
51
To determine if angina or MI
-cardiac catheterization: evidence of occlusion
-stress test (exercise of pharmacologic): performed if no EKG changes present or rise in troponin
52
Myocardial Infarction= MI
plaque rupture- thrombosis formation-complete occlusion of artery- ischemia-necrosis of the myocardium
-infarction develops over minutes to hours- permanent damage to myocardial tissue
-ischemic cardiac muscle- cardiac enzymes released into the bloodstream
TIME IS MUSCLE!! early recognition and treatment improves chances of survival
-must have elevated cardiac biomarkers and one of: 1-S/Sx of ischemia, 2- EKG changes, 3-damage to heart wall on echo
-extent of damage is associated with MI location- LAD worst
53
Assessment of MI
-patient description of presenting symptoms
-previous cardiac hx
-family cardiac hx
-review of risk factors
-serial cardiac biomarkers with ECGs q6 hours x 3
-presence of restlessness
-skin color, temp, peripheral pulses
-presence of diaphoresis
-monitor urine output
54
Symptoms of MI
-chest pain
-apprehension, anxiety, feeling of impending death/doom
-SOB
-pallor
-diaphoresis
-cool skin
-increased HR and RR
-indigestion
-EKG changes? ST elevation, depression? inverted T waves?
-elevated troponin?
-nausea
55
Complications of MI
-heart failure
-arrhythmias: symptomatic bradycardia, heart block, ventricular arrhythmias (V-fib), asystole
-death
56
Genetic predisposition of MIs
males more prone than females
57
Location of heart valves
-atrioventricular: mitral and tricuspid
-semilunar: aortic and pulmonic
58
Stenosis
Narrowing of valvular orifice
59
Regurgitation or insufficiency
Back flow of blood
60
Prolapse
Valvular leaflets fail to close adequately
61
Causes of valvular heart disease
-Rheumatic fever=untreated strep throat
-infective endocarditis
-MI
-heart failure
-cardiomyopathy
-advanced high blood pressure
-congenital problem
-degeneration and calcification of the valve tissue-age related
-Marfan syndrome
-autoimmune disorders- lupus, rheumatoid arthritis, ankylosing spondylitis
-pregnancy
62
Symptoms of valve disorders
-all tend to be asymptomatic until hypertrophy and/or HF is present
-MURMUR is first indicator of valve disorder
-SOB, angina, syncope, dysrhythmia, palpitation, dizziness, fatigue, weight gain, poor color, cool extremities, weak peripheral pulses
-complications: HF, cardiogenic shock, thromboembolism, stroke, bleeding from anticoagulation, endocarditis, dysrhythmias
63
diagnostics for valvular and cardiac disorders
-echocardiogram/echo: moving image of the heart's valves and chambers using sound waves from a handheld wand placed on chest (shows chamber size, valve dysfunction, EF, amount of regurgitation)
-transesophageal echocardiogram/TEE: ultrasound of your heart performed by inserting a probe with an ultrasound transducer down esophagus, providing a clearer image than a regular echo because esophagus sits very close to the heart. NPO 6-8 hours before.
-exercise stress echo: walk on treadmill or ride bike then an echo is performed to see how the valves and heart function respond to exercise
-chest x-ray: shows cardiac enlargement and pulmonary congestion
-ECG: electrical activity
-Angiography/cardiac cath: injection of contrast due into a catheter (radial or femoral) to evaluate coronary arteries, heart chambers, and heart valves
64
Mitral valve prolapse
leaflets of mitral valve balloon back into the left atrium when the left ventricle contracts, but the valve may still function normally or have only minimal leakage (regurgitation)
-asymptomatic or symptomatic
-overtime causes mitral valve regurgitation which can lead to heart failure
-if palpitations are occurring: stop caffeine, ETOH, smoking, and start anti-arrhythmic medications if needed
-characteristic click sound- mid systolic click!!!
65
Mitral valve regurgitation
Mitral valve doesn't close properly, causing blood to leak backward into the left atrium during systole, increasing workload of the heart.
-backward flow of blood into the LA increases blood volume and raises pressure in the LA and pulmonary vessels- this leads to pulmonary edema and left-sided HF (crackles)
-typically progressive if untreated- heart failure, atrial fibrillation, pulmonary hypertension
-treatment: treating HF (diuretics), valve repair, valve replacement
66
Mitral valve stenosis
mitral valve is narrowed or obstructed, making it harder for blood to flow from the LA into the LV. causes increased pressure in the LA, lungs, and RV. decreased blood flow into LV-reduced LV filling causing decreased CO. can cause atrial fibrillation, pulmonary hypertension, HF-left sided and progress to right sided, stroke, infective endocarditis.
-treatment: medications (BB,CCB, diuretics, anticoagulants, antiarrhythmics), balloon valvuloplasty, mitral vale repair or replacement.
67
Aortic valve stenosis
valve is narrowed and restricts blood flow from the LV into the aorta and out to the body. LV hypertrophy develops to generate adequate force to open the valve and maintain CO. over time, the LV fails, resulting in left-sided HF, arrhythmias, sudden cardiac death.
-treatment: medications, AVR, balloon valvuloplasty
67
Aortic valve regurgitation
valve does not close properly and blood leaks backward from the aorta into the LV during diastole.
-chronic: develops slowly, asymptomatic for a long time
-acute: develops quickly-MEDICAL EMERGENCY!
-results in LV hypertrophy, left sided HF, AF, pulmonary hypertension, sudden cardiac death
-treatment: medications (vasodilators, diuretics, BB, anticoagulants), surgery (aortic valve replacement (AVR)
68
Surgical intervention- valvuloplasty
procedure to treat heart valve stenosis. involves using a balloon catheter to widen a narrowed heart valve and improve blood flow. used for patients who have significant valve stenosis but may not be suitable for or do not need immediate surgical valve replacement.
-balloon valvuloplasty: a catheter with a balloon at its tip is inserted into a blood vessel and guided to the heart. once in position across the narrowed valve, the balloon is inflated which expands the valve and helps improve blood flow. after inflation, the balloon is deflated and removed, leaving the valve widened. used for aortic valve stenosis and mitral valve stenosis.
69
Surgical intervention- valve replacement
replaces damaged valve with a mechanical valve, bioprosthetic valve (pig, cow, human), or percutaneous valve. open heart surgery (sternotomy), minimally invasive valve surgery (MIVS) using davinci robot, transcatheter aortic valve replacement (TAVR- newer procedure with less pain and shorter post-op)
-mechanical valve: lifelong anticoagulation required, lasts a long time around 20-30 years, audible clicking sound ideal for young patients
-tissue valve: replaced every 7-10 years (may need), silent, for older patients or those with contraindications for anticoagulation
70
Assessment of valvular disorders
-VS
-pain (chest pain?)
-monitor for dysrhythmias, palpitations
-heart sounds-murmur
-lung sounds- crackles, orthopnea= pulmonary congestion
-peripheral vascular-S/Sx of poor perfusion
-activity tolerance- S/Sx of worsening HF
-daily weights, Is and Os
-INR monitoring if taking warfarin post-op valve replacement
-actions: HOB elevated, apply O2, medications as ordered (inotropes like Dig), restrict Na and fluids
-educate: regular follow ups, protecting valve from further damage and reducing risk of infective endocarditis-communicate with providers of hx and need for prophylactic antibiotics, good oral care, s/sx of infection, medications, s/sx of decreased CO, daily weights and reporting weight gain, conserve energy, restrict caffeine, ETOH, fluids, and Na
71
Cardiomyopathy
Heart muscle becomes weak due to structural changes-inadequate pumping with low CO and arrhythmias
-types:
-dilated=enlarged
-hypertrophic=thick
-restrictive=rigid
72
Causes of cardiomyopathy
-HTN
-heart failure
-diabetes
-ESKD
-HIV
-high cholesterol
-family hx
-pregnancy
-obesity
-lifestyle (diet, sedentary)
-smoking, alcohol, cocaine
73
Symptoms of cardiomyopathy
-angina: CP, dizziness, indigestion, N/V, sweating, palpitations, SOB, increasing fatigue
-HF: rapid or irregular heart rate, SOB with or without activity, SOB while lying flat, edema
-pulmonary congestion
-murmur
-JVD
-hepatomegaly
-sleeplessness
-cough
-fainting
-depression
-loss of appetite
complications: HF, dysrhythmias, thrombosis
74
Dilated cardiomyopathy
-most common type of cardiomyopathy
-LV becomes enlarged/dilated, and weakened- walls become thin and pump with less force
-reduces heart's ability to pump blood effectively-heart struggles to meet body's needs for oxygenated blood-decreased CO and EF!
-over time leads to HF (3rd leading cause)
-risk of thrombi forming due to blood pooling
-decreased HR and BP
75
Hypertrophic cardiomyopathy
-characterized by abnormal thickening/hypertrophy of the heart muscle, particularly the left ventricle
-interferes with the heart's ability to pump blood effectively
-obstructs blood flow out of the heart-decreased CO
-impaired ability to relax and fill properly-decreased preload
-leading cause of sudden death in adolescents and young adults, particularly in athletes
76
Restrictive cardiomyopathy
-least common
-ventricles become rigid/stiff and resistant to filling (decreased stretch)- muscle replaced with fibrotic tissue and scarring
-impaired filling leads to diastolic heart failure and can affect blood flow to the body and lungs
-decreased CO and SV
77
Diagnosis and treatment of cardiomyopathy
-Diagnosis: echo, ECG, CXR, cardiac MRI, cardiac cath, BNP labs
-Treatment: no cure, only supportive care, encourage frequent rest, lifestyle changes, manage HTN, manage HF, prevent thrombosis, pacemaker, implanted cardiac defibrillator, surgical procedures, heart transplant, VAD=ventricular assistive device-helps with contractions
78
Assessments of cardiomyopathy
-VS: BP, O2 sat
-pain- CP?
-monitor for dysrhythmia
-neuro- signs of decreased CO=change in LOC (watch sodium)
-lung sounds-crackles, orthopnea=pulmonary congestion
-urine output
-activity intolerance-S/Sx of worsening HF
-labs= BNP, Cr/BUN, LFTs
-actions: HOB elevated, apply O2, medications as ordered, restrict Na and fluids, restrict activity, quiet relaxed environment
-educate: regular follow up visits, medications, S/sx of HF, daily weights and reporting weight gain, restrict fluid and Na, moderate exercise
79
Endocarditis
Infection of the endocardium that affects the heart valves. bloodstream infection that causes infection in the lining of the heart, most commonly affecting the heart valves.
-thrombotic endocardial lesion develops= vegetation
-send for TEE!
80
Most common risk factors for endocarditis
-IV substance abuse
-Age
-prosthetic heart valve
-prior history
-immunosuppression
-heart defect or disease
-implanted cardiac device (pacemaker)
-intravascular access device
-poor oral hygiene or periodontal disease
-dialysis
81
Symptoms of endocarditis
-splinter hemorrhages
-osler nodes (on fingers)
-janeway lesions (painless dots on hands and feet)
-roth sports (eye redness)
-fever
-murmur
-chest pain
-petechiae-skin, conjunctiva, mucous membranes)
-SOB
-fatigue
-malaise
complications: embolic stroke (ischemic)-left sided, pulmonary embolism- right side, heart failure, sepsis
82
Diagnosis of endocarditis
-blood cultures: 2 sets, different locations
-echocardiogram: transthoracic echo (TTE), or transesophageal echo (TEE)- identify valve dysfunction, vegetation, abscess, heart size, pumping ability
-increased WBC
83
Prevention and treatment of endocarditis
-prevention: meticulous oral hygiene, avoid infections, treat infections promptly, prophylactic abx before dental procedures for high-risk patients, manage chronic conditions (diabetes, CKD), regular medical follow up
-treatment: infectious disease consult, medications: IV abx 4-6 weeks or longer until blood cultures are negative (dependent on result of blood culture), surgery: valve repair or replacement, debridement of vegetation
84
Assessments for endocarditis
-VS: fever, if HF or sepsis is present: hypotension, tachycardia, tachypnea, low SpO2
-heart sounds-murmur
-lung sounds-crackles if HF develops
-neuro- signs of stroke
-skin- osler's nodes, janeway lesions, splinter hemorrhages
-extremities- signs of decreased perfusion (peripheral embolization), edema (HF)
-labs: blood cultures (initially two sets, repeat as ordered during treatment until negative), echo (size of vegetation and valve function), WBC count increased
-Hx of drug use and risk factors
actions: administer abx, maintain IV access, social support if isolated due to prolonged hospitalization, addiction counseling for IV drug abuse, meds for HF as needed, discharge planning for continued IV abx- home care, skilled rehab
teaching: importance of oral hygiene and routine dental care, notify providers of any hx of endocarditis, complete full regimen of abx
85
Myocarditis
inflammation of the myocardium caused by viral or bacterial infection, autoimmune disease, or toxin exposure
86
Symptoms of myocarditis
-can be asymptomatic in mild cases
-CP
-dyspnea
-palpitations
-dysrhythmias
-syncope
-fatigue
complications: dilated cardiomyopathy, heart failure, cardiac arrest
87
Diagnosis and treatment of myocarditis
-diagnosis: DEFINITIVE TEST= endomyocardial biopsy, patient history, labs (C-reactive protein, ESR, troponin, BNP, pro-BNP, ECG, echocardiography
-treatment: based on cause (abx, antivirals, immunosuppressants, immunotherapies), anticoagulants prophylactically, manage complications (HF, dysrhythmias, cardiomyopathy -IV inotropes, pacemaker, VAD, ECMO=extracorporeal membrane oxygenation, heart transplant), cardiac rehabilitation
88
Assessments for myocarditis
-VS: fever, if HF- hypotension, tachycardia, tachypnea, low SpO2
-telemetry
-S/Sx of HF: fluid overload-crackles, JVD, weight gain, decreased urine output
-actions: administer meds based on cause (antivirals, antimicrobials, immunosuppressives, immunoglobulins, manage dysrhythmias and HF), bedrest and limit activity, fluid restriction with HF, oxygen support, emotional support
-teaching: complete med regimen even if feeling better, athletes should NOT participate in competitive sports while inflammation is present and need to be re-evaluated in no less than 3-6 months before resuming sport to reduce risk of sudden cardiac death, avoid alcohol, manage risk factors.
89
Pericarditis
inflammation of the pericardium. may be infectious or non-infectious
90
Symptoms of pericarditis
-pleuritic CP: relieved by sitting up and leaning forward, and worsens with inspiration or coughing
-pericardial friction rub: scratchy sounds that occur with each heartbeat (hear rubbing!)
-low grade fever
-ECG changes: ST segment elevations or PR depression
-complications: pericardial effusion- >60-100 mLs of extra fluid in the pericardial sac, cardiac tamponade: life threatening EMERGENCY!! rapidly growing effusion that needs quick decompensation- pericardiocentesis or pericardial window
91
Diagnosis and treatment of pericarditis
-diagnosis: ECG, CXR, echo (TTE,TEE), cardiac CT/MRI, labs- serial cardiac biomarkers, blood cultures, CBC, C-reactive protein or sedimentation rates
-treatment: determine cause, manage pain, control inflammation-ASA, NSAIDs, steroids, abx if indicated, watch for S/Sx cardiac tamponade (need pericardiocentesis and pericardial window
92
Assessments of pericarditis
-VS: hypotension, tachycardia, tachypnea with cardiac tamponade, fever if infectious
-pain
-heart sounds-friction rub, muffled
-ECG- ST elevation or PR depression
-actions: HOB elevated to relieve SOB and pleuritic chest pain, medications (anti-inflammatories-NSAIDs, steroids added if needed), emotional support-anxiety
-teaching: avoid strenuous activity until symptoms resolve or laboratory values return to normal. HR should be kept to <100 bpm. differentiate between pericarditis and MI
93
disorders of the pituitary gland
-diabetes insipidus
-syndrome of inappropriate antidiuretic hormone (SIADH)
-hypophysectomy
94
disorders of the adrenal gland
-addision's disease
-cushing's syndrome
-pheochromocytoma
95
disorders of the thyroid gland
-hypothyroidism
-hyperthyroidism
-thyroidectomy
96
disorders of the parathyroid gland
-hypoparathyroidism
-hyperparathyroidism
97
ADH
-antidiuretic hormone
-regulates fluid balance
-produced by hypothalamus
-stored in and released from posterior pituitary
98
diabetes insipidus
an imbalance of water in the body, leading to intense thirst and the excretion of large amounts of dilute urine.
-caused by a deficiency of ADH or a failure of the kidneys to respond it to:
- central or neurogenic DI: caused by insufficient production or release of ADH by the posterior pituitary gland
-nephrogenic DI: kidneys are unable to respond to ADH and concentrate urine
-causes: brain tumor, intracranial surgery, trauma
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symptoms and complications of DI
-polydipsia
-polyuria (>250mL/hr) of very dilute urine- can be up 20L/urine/day
-dehydration: dry mouth and skin, fatigue, dizziness (check BUN/Cr, electrolytes)
-hypovolemia: hypotension, tachycardia- hypovolemic shock
-hypernatremia- confusion (kidney's don't absorb water leading to too much sodium- Na shifts from cell to blood)
complications: hypervolemia (circulatory collapse/shock- too much volume due to increased Na in blood), hypernatremia (arrhythmias, confusion, seizures, coma), dehydration and hypernatremia (cerebral edema) EMERGENCY
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diagnosis of DI
urine specific gravity of less than 1.005 and urine osmolality less than 200 mOsm/kg are key indicators of DI
-decreased ADH
-serum and urine electrolytes-hypernatremia, hyperkalemia
-serum and urine osmolality <200 mOsm/kg
-CT or MRI of head for presence of tumor
-water deprivation test (withhold water and check labs)
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medical management of DI
-hydration: give fluids!!! monitor Na level during fluid administration- if decreasing too rapidly can cause cerebral edema
-administer synthetic ADH (desmopressin and vasopressin)
-frequent monitoring of fluid status, serum electrolytes, and urine output
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education for DI
-med importance
-weigh daily- same time and scale, report >2 lb gain in 1 day
-diet changes: follow any prescribed low-sodium diet, limiting caffeine and alcohol that cause diuresis
-s/s of DI
-s/s of dehydration
-s/s of fluid overload when overcorrecting ADH
-orthostatic hypotension safety
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SIADH
syndrome of inappropriate diuretic hormone
-the body produces excess ADH leading to water retention (hypervolemia, water intoxication) and Na excretion (hyponatremia)
-causes: stroke, trauma, stress, medications like SSRIs, chemotherapy agents, and NSAIDs
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symptoms of SIADH
-hyponatremia secondary to hemodilation (no decrease in total body Na!!!!)
-NV
-confusion
-change in LOC
-fluid retention-tachycardia, HTN, crackles, JVD, weight gain
-decreased urine output, very concentrated urine
-anorexia
-malaise, HA, irritability
-muscle cramps
complications: hyponatremia confusion-seizures-coma-cerebral edema and increased ICP!
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diagnosis of SIADH
-hyponatremia: serum sodium level less than 135, decrease in serum osmolality, elevated urine specific gravity
-increased ADH levels
-serum and urine electrolytes- hyponatremia
-serum and urine osmolality- serum osmolality <275 mOsm, increased urine osmolality
-urine SG: >1.030
-decreased urine output
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medical management of SIADH
-treat underlying cause!
-correct hyponatremia: fluid restriction <1000 mL/day, IV hypertonic fluids
-vasopressin receptor antagonist
-diuretics (furosemide)
-demecocycline (declomycin)- diuresis
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SIADH education
-fluid restriction
-weigh daily- same time and scale
-change positions slowly
-importance of taking medication as ordered
-S/S of fluid overload
-S/S of hyponatremia
-seizure precautions and fall risk
-fluid restrictions 500-1000 mL/day
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transsphenoidal hypophysectomy
hypersecreting tumors of the pituitary gland are surgically removed by transsphenoidal hypophysectomy
-2 approachs: sublabial transseptal or nasal (endoscopic)
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post-op care and nursing management for transsphenoidal hypophysectomy
-nasal packing and moustache dressing
-monitor for CSF LEAK AND RHINORRHEA- report! (clear watery nasal drainage test for glucose!! if present then CSF!) development of DI, increased ICP, infection
-neuro and LOC
-avoid activities that increase pressure at site
-lifelong hormone replacement therapy- desmopressin, hydrocortisone
-oral care: rinses, avoid brushing teeth or use an extremely soft toothbrush to treat dry mucous memrbanes
-airway patency
-fluid balance and urine output- polydipsia, polyuria, Is and Os, SG, serum Na, osmolality
-incision site
-visual acuity
-signs of meningitis- neck stiffness, high fever, photophobia
-pain
-maintain HOB at 30/45-60 degrees!!!
-provide fluids orally
-humidified o2 as ordered
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addison's disease
a condition in which the adrenal glands are damaged and cannot produce enough cortisol or aldosterone (adrenal insufficiency)
-cortisol= glucocorticoid-suppression of immune response, control stress response
-aldosterone= mineralocorticoid-sodium and water reabsorption, potassium excretion
cause: autoimmune destruction, infections, tumors, adrenalectomy, sudden withdrawal from corticosteroids (like prednisone)
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symptoms of addison's disease
-skin hyperpigmentation-bronze
-hypotension- loss of fluid and Na leads to decreased cortisol and aldosterone
-weight loss, decreased appetite, salt craving
-NVD
-hypoglycemia due to decreased cortisol
-hyperkalemia and hyponatremia due to decreased aldosterone
-fatigue and weakness
-irritability, depression, confusion
-pain-abdomen, muscles, joints
complications: adrenal crisis MEDICAL EMERGENCY when cortisol levels drop suddenly due to illness, stress, or injury
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diagnosis of addison's disease
-serum cortisol-decreased, drawn in the morning
-ACTH levels- increased
-electrolytes- hyponatremia, hyperkalemia, hypoglycemia
-CT or MRI- shrinking adrenal gland (autoimmune), enlarged (infection)
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medical management of addison's disease
-acute: IV fluids, glucose, flucocorticoid (hydrocortisone sodium succinate, dexamethasone), kayexalate for hyperkalemia
-chronic: lifelong corticosteroids and mineralocorticoids, oral hydration
-adrenal crisis: prevention (additional doses of glucocorticoid during periods of stress), IV hydrocortisone, fluids, glucose, electrolyte management, vasopressors
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nursing management and education for Addison's disease
-lifelong daily hormone replacement
-medical alert bracelet
-carry a glucocorticoid injection kit
-avoid stress, infections, or injury- increase corticosteroid dose
-increased salt intake before exercise or in hot water
-adequate rest and nutrition to prevent fatigue and stress
-s/s of adrenal insufficiency and crisis
-s/s of corticosteroid excess
-follow up and labs
-fall risk for orthostatic hypotension
-treat hypoglycemia
-increase sodium in diet
-skin turgor and color
-cardiac monitoring
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Cushing's disease
a form of cushing's syndrome, that results from excess of cortisol due to the overproduction of adrenocorticotropic hormone (ACTH) by a pituitary adenoma (benign tumor)
-cushing's syndrome: broader term to describe excess adrenal hormone production-can be caused by taking corticosteroid medications (like prednisone)
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symptoms of cushing's syndrome
-moon face
-buffalo hump
-truncal obesity
-thin extremities
-weight gain
-purple striae (abdomen, thighs, breasts, arms)
-thin fragile skin, acne
-muscle weakness, wasting
-hypertension
-hyperglycemia
-hypernatremia
-hypokalemia
-depression, irritability, anxiety, difficulty with memory and concentration
-immune suppression
complications: osteoporosis, fractures, hard to control BG (diabetics), GIB
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diagnosis of cushing's disease
-labs: increased cortisol and ACTH, hypokalemia, hyperglycemia
-24 hour urine free cortisol test
-late-night salivary cortisol test
-dexamethasone suppression test
-CT or MRI
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medical management and education of cushing's disease
-prevent complications from and manage symptoms of hyperglycemia, fluid overload, immunosuppression, skin integrity
-medications:
-ketoconazole: reduce cortisol production
-pasireotide: inhibit ACTH production
-mifepristone: blocks effects of cortisol
-surgery: transsphenoidal hypophysectomy or adrenalectomy
-radiation for pituitary
-wound healing and skin
-signs of infection, osteoporosis, fracture
-educate on hormone replacement therapy after surgery if needed
-decreased Na and fluid intake
-early signs of hypercortisolism and adrenal insufficiency
-low Na, high protein, low calorie diet
-fall risk!
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pheochromocytoma
a rare, usually benign rumor that develops in the adrenal medulla (inner adrenal gland) that leads to excessive production of catecholamines (epinephrine and norepinephrine) which can lead to life-threatening hypertension or cardiac arrhythmias, leading to sudden death.
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symptoms and complications of pheochromocytoma
-classic triad= severe headaches, palpitations, diaphoresis
-HTN- persistent, episodic, or paroxysmal (sudden spike triggered by stressor)
-tachycardia
-CP, abd pain (dont palpate abd!)
-hyperglycemia
-pallor
-weight loss (hypermetabolism)
complications: HTN crisis (stroke, MI, HF), cardiac arrhythmia, multi-organ failure, shock, death
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diagnosis of pheochromocytoma
-clinical manifestations (s/s and BP >250/150)
-labs: increased epi and norepi
-24 hour urinary catecholamines
-plasma free metanephrines
-CT or MRI
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medical management of pheochromocytoma
-control HTN and hyperglycemia
-adrenelctomy: alpha adrenergic blockers start 7-10 days prior with goal BP of 120/80, BB for HR control, prevent HTN crisis during surgery due to tumor being manipulated-treat with Na nitroprusside or alpha adrenergic blockers
DON'T GIVE BB BEFORE ALPHA BLOCKERS- can lead to HTN crisis!!!!
-post-op: monitor BP, HR, blood glucose (can develop hypotension and hypoglycemia due to sudden decrease in catecholamines)
-bilateral adrenalectomy: surgery induced adrenal insufficiency-lifelong hormone replacement (cortisol)
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nursing management and education for pheochromocytoma
-neuro assessment
-skin assessment
-cardiac and glucose monitoring
-IV antihypertensives
-bedrest with HOB elevated
-calm environment
-alpha and beta blockers as prescribed
-prevent dehydration or fluid overload
-administer glucocorticoid the morning of surgery for adrenalectomy
-educate how to measure BP and when to notify provider
-teach avoiding activities that could trigger a HTN crisis like lifting or stress
-clinical manifestations of adrenal insufficiency
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hypothyroidism
thyroid gland does not produce enough thyroxine (T4) and triiodothyronine (T3) that regulate metabolism, heart rate, and body temp- the body's processes slow down!
-causes: autoimmune disease (hashimoto's thyroiditis), thyroidectomy or radiation therapy, iodine deficiency (iodine is crucial to thyroid function), secondary hypothyroidism (pituitary gland or hypothalamus fails to simulate the thyroid gland)
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symptoms of hypothyroidism
-fatigue
-weight gain
-cold intolerance
-constipation
-dry skin and hair, hair loss
-depression, memory loss
-bradycardia
-hypotension
-muscle weakness or stiffness
-goiter= enlarged thyroid
-heavy or irregular menstrual periods
complications: myxedema coma= occurs if hypothyroidism is left untreated which is lIFE THREATENING!! generalized non-pitting edema (puffy face), hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, confusion, respiratory failure, multi-organ failure
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diagnosis of hypothyroidism
-h+p
-free t3 and t4 are decreased
-TSH is increased
-ultrasound-size and characteristics of thyroid (nodules, goiter)
-radioiodine uptake scan- measures thyroid function by its ability to absorb radioactive iodine
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medical management for hypothyroidism
-levothyroxine (synthetic thyroid hormone)- daily PO replacement of thyroid hormone: take in the morning, same time everyday, on empty stomach- dose adjusted based on TSH and t4 levels
-regular blood work
-myxedema coma- immediate, aggressive tx in the ICU: IV levothyroxine, corticosteroid (hydrocortisone), electrolytes, mechanical ventilation, rewarming, telemetry
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nursing management and education of hypothyroidism
-levothyroxine- administer and when and how to take
-mental status
-presence of edema or swelling
-daily weights
-bowel elimination
-decreased HR, BP, RR, temp
-lotion skin and warm blankets
-stool softeners and laxatives
-educate on s/s of hyper and hypothyroidism due to treatment
-report chest pain
-may have overreaction to sedatives!
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hyperthyroidism
a condition where the thyroid gland produces excessive amounts of thyroid hormones- speeds up the body's metabolism, also known as thyrotoxicosis
causes: graves disease- most common, autoimmune disorder. thyroid nodules-produce excess hormones. thyroiditis- inflammation of the thyroid
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symptoms of hyperthyroidism
-weight loss
-increased appetite
-tachycardia, bounding pulse, palpitations
-HTN
-heat intolerance
-exophthalmos= protrusion of eyeballs with Grave's disease
-goiter
-skin-warm, flushing, moist, soft velvety feel
-fatigue
-frequent bowel movements
-nervousness, anxiety
-sleep disturbances
complications: thyrotoxic crisis=thyroid storm!!! extreme form of hyperthyroidism from untreated or poorly treated hyperthyroidism-LIFE THREATENING!!!
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thyroid storm/thyrotoxic crisis
triggers: infection, trauma, surgery, uncontrolled hyperthyroidism, heart attack
symptoms: similar to thyrotoxicosis but more severe!
-high fever (often >104)
-severe tachycardia
-profound agitation or delirium
-HF (CP, SOB)
-vomiting, diarrhea
-jaundice in severe cases
-coma in most extreme
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key differences of thyrotoxicosis and thyroid storm
-thyrotoxicosis: range from mild to severe, depending on hormone levels and how long the condition has been present. onset- can develop gradually over weeks or month.
-thyroid storm: life-threatening exacerbation of thyrotoxicosis with rapid deterioration in health. onset- develops suddenly and in response to a precipitating event.
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diagnosis of hyperthyroidism
-H+P
-free T4 and T3 increased
-TSH decreased
-TSH antibodies-present in Graves
-thyroid scan
-radioiodine uptake scan
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medical management of hyperthyroidism
-management of clinical manifestations-BB
-non-surgical: adequate fluid intake, monitoring CV complications, promoting a quiet environment
-medications: BB-slow HR and tx palpitations, antithyroid meds (propylthiouracil/PTU, methimazole, lithium carbonate), iodine preparations (radioiodine I-131 short term prior to surgery)
-surgical: thyroidectomy
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nursing management and education for hyperthyroidism
-decreased HR, BP, RR, temp
-daily weights
-sleep pattern
-weakness or muscle ache
-JVD and edema
-emotional status
-eyes, vision
-prep for surgery
-radioiodine precautions
-exophthalmos-artificial tears, eye patches, tape eyelids closed at night
-educate on s/s of hyper and hypothyroidism-progress to myxedema or over-treatment
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thyroidectomy
types:
1- total=removal of the entire thyroid gland
2- partial= removal of one lobe or part of thyroid
3- subtotal= removal of most but not all of the thyroid tissue
procedure: general anesthesia, small incision at front of neck, taking care to avoid the parathyroid glands (regulate calcium!), and the laryngeal nerves (control vocal cords!)
complications:
-impaired airway=stridor
-hypothyroidism= if entire thyroid is removed, will no longer produce thyroid hormones- need lifelong thyroid hormone replacement therapy through levothyroxine, follow apts and labs
-hypocalcemia: damage to the parathyroid glands can cause hypocalcemia, requiring calcium and vitamin D supplementation, ASSESS FOR TETANY!!!
-voice changes: injury to laryngeal nerve can cause hoarseness or voice changes. this is usually temporary but can be permanent
-bleeding or infection
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thyroidectomy post-op care
-check Ca and Mg, vitamin D to help intestinal absorption of Ca
-monitor for airway compromise, hemorrhage, hypocalcemia and tetany, and damage to the laryngeal nerve
-keep neck in neutral position: sandbags or pillows
-semi-fowlers position
-humidification
-keep oral suctioning and trach tray at bedside
-voice assessments
-symptoms of tetany: muscle spasms (hands, feet, face, throat/laryngospasm), tingling and numbness around the mouth, fingers, and toes
-Chvostek's sign: twitching of facial muscles when tapping the facial nerve shows hypocalcemia
-Trousseau's sign: a carpal spasm induced by inflating a blood pressure cuff, indicating low calcium levels
-patient will need lifelong Ca and vitamin D replacement with total thyroidectomy or if parathyroid glands don't regain function
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hypoparathyroidism
a condition characterized by inadequate secretion or action of parathyroid hormone (PTH), which leads to disturbances in calcium, phosphate, and bone metabolism, can be induced from total thyroidectomy.
-when these glands fail to produce sufficient PTH, calcium levels drop, and phosphate levels increase, leading to symptoms associated with hypocalcemia
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symptoms of hypoparathyroidism
-numbness and tingling around mouth, hands and feet
-severe muscle cramps, spasms hands and feet
-chvostek sign
-trousseau sign
-fatigue, weakness
-depression, anxiety, irritability, difficulty concentrating
-hypotension
complications: tetany- laryngospasm- airway compromise, seizures, prolonged QT-arrhythmias
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diagnosis of hypoparathyroidism
serum electrolytes: decreased CA, increased phosphate, decreased Mg
-decreased PTH
-ECG
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medical management of hypoparathyroidism
-acute hypocalcemia: IV calcium gluconate or Ca chloride, followed by oral Ca carbonate or Ca citrate, vitamin D supplementation
-chronic hypoparathyroidism: oral Ca carbonate or Ca citrate, vitamin D supplementation, Mg supplements, close monitoring of serum Ca levels, monitor for the development of renal calculi and osteoporosis
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nursing management and education of hypoparathyroidism
-cardiac monitoring
-labs: decreased Ca and PTH, increased phosphate
-neuromuscular activity, tetany
-diet: high Ca, low phosphate
-seizure precautions
-oral suction equipment and trach tray at bedside
-educate on lifelong daily supplementation
-foods high in calcium but low in phosphorus
-signs of hyper and hypocalcemia
-immediate medical help for severe muscle cramps, tingling, seizures, or cardiac symptoms
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hyperparathyroidism
a condition characterized by the overproduction of parathyroid hormone (PTH) by the parathyroid glands, leads to hypercalcemia
-bones and kidneys: breakdown and demineralization of bone- increased reabsorption of Ca (risk for osteoporosis and renal calculi)
-bowel: increased Ca reabsorption
causes: tumor, cancer, CKD, vitamin D deficiency, malabsorption
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symptoms of hyperparathyroidism
can be asymptomatic!
-bone pain, fractures
-polyuria
-polydipsia
-abdominal pain
-N/V
-anorexia
-constipation
-fatigue, muscle weakness and atrophy
-depression, anxiety, difficulty concentrating or confusion
-prolonged PR interval, shortened QT interval
-HTN
complications: arrhythmias, peptic ulcers, pancreatitis, renal calculi, osteoporosis-fractures!
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diagnosis of hyperparathyroidism
-labs: increased PTH, Ca, decreased phosphate, BUN/Cr
-EKG
-biopsy
-bone density scan
-x-rays, CT, MRI
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medical management of hyperparathyroidism
lower PTH levels
-surgical intervention: parathyroidectomy (check Ca post-op!)
-increased fluid intake
-medications: loop diuretics, phosphate (prevents bone breakdown), biphosphonates (stop "intruders" from breaking down bone)
-dietary changes- limit calcium rich foods and avoid excessive vitamin D intake
-decrease consumption of calcium-containing antacids and vitamin D
-avoid thiazide diuretics (increases reabsorption of Ca!)
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nursing management and education of hyperparathyroidism
-urine output, flank pain, hematuria
-bone pain, fractures
-neuro status
-increase fluid intake 3000 mL/day
-use a lift sheet to prevent bone injury
-fall precautions
-strain urine
-stay hydrated
-low calcium diet
-increase mobility
-post op Ca and vitamin D supplements
