Exam 1 (3/1) Flashcards
components of a cardiac assessment
gather health history:
Chest pain/discomfort
Pain/discomfort in other areas of the upper body
SOB/dyspnea
Peripheral edema, weight gain, abdominal distention
Palpitations
Unusual fatigue, dizziness, syncope, change in LOC
gather past health, family and social history: Medications Nutrition Elimination Activity, exercise Sleep, rest Self-perception/self-concept Roles and relationships Coping and stress
Physical assessment: General appearance Skin and extremities Pulse pressure Blood pressure; orthostatic changes Arterial pulses Jugular venous pulsations Heart inspection, palpation, auscultation Assessment of other systems
Lab tests for the heart
Biomarkers—cardiac enzymes (CK, CK-MB, trop)- from myocardial cells r/t prolonged ischemia or trauma.
BUN—Blood urea nitrogen (and creatine)– kidneys
Lipids monitored in the development of CAD
Brain (B-type) natriuretic peptide- a neurohormone that helps regulate BP and fluid volume.
C-reactive protein- Liver Inflammation noted with atherosclerosis.
Homocysteine— atherosclerosis
age related changes in the cardiac system
Loss of function of the cells leading to slower heart rate
Size of heart increases due to hypertrophy
Reduced volume of blood
Reduced strength of contraction
Valves stiffen
Backflow of blood creates heart murmurs
cardiac tests
-Exercise stress test:
Pt walks on treadmill with intensity progressing according to protocols
ECG, V/S, symptoms monitored
Terminated when target HR is achieved
- Echocardiogram:
Noninvasive ultrasound test that is used to:
Measure the ejection fraction
Examine the size, shape, and motion of cardiac structures - Transthoracic endocardiogram
- Transesophageal endocardiogram
- Chest X-Ray (CXR)
- Fluoroscopy: moving images on xray
What is an (ECG)?
12 lead ECG:
graphic representation of the electrical currents of the heart
diagnose dysrhythmias, conduction abnormalities, and chamber enlargement, as well as myocardial ischemia, injury, or infarction
All ECG’s:
Monitor more than one ECG lead simultaneously
Monitor ST segments (ST-segment depression is a marker of myocardial ischemia; ST-segment elevation provides evidence of an evolving MI)
Provide graded visual and audible alarms (based on priority, asystole merits the highest grade of alarm)
Interpret and store alarms
Trend data over time
Print a copy of rhythms from one or more specific ECG leads over a set time (called a rhythm strip)
What are cardiac enzymes? What are the expectations and concerns related to these?
Myocardial cells that become necrotic from prolonged ischemia or trauma release specific enzymes
These substances leak into the interstitial spaces of the myocardium and are carried by the lymphatic system into general circulation. As a result, abnormally high levels of these substances can be detected in serum blood samples
Heart catheterization
Invasive procedure used to diagnose structural and functional diseases of the heart and great vessels
Right Heart Cath: Pulmonary artery pressure and oxygen saturations may be obtained; biopsy of myocardial tissue may be obtained
Left Heart Cath: Involves use of contrast age
Post procedure care: Observe cath site for bleeding, hematoma Peripheral Neurovascular assessment Evaluate temp, color, and cap refill of affected extremity Screen for dysrhythmias Maintain bed rest 2 to 6 hours Instruct patient to report chest pain, bleeding Monitor for contrast-induced nephropathy Ensure patient safety
age-related changes in cardiac system
Loss of function of the cells leading to slower heart rate
Size of heart increases due to hypertrophy
Reduced volume of blood
Reduced strength of contraction
Valves stiffen
Backflow of blood creates heart murmurs
Causes of Heart failure
causes: coronary artery disease, hypertension, cardiomyopathy, valvular disorders, renal dysfunction, diabetes, atherosclerosis
patho: body activates compensatory hormines, structure of heart changes leading to low CO
Manifestions of Heart Failure
RIGHT SIDED: viscera & peripheral conjestion JVD dependent edema hepatomegaly ascites (accumulation of fluid in abdomen) weight gain LEFT SIDED: pulmonary congestion "crackles" S3 or "ventricular gallops" dyspnea on exertion low O2 sat dry nonproductive cough oliguria (small amount of urine only)
Management of Heart Failure
Angiotensin-converting enzyme (ACE) inhibitors: vasodilation; diuresis; decreases afterload; monitor for hypotension, hyperkalemia, and altered renal function; cough
Angiotensin II receptor blockers: prescribed as an alternative to ACE inhibitors; work similarly
Hydralazine and isosorbide dinitrate: alternative to ACE inhibitors
Beta-blockers: prescribed in addition to ACE inhibitors; may be several weeks before effects seen; use with caution in patients with asthma
Diuretics: decreases fluid volume, monitor serum electrolytes
Digitalis: improves contractility, monitor for digitalis toxicity especially if patient is hypokalemic
IV medications: indicated for hospitalized patients admitted for acute decompensated HF
Milrinone: decreases preload and afterload; causes hypotension and increased risk of dysrhythmias
Dobutamine: used for patients with left ventricular dysfunction; increases cardiac contractility and renal perfusion
Nursing Process with HF
Assessment: Focus on: -Effectiveness of therapy -Patient’s self-management -S&S of increased HF -Emotional or psychosocial response Health history Physical Exam Mental status lung sounds: crackles and wheezes heart sounds: S3; fluid status or signs of fluid overload daily weight and I&O assess responses to medications
Diagnosis:
Activity intolerance related to decreased CO
Excess fluid volume related to the HF syndrome
Anxiety-related symptoms related to complexity of the therapeutic regimen
Powerlessness related to chronic illness and hospitalizations
Ineffective family therapeutic regimen management
Planning:
-Goals-
-Promote activity and reduce fatigue
-Relieving fluid overload symptoms
-Decrease anxiety or increase the patient’s ability to manage anxiety
-Encourage the patient to verbalize his or her ability to make decisions and influence outcomes
-Educate the patient and family about management of the therapeutic regimen
-interventions-
activity intolerance:
Bed rest for acute exacerbations
Encourage regular physical activity; 30 to 45 minutes daily
Exercise training
Pacing of activities
Wait 2 hours after eating for physical activity
Avoid activities in extreme hot, cold, or humid weather
Modify activities to conserve energy
Positioning; elevation of the head of bed to facilitate breathing and rest, support of arms
Fluid volume excess:
Assessment for symptoms of fluid overload
Daily weight
I&O
Diuretic therapy; timing of meds
Fluid intake; fluid restriction
Maintenance of sodium restriction
Potential complications: Hypotension poor perfusion cardiogenic shock Dysrhythmias Thromboembolism Pericardial effusion cardiac tamponade
Heart failure pt education & end of life considerations
-education-
Medications
Diet: low-sodium diet and fluid restriction
Monitoring for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight
Exercise and activity program
Stress management
Prevention of infection
Know how and when to contact health care provider
Include family in education
-end of life-
HF is a chronic and often progressive condition:
Need to consider issues related to the end of life
When palliative or hospice care should be considered
Pulmonary edema Patho
Acute event results in LV failure
As LV begins to fail, blood backs up into the pulmonary circulation, causing pulmonary interstitial edema
Results in hypoxemia, often severe
manifestations of Pulmonary edema
restlessness, anxiety, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood tinged), decreased level of consciousness
Management of pulmonary edema (fluid in the lungs)
Easier to prevent than to treat
Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention
Minimize exertion and stress
Oxygen; nonrebreather
Medications: Diuretics (furosemide), vasodilators (nitroglycerin)
Nursing Management:
Positioning the patient to promote circulation- Positioned upright with legs dangling
Providing psychological support- Reassure patient and provide anticipatory care
Monitoring medications- I&O
Risk factors of Peripheral Areterial Occlusive Disease (PAD)
Modifiable: Nicotine, diet Hypertension Diabetes Obesity Stress Sedentary lifestyle C-reactive protein Hyperhomocysteinemia
Non-modifiable
Age
Gender
Familial predisposition and genetics
Manifestations of PAD
Intermittent claudication (aching, cramping, fatigue/weakness)
Occurs with activity, relieved with rest
Pain is due to critical ischemia
Persistent, aching, boring (rest pain)
Usually worse at night
Nursing Prosess for PAD
Assessment:
Health history
- Intermittent claudication
- Location of the pain (persistent in forefoot)
Physical assessment
- Skin (blue color (rubor) and cool/pale)
- Pulses (you cant feel it so use a doppler)
Diagnosis:
Ineffective Tissue Perfusion
Diagnostic evaluation:
Doppler Ultrasound
Magnetic Resonance Angiography
Angiography-
- confirms location of an obstruction or aneurysm
-Allergy to contrast:
- normal-sensation of warmth, local irritation at injection site
- Allergy reaction may be immediate or delayed—Dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities
any reactions should be reported to the interventionalist immediately
Treatment generally includes epinephrine, antihistamines, and/or corticosteroids
Planning: Medical Management -Low-fat diet -Controlled exercise -Medication -Antilipemics -Anti-hypertensives Surgical/Radiologic Interventions -Angioplasty -Atherectomy -Stent grafts
Implementation: Lower extremities below the level of the heart Promote vasodilation Application of warmth Smoking cessation Stress reduction Encourage walking Relieve pain (analgesics) Maintain tissue integrity
Evaluation: Extremities warm to touch & improved color Walks further & with less pain Reports less pain Absence of injury or ulceration
Educate: lower the extremity below the heart, encourage moderate exercise, don’t be on extremity for too long
Venous Insufficiency
Chronic venous stasis: Edema Altered pigmentation Pain Stasis dermatitis
Prevention: Application of graduated compression stockings Pneumatic compression devices Early ambulation Subcutaneous heparin or LMWH Lifestyle changes Weight loss Smoking cessation Regular exercise
Varicose veins
Dilated, tortuous veins: Dull aches Muscle cramps Muscle fatigue lower legs Nocturnal cramps
Prevention:
Avoid activities that cause venous stasis (wearing socks that are too tight at the top or that leave marks on the skin, crossing the legs at the thighs, and sitting or standing for long periods)
Elevate the legs 3 to 6 inches higher than heart level
Encourage to walk 30 minutes each day if there are no contraindications
Wear graduated compression stockings
Overweight patients should be encouraged to begin weight reduction plans
Leg Ulcers
Venous insufficiency can result from obstructed venous valves
Edema, altered pigmentation, pain, stasis dermatitis
Assessment: H & P
Diagnosis: Impaired skin integrity
Plan: Restoration of skin integrity
Interventions Medication - antiseptic agents, oral antibiotics, topical agents GCS, elastic wraps, Unna boots Debridement Dressings Hyperbaric oxygen Negative pressure wound therapy
Lymphangitis
inflammation or infection of the lymphatic channels
Hemolytic streptococcus
Red streaks
Treat with antibiotics
Lymphadenitis
tissue swelling related to obstruction of lymphatic flow
Hemolytic streptococcus
Red streaks
Treat with antibiotics
Cellulitis
S&S: localized swelling or redness, fever, chills, sweating
Treat with oral or IV antibiotics based on severity
Nursing interventions:
Elevate affected area
Warm, moist packs to site every 2 to 4 hours
Educate regarding prevention of recurrence
Reinforce education about skin and foot care
look for points of entry
Lymphedema and elephantiasis
Tissue swelling due to increase lymph that results from obstruction of lymphatic vessels
- Exercise
- GCS
- Manual lymphatic drainage
- Diuretics
- Surgery
Venous Thromboemolism (VTE) preventiosn risk factors
Endothelial damage (trauma, surgery, central venous or dialysis catheters, pacing wires, local vein damage, repetitive motion injury) Venous stasis (bed rest/immobilization, obesity, spinal cord injury, age >65) Altered coagulation (cancer, pregnancy, oral contraceptives, sepsis, polycythemia, protein C or S deficiency, factor V leiden defect)
Manifestation VTE
Swelling Throbbing pain Warm skin Red or darkened skin Swollen veins that are hard/sore when touched
Nursing Process for VTE
Planning: Decrease Venous Congestion Medical/Nursing Management: Anti-gravity activities Graduated compression stockings Encourage walking Maintain tissue integrity
Diasgnosis:
Ineffective Tissue Perfusion
Duplex Ultrasonography
Contrast Phlebography (Venography)
Implementation
Elevate extremities above the level of the heart
Discourage standing or sitting for prolong periods
Discourage constrictive clothing
Avoid crossing legs
evaluation: decreased edema
Management of VTE
Elevate extremity, GCS, SCDs
Warm, moist packs
Anticoagulants:
Monitor lab values
Monitor for bleeding
Know how to reverse anticoagulation effects
Encourage walking AFTER anticoagulation therapy has been started
Prophylactic medication- heparin, enoxaparin
DVT
Prevention: Identify high-risk patients—Endothelial damage (trauma, surgery, central venous or dialysis catheters, pacing wires, local vein damage, repetitive motion injury), venous stasis (bed rest/immobilization, obesity, spinal cord injury, age >65), altered coagulation (cancer, pregnancy, oral contraceptives, sepsis, polycythemia, protein C or S deficiency, factor V leiden defect. GCS Early ambulation Leg exercises Prophylactic medication Heparin, Enoxaparin
Management: Elevate extremity, GCS, SCDs Warm, moist packs Anticoagulants Monitor lab values Monitor for bleeding Know how to reverse anticoagulation effects Encourage walking AFTER anticoagulation therapy has been started
Hypertension categories
Primary or essential (95%)
secondary (5%)
gestational
Manifestations of hypertension & complications
vague symptoms headaches shortness of breath nosebleeds flushing dizziness chest pain visual changes blood in the urine
complications: Left ventricular hypertrophy Myocardial infarction Heart failure Transient ischemic attack (TIA) Cerebrovascular disease (CVA, stroke, or brain attack) Renal insufficiency and chronic kidney disease Retinal hemorrhage
how to treat HTN
- try to change lifestyle, 2. if that does not work then add medication 3. if that doesnt work add or change med 4. add more meds
older adults start taking meds if SBP 150mm HG or > or if DBP 90 mmHg or >
interventions: Emphasize control, not cure.
Emphasize medication compliance, for rest of life- Discuss consequences of noncompliance.
Diet changes: Reduce salt & fat. Increase fruits & vegetables.
Regular physical activity.
Meds: Teach to identify, report, & minimize SE/AE:
- Orthostasis, sexual dysfunction, dry mouth, frequent urination
-Inform about rebound hypertension: Need adequate supply of meds available, esp. when traveling.
Support groups: AHA, National Heart, Lung & Blood Institute
Inform about need for regular follow-ups.
Hypertensive Crisis
Symptoms: Neuro: ha, confusion, change in LOC blurred vision CV: tachycardia Resp: tachypnea & dyspnea
Assess:
BP every 5-30 min.
Hemodynamic monitoring
I & O
Have emergency equipment available.
Slowly reduce BP:
20%-25% in first hr
Over next 6 hr, reduce to goal 160/100 mm Hg
Then further reduction
Pharmacologic therapy:
vasodilators (sodium nitroprusside, nicardipine, enalapril, NTG)
HTN urgency: oral agents
Position: bed rest, HOB 45 degrees
Assess for hypotension r/t vasodilators
Fluid replacement, if needed
Symptoms of Hypoxia (do not have enough oxygen in their system)
Early
R- restlessness
A- anxiety
T- tachycardia /tachypnea
is late to
B- bradycardia
E- extreme restlessness
D- dyspnea
(in prediatrics) F- feeding difficulty I- inspiratory stridor N- nares flare E- expiratory grunting S- sternal retractions
3 P’s of dyspnea
Pulmonary bronchial constriction
possible foreign body
pulmonary emboulus
pump failure
Pneumothorax: Do not have enough room for the lungs to expand.
Pneumonia: Do not have enough capacity for air to get into lungs.
Physical assessment of Respiratpry system
Normal breath sounds (vesicular, bronchovesicular, bronchial)
Abnormal breath sounds:
Crackles:
Short, discrete, crackling or bubbling sounds
Noted in pneumonia, bronchitis, CHF
Wheezes:
Continuous, musical sounds
Heard in bronchitis, emphysema, asthma
Rhonchi:
Deep, low-pitched rumbling sounds heard primarily during expiration.
Caused by air moving through narrowed tracheobronchial passages
Diagnostic tests for the respiratory system
Pulmonary Function Tests Cultures- throat, nasal, nasopharyngeal Sputum Studies Endoscopic Procedures Bronchoscopy: For invasive procedures we need consent, nothing by mouth, pre and post procedure considerations. Thoracoscopy Thoracentesis
Imaging studies: Chest X-Ray Computed tomography (CT) Magnetic resonance imaging (MRI) VQ Scan Preparation, consent, NPO, Pre & Post-procedure considerations Pulmonary angiography- To diagnose a PE
Laryngectomy Nursing Process
Assessment:
H&P
Nursing Diagnoses: Ineffective airway clearance Impaired verbal communication Imbalanced nutrition Risk for aspiration
Plan:
Airway
Alternative means of communication
Nutrition and hydration
Interventions: Monitor respiratory status Position in semi-fowler or Fowler’s Perform laryngectomy/tracheostomy tube care Provide humidification Utilize writing, hand gestures Administer IV fluids, enteral (NG or GT), and/or parenteral nutrition Obtain swallow study before PO
Atelectasis
I = incentive spirometry C = cough and deep breathing O = oral care U = understanding G = getting out of bed H = head of bed elevated
Aspiration
Inhalation of foreign material into the lungs
Risk Factors- seizure activity, brain injury, decreased LOC, flat body positioning, enteral tube feedings, swallowing disorders (dysphagia)
prevention:
HOB 30-45 degrees
Use sedatives sparingly
Enteral tubes - confirm tip location, check for residuals, avoid bolus feedings
Swallow evaluation before initiating PO feedings in patients intubated >2 days
Maintain endotracheal cuff pressure and suction before deflating
Tests: Bedside Swallow Screen
Pneumonia classifications
inflammation of lung parenchyma from bacteria, fungi and viruses:
Community acquired (vaccine only good for this)
Health care associated
Hospital acquired (resistant to some antibiotics)
Ventilator associated
Pneumonia risk factors
PREVENTION IS KEY Elderly, Chronic health or coexisting condition Not vaccinated, Immunocompromised, Immobility, CVA, decreased LOC Tobacco, alcohol use, Upper airway infections NPO status, placement of NG/OG, endotracheal, or tracheostomy tube, Mechanical ventilation CAUSED A LOT BY ASPIRATION
Nursing interventions for pneumonia
antibiotics (bacterial pneumonia)
supportive (viral pneumonia): rest, hydration, antipyretics, antitussive, antihistamines, decongestants
Airway – oxygen, chest physiotherapy, TCDB (turn, cough, deep breath)
Fluid – at least 2L/day
Nutrition – small, frequent meals
Physical exam for pneumonia
Flushed cheeks, anxiety
Myalgia, headache, chills
Pleuritic pain
Accessory muscle use- Chest muscle weakness (from coughing)
Cough, sputum (purulent, blood-tinged or rust-colored)
Diagnosic tests of pneumonia
CXR: Most common dx test
(may not show changes until 2 or more days after sx are present)
Sputum: gram stain & culture: obtain sputum culture prior to antibiotic therapy
Blood culture: bacteremia occurs frequently
CBC: WBC > 11,000 w/bacterial
Oximetry; ABGs
Fiberoptic bronchoscopy: Obtain sputum specimen or remove secretions, use this when pneumonia is bad
Pneumonia symtpoms
cough fever chills tachycardia tachypnea dyspnea pleural pain malaise respiratory distress decresed blood sounds
complications of pneumonia
obstruction of broncioles
decreased gas exchange
increased exudate
Tuberculosis risk factors
Constant frequent contact with people
Congregate settings (ex. Jails, shelters)
Medically underserved
Poor nutrition
Immune dysfunction or sick with other diseases
HIV+
Immigrants
Age: Babies or children under 15 or elderly
People living in or traveling to Mexico, Philippines, Latin American, Cuba, or Southeast Asia, plus more
Being infected with TB bacteria within the last 2 years
Illegal drug use
TB manifestations
Low-grade fever (late-afternoon) Cough: nonproductive to sputum filled Night sweats Fatigue Weight loss Pleuritic chest pain Hemoptysis (advanced state)- coughing up blood
TB diagnostic tests
TB Skin Test (Mantoux test): Intradermal Prified protein Derivative (PPD)
only shows if person was ever exposed, not that they are necessarily infected. If skin test is + then one must get a chest xray.
measures delayed cell-mediated (Type IV) hypersensitivity reaction (develops within 3-10 weeks after infection)
Once a person becomes positive, they usually remain so for life.
If pt received the BCG vaccine, TB skin test is not contraindicated, but may need further evaluation (CXR) to diagnose TB
POSITIVE SKIN TEST RESULT:
Measure diameter of the induration (not erythema- bump/hard center).
>10 mm induration
> 5 mm if high-risk (HIV)
Exposed but not infected
Infected but no active disease
Active TB disease
NEGATIVE SKIN TEST RESULT
0-10 mm induration
“Never exposed”
Calcified Lesions on CXR: Chest X-ray to look for any lesions on the lungs (usually in upper lobes)
QuantiFERON- TB Gold:
Whole-blood test
If TB +: Enzyme-linked immunosorbent assay (ELISA) detects release of interferon-gamma by WBCs
Results available in 24 hours
Results not affected by prior BCG vaccination
THIS IS EXPENSIVE, USE ONLY IS REALLY NEEDED
Sputum Studies
•Sputum smear- Acid-fast Bacilli (AFB)
•Sputum culture- TB
Biopsy
findings: lesions on upper lobes
TB nursing process
assessment:
complete history: Past and present medical history is assessed as well as both of the parents’ histories.
physical examination: A TB patient loses weight dramatically and may show the loss in physical appearance.
tuberculin skin test
chest x-ray
Drug susceptibility testing
If symptoms are present then further assessment will be done on respiratory function: breathing sounds, fremitus (vibrations), and egophony (increased resonance to voice sounds when auscultating)
Interventions:
Promote airway clearance: postural drainage: sit up right and increase fluid intake
Promote adherence to treatment regimen: must stick to exact regimen in order to be most effective and prevent transmission
Promoting activity and adequate nutrition
Prevent transmission of TB infection: instruct the patient about important hygiene measures, including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and hand hygiene. Also educate that it can spread to nonpulmonary sites on the infected as well as be transmitted to others.
Diagnosis:
Risk for infection related to inadequate primary defenses and lowered resistance.
Ineffective airway clearance related to thick, viscous, or bloody secretions.
Risk for impaired gas exchange related to decrease in effective lung surface.
Activity intolerance related to imbalance between oxygen supply and demand.
Imbalanced nutrition: less than body requirements related to inability to ingest adequate nutrients.
TB medical management
People with disease: treated with 4 medications for 2 months and then 2 medications for 4-7 months
Other people exposed or recent positive skin test: use a med just a few months
Treated with Anti-TB agent for 6-12 months (total time)
- Isoniazid (INH) - dose, SE (peripheral neuritis, hepatic enzyme elevation, hepatitis), interactions (pg. 603), teaching, use for 6-9 months unless for prevention Effects Liver
- Rifampin- SE (hepatitis, orange-red coloration of body secretions) Effects Liver
- Rifabutin
- Rifapentine
- Pyrazinamide (PZA)- hyperuricemia (monitor uric acid) Effects Liver
- Ethambutol
- Combination drugs
clinical manifestations of Pulmonary Embolism
Dyspnea Chest pain Tachycardia Hemoptysis Tachypnea hypoxia
Nursing process with pulmonary embolism
assessment:
Death commonly comes 1 hr after symptoms start so early detection is key
clinical assessment: focus on the clinical probability of risk, clinical history, symptoms, signs, and testing
Health history:
Family history:
Medication record:
Physical exam: Extremities are evaluated for warmth, redness, and inflammation.
Diagnostic Findings: can show abnormal lung function
CXR:
ECG:
ABG:
V/Q scan: most important, evaluates the different regions of the lung and allows comparisons of the percentage of ventilation and perfusion in each area.
Diagnosis:
Ineffective peripheral tissue perfusion related to obstructed pulmonary artery.
Risk for shock related to increased workload of the right ventricle.
Acute pain related to pleuritic origin.
Goals: Increase perfusion Verbalize understanding of condition, therapy regimen, and medication side effects. Display hemodynamic stability. Report pain is relieved or controlled. Follow prescribed pharmacologic regimen.
Interventions:
Prevent venous stasis: Encourage ambulation and active and passive leg exercises to prevent venous stasis.
Monitor thrombolytic therapy:Monitoring thrombolytic and anticoagulant therapy through INR or PTT.
Manage pain: Turn patient frequently and reposition to improve ventilation-perfusion ratio.
Manage oxygen therapy: Assess for signs of hypoxemia and monitor the pulse oximetry values.
Relieve anxiety: Encourage the patient to talk about any fears or concerns related to this frightening episode.
evaluate:
Increased perfusion.
Verbalized understanding of condition, therapy regimen, and medication side effects.
Displayed hemodynamic stability.
Reported pain is relieved or controlled.
Followed prescribed pharmacologic regimen.
Management of Pulmonsry embolism
Anticoagulation therapy: Heparin, and warfarin sodium has been traditionally been the primary method for managing acute DVT and PE.
Thrombolytic therapy: Urokinase, streptokinase, alteplase are used in treating PE, particularly in patients who are severely compromised.
Surgical embolectomy: the removal of the actual clot and must be performed by a cardiovascular surgical team with the patient on cardiopulmonary bypass.
Transvenous catheter embolectomy: a technique in which a vacuum-cupped catheter is introduced transvenously into the affected pulmonary artery.
Interrupting the vena cava: prevents dislodged thrombi from being swept into the lungs while allowing adequate blood flow.
risk factors of COPD
Smoking Environmental exposure: aire pollution, second hand smoke, chemicals, allergens Recurrent URI Age Genetic predisposition Air-way hyper-responsiveness No gender predisposition
Manifestations of COPD
Dyspnea, persistent and progressive Chronic cough Sputum productions Increase A to P diameter (AKA:Barrel Chest) Intercostal retractions Wheezing, rhonchi Body position; tripod Weight loss Fatigue Use of accessory muscles to breath Clubbing Pursed-lip breathing
Nursing process for COPD
Assessment:
Health history: obtain a thorough health history from patients with known or potential COPD.
Assess patient’s exposure to risk factors.
Assess the patient’s past and present medical history.
Assess the signs and symptoms of COPD and their severity.
Assess the patient’s knowledge of the disease.
Assess the patient’s vital signs.
Assess breath sounds and pattern.
Diagnosis: Blood Tests -ABG -CBC- will affect how it correlates with PaO2 Sputum studies Chest x-ray (CXR) Pulse Oximetry- fingers, toes, ear lobe, or forehead Pulmonary function test/Spirometry Bronchoscopy
Planning/goals
Improvement in gas exchange.
Achievement of airway clearance.
Improvement in breathing pattern.
Independence in self-care activities.
Improvement in activity intolerance.
Ventilation/oxygenation adequate to meet self-care needs.
Nutritional intake meeting caloric needs.
Infection treated/prevented.
Disease process/prognosis and therapeutic regimen understood.
Plan in place to meet needs after discharge.
Interventions:
High Fowler’s position and Tripod position
Monitor vital signs, pulse ox, and sputum
Encourage diaphragmatic & pursed lip breathing
Encourage “Huff” coughing
Respiratory treatments
Bronchodilators
LOW concentration of O2 (1-2 L/min) as ordered
Chest physiotherapy
Suction if necessary
Monitor weight
Promote nutrition
Small, frequent meals (High cal., high protein)
Activity as tolerated
Medications as prescribed
Prevent infection: flu & pneumonia vaccines
Smoking cessation
Self-care strategies
Evaluation
Identifies the hazards of cigarette smoking
Identifies resources for smoking cessation
Enrolls in smoking cessation program
Minimizes or eliminates exposures
Verbalizes the need for fluids
Is free of infection
Practices breathing techniques
Performs activities with less shortness of breath
Managing COPD
Smoking cessation
Education/Self-Management
Pharmacologic Therapy: alpha1-antitrypsin augmentation therapy, antibiotic agents, mucolytic agents, antitussive agents, vasodilators, and narcotics
Bronchodilators: relieve bronchospasm by altering the smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation
Corticosteroids: A short trial course of oral corticosteroids may be prescribed for patients to determine whether pulmonary function improves and symptoms decrease
Pulmonary rehab
Oxygen
surgery
clinical manifestations of asthma
Cough Wheezing (initially on expiration, severe=inspiration too Dyspnea Chest tightness Tachypnea Tachycardia Use of accessory muscles Restlessness Decreased O2 sat Cyanosis Hyperresonance Diaphoresis (if severe) Widened pulse pressure (if severe)
Nursing Process for asthma
Assessment: fam history hisotry Assess respiratory status: Assess the patient’s respiratory status by monitoring the severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs. assess medications
Diagnostic Tests: Spirometry: Forced vital capacity (FVC) Forced expiratory volume in 1 second (FEV 1) FEV1/FVC ratio (FEV1/FVC): % <70% Blood tests: IgE immunoglobulin: because asthma is an allergic reaction Arterial Blood Gas (ABG) Chest x-ray (CXR) Pulse oximetry: Peak Flow: measure the highest airflow during a forced expiration, helps measure asthma severity and, when added to symptom monitoring, indicates the current degree of asthma control Measure same time everyday Repeat 3 times Record highest reading Zones for assessment
Diagnosis:
Nursing Diagnoses:
Ineffective airway clearance related to increased production of mucus and bronchospasm.
Impaired gas exchange related to altered delivery of inspired O2.
Anxiety related to perceived threat of death.
Interventions:
Pharmacologic therapy: Administer medications as prescribed and monitor patient’s responses to medications.
Fluid therapy: Administer fluids if the patient is dehydrated.
Planning/Goals:
Maintenance of airway patency.
Expectoration of secretions.
Demonstration of absence/reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange.
Verbalization of understanding of causes and therapeutic management regimen.
Demonstration of behaviors to improve or maintain clear airway.
Identification of potential complications and how to initiate appropriate preventive or corrective actions.
Evaluation:
Maintenance of airway patency.
Expectoration or clearance of secretions.
Absence /reduction of congestion with breath sound clear, noiseless respirations, and improved oxygen exchange.
Verbalized understanding of causes and therapeutic management regimen.
Demonstrated behaviors to improve or maintain clear airway.
Identified potential complications and how to initiate appropriate preventive or corrective actions.
Managing Asthma
High Fowler’s position Vital signs & Pulse ox Peak flow O2 as ordered Patient education: ID triggers and measures to prevent exposure Lifelong management Medication administration Use of peak flow meter Asthma Action Plan: Help pt to develop their asthma action plan so they can prevent attacks and have a better quality of life
A- adrenergics S- steroids T- theophylline H- Hydration (IV) M- mask O2 A- anticholingergics
Triggers for asthma
hypersensitivty URI exercise air pollutants GERD
GI Assessment
-Pain: duration, pattern, frequency, location, referred
-Previous GI disorders, abdominal surgeries
-GI symptoms:
Change in appetite, weight (gain or loss)
-Medications
-Social history
-Travel history
-Nutritional history
Special diet needs
Food alleergies, intolerances
Change in eating habits
socioeconomic status
Culture/ethnicity
GI Physical Examination
-Inspection: Mouth, tongue, buccal mucosa, teeth and gums, abdominal skin
-Auscultation: Always precedes percussion and palpation
-Percussion: Percussion of entire abdomen
-Palpation:
Assess area of tenderness last.
Murphy’s sign and rebound tenderness
-Rectal examination
Last part, most uncomfortable
Diagnostic Evaluation of GI System
-Serum labs: CBC and metabolic profile Liver enzymes (AST & ALT) and cholesterol and triglycerides, PT/PTT Bilirubin; amylase and lipase Ammonia -Stool tests: FOBT, steatorrhea, ova parasites, C. Diff -Abdominal ultrasonography -Imaging Studies: Upper and lower GI tract studies CT, MRI, PET, motility studies
Barium Enema
Purpose:
- Identify structural abnormalities of rectum, colon
- Barium enema enhances radiographic visualization
Before Test:
- Clear liquid diet 24 hours
- NPO 8 hours
- Bowel cleansing with laxatives, enemas, suppositories evening before
After the test:
- Increase fluids to wash out enema.
- Stool may be chalky white for 24 to 72 hours when it comes out.
Small Bowel Series
Before test: -Low-residual diet for 48 hrs. -No food for 8 hrs. No fluids for 4 hrs. -Withhold analgesics & anticholinergics for 24 hr. -Patient drinks 16 oz. of barium During: -Films taken every 20min. until medium reaches terminal ileum -Rotate examination table After test: -Increase fluids -Mild laxative or stool softener -Stools may be chalky white for 24 to 72 hr.
Esophagogastroduodenoscopy
Purpose: visualize esophagus, stomach, & duodenum
Before test:
-Avoid anticoagulants, ASA, NSAIDs for several days
-NPO 8 hr. Position left lateral.
-Conscious sedation: spray anesthetic, midazolam IV, atropine, glucagon
After test:
-Assess VS, O2 sat, LOC, & pain every 30 min.
-NPO until gag reflex returns.
-Throat discomfort possible for several days.
-Must be transported home by another person.
Complications: perforation (pain, bleeding), dysphagia, rapidly elevated temperature
Colonoscopy
Purpose: Visualize entire colon to ileocecal valve. Identify tumors, polyps, inflammatory bowel disease
-Before test:
Bowel prep varies by physician/clinic
Liquid diet for 12-24 hr before; NPO for 6 to 8 hr
-During test: Same as for EGD
-After test: Same as for EGD
If polypectomy or tissue biopsy, visible blood in stool is possible
Teach: flatus
Complications: perforation
Report: abd. pain, chills, fever, rectal bleeding, mucopurulent discharge
Hiatal Hernia
Patho: upper stomach and gastroesophageal junction pushes through diaphragm and moves into thorax.
Causes: Increased abdominal cavity pressure (coughing, straining, lifting, pregnancy, obesity)
Manifestations:
-50% asymptomatic
-Heartburn, pyrosis, regurgitation, dysphagia
Complications:
-hemorrhage, obstruction, strangulation
Assessment: -Differentiate chest pain (angina) from CP caused by reflux -Auscultate lungs (asthma) Diagnosis: -Barium swallow with fluaroscopy -EGD -Esophageal manometry -pH test -Gastric emptying study
Management:
-Frequent, small meals
Avoid eating late in evening
-Avoid acidic and fatty foods. Avoid caffeine, alcohol, ketchup and mustard, vinegar
-Elevate head after eating. Do not recline for at least 1 hr pc
-Elevate HOB
-Lose weight
-Quit smoking
-Avoid wearing a tight belt, clothing. Avoid straining
-Take meds that reduce acid in stomach
Gastroesophageal Reflux Disease (GERD)
Contents flow back into esophagus
Causes:
- Incompetent Les or relaxation of LES
- Increased gastric volume (after meals)
- Positioning (bending over, lying down)
- Increased gastric pressure (pregnancy, obesity)
- Hiatal hernia
Risk Factor: Obesity
Medications: -PPI (omeprazole) most effective! take 30 minutes before eating twice daily dosing -gaviscon (antacid) -carafate -H2 receptor antagonists (cimetidine) -baclofen
endoluminal therapies
-Transoral incisionless fundoplication (TIF)
Surgery: fundoplication
Manifestations: -Dyspepsia: “heartburn” (usually after meals, when bending over or reclining) Regurgitation of sour substance into mouth -Hypersalivation (water brash) -Eructation (belching) -Flatulence (gas) -Bloating -Odynophagia (painful swallowing) -Pain after eating -Dysphagia -N & V
other manifestations:
- Chest pain
- Wheezing
- Coughing
- Dyspnea
GERD Teaching
- Lose weight
- Diet: small, more frequent. Avoid carbonated drinks, alcohol, caffiene, tobacco, high-fiber and low fat diet recommended.
- After you eat don’t lay down
- Avoid tight clothing
- Regular sleeping patterns, don’t stay up late
- Avoid eating right before bed
Fundoplication
Fundus is wrapped around distal esophagus: Nissen fundoplication for GERD or hiatal hernia repair.
Post-op management:
- Respiratory care
- NG managment
- Nutrional care
Post-op Teaching:
-Activity restrictions: no driving for 1 week, do not drive if taking opioids, walk every day, no heavy lifting.
- Complications:
- Temp greater than 101. 100 for elderly
- N/V, uncontrollable bloating, pain
- Temporary dysphagia
- gas bloat syndrome
- atelectasis, pneumonia
- Obstructed NG tube
GERD: Complications
- Acidic stomach contents damage esophagus
- Leads to Esophagitis and ulcers develop. Healing occurs, but may substitute Barrett’s epithelium for normal squamous cell epithelium
- Barrett’s esophagus (Premalignant)-> esophageal scarring and strictures -> esophageal cancer -> hemorrhage, aspiration penumonia, asthma laryngitis, dental decay, cardiac disease
- Asthma
Barrett’s esophagus
Lining of the esophageal mucosa is altered
- Manifestations and Assessment:
- Complains of s/s of GERD
- Frequent heartburn
Management
- EGD performed
- Monitoring
Gastritis
- Inflammation of gastric mucosa
- Impaired mucosal barrier allows HCl to come into contact with gastric mucosa
- Epigastric pain, anorexia, hiccups, n/v
Peptic Ulcer Disease (PUD)
Risk Factors:
- 40-60 years old
- H. pylori infection
- familial tendancy (type O blood)
- chronic use of NSAIDs, alcohol, smoking
Manifestations:
- May be asymptomatic
- dull, gnawing pain, burning in midepigastrium or back
- Pain often relieved by eating
- heartburn, V/C/D, bleeding
Treatment:
- combination of antibiotics to eradicate H. pylori
- H2 receptor antagonists
- PPIs
- Surgery
Assessment: -Pain -72 hour diet recall -VS -Meds? NSAIDS? Gi: melena, occult? Lifestyle? Habits?
Nursing Dx:
-Acute pain
-Anxiety
Imbalance Nutrition
Interventions:
- Relieve pain
- Lifestyle management: reduce anxiety, adeq. rest, smoking cessation
- Maintain optimal nutrition
- Manage complications
- Home Care
Evaluation
Complications of PUD:
Hemorrhage
Perforation
