Exam 2 Flashcards
Palliative care
Care for seriously ill; includes psychosocial care, spiritual support, pain control, interdisciplinary collaboration
- “Anyone” can be on palliative
Hospice care
Care for seriously ill; must accept death; illness not responding to curative care; strict reimbursement policies
Advanced directive
Oral and written instructions about end of life care, should the Pt become unable to
make decisions
Durable power of attorney
A legal doc that authorizes an individual to make medical decisions on behalf of the
patient
Living Will
Type of advanced directive
Physician Orders for Life-Sustaining Treatment
Translates the advanced directives into medical orders.
Kubler-Ross Model
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Cachexia
“Wasting syndrome”
A general state of ill health involving marked weight loss and muscle loss.
Cheyne-Stokes breathing
An atypical pattern of breathing involving deep breathing followed by shallow breathing.
Partial pressure
The pressure of a gas in a mixture
The exertion of the gas particles against the arteries in the alveoli
Atelectasis
Collapsed alveoli
Tidal Volume
Normal volume of air that flows in and out in one breath
Includes dead space, or the air that sits in the bronchial tree
Oxygenation
Obtaining oxygen from the air for gas exchange
Ventilation
The movement of the walls of the thoracic cage
- Diaphragm moving up and down
- Ribs widening and relaxing
Elastic recoil
Lungs ability to return to it original size
Things that effect ventilation
Gravity: Pt sitting upright can breathe better
Airway blockage
Pt effort and strength
Compliance: Lungs ability to expand and contract
- Fibrosis, obesity, pneumothorax,
Resistance: Relationship between airflow and pleural pressure (determined by bronchi condition)
Ventilation perfusion ratio
Amount of air getting to alveoli : amount of blood being sent to lungs
- AKA VQ
What controls respirations
Chemoreceptors: Located in medulla, respond to hydrogen changes
- Chemoreceptors in carotid arteries respond to low oxygen
Mechanical receptors: Located in smooth muscle of lungs, upper airway, chest, and diaphragm; controls stretch and respiration or inhibits lung expansion
- Stimulated by irritants
Age related changes : defense system
Decreased cilia, decreased mucus, decreased cough and gag
Decreased protection against foreign invaders, increased risk of infection
Age related changes : Lungs
Narrowing airway, increased thickness of alveoli, decreased elasticity
- Increased airway resistance
- Decreased O2 levels, increased CO2 levels
Age related changes : Chest
Decreased continuity of diaphragm, increased stiffness of thoracic cage
- Increased use of accessory muscles, harder to breath
- Barrel chest, kyphosis, SOB
Tactile fremitus exam
Pt says “99” as you move palm of hand around pt’s back
Vibration increases over areas of congestion
Chest expansion exam
Chest should expand symmetrically
Normal breath sounds
Bronchial: Heard over the sternum, larynx and trachea
Bronchovescicular: Heard in center of chest
Vesicular: Heard over periphery of lungs
Crackles
Popping; usually first heard in base of lungs
- Ex. CHF, infiltrate
Wheezes
Whistling; usually heard in upper airway
- Ex. asthma - narrowing airway
Stridor
Course/snoring;
- Ex. Obstruction, airway blockage, snoring
Hyper-resonance
Increased loudness over areas of increased air
- Hyper-resonance bilaterally can indicate emphysema (air trapping)
- Hyper-resonance on one side may indicate pneumothorax
Tympany
Loud, hollow, drum-like sounds
- May indicate pneumothorax
What lab represents respiratory health?
CO2
What lab represents metabolic health?
Bicarbonate (HCO3)
- More = basic
- Less = acidic
Bronchoscopy
Lighted camera used to visualize the larynx, trachea, and bronchi
- Can get tissue sample or remove tumor/foreign body
Bronchoscopy nursing considerations
- Pt NPO 48 hrs prior
- Aspiration risk
- Be sure gag reflex returns post-op before offering ice chips
- Monitor pulse ox - high risk for perforation
Thoracoscopy
Light scope used to visualize pleural cavity
Enters between intercostal space
Thoracoscopy nursing considerations
Pt NPO at midnight
Look for signs of bleeding and infection
Monitor respiratory status (lung perforation risk)
Thoracentesis
Removing fluid from pleural space
Diagnostic or therapeutic (pleural effusion)
Nursing considerations post thoracentesis
Airway (!), SOB, pain, infection, drainage, redness
Tidal volume (TV)
Volume of air in each breath
- Spirometry can be used to measure this
- Measure several to get a range
Forced vital capacity (FVC)
Amount of air forced out with exhalation
How does asthma effect FVC?
They show a decrease of 15-20%
Nursing considerations before FVC test
NPO
Hold sedatives
Give any medications prior to testing
Light meal after
Avoid smoking for 3 days
Nose will be clipped during test
Forced expiratory volume in first second (FEV1)
Amount of air forced out of lungs in 1 second
Peak expiratory flow rate (PEFR)
Volume of air forcefully expelled from the lungs in one quick exhalation
Peak flow meter
Used by asthmatics to measure FVC
Sputum culture nursing consideration
Best obtained in the morning before meals
What does a chest xray (CXR) look for?
Foreign bodies, tumors
Fluoroscopy
Live xray view with camera; may use a dye
Views movement of the chest wall, diaphragm, or heart to locate masses
May be used during needle biopsy or bronchoscopy
CT
Cross section to see tissue density, tumors, abnormalities on bone that isn’t easily seen with chest xray
May be used with contrast
MRI
Better for distinguishing normal/abnormal tissue (nodules, cancer, inflammation, or embolism)
Angiography
Looks at the vasculature of the vessels with a radio-opaque dye
Looking at pulmonary embolism or thromboembolism
Angiography nursing consideration
Check for allergy to shellfish or iodine
Check kidney function
Explain that a warm feeling or chest pain is normal when the dye is injected
Encourage fluids to excrete dye
VQ Scan
Uses injected radio isotope to view blood flow
Gallium scan
Uses an isotope to look for inflammation
Tumors, abscesses, adhesions
PET Scan
Uses an isotope to look at metabolic changes from malignancies
Pneumoconiosis types
Silicosis
Asbestosis
Coal Miners Pneumoconiosis (CWP)
Pneumoconiosis pathophysiology
Changing of lung tissue that occurs from inhaled particles
Lungs become fibrotic
- Symptoms may not show for 10-15 years after exposure
Silicosis
Inhaled silica - the primary ingredient in glass production
Nodules and fibrotic changes lead to lung disease and emphysema/pulmonary hypertension
Body tries to encapsulate the foreign particle
Silicosis s/sx
Does not present for about 5 years
SOB, fever, cough, weight loss
Can lead to heart failure
Asbestosis pathology
Asbestos enters alveoli and becomes encased in fibrotic tissue which may lead to plaques
Gas exchange is impaired
Can lead to mesothelioma and other lung cancers
Asbestosis s/sx
SOB, dry cough, chest pain, weight loss, clubbed fingers
Coal Miners Pneumoconiosis (CWP) pathology
Macrophages encase the coal and become fibrotic, alveoli are filled with dust
Can lead to lesions, emphysema, respiratory failure
Coal Miners Pneumoconiosis (CWP) s/sx
SOB, chronic cough, black or grey expectorant
Obstructive sleep apnea
Recurrent and repetitive upper airway obstruction
10 seconds or longer, at least 5 episodes per hour
Reduced ventilation or apnea during sleep
Obstructive sleep apnea risk factors
Male gender
Obesity
Post menopausal female
Obstructive sleep apnea pathology
Larynx is collapsible and can be compressed by surrounding soft tissue
Reduced upper airway during sleep
- Leads to hypoxia and hypercapnea, which causes hypertension and increased risk for MI or stroke
3 S’s of obstructive sleep apnea characteristics
Snoring
Sleepiness
Significant other report of apnea
Obstructive sleep apnea s/sx
Daytime sleepiness, headache, irritability, weight gain, dysrhythmias
How to dx obstructive sleep apnea
Sleep study with EKG
Deviated septum
Shift from midline
Usually from fracture from assault
Deviated septum s/sx
Pain, bleeding, swelling, deformity, obstruction, crepitus
(AIRWAY)
Deviated septum and fracture tx
Avoid NSAIDs (risk for bleeding)
Pack nose and cold compress
Closed reduction (best done within 3 hours)
Rhinoplasty - reshaping exterior
Septorhioplasty - repairing deviated septum
Epistaxis risk factors
Dry mucous membranes, hypertension, trauma, aspirin use
Epistaxis treatment
Anterior nose bleed: Pressure for 10 minutes, ice, tilt head forward, nasal decongestant spray (vasoconstrictor), silver nitrate cauterization, do not blow nose for 24 hours, avoid exercise
Posterior nose bleed:Emergent: packing placed for days, packing balloon
Packing balloon (epistaxis) nursing considerations
Assess respiratory status for distress
Give humidifier air/oxygen
Bed rest
Antibiotic (risk for toxic shock syndrome)
Pain medication
Obstructive sleep apnea tx
Tonsillectomy, uvulopalatopharyngoplasty, nasal septoplasty
May need tracheostomy if not relieved
Deviated septum and fracture nursing considerations
Avoid NSAIDs (risk for bleeding)
Pack nose and cold compress
Clear liquid from nose could be cerebral spinal fluid
Monitor airway
Monitor for swallowing
Semi-fowlers to help with breathing
Allergic rhinitis
Can be seasonal (intermittent) or persistent (pet dander)
Caused by allergens, defects, or virus
May be associated with changes in temperature, humidity, or age
Allergens can be foods, medications, environmental particles
Acute viral rhinitis
Common cold; upper respiratory infection (URI)
Often occurs in fall, winter, and spring
Most common cold caused by “rhinovirus organism and influenza virus”
Allergic rhinitis tx
Remove allergen
Steroid, antihistamines, decongestants, pseudoephedrine, nasal spray (Flonase)
Rhinitis from deformity tx
Remove nasal polyps
Viral rhinitis tx
Treat symptoms
Expectorant (Mucinex), steam, other meds similar to allergic rhinitis tx
Influenza
Highly contagious respiratory illness
Influenza patho
Virus that mutates, difficult to build immunity
Spread through infected droplets
How to dx influenza
Cultures, nasal swab
Influenza s/sx
Abrupt onset, fever, chills, H/A, cough, sore throat, fatigue, SOB, crackles, weakness, lethargy
Influenza tx
Prevent with vaccine (takes 2 weeks to work)
Tamiflu, antivirals, treat symptoms
Rhinosinusitis and sinusitis patho
Inflammation of paranasal sinus and nasal cavity
Rhinosinusitis/sinusitis causes
Mechanical obstruction (polyp or tumor)
Hormonal
Infectious
Chronic inflammation
Rhinosinusitis/sinusitis classifications
Acute: acute bacterial or acute viral (edema, strep., influenza, or staph. grow easily)
Chronic: 8 weeks or longer of two or more symptoms
Recurrent: 4 or more episodes of acute bacterial
Rhinosinusitis/sinusitis s/sx
Nasal congestion (due to inflammation or obstruction)
Drainage
Sinus pain
Pressure in periorbital area
Teeth/ear/nose pain
Transillumination shows blockage
Redness in nasal airway
Droopy eyelids from edema
Hoarseness
Headache around eyes
Difference between acute bacterial and acute viral rhinosinusitis
Acute bacterial: Lasts more than 10 days, accompanied by fever
Acute viral: Less than 10 days, no fever, lesser symptoms
Rhinosinusitis dx
Xray or CT of sinuses
Culture and sensitivity of mucous
Rhinosinusitis tx
Viral: Treat symptoms
Bacterial: Antibiotic
Chronic: Treated for 2wks-12months; may have sinus surgery - functional endoscopic sinus surgery (FESS)
What can untreated chronic rhinosinusitis lead to
Osteomyelitis, meningitis, or brain abscess
Pt education for rhinosinusitis
Recurrent - begin decongestants
When to see provider:
Periorbital edema or pain
Nuchal rigidity or high fever - immediate treatment, may be meningitis
Nasal obstruction causes
Deviated septum
Bone
Polyps
Nasal obstruction s/sx
Mouth breathing, dry mouth, cracked lips, sleep deprivation, voice quality changes
Nasal obstruction tx
Depends on cause:
Deviated septum - surgery
Polyps - corticosteroids for small ones, polypectomy for larger
Education for nasal obstruction post op
Avoid blowing nose
Watch for s/sx of bleeding and infection
Pharyngitis
Sudden, painful inflammation of back of throat, back of tongue, tonsils, soft palate
Causes of acute pharyngitis
Viral: Influenza, Epstein Barr virus, herpes
Bacterial: Strep
Causes of chronic pharyngitis and types
Smoking, alcohol, dust, allergens
Hypertropic: generalized thickness of pharyngeal mucus membrane
Atrophic: late stage of first
Chronic granular: numerous swollen lymph follicles
Pharyngitis dx
Rapid antigen detection test
Pharyngitis s/sx
Inflammation, redness, bad breath, white exudate, enlarged lymph nodes
Bacterial: Temp over 101
Chronic: Complaints of fullness in throat
Pharyngitis tx
Viral: Self limiting, 3-10 days (throat drops, gargling)
Bacterial: Antibiotic
Chronic: Tonsillectomy or remove irritant
What can untreated bacterial pharyngitis lead to
Meningitis and rheumatic fever
What patients are more at risk for strep throat
Those with a history of scarlet fever, rheumatic fever, or signs of an abscess
- Call doctor at first sign of pharyngitis
Tonsillitis and Adenoiditis patho/cause
Acute:
Viral: Epstein Barr
Bacterial: Strep
Chronic: Can be mistaken for allergies, asthma, rhinosinusitis
Tonsillitis and Adenoiditis s/sx
Sore throat, fever, snoring, enlarged adenoids, difficulty swallowing, ear infections, draining ears, bronchitis
Tonsillitis treatment
Viral: Supportive measures (throat drops, gargling, analgesics)
Bacterial: Antibiotics (PCN, cephalosporin)
Surgical removal: After repeated episodes despite ABX
What can bacterial tonsillitis/adenoiditis lead to if untreated
Otitis media, abscess, meningitis, rheumatic fever, nephritis
Nursing considerations for tonsillitis/adenoiditis post op
Monitor for hemorrhage
Turn pt to side and elevate HOB to facilitate drainage
Provide ice chips and ice packs
No dairy, heat, or scratchy foods
Peritonsillar abscess patho
“The Quincy”
Bacterial: staph
Suppurative (pus forming) complication of tonsillitis
Peritonsillar abscess s/sx
Fullness in voice, displaced uvula, severe sore throat, fever, difficulty swallowing, ear pain
Peritonsillar abscess tx
Needle aspiration
Antibiotics
Corticosteroids
Tonsillectomy
What can peritonsillar abscess lead to if left untreated
Intracranial abscess, empyema (infection of pleural space)
Laryngitis patho
Due to snoring, exposure to irritants (dust, chemicals, smoke), allergens, GERD, or infection
Laryngitis classifications
Acute:
Viral: often same virus that causes common cold
Bacterial: may be secondary to other bacterial infection
Chronic: Can be mistaken for allergies, asthma, rhinosinusitis
Laryngitis s/sx
Hoarseness, aphonia (complete loss of voice)
Sometimes worse in am, improves over day, and may worsen in evening
Laryngitis tx
Acute viral: Rest voice, avoid irritants, avoid smoking
Acute bacterial: Antibiotics
Chronic: Corticosteroids, GERD - PPI
Obstructive pulmonary disease patho
Preventable and slowly progressive
Changes in pulmonary vessels and narrowing in airway
Airway limitations due to chronic inflammation caused by thickening from fibrosis or scar tissue
Alveoli may have lost elasticity and recoil
Pulmonary veins and arteries can thicken and cause smooth muscle of the lung tissue to hypertrophy
What diseases are included in obstructive pulmonary disease
Bronchiectasis
Cystic fibrosis
Asthma
Chronic bronchitis
Emphysema
Bronchiectasis
Chronic irreversible dilation of bronchi and bronchioles
Bronchiectasis patho
Inflammation damages bronchiol wall, resulting in sputum
Sputum drains through the bronchi, then into lower lobes and alveoli
Causes reduced vital capacity and decreased ventilation
Bronchiectasis causes
Airway obstruction
Congenital disorders - cystic fibrosis, childhood recurrent respiratory problems, measles, flu, immune deficiencies
Bronchiectasis dx
CT scan: dilation of bronchioles
- Often misdiagnosed for chronic bronchitis
Sputum cultures - looking for Pseudomonas aeruginosa
Bronchiectasis s/sx
Chronic productive cough with sputum
Possible hemoptysis
Clubbed fingers
Cystic fibrosis patho
Lethal genetic disease
Error of chloride transport, producing thick mucus with low water content
Mucus plugs up glands in lungs, pancreas, liver, salivary glands, and testes, causing atrophy and organ dysfunction
Cystic fibrosis dx
Sweat chloride analysis - increased sodium and chloride
GI enzyme evaluation - pancreatic enzyme deficiency
CXR - will show hyperinflation of lungs
Cystic fibrosis s/sx
Chest congestion
Limited exercise tolerance
Sputum production
Use of accessory muscles
Decreased pulmonary function
Increased A:P diameter
Abdominal distention
Rectal prolapse/steatorrhea
Nursing considerations for cystic fibrosis
Administer pancreatic enzymes with meals
Diabetic diet
Assess for s/sx of infection
Encourage fluids
Chest physiotherapy
Comorbidities of cystic fibrosis
Vitamin deficiencies
DM: due to pancreatic enzyme deficiency
Osteoporosis
GERD
Cystic fibrosis medication management
Mucolytics
Nebulized antibiotic
Inhaled hypertonic saline - hydration
Pancreatic enzyme therapy
Heliox therapy - helium + oxygen
Cystic fibrosis surgical management
Lung or pancreas transplant
What diseases fall under the COPD umbrella?
Chronic bronchitis
Emphysema
Irreversible or Refractory asthma
Asthma
Chronic inflammatory disease of the airway that causes intermittent hyper responsiveness, mucosal edema and mucus
AKA Reactive Airway Disease
Asthma exacerbation complications
Can be severe and life threatening
Acute episode of airway obstruction that intensifies
Complications: Pneumothorax, cardiac/respiratory arrest
Asthma risk factors
Intrinsic: Sensitivity to NSAID’s or Aspirin, prone to respiratory infections, GERD, eczema
Extrinsic: Exposure to dust, pollen, and cigarette smoke
Asthma patho
Allergen activates mast cell to release histamine, creating inflammation, increased blood flow, vasoconstriction, and bronchoconstriction
Also attracts WBC’s and mucus to the area
Ways an airway obstruction occur in asthma
Reversible inflammation of pulmonary airway: Response to cold air, allergen, irritant
Airway hyper-responsiveness: Bronchoconstriction during exercise, GERD, or respiratory illness
Asthma s/sx
Chest tightness, wheeze with inspiration, increased RR, SOB, cough, use of accessory muscles, “barrel chest” from air trapping, long breathing cycle, cyanosis, hypoxemia, tachycardia, changes in LOC
Asthma dx
CXR
Pulmonary function tests
ABGs
Asthma nursing considerations
Asthma action plan - diff medication plan for “green”, “yellow”, and “red” days
Educate:
Avoid triggers
Raise HOB - GERD
CPAP - sleep study if pt is snoring
Bronchodilators used for asthma
Short and long-acting beta2 agonists (Ventolin/Serevent)
Cholinergic antagonists (Spiriva)
Methylxanthines
Anti-inflammatory drugs used for asthma
Corticosteroids (Flovent, Pulmacort)
Leukotriene antagonists (Singular)
Cromones
Immunomodulators (Xolair)
Combination drugs used for asthma
Long acting beta 2 and corticosteroid (Advair Diskus)
Other drugs used for asthma
Mucolytics, antibiotics, vasodilators, A1A treatment, vaccines
**Meter Dose Inhaler considerations
Timing has to be accurate - spacer
Rinse mouth after use
**Dry Powder Inhaler considerations
Rapid inhaled delivery - must take deep breath
Status asthmaticus
Complication of asthma
Rapid and persistent asthma exacerbation
EMERGENT
Status asthmaticus s/sx
Labored breathing, wheezing, unable to speak, drowsy/coma, poor respiratory effort, bradycardia, paradoxical thoraco-abdominal breathing, silent chest, cyanosis, oxygen sat under 92%
Status asthmaticus dx
ABGs
Pulmonary function tests (PFTs)
Status asthmaticus tx
Short acting beta-adrenergic agonist nebulizer, steroid
Chronic bronchitis and emphysema risk factors
Smoking, second-hand smoke, dust, chemicals, pollution, history of respiratory illness, allergies, asthma, polyps
A1A deficiency: genetic condition associated with emphysema
Chronic bronchitis and emphysema assessment findings
SOB, barrel chest, clubbing, accessory muscle use, coughing, peripheral edema, anxiety
Chronic bronchitis and emphysema dx
ABGs
Spirometry
Pulmonary function tests (PFTs)
CXR
Chronic bronchitis and emphysema complications
Respiratory failure, hypoxemia, acidosis, respiratory infections (pneumonia), cardiac failure, dysrhythmias
Chronic bronchitis s/sx
Chronic cough with sputum, dusky/cyanotic color, hypercapnia, increased RR, exertional dyspnea, clubbing
Chronic bronchitis patho
Chronic irritants that produce mucous, which interferes with the cilia
Bronchioles and alveoli may become irreversibly damaged and fibrotic
Pt is susceptible to infections from increased macrophages
Chronic bronchitis nursing considerations
O2 therapy
Conserving energy
Long term steroids and mucolytics
Assess for infections
Educate pt to get pneumonia vaccine
Stop smoking
Emphysema
Chronic progressive lung disease
Impaired gas exchange that results in over distention and destruction of alveoli
Pulmonary veins resist blood flow causing pulmonary artery hypertension (Cor pulmonale-right sided HF)
Panlobular vs Centrilobular emphysema
Panlobular: Bronchioles, alveolar ducts, and alveoli and enlarged
Centrilobular: Enlarged alveoli lobes
Emphysema s/sx
Hypercapnia, purse lip breathing, hyperresonance on chest percussion, thin appearance, barrel chest, increased RR
Emphysema tx
Bronchodilators: Short acting (albuterol) and Long acting (bromides)
Corticosteroids
Lung reduction surgery: removes hyper-inflated lung tissue
COPD exacerbation
Acute change or worsening of symptoms
Cor pulmonale, worsening cyanosis, peripheral edema, SOB, confusion, lethargy
COPD exacerbation causes
Need for new medication management
New allergen or season
**COPD exacerbation tx
Oxygen - for severe only, watch for toxicity (O2 sat 90-95%)
Surgery - Bullectomy: removes enlarged airspaces, Lung Volume Reduction: removed damaged lung tissue, Lung transplant
Types of chest physiotherapy
Postural drainage: Changing positions to loosen secretions
Chest percussion/vibration: Cupping hands, lightly strike chest wall
Breathing retraining: Pursed lip and diaphragmatic breathing
Incentive spirometry
Oxygen delivery methods
Low Flow
Nasal cannula: 1-6L
Face mask: 6-12 L
Partial/Non Rebreather: 10-15L
Non-Invasive Positive Pressure Ventilation:
CPAP/BiPAP
High Flow
Venturi mask: measured in oxygen %
Trach collar/T tube
High flow nasal cannula: Max 60L, 100%
Trach cuff pressure
Check Q8h
Should be 15-22 mmHg or 20-25 cmH2O
During what part of the cardiac cycle does the heart receive oxygenation
Diastole
Layers of the heart
Outer - pericardium
Middle - myocardium
Inner - endocardium
Layers of pericardium
Visceral layer - epicardium
- Fluid between these layers
Parietal layer - outer layer
Cardiac conduction pathway
Sinoatrial node (SA node) - 60-80 bpm
Atrioventricular node (AV node) - 40-60 bpm
Bundle of HIS
Purkinje fibers - stimulates ventricular contraction - 30-40 bpm
P wave represents
SA node
Depolarization =
Discharged energy
Repolarization =
Rest
Cardiac cycle
of cardiac cycles = HR
All events that occur from one beat to the next
Number of cardiac cycles = HR
Atrial kick
Atria push 15-20% more blood just before the ventricles contract
Cardiac output
Stroke volume x heart rate
Total amount of blood pumped by the left ventricle in liters per minute
4-6L per minute is normal
Stroke volume
Amount of blood ejected by the left ventricle during one contraction
What affects stroke volume
- Baroreceptors: In aortic arch and carotid arteries, affect vasoconstriction and dilation
- Preload and afterload
What affects heart rate
SA node gets info from the parasympathetic and sympathetic NS to adjust HR
Preload
How much cardiac muscle fibers can stretch during diastole
Afterload
Resistance the ventricles must overcome to eject blood out of the heart
Contractility
The strength of myocardium contraction
Reduced by hypoxemia, acidosis, and medications such as beta blockers
Ejection fraction
% of blood ejected from the heart at the end of each beat
LV ejects 55-65% (40% = HF)
S3 might mean
Ventricular gallop
S4 might mean
Atrial gallop
CK
Creatine kinase
Cardiac enzyme
Found in brain, heart, and skeletal muscle
CK-MB
Creatine kinase-myocardial band
Cardiac enzyme
Heart specific
After MI shows rise and fall over 3 day period, peaks at 24 hours
Troponin
Protein that represents cardiac necrosis
Myoglobin
In cardiac and bone
Rises 30-60 minutes after MI, declines after 7 hours
BNP
B-type natriuretic peptide
Neurohormone that regulates BP and fluid volume
>100 = HF
C-reactive protein
Produced in liver
Shows inflammation
3 or > = CVD
Homocysteine
Amino acid linked to atherosclerosis
>15 = CAD risk, stroke, PVD
PT/INR
Prothrombin Time
For pt taking Coumadin (warfarin)
PTT
Partial prothromin time
For pt on heparin
Erythrocyte sedimentation rate
Indicates inflammation
AP and lateral CXR
Shows size and position of heart
Calcifications
Can show HF
Fluoroscopy
Dye used with xray to show heart as it is moving
Myocardial perfusion testing
Isotope via IV to look at blood flow perfusion
Multiple-Gated Acquisition (MUGA) scan
Radio isotope is used to take pictures
Measures ejection fraction
CT scan for cardiac dx
Evaluates ventricle wall for thickness, lesions, tumors, masses, calcium deposits
May or may not use dye (kidney function and allergies)
Calcium score
Determines risk for future cardiac event
Positron Emission Tomography (PET) scan nursing consideration
No tobacco or caffeine for 4 hours before
Diet before depends on facility
Glucose need to be WNL
Magnetic Resonance Angiography (MRA) what is it and nursing considerations
Magnet to look at heart, pericardium, great vessels, and lesions
Can’t be done on pts with pacer or metal
Cardiac catheterization and angiography
Radiopaque iodine dye used to visualize arteries
Looks for CAD, atherosclerosis, valve disease
Cardiac catheterization and angiography nursing considerations
Monitor ECG and BP during procedure
Check for allergies and kidney function (use of dye)
NPO 8-12 hours before
Pt may feel palpitations as catheter is inserted
Radial artery - pressure for 2 hours, Femoral artery - manual pressure for 30 minutes
Electrophysiologic testing
Evaluation of AV node and dysrhythmias if ECG isn’t enough
Electrophysiologic testing nursing considerations
NPO for 6-8 hours
Explain procedure
Lasts 1-4 hours
Pressure on puncture site
Cardiac mapping
Shows electrical cells firing in addition to SA and AV nodes
Mapping will locate the origin of arrhythmias
Radiofrequency ablation for arrhythmias
Uses radiofrequency energy to destroy the heart tissue that is causing rapid and irregular heartbeats
Helps restore your heart’s regular rhythm
Catheter through femoral artery into heart
Radiofrequency ablation nursing considerations
Leg straight for 6-8 hours
Monitor pulse and BP
Teach to report pain or bleeding at puncture site and chest pain
Central Venous Pressure Monitoring (CVP)
Used to monitor right ventricular functioning
2-6 mmHg, 6+ = elevated LV preload
*don’t need to know details
Pulmonary Artery Pressure Monitoring (PAPM)
Monitor and assesses LV function - measures cardiac output
Used to assess the patients response to IV fluids, medications, and interventions
*don’t need to know details
Systemic or Intra-arterial Blood Pressure Monitoring (SAPM)
For continuous BP monitoring for patients with high or low BP and when frequent ABG’s are needed
Hypertension dx
Urinalysis
Labs (sodium, potassium, BUN, creatinine, lipids)
Renin levels
24 hours urine
EKG
HTN s/sx
“silent killer” - sometimes no symptoms
Retinal damage
Nocturia
H/A, flushing, dizziness
TIAs (transient ischemic attacks)
Chest pain
Intermittent claudication (muscle pain with activity)
HTN complications
CAD, left ventricular hypertrophy, HF, resistant HTN, orthostatic hypertension, hypertensive crisis (180+/120+)
Coronary artery disease
Blockages of one or more of the arteries that supply the heart
- Usually due to arteriosclerosis and atherosclerosis
Arteriosclerosis
Thickening or hardening of arterial wall
- often associated with aging
Atherosclerosis
Intima accumulates with lipids, calcium, and carbs to make plaque
Two types of lesions (CAD)
- Fatty streaks: Yellow and smooth, protrude slightly into the lumen
- Fibrous plaques: Whiteish, sometimes completely protrude into the lumen; often in abdominal aorta
- Plaques form over fatty streak
- Plaques are either stable or unstable
Collateral circulation
Capillaries form around a clot to provide circulation
Peripheral arterial disease (PAD)
Thickening of arterial wall due to atherosclerosis
Peripheral arterial disease risk factors
Hypertension, hyperlipidemia, DM, smoking, obesity, family hx
Lower extremity occlusion s/sx
Pain, intermittent claudication (calf pain with activity, worse at night, better with dangling legs)
Peripheral arterial disease dx
Doppler
Angiography
Aortoiliac occlusive disease
Form of PAD
Blockage of abdominal aorta as it transitions into the common iliac arteries
Aortoiliac occlusive disease s/sx
Butt or low back pain associated with walking
Men - impotence
Aortoiliac occlusive disease dx
Doppler
Angiography
Aortoiliac occlusive disease tx
Aortoiliac and Aortofemoral bypass
Aortoiliac occlusive disease nursing consideration
Surgery interventions
Abdominal assessment - returned bowel sounds in 3 days, NGT secretions, post op care, advance diet slowly
Doppler ultrasound flow study
Transducer probe detects blood flow and measures pressure in lower extremities at different intervals to determine inflow vs outflow disease
- Use Doppler if having trouble obtaining pulse
- More useful when combined with ankle blood pressure to determine ABI
Ankle-brachial index (ABI)
The ratio of systolic BP in the ankle compared to both arms
Duplex ultrasonography
Doppler showing color flow
Non invasive
NPO for 6 hours - for decreased abdominal gas which can interfere with test
Arteriogram
Radiopaque dye injected into arterial system to watch blood flow
Used to visualize aneurysms and collateral circulation
Venogram
Radiopaque dye injected into venous system to watch blood flow
Lymphoscintigraphy
Radioactive colloid to study lymphatic system
C reactive protein
A protein produced in the liver
Nonspecific marker of inflammation
Increase is associated with vascular damage
Arterial disease s/sx
Decreased/absent peripheral pulse
NO LE edema
Loss of hair, shiny, cool skin
Dependent rubor
Extremity is cool/blue
Pallor with elevation
Bruit
Venous disease s/sx
LE edema
Peripheral pulses present but different due to edema
Skin is thick and warm, thick toenails
What patients should not take statins/niacin
Patients with liver disease - can cause muscle pain and elevated liver enzymes
Peripheral vascular/arterial disease nursing considerations
Antiplatelet medications
Exercise and positioning - exercise to point of pain then rest
**Vasodilation - socks, but NOT heating pad (numbness) **
Percutaneous transluminal angioplasty (PTA)
Foot care
Percutaneous transluminal angioplasty (PTA)
Balloon catheter through groin towards occlusion and scrapes the plaque
Surgical management techniques for PAD
Inflow procedures: Improves blood flow from aorta into femoral artery
Outflow procedures: Provides blood supply to vessels below femoral artery
Endarterectomy: Removal of plaque from internal layer of artery
Femoral popliteal bypass: Reroute blood flow around stenosis
Axillofemoral bypass: Reroute blood flow around stenosis
Radiological intervention for an isolated lesion
Percutaneous transluminal angioplasty (PTA) and stent graft
6 P’s for PAD
Pain
Pallor
Pulselessness
Paresthesia (numb skin)
Paralysis
Poikilothermia (inability to maintain temperature)
Nursing consideration for PAD post op
Ankle-brachial pulse (ABI) Q8H for first 24 hours then QDay
Compartment syndrome - swelling that reduces circulation
Thromboembolism
Can be arterial or venous
Thromboembolism causes
Afib
MI
HF
Endocarditis
Less common: Crush injury, fracture, or penetrating wound
Thromboembolism patho
Lack of blood flow doesn’t allow for clearing of vessels
Thromboembolism complications
Breaks off and becomes embolism (blood or fat)
Travels to brain, heart, lungs, extremities
Gets caught in biforcation of arteries or spots of atherosclerosis
Thromboembolism s/sx
Depends on size/location
Change in the 6 P’s
Thromboembolism dx
CXR
TEE (transesophageal echo)
ECG
Doppler ultrasound
Thromboembolism tx
Depends on cause
Heparin
Fibrinolytics/Thrombolytics (TPA)
Embolectomy/thrombectomy: for more emergent, if pt cannot tolerate slow therapy
Pulmonary embolism patho
Ischemic disorder of the veins of the lungs
Can be life threatening
Pulmonary embolism s/sx
SOB, chest pain, tachypnea, tachycardia
Pulmonary embolism dx
CXR, Vqscan, angiogram, D-dimer
Pulmonary embolism nursing consideration
Raise HOB, apply O2, call rapid response team
Pulmonary embolism tx
Heparin, clot busters
Coumadin for 6 months
Prevent with compression hose, anticoagulants
Buerger’s disease patho
Occlusive arterial disease resulting in fribosis and scarring of vessels and nerves
Buerger’s disease cause
Unknown, but associated with smoking
Buerger’s disease s/sx
Pain due to inadequate blood supply
Discolored finger tips
Buerger’s disease tx and nursing considerations
Smoking cessation halts progression
Promote vasodilation
Pain control
Manage ulcerations or gangrene
Raynaud’s phenomenon patho
Intermittent arterial vasoconstriction in fingers/toes
Defect in basal heat production that decreases ability of vessels to dilate
Raynaud’s phenomenon forms
Primary/idiopathic: Independent of comorbidities
Secondary: Occurs in association with underlying disease, such as lupus, rheumatoid arthritis, trauma
Raynaud’s phenomenon triggers
Emotional, stress, cold temperatures
Raynaud’s phenomenon s/sx
Coldness, pain, numbness, pallor, cyanosis
Raynaud’s phenomenon tx
Calcium channel blocker - if severe
Raynaud’s phenomenon nursing considerations
Keep core warm
Avoid triggers
Use gloves
No heating pads if pt is in vasoconstriction
Aortic aneurysm patho
Dilation or sac at a weak point in artery
Aortic aneurysm forms
Fusiform: entire portion of vessel out pouches
Saccular: protrusion on one side of vessel
Mycotic: small, localized aneurysm
Aortic aneurysm causes
Atherosclerosis in aorta
Aortic aneurysm risk factors
HTN, hyperlipidemia, smoking
Age, gender, family hx, Marfan’s syndrome
Aortic aneurysm common locations
Thoracic aortic
Abdominal aortic
Aortic aneurysm s/sx
Some are asymptomatic
Abdominal, flank, back pain - gnawing quality
Aortic aneurysm dx
CT scan, xray, duplex ultrasound
Aortic aneurysm tx
Modifiable life changes
Anti hypertensives
Surgery: Thoracic endograft
Aortic aneurysm nursing consideration
Observe for sign of rupture in peritoneal cavity - sudden, severe back pain; most common complication; life threatening
Watch kidney function post op
Monitor cardiac status, BP, hemorrhage, s/sx infection
Aortic dissection patho/causes
Caused by poorly controlled HTN, blunt chest trauma, cocaine use, atherosclerosis, CT disorders - Marfan’s, aortic aneurysms - weaken aortic wall
Aortic dissection s/sx
Tearing chest pain, sweating, N/V, fainting, tachycardia, apprehension/feeling of impending doom, rapid hypotension, decreased/absent pulses in LE, unequal BP
Aortic dissection dx
CT, MRA, duplex ultrasonography
Aortic dissection tx
Modifiable life changes
Anti hypertensives
Surgery: Thoracic endograft, stent
*same as aneurysm
Thoracic endograft nursing considerations
Observe for sign of rupture in peritoneal cavity - sudden, severe back pain; most common complication; life threatening
Watch kidney function post op
Monitor cardiac status, BP, hemorrhage, s/sx infection
*same as aneurysm
Venous thromboembolism (VTE) or deep vein thrombosis (DVT) causes/risk factors
Virchow’s triad: Venous stasis, vascular/endothelium damage, hypercoagulation
Venous thromboembolism (VTE) or deep vein thrombosis (DVT) s/sx
Calf pain, groin tenderness, swelling in one leg, warmth, bluish color
Venous thromboembolism (VTE) or deep vein thrombosis (DVT) dx
Venous flow studies, VQ scan, D-dimer
Venous thromboembolism (VTE) or deep vein thrombosis (DVT) tx
Anticoagulants, thrombolytics, heparin, Coumadin
Vena Cava filter: Greenfield filter, placed as the clot is removed
Venous thromboembolism (VTE) or deep vein thrombosis (DVT) nursing considerations
Evaluate anticoagulation therapy - monitor PT/INR PTT, platelets, signs of bleeding
Elevate LE
Pain meds
Compression stockings, SCD’s
Early ambulation
Cough, deep breathing
Educate pt to monitor for signs of PE
Varicose veins patho
Abnormally dilated veins
Varicose veins s/sx
Cramps, edema, protrusion of vein
Varicose veins dx
Duplex ultrasound
Varicose veins tx
Ligation, stripping: Cut or remove vein
Ablation: Electrical heat to decompress vein
Sclerotherapy: Chemically shrinking
Chronic venous insufficiency patho
Valves in veins get damaged by obstruction or reflux
Veins have thin walls so venous pressure causes veins to distend
Valves in distended veins don’t meet each other to close, so blood backflows and pools
Chronic venous insufficiency s/sx
Pain, swelling, change in color, less symptoms in morning worse in daytime
Chronic venous insufficiency complications
Cellulitis
Leg ulcers
Chronic venous insufficiency nursing consideration/tx
Compression stocking, avoid extreme temperature, warm packs to promote circulation
Leg ulcer patho
Poor oxygenation leads to cell death
Leg ulcer s/sx
Arterial ulcer: Intermittent claudication - pain with activity, continuous pain, smaller ulcer, deep, tips or webs of toes
Venous ulcer: Achy pain, foot/ankle edema, larger wounds, extravasation, fluid, exudate, sides of feet/ankles
Leg ulcer tx
Compression stocking
Debridement with dressing changes
- Surgical
- Enzymes on dressing
- Wound vac
Lymphangitis
Acute lymph channel inflammation
Lymphadenitis
Large, red, tender lymph node
Lymphangitis and Lymphadenitis cause
Infection from strep
Lymphangitis and Lymphadenitis s/sx
Red streak up arm/leg from infected lymph system
Lymphangitis and Lymphadenitis tx
Antibiotic
Lymphedema patho
Tissue swelling due to increased lymph fluid
Due to blockage in drainage fluid (congenital or trauma - breast CA)
Chronic swelling leads to elephantiasis
Lymphedema tx/nursing considerations
Compression socks
Diuretics (Lasix)
Elevation
Surgery to remove tissue, followed by skin graft - infection, rejection
Cellulitis patho
Bacterial infection in subcutaneous tissue
Cellulitis s/sx
Localized swelling, redness, pain, fever, chills, sweating
Regional lymph nodes may be tender and enlarged
Cellulitis tx
Antibiotic
Severe: inpatient treatment
Stroke types/patho
Change in normal blood supply to brain - brain tissue dies (infarction)
Stroke causes
HTN
Arteriovenous malformation (AVM)
Stroke types/classifications
Ischemic: Blockage of cerebral artery from thrombus (gradual) or embolus (abrupt)
Hemorrhagic: Vessel integrity is interrupted, leaks into brain space
Ischemic stroke causes
HTN, afib, dysrhythmias, murmurs
Hemorrhagic stroke causes
Aneurysm, vasospasm, AVM
Stroke s/sx
Motor changes: Hemiplegia, hypotonia/hyporeflexia, hypertonia/hyperflexia, dysphagia, akinesia
Communication changes: Aphasia, dysphasia, agraphia, dysarthria
Cognitive changes: L damage = ride side impairment, R damage = left side impairment
Sensory changes: Agnosia, apraxia
Stroke dx
CT scan - better for hemorrhagic stroke
MRI - better for ischemic stroke, after 24 hours ischemia and edema will start to show
Stroke tx
Endartectomy: Remove thrombus
Embolectomy: Remove embolus
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