Exam 2 Study Guide Flashcards
1
Q
Lab Assessments - Male Reproductive: Prostate-Specific Antigen (PSA) Test
A
- Normal <2.5ng/mL for age <50 & incrs w/ age (possibly up to 6.5ng/mL)
- Used as a screening lab for prostate cx bc other prostate probs can incr the level
- Some variance on the PSA & how it is affected by age
2
Q
Lab Assessments - Male Reproductive: Early Prostate Cx Antigen (EPCA-2) & Serum Acid Phosphatase
A
- Elevations indicative of prostate cx
- EPCA-2 is very sensitive & can detect early
3
Q
Lab Assessments - Male Reproductive: Alpha-Fetoprotein (AFP), Beta Human Chorionic Gonadotropin (hCG), & Lactate Dehydrogenase (LDH)
A
- Elevations indicative of testicular cx
- Indicative of testicular cx
4
Q
Lab Assessments - Female Reproductive: Pap Smear
A
- Cytologic study effective in detecting precancerous & cancerous cells from cervix
- Annual Pap test starting at 21
5
Q
Lab Assessments - Female Reproductive: Human Papilloma Virus (HPV)
A
- Used to identify many high-risk types of HPV associated w/ development of cervical cx
- Cells are collected from cervix at same time a Pap test is completed
6
Q
Lab Assessments - Female Reproductive: Vaginal Cultures
A
Used to detect bacterial, viral, fungal, & parasitic disorders
7
Q
Lab Assessments - Female Reproductive: Alpha Fetoprotein (AFP)
A
Elevated w/ ovarian cx
8
Q
Lab Assessments - Female Reproductive: Cancer Antigen 125 (CA 125)
A
Elevated w/ ovarian cx
9
Q
Assessment - Imaging: CT
A
- Evaluate for metastasis w/ different reproductive cancers
- Evaluate for ovarian cx
10
Q
Assessment - Imaging: MRI
A
Evaluation for breast cx for women w/ high risk factors
11
Q
Assessment - Imaging: Ultrasonography
A
- Transvaginal ultrasound: ovarian & endometrial cx
- Transrectal ultrasound: prostate cx
- Ultrasound: evaluate for testicular masses vs fluid
- Also used for breast cx evaluation
12
Q
Assessment - Imaging: Hysterosalpingography
A
- X-ray tht uses an injection of contrast medium to visualize cervix, uterus, & fallopian tubes
- Used to evaluate tubal anatomy & potency & uterine problems such as fibrosis, tumors, & fistulas
- Pre: assess for allergies to contrast dye
- Post: some pelvic & referred shoulder pain
13
Q
Endoscopic Studies: Colposcopy
A
- Examination of cervix & vagina using a colposcope
- Allows 3D magnification & intense illumination of epithelium w/ suspected disease
- Locate exact site of precancerous & malignant lesions for biopsy
14
Q
Endoscopic Studies: Laparoscopy
A
- Direct examination of pelvic cavity through an endoscope
- Performed under anesthesia
- Pre: NPO
- Post:
> some pelvic & referred shoulder pain
> observe incision sites for infection - Can also be used during surgical procedures
15
Q
Endoscopic Studies: Hysteroscopy
A
- Fibroptic camera tht is inserted into vagina
- Examines the cervix & uterus
- Performed w/ regional nerve block
- Post: some pelvic & referred shoulder pain
16
Q
Assessment - Imaging: Mammography
A
- X-ray of soft tissue of breast
> now have 3D mammograms tht allow visualization of layers of breast tissue - Pre: no creams, lotions, powders or deodorant on breast or under arms
- May experience discomfort during procedure
- Post: reinforce continued self breast exams & clinical breast exams
17
Q
Biopsy Studies: Cervical
A
- Cervical tissue is removed for cytologic study
- Early in menstrual cycle so less vascular
- Pre:
> depends on anesthesia used
> address anxiety - Post:
> monitor for bleeding & infections
> nothing in vagina for 2 wks
> no heavy lifting
18
Q
Biopsy Studies: Endometrial
A
- Used to obtain cells directly from lining of uterus to assess for cx of endometrium
- Assess menstrual disturbances infertility
- Post:
> some cramping may occur
> monitor for bleeding & infections
> spotting for 1-2 days
> nothing in vagina for 1-2 days
19
Q
Biopsy Studies: Breast
A
- Tissue aspirated through a large bore needle or through small incision
- Local anesthetic
- Aspirated fluid from benign cysts may appear clear to dark green-brown
- Bloody fluid suggests cx
- Pre:
> depends on anesthesia used
> address anxiety - Post:
> mild pain alleviated w/ analgesics, ice, or heat
> monitor incision for bleeding & infection
> numbness may occur around site
> wear a supportive bra for 1wk
20
Q
Biopsy Studies: Prostate
A
- Definitive diagnostic tool for prostate cx
- Transurethral biopsy
> insert needle through area of skin btwn anus & scrotum - Transrectal biopsy
> passing needle through wall of rectum - Pre:
> discuss positioning & discomfort during procedure
> address anxiety - Post:
> educated regarding soreness & light rectal bleeding, blood in urine & stool for few days plus rust colored semen for several wks
> monitor for signs of excessive bleeding, infection, & urinary retention
> post biopsy antibiotic
21
Q
Benign Prostatic Hyperplasia (BPH)
Define
Cause
Risk Factors
Prevention
A
- Enlarged Prostate Gland
> prostate gland enlarges & extends inward
> causes bladder outlet obstruction
> 50% of men >60 affected - Causes:
> unclear
> likely the result of aging and the influence of androgens (male hormones) that are present in the prostate tissue - Risk Factors:
> obesity
> testosterone & androgen supplements - Prevention:
> avoid any drugs tht can cause urinary retention
> EX: anticholinergics, antihistamines, & decongestants
22
Q
Benign Prostatic Hyperplasia (BPH) - Assessment
A
- Hx
- CMs:
> urinary frquency & urgency
> nocturia
> difficulty in starting (hesitancy) & continuing urination
> sensation of incomplete bladder emptying
> straining to begin urination
> post-void dribbling or leaking
> hematuria - Physical Assessment by provider
> inspection, palpation, & percussion of abdomen
> digital rectal examination (DRE): BPH is uniform, elastic non-tender enlargemnt vs hard nodule w/ prostate cx
23
Q
Benign Prostatic Hyperplasia (BPH) - Lab Assessment
A
- Urinalysis & Culture
> incrd WBCs if infection present
> microscopic hemturia - Prostate-Specific Antigen (PSA)
> can be elevated in BPH but also other prostate issues - Other labs to rule out other causes:
> CBC: systemic infection (elevated WBCs) & anemia (dcrd RBCs from hematuria)
> BUN & Serum Creatinine: both elevated if leads to kidney disease
> Culture & Sensitivity of Prostatic Fluid: could be expressed during DRE to check for prostatitis
24
Q
Benign Prostatic Hyperplasia (BPH) - Diagnostics
A
- Imaging
> transabdominal ultrasound
> trasnrectal ultrasound
> tissue biopsy: used to rule out prostate cx
> cystoscopy: scope used to evaluate for bladder neck obstruction
> bladder ultrasound scan: evaluates for post void residual
25
Post Operative Care for Transurethral Resection of the Prostate (TURP)
## Footnote
CBI
- Continuous Bladder Irrigation (CBI) in place post surgery
> 3 way catheter in place w/ continuous irrigation
> normal saline used to irrigate
> maintain rate of CBI to ensure clear urine w/out clots & bleeding
- Assess color, consistency, & amnt of urine output
> normal for urine to be blood-tinged after surgery
- Check drainage tube frequently
> monitor for external obstructions (kinks)
> monitor internal obstructions (blood clots, dcrd output, bladder spasms)
> if becomes obstructed will have to manually irrigate w/ NS
- After cath is removed, may experience buring on urination, urinary frequency, dribbling, leakage
> symps are normal & will dcr
> may also pass small clots & tissue debris for several days
26
Post Operative Care for TURP
- Inct fluid intake
> at least 2000-2500mL daily
> will dcr dysuria & keeps urine clear
- Monitor for infection
- Prevent complications of immobility
- Assess pain and VS q2-4hrs
27
Prostate Cancer
## Footnote
Causes
Risk Factors
Health Promotion
- 2nd most common type of cancer in men, if found early has a near 100% cure rate
- Slow growing
- Causes: number of factors
- Risk Factors:
> over 65yrs
> race: african american more often affected
> family hx of prostate cx
- Health Promotion & Maintenance
> screening: consider at 50yrs old
> healthy, balanced diet: dcr animal fats (red meats), incr fruits, veggies, & high fiber foods
28
Prostate Cancer - Assessment
## Footnote
cm
lab
other diagnostics
- History
- CMs:
> EARLY: urinary retention, frquent bladder infections, difficulty starting urination
> ADVANCED: hematuria, swollen lymph nodes (esp in groin), pain, unexpected weight loss
- Lab:
> Prostate Specific Antigen (PSA): think previous slide (this is a SCREENING tool)
> Early Prostate Cx Antigent (EPCA-2): can detect changes in prostate gland early & is very sensitive
> Elevated Serum Acid Phosphatase: w/ advanced disease
- Other diagnostic assessment:
> transrectal ultrasound (TRUS)
> Biopsy
29
Prostatitis Assessment
## Footnote
define
acute
chronic
- Inflammation of prostate gland
- Acute bacterial postatitis
> occurs w/ urethritis or an infection of lower urinary tract
> organisms may reach prostate via bloodstream or urethra
> symps: fever, chills, dysuria, urethral discharge, boggy & tender prostate
- Chronic Bacterial Prostatitis
> occurs in older men
> symps less dramatic
> symps: hesitancy, urgancy, dysuria, difficulty initiating & terminating flow of urine, dcrd strength & vol of urine, discomfort in perineum, scrotum & penis
30
Testicular Cancer Assessment
## Footnote
CMs
lab assessment
other diagnostics
- Rare cancer, most often affecting men btwn 25-35yrs
- Common manifestation
> painless, hard swelling or enlargment of testicle
- Lab Assessment
> Alpha-fetoprotein (AFP)
> Beta Human Chorionic Gonadotropin (hCG)
> Lactate Dehydrogenase (LDH)
- Other Diagnostic Assessment
> ultrasonography: identify fluid or solid mass & benign vs malignant
> CT & MRI: check for metastsis
31
Endometrial (Uterine) Caner
## Footnote
define
stages
- Cancer of inner uterine lining
- Most common gynecologic malignancy
- Good prognosis
- Adenocarcinoma most common type of tumor
- Grows slowly in most cases:
> Stage 1: confined to endometrium
> Stage 2: also involves cervix
> Stage 3: reaches vagina & lymph nodes
> Stage 4: spread to bowel or bladder mucosa and/or beyond pelvis
32
Endometrial (Uterine) Cancer - Etiology/Risk Factors
- Strongly associated w/ prolonged exposure to estrogen w/out protective effects of progesterone
- Women in reproductve yrs
- Nulliparity
- Family hx
- DM
- HTN
- Obesity
- Uterine polyps
- Late menopause
- Smoking
- Tamoxifen given for breast cx
33
Enodmetrial (Uterine) Cancer - Symptoms
- Postmenopausal vaginal bleeding - **main symptom**; early symps of vaginal bleeding generally lead to prompt evaluation & treatment
- Watery, bloody vaginal discharge
- Low back or abdominal pain
- Low pelvic pain (caused by pressure of enlarge uterus); uterus is enlarged if cx is advanced
34
Endometrial (Uterine) Cancer - Lab Assessment
- CBC (may show anemia)
- Cancer Antigen 125 (CA-125): elevated in ovarian cx
- Alpha-Fetoprotein (AFP): elevated in ovarian cx
- Human Chorionic Gonadotropin (hCG): elevated lvl may indicate pregnancy, pregnancy should be ruled out b4 treatment begins
35
Endometrial (Uterine) Cancer - Diagnostic Assessment
- Transvaginal ultrasound
- Endomentrial biopsy
- Other diagnostic tests may be done to determine pt's overall hlth status & presence of metastasis
36
Cervical Cancer
- Progressive cx:
> normal cervical cells
> atypical (suspicious)
> cervical intraepitheilial neoplasia (CIN)
> carcinoma in situ (CIS)
- Generally takes yrs for cervical cells to transform from normal to premalignant to invasive cx
37
Cervical Cancer Etiology/Risk Factors
- Most cases are caused by certain types of HPV (most common typs of STD in US)
- Multiparity
- Smoking
- African American
- Oral contraceptice use
- Hx of STI
- Obesity
- Family hx
- HIV/AIDS
- Younger than 18 at 1st intercourse
38
Cervical Cancer Health Promotion & Maintenance
- Gardasil & Cervarix
> ideally given before 1st sexual contact for girls & young women (9-26yrs)
> also given for boys & young men to prevent genital warts, transmission & certain types of cx
> protection against highest-risk HPV types tht are responsible for most cervical cxs
- Periodic pelvic examinations & PAP tests at 21yrs for women
39
Cervical Cancer - Assessment
- Asymptomatic in preinvasice cancer
- CMs for invasive cancer:
> painless vaginal bleeding (classic symp)
> LATE: watery, blood-tinged vaginal discharge tht becomes dark & foul-smelling, leg pain (along sciatic nerve) or swelling of one leg, flank pain (symp of hydronephrosis); cx may be pressing on ureters, backing up urine into kidneys
40
Cervical Cancer - Diagnostic Assessment
- HPV-typing DNA test if PAP results are abnormal
- Colpscopy
41
Ovarian Cancer
- Most ovarian cxs are epithelial tumors tht grow on surface of ovaries
- Tumors grow rapidly, spread quickly, & are often bilateral
- Leading cause of death from femal reproductive cxs
> survival rates are low bc ovarian cx is often not detected until its in late stages
> 2nd most common type
- Incidence incrs in women older than 50yrs, & most are diagnosed after menopause
- Teach women to "think ovarian" if they have vague abdominal & GI symps
42
Ovarian Cancer - Risk Factors
- Older than 40yrs
- Family hx of ovarian or breast cx or hereditary nonpolyposus colon cx
- DM
- Nulliparity
- Older than 30yrs at 1st pregnancy
- Breast cx
- Colorectal cx
- Infetility
- BRCA 1 or BRCA 2 gene mutations
- Early menarche/late menopause
- Endometriosis
- Obesity/high-fat diet
43
Ovarian Cancer - Assessment
- CMs:
> mild symptoms for several mnths but may have thought they were due to normal perimenopausal changes or stress
> abdominal pain or swelling
> vague GI disturbances such as dyspepsia (indigestion) & gas ("think ovarian")
> any enlarged ovary found after menopause should be evaluated as though it were malignant
- Diagnostic Assessment:
> CA-125 may be elevated in ovarian cxm but for other reasons too
> transvaginal ultrasonosgraphy, CXR, CT
44
Breast Cancer - Assessment
- History
- Phsyical Assessment / CMs
> Breast mass: identify location by using "face of the clock" method, describe shape, size, & consistency, mass will be hard & foxed vs mobile
> Note any skin changes around mass: dimpling, redness, warmth
> Nipple retraction or ulceration
> Assess the adjacent lymph nodes for swelling
> Pain or soreness
- Psychosocial
- Lab assessment:
> biopsies: pathologic examination of tissue from breast mass, pathologic study of lymph nodes
45
Breast Cancer - Imagining Assessment
- Mammography
- Ultrasonography
- MRI
- Chest X-Ray
> screen for lung metastases
- CT scans
> screen for bone, liver, & brain metastases
- **Breast tissue biopsy is the only definitive way to diagnose breast cx**
46
Breast Cancer - Intervention
## Footnote
Coping strategies
Dcr risk for metastasis
- Develop coping strategies
> dcr anxiety
> offer outside resources
> assess need for knowledge
- Dcr risk for metastasis
> Nonsurgical involved
> follow up w/ adjuvant radiation, chemotherpay, hormone therapy, or targeted therapy
> promote comfort (palliation) for those who can't have surgery or whose cx is too advanced
> CAM
> vitamins, special diets, herbal therapy, prayer, guided imagery, massage
> 80% of women use fome form during breast cx treatment, should not be used in place of standard treatment
> check w/ HCP before using
47
Breast Cancer - Surgical Interventions
- Preoperative Care
> relieve anxiety & provide info to incr pt knowledge
> include spouse or partner
> address body image issues b4 surgery
- Operative Procedures
> Lumpectomy: tumor & small amnt of tissue removed
> Partial Mastectomy: part of breast & some noraml tissue around it removed
> Total (simple) Mastectomy: removal of entire breast
> Modified Radical Mastectomy: breast & some lymph nodes removed, part of chest wall muscle may also be removed
48
Breast Cancer - Interventions
## Footnote
Postop Care
- Avoid using the affected arm for measuring BP, giving injections, or drawing blood
- Observe for signs fo swelling & infection
- Wound care
- Drainage tube care
- HOB elevated 30 degrees
- Elevate arem of affected side on pillow while awake (promotes lymphatic fluid return)
- Repositioning
- Analgesics
- Breast reconstruction
49
Breast Cancer - Interventions
## Footnote
Adjuvant Therapy
- Radiation therapy
- Drug therapy
> chemotherapy, targeted therapy, hormonal therapy
- Use depends on:
> stage of disease
> pt's age & menopausal status
> pt preferences
> pathologic examination
> hormone receptor status
> presence of a known genetic predispostion
50
Breast Cancer Overview
- Excluding skin cxs, breast cx is the most commonly diagnosed cx in women
> 2nd only to lung cx as a cause of female cx deaths
- **Early detection** is key to effective treatment & survival
- **Five-year Survival Rate**
> lower for women diagnosed w/ an advanced stage of breast cx
> 98.6% for localized breast cx
> 83.3% when cx has spread to regional lymph nodes
> survival drops dramatically when breast cx is mestastatic
51
Noninvasive Breast Cancer
- 20%
- **Ductal Carcinoma in Situ (DCIS)**
> Cx cells are located w/in duct & have not invaded surrounding fatty breast tissue
> 14%-53% become invasive & spread into breast tissue surrounding ducts over a period of 10yrs if not treated
- **Lobular Carcinoma in Situ (LCIS)**
> rare
> occurs as an abnormal cell growth in lobules (milk-producing glands)
> treated w/ close observation only but women w/ breast cx risk factors amy consider prophlyactic treatment
52
Invasive Breast Cancer
- 80%
- **Infiltrating Ductal Carcinoma**
> most common type
> originates in mammary ducts & grows in epithelial cells lining these ducts
> dimpling & an edematous thickening & pitting of breast skin called peau d' orange (orange peel skin) may be seen as tumor continues to grow
- **Inflammatory Breast Cancer (IBC)**
> rare but highly aggressive
> symptoms include swelling, skin redness, pain in breasts
> usually diagnosed at a later stage than other types so it's harder to treat successfully
53
Breast Cancer in Young Women
- 4.6% occur in women younger than 40
- Genetic predispostion is a stronger risk factor for younger women than older
- Frequently present w/ more aggressive forms of disease, & the # of cases incring
- Screening tools are less effective bc the breasts are denser
54
Breast Cancer in Men
- Rare, occuring in fewer than 1% of all cases
- Avg onset 68
- Symptoms: hard, painless, subareolar mass
- Gynecomastia may be present
- Diagnosis frequently delayed
55
ECG Rhythm Analysis
## Footnote
1st 2 steps
P waves
- Determine HR
- Determine heart rhythm; can be regualr or irregualr
- Analyze P waves
> are P waves present?
> are the P waves occuring regualry?
> is there one Pwave for each QRS complex?
> are the Pwaves smooth, rounded, & upright or are they inverted?
> do all P waves looks similar?
56
ECG Rhythm Analysis
## Footnote
PR interval
QRS duration
- Measure PR interval (normal .12-.20)
> are PR intervals >0.20secs
> are PR intervals <0.12secs
> are PR intervals constant across the strip
> measure from beginning of P wave to beginning of QRS
- Measure QRS duration (normal .06-.12)
> are QRS intervals < or > 0.12sec
> are the QRS complexes similar in appearance across ECG
> measure from beginning of QRS to end of S wave
57
ECG Rhythm Analysis
## Footnote
ST segment
- Examine ST segment
> elevation may indicate myocardial infarction, pericarditis, hyperkalemia
> depression is associated w/ hypokalemia, myocardial infarction, ventricular hypertrophy
- Interpret rhythm & differentiate noraml & abnormal cardiac rhythms
58
Normal Sonus Rhythm (NSR)
- Rate: 60-100 bpm
- Rhythm: atrial & ventricular rhythms are regualr
- P waves: present, consistent configuration, one P wave b4 each QRS complex
- PR interval: .12-.2- second & constant
- QRS duration: .06-.12 second & constant
59
Sinus Arrhythmia (SA)
- Variant of NSR
- Results from changes in intrathoracic pressure during breathing
- Has all characteristics of NSR expect for its irregularity
- The PP & RR intervals vary, w/ the difference btwn the shortest & the longest intervals being greater than .12 sec (3 small blocks)
60
Tachydysrhythmias
Heart rates greater than 100 bpm
61
Bradydysrhythmias
Heart rates less than 60 bpm
62
Premature Complexes
- Early rhythm complexes
- If they become mroe frequent, esp those that are ventricular, the pt may experience symptoms of dcrd cardiac output
63
Repetitive Rhythm Complexes
- Bigeminy
- Trigeminy
- Quadrigeminy
64
Dysrhythmias
- Any disorder of the heartbeat
- Etiology: may occur for amny reasons
- Can be classified by their site of origin in heart (sinus, atrial, ventricular)
- Managed w/ antidysrhythmic drug therapy
> Vaughn-Williams classification used to caregorize drugs according to their effects on the action potential of cardiac cells (classes 1-4)
> Other drugs: digoxin, atropine sulfate, adenosine
65
Atrial Dysrhythmia - Premature Atrial Complexes (PAC)
- Ectopic focus of atrial tissue fires an impulse b4 nect sinus impulse is due
- Premature P wave may not always be clearly visible bc it can be hidden in preceding T wave
- A PAC is usually followed by a pause
66
Supraventricular Tachycardia (SVT)
- Rapid stimulation of strial tissue occurs at rate of 100-280 bpm in adults
- P waves may not be visible, bc they are embedded in preceding T wave
- Paroxysmal supraventricular tachycardia (PSVT) rhythm is intermittent, initiated suddleny by a premature complex such as a PAC & terminated suddenly w/ or w/out intervention
67
Atrial Fibrillation (AF)
- Most common dysrhythmia
- Associated w/ atrial fibrosis & loss of muscle mass
- Common in heart disease such as HTN, HF, CAD
- Many risk factors
- Cardiac output can dcr by as much as 20%-30%
68
Care for Patient with Dysrhythmias
- Assess VS q4hrs
- Montior for cardiac dysrhythmias
- Evaluate & document pt's response
- Encourage pt to notify nurse if chest pain occurs
- Assess for chest pain & respiratory difficutly
- Assess peripheral circulation
- Adminster med & monitor response
- Monitor lab values
- Monitor activity tolerance & schedule exercise/rest periods to avoid fatigue
- Promote stress reduction
- Offer spiritual support
69
Atrial Fibrillation - Assessment
- Assess for fatigue, weakness, SOB, dizziness, anxiety, syncope, palpitations, chest discomfort or pain, hypotension
- High risk for PE, VTE, stroke
70
Atrial Fibrillation - Treatment
- Drug Therapy
> Calcium channel blocker: diltiazem (Cardizem)
> Aminodarone (Cordarone); class 3 antiarrythmic agent
> Beta blockers: metoprolol (Toprol) & esmolol (Brevibloc); slows ventricular response
> Digoxin (Lanoxin): for pts w/ HR & AF
> Anticoagulants: Heparin, enocaparin (Lovenox), warfarin (coumadin)
> Antiplatelet: aspirin, clopidogrel (Plavix)
- Cardioversion
- Percutaneous radiofrequency catheter ablation
- Bi-ventricular pacing
- Surgical maze procedure
71
Ventricular Dysrhythmias
- More life-threatening than atrial
- Left ven pumps oxygenated blood throughout body to perfuse vital organs & ptehr tissues
- Most common or life-threatening:
> premature ventricular complexes
> ventricular tachycardia
> ventricular fibrillation
> ventricualr asystole
72
Premature Ventricular Complexes (PVC)
- Result from incrd irritability of ventricular cells & are seen as early ventricular complexes followed by a pause
- May occur as:
> bigeminy (every other beat is PVC)
> trigeminy (every 3rd beat is PVC)
> quadrigeminy (every 4th beat is PVC)
> couplet (2 consecutive PVCs)
> nonsustained ventricular tachycardia or NSVT (3 or more consecutive PVCs)
- PVCs w/ acute myocardial infarction can lead to VT or VF, if not treated
- Common & incrs w/ age
- Treatment depends on cause
73
Ventricular Tachycardia (VT)
- V tach
- Repetitive firing of an irritable ventricular ectopic focus, usually at 140-180 bpm or more
74
Stable Ventricular Tachycardia
- Treatment: oxygen, amiodarone (Cordarone), lidocaine, or magnesium sulfate, elective cardioversion, radiofrequancy catheter ablation, implantable cardioverter debrillation
- Oral antidysrhythmic agent: mexiletine (Mexitil) or sotalol (Betapace) to prevent further occurences
75
Unstable Ventricular Tachycardia
- Can cause cardiac arrest, unstbale VT w/out a pulse is treated the same way at ventricular fibrillation
- Assess pt's airway, breathing, circulation, LOC, & oxygenation lvl
76
Treatment for Ventricular Fibrillation (VF)
- Life threatening: no cardiac output or pulse, blood is no longer being pumped out of the heart & brain not receiving blood
- May be the 1st manifestation of CAD
- Pts w/ MI are at high risk
- 1st priority: defibrillate the pt immediately
- Continue high quality CPR, provide airway management, follow ACLS protocol
77
Ventricular Fibrillation (VF)
- V fib
- Result of electrical chaos in ventricles
78
Ventricular Asystole
- Ventricular standstill
- Complete absence of any ventricular rhythm
79
Treatment for Ventricular Asystole
- Full cardiac arrest: no cardiac output or perfusion to the rest of the body
- Prognosis for the pt is poor
- Manage airway
- Administer CPR: compressions, airway, breathing
- Do NOT befibrillate
- Follow ACLS protocol
80
Patient Teaching - Dysrhythmias
- Prevention, early recognition, & management
- Lifestyle modifications (avoid caffeinated beverages, stop smoking, drink alcohol in moderation, follow prescribed diet)
- Drug therapy instructions
- Teach the pt & family how to take a pulse and/or BP & report any changes
- Provide oral & written instructions for pacemakers, ICDs, cardiac exercise programs, support groups as applicable
81
Assessment Methods - Cardiovascular System
- Pt hx
- Nutrition hx
- Family & genetic hx
- Current health concerns
- Functional hx
- Phsyical assessment
82
Patient History - CV System
- Focus on risk factors & symptoms
- Assess nonmodifiable risk factors
> age, gender, ethnicity, family hx
> EX: men & post menopausal women at higher risk for CAD
- Assess modifiable risk factors
> obesity, smoking, inactivity, psychological stress
- Assess for chronic diseases
> EX: diabetes pts at higher risk
83
Nutrition & Family+Genetic History - CV System
- EX: high sodium, fat, & cholesterol can incr risk for CV disease
- Screen 1st degree relative for history of CAD, HTN, sudden cardiac death
84
Current Health Concerns/Symptoms - CV System
- Chest pain or discomfort
- Dyspnea
- Fatigue
- Palpiations
- Edema
- Syncioe
- Extremity pain
- Functional history
85
Phsyical Assessment - CV System
## Footnote
general appearance
- General appearance
- Skin
> assess color & temp
> assess nail beds, mucous membranes, & conjunctival mucosa
> dcrd perfusion can be manifested as cool, pale, cyanotic, gray and/or moist ski
- Extremities
> assess for dehydration; skin turgor
> assess for edema (location & 1+,2+,3+,4+)
> vascular changes (paresthesia, muscle fatigue, pain, numbness, coolness, loss of hair)
86
Physical Assessment - CV System
## Footnote
BP
- HTN
> systolic BP >140mmHg
> diastolic BP >90mmHg
> taking drugs to control BP
- BP <90/60 may not be adequate for providing enough oxygen & sufficient nutrtion to body cells
- Postural (orthostatic) hypotension
> dcr of more than 20mmHg of the SBP or more than 10mmHg of the DBP & 10-20% incr in HR w/ changes in position
- Pulse pressure
> difference bttwn systolic & diastolic values, used an indirect measure of cardiac output
87
Physical Assessment - CV System
## Footnote
venous & arterial pulses
precordium
- Venous & Arterial pulses
> venous pulsations in neck assess for jugular venous distention (JVD)
> assess all major peripheral pulses
> hypokinetic pulse; weak pulse
> hyperkinetic pulse; boudning pulse
> auscultate carotid for bruits; normally there are no sounds if the artery has uniterrupted blood flow
- Precordium (area over heart)
> inspection
> auscultation
> S1: mitral & tricuspid valve closing
> S2: pulmonic & aortic valve closing
> abnormal (splitting of S2; S3, S4, murmurs, pericardial friction rub)
88
Lab Assessments
Cellular injury causes a release of enzymes & those enzyme lvls are used to diagnose Acute Coronary Syndrome (ACS)
89
Troponin
- Myocardial muscle protein released when there is injury to myocardial muscle
- Normal = T<0.10ng/mL & I < 0.03ng/mL
90
Creatine Kinase (CK)
- Enzyme specific to cells of the brain, myocardium, & skeletal muscle
- CK indicated tissue necrosis or injury
- Normal = females 30-35 units/L & males 55-170 units/L
91
CK-MB
- Specially found in myocardial muscle
- Normal = 0% of total CK
92
Myoglobin
- Protein found in cardiac & skeletal muscle
- Normal = <90mcg/L
93
Serum Lipids
- Elevated lvls incr risk for CAD
- Cholesterol: <200mg/dL
- Triglycerides: btwn 40 & 160 mg/dL for men and btwn 35 & 135 mg/dL for women
- HDL: >45 mg/dL for men and >55 mg/dL for women
> considered good cholesterol
- LDL: <130 mg/dL
- HDL:LDL ratio
> 3:1 ratio
94
B-Type Natriuretic Peptide (BNP)
- Will be elevated & used for diagnosing heart failure: >100 is diagnostic & the higher the worse the HF
- BNP is produced & released by the ventricles when they are stretched and fluid overload
- Natriuretic peptides are neurohormones tht promote vasodilation and diuresis through sodium loss in the renal tubules
95
Coagulation Studies
- Evaluates the ability of blood to clot
- Monitor when pts on anticoagulants
96
Homocysteine
- Amino acid produced when proteins break down
- Elevated lvls indicates incr the risk for cardiac disease
- Normal: <14mmol/dL
97
C-Reactive Protein (CRP)
- Any inflammatory process can produce CRP in the blood
- Normal: <1.0 mg/dL
- >3 mg/dL indicates high risk for heart disease
- Elevations are also seen w/ HTN, infection, & smoking
98
Microalbuminuria
- Small amnts of protein in the urine
- Indicates andothelial dysfunction
99
Hypokalemia
Incrd electrical instability, ventricular dysrhythmias, incrd risk for digitalis toxicity
100
Hyperkalemia
Slowed ventricular conduction, peaked T waves in the ECG, & contraction followed by asystole
101
Hypocalcemia
Ventricular dysrhythmias, a prolonged QT interval, cardiac arrest
102
Hypercalcemia
Shortens the QT interval & causes AV block, digitalis hypersensitivity, and cardiac arrest
103
Hypemagnesemia
Prolongs the QT interval causing a specific type of ventricular tachycardia
104
Chest X-Ray
Excamine size, silhouette, & position of heart
105
Angiography or Arteriography
- Uses contrast dye and fluroscopy to examine arterial vessels
- Prep: screen for allergy to dye, sedation required, usually NPO
106
Electrocardiogram (ECG)
- Very common & valuable diagnostic
- Examines electrical activity of heart
- Prep: none required
107
Echocardiography (Echo)
- Uses ultrasound to assess cardiac structure & mobility
- Specifically looks at valves
- Prep: none required
108
Exercise Electrocradiography (EPS)
- "stress test"
- Assesses cardiovascular response to an incrd workload
- Pt Prep:
> encourage rest night before procedure
> light meal 2hrs before test (depends on physician order)
> avoid smoking, alcohol, & caffeine-containing drinks on day of test
> beta blockers & calcium channel blockers usually held
> to allow HR to incr w/ stress
> wear comfortable clothing & rubber-soled supportive shoes
109
Transesophageal Echocardiography (TEE)
- Examines cardiac structure & function using ultrasound that is placed behind heart in the esophagus or stomach
- Sedation is required
- Prep: similar to upper GI endoscopic exam
110
Myocardial Nuclear Perfusion Imaging
- Radioactive tracer substances used to view cardiovascular abnormalities
- Can view myocardial blood flow & left ventricular function
- Prep: NPO, no caffeine or smoking 4hrs prior
111
Magnetic Resonance Imaging (MRI)
- Magnetic & radio waves used to view cardiac wall thickness, heart chambers, valve & ventricular function, & blood movement
- Prep: screen for metallic objects
112
Cardiac Catheterization
- Studies of the right or left side of the heart and the coronary arteries using fluroscopy and contrast dye
- Prep:
> renal protection from contrast dye
> fluids may be given 12-24hrs before procedure for renal protection
> administer acetylcysteine
> CXR, CBC, coagulation screen, & ECG done
> NPO after midnight or liquid breakfast if procedure scheduled in afternoon
> assess pt for contrast dye allergy (antihistamine or steriod may be given)
> sedative may be given
> hold digitalis or diuretic prior to procedure
113
Cardiac Catheterization
## Footnote
post procedure
- Bed rest & keep insertion site extremity straight
- monitor VS
- assess insertion sire for drainage or hematoma
- assess peripheral pulses, temp, & color in affected extermity
- monitor I&O
- maintain hydration
- observe for complications
114
Hypertension
- Most common health problem seen in primary care settings
- AHA 2017 guidlines below 130/80
> desired BP below 150/90 (60yrs+)
> desired BP below 140/90 (>60yrs)
> desired BP below 130/90 (pts w/ DM & heart disease)
- Continuous BP elevation results in damage to organs
> causes thickening of arterioles
> as the blood vessels thicken, perfusion dcrs & body organs are damaged
115
HTN is a major risk factor for
- Stroke
- Myocardial infarction
- Kidney failure
- Death
116
Classifications & Etiology of HTN
## Footnote
primary
secondary
- Primary (essential)
> most common type
> not caused by an existing heart problem; can develop when a pt has nay one or more of the risk factors
> family hx
> african american
> hyperlipidemia
> smoking
> older than 60 or postmenopausal
> excessive sodium & caffeine intake
> overweight/obesity
> physical inactivity
> excessive alcohol intake
> low potassium, calcium, or magnesium intake
> excessive & continuous stress
- Secondary
> results from specific disease & some drugs
> kidney disease is one of the most common causes of secondary HTN
117
Assessment of Hypertension
- Phsyical assessment/CMs
> most ppl have no symptoms
> some pts experience headaches, facial flushing (redness), dizziness, fainting
> BP screenings
> take in both arms
> 2+ readings at a visit
> use appropriate size cuff
- Orthostatic hypotension
> dcr in BP w/ changes in position
> 20mmHg for systolic and/or 10mmHg for diastolic
- Psychosocial
> assess for stressors tht can worsen HTN
- Diagnostic Assessment
> no specific lab or x-rays are diagnostic of primary HTN
> secondary HTN can be screened w/ labs specific to underlying disease
> EX: kidney disease
118
Interventions for HTN
- Lifestyle changes
> dietary dosium restriction to >2g
> reduce weight
> use alcohol sparingly
> exercise 3-4 days a week for 40mins
> use relaxation techniques to dcr stress
> acoid tobacco & caffeine
- Complementary & alterbative therapies
> biofeedback
> meditation
- Drug therapy
- avoid OTC meds (NSAIDs & decongestants)
119
VTE Prevention
## Footnote
prevention is key
- Pt education
- Leg exercises
- early ambulation
- adequate hydration
- graduated compression stockings
- intermittent pneumatic compression (SCDs)
- venous plexus foot pump
- avoid oral contraceptives
- anticoagulant therapy
120
Venous Thrombeembolism (VTE)
- Includes both deep vein thrombosis (DVT) & pulmonary embolism (PE)
- Risk Factors:
> Virchow's Triad
> stasis of blood
> vessel wall injury
> altered blood coagulation
121
Symptoms of DVT
- May be symptomatic or asymptomatic
- **Classic s/s**:
> **calf or groin tenderness & pain
> sudden onset of unilateral swelling of leg**
- induration (hardening) along the blood vessel
- warmth, edema, redness
- checking a Homans' sign is not advised bc it is an unreliable tool
- phsyical exam findings may be adequate for diagnosis
122
Diagnostic Assessments of DVT
- **Preferred diagnostic test**:
> **venous duplex ultrasonography**
> assesses flow of blood thrpugh veins of arms & legs
- Lab Testing:
> negative d-dimer test can exclude a DVT
> used for diagnosis DVT when pt has few clinical signs
123
DVT Interventions
- Goals:
> prevent pulmonary emboli, further thrombus formation, or an incr in size of thrombus
- Observe for symptoms of pulmonary emboli:
> SOB, chest pain, acute confusion
- Elevate legs when in bed or chair
- Do not massage affected extremity
- Drug therapy:
> anticoagulants
> heparin
> enoxaparin (Lovenox)
> warfarin (Coumadin)
124
Unfractionated Heparin THerapy (UFH)
- baseline PT, aPTT, INR, CBC w/ platelet count
- anti-factor Xa assay 6hrs after initiation & every day once 2 consecutive results are w/in therapeutic range
- platelet count 24hrs after initiation & then every other day
- IV boul (based on body weight) followed by IN infusion
- notufy provider for:
> suspected or confirmed bleeding: hematuria, frank or occult blood in stool, exxhymosis, petechiae, altered LOC, or pain (esp abdominal pain)
> dcr of 50% from initial platelet count anytime during therapy
> dcr in hemoglobin of greater than 2g/dL anytime during therapy
- Heparin-induced thrombocytopenia (HIT); life-threatening complcication of heparin therapy
- have antidote available for excessive bleeding
> protamine sulfate
- to prevent DVT, unfractionated heparin may be given in low doses SQ for high-risk pts
125
Low-Molecular Weight Heparin (LMWH)
- Preferred for prevention & treatment of VTE
- EX: enoxaparin (Lovenox) given SQ
- dosed based on weight (1mg/kg)
- monitor PT & INR (per textbook)
- monitor anti-factor Xa assay (per St Luke's)
- Serum creatinine & platelet counts are also monitored
- assess for signs of bleeding: hematuria, frank or occult blood in stool, ecchymosis, petechiae, altered LOC, or pain
- have antidote available for excessive bleeding
> protamine sulfate
- if treating acte DVT or PE, may see overlap of enoxaparin & warfarin given
- pt can self administer at home
126
Warfarin
- given PO
- monitor PT, INR
> INR is mroe reliable
> need to adjust med based on INR to achieve desired range
- assess for signs of bleeding: hematuria, frank or occult blood in stool, ecchymosis, petechiae, altered LOC, or pain
- have antidote available for excessive bleeding
> vitamin K
- PCP specifies the desired INR lvl to obtain
- teach pts to avoid foods w/ high concetrations of vitamin K
> dark green leafy vegetables
> more difficult to acheive desired lvls
127
Other DVT Interventions
- other meds for clot prevention:
> Rivaroxaban (Xarelto)
> no labd required
> no antidote is available
- Thrombolytics
> tissue plasmsinogen activators (TPA)
> administered directly into clot through a catheter
> not used often
> high risk for bleeding
- Surgical Management
> thrombectomy
> inferior vena cava filtration
> very common for recurrent DVT
128
Atheriosclerosis
Thickening, or hardening, of the arterial wall tht is often associated w/ aging
129
Atherosclerosis
- Type of arteriosclerosis
- involved the formation of plaque w/in arterial wall
- leading risk factor for cardiovascular disease
130
Risk Factors for Atherosclerosis
- Low HDL-C (high density lipoprotein)
- HIgh LDL-C (low density lipoprotein)
- incrd triglycerides
- genetic disposition
- DM
- obesity
- sedentary lifestyle
- smoking
- stress
- african-american or hispanic ethnicity
- older adult
131
Atherosclerosis Lab Assessments
- Elevated lipids (cholesterol & triglycerides)
- Total Serum Cholesterol
> should be below 200 mg/dL
- LDL (bad) cholesterol
> incrd lvls indicated incrd risk
> should be <130
- HDL (good) cholesterol
> incrd lvls, lower risk of CAD
> should be >50
132
Atherosclerosis Interventions
- Lifestyle modifcation such as smoking, weight management, exercise, & nutrition
- Drug therapy
> statin or other lipid-lowering agents
133
Statins (HMG-CoA)
- Common statin EX:
> Lovastatin (Mevacor)
> Atorvastatin (Lipitor)
> Simvastatin (Zocor)
> Rosuvastatin (Crestor)
> Pravastatin (Pravachol)
- Reduce cholesterole synthesis in liver & incr clearance of LDL from blood
- Contraindicated in active liver disease or during pregnancy
- D/C if pt experiences muscle cramping or elevated liver enzyme lvls
- avoid grapefruit juice
134
Interventions for PAD
- Exercise
- Positioning
> avoid crossing legs & weraing restrictive clothing
> elevated legs/feet avoid raising above heart lvl
> extreme elevation slows arterial blood flow to feet
- Promote vasodilation
> avoid cold exposure to affected extremity w/ warm socks & room temp modulation
> avoid applying direct heat (heating pad, hot water) to limb
> avoid emotional stress, caffeine, & nicotine (can cause vasoconstriction)
- Drug Therapy
> hemorheologic agents Pentoxifylline (Trental)
> Antiplatelet agents ASA, Clopidogrel (Plavix)
- Control BP
- Invasive nonsurgical procedures
> percutaneous transluminal angioplasty (PTA)
> atherectomy
- Surgical Management
> arterial revascularization
135
Acute Peripheral Arterial Occlusion
- Occlusions may be sudden & dramatic
- caused by embolus or thrombus
> embolus is the most common cause
- More common in lower extremities
- most pts w/ an embolic occlusion have had a recent acute MI and/or artial fibrillation
- CMs
> cool or cold, pulseless, and mottled affected extremity
- "Six P's" of ischemia
> pain, pallor, pulselessness, paresthesia, paralysis, poikilothermy (coolness)
136
Acute Peripheral Arterial Occlusion Interventions
- Prompt treatment is essentail to avoid permanent damage or loss of an extremity
- Anticoagulant therapy (Heparin)
- Surgical
> embolectomy or thrombectomy
137
Aneurysms
## Footnote
types
- Permanent localized dilation of an artery, enlarges the artery to at least 2x normal diameter
- Types:
> abdominal aortic aneurysms (AAAs) account for most aneurysms, commonly asymptomatic, & frequently rupture
> CMs: abdominal, flank, or back pain tht is usually steady, w/ a gnawing quality, is unaffected by movement, & may last for hrs or days; prominent pulsation in upper abdomen (do not palpate)
> thoracic aortic aneurysms (TAAs)
- Rupture is most frequent complication & is life threatening bc abrupt & massive hemorrhagic shock results
> pain described as tearing, ripping, & stabbing & located in chest, back, abdomen; symps of hypovolemic shock, N/V, & apprehension
138
Aneurysms
## Footnote
etiology
imaging
management
- Etiology
> atherosclerosis
> HTN
> hyperlipidemia
> smoking
- Imaging
> CT scan w/ contrast is standard tool for assesing size & location
- Size of aneurysms & presence of symps determine pt management
- Nonsurgical Management
> monitor growth & maintain BP at normal lvl to dcr the risk for rupture
- Surgical Managment
> resection or rapair (aneurysmectomy)
> high risk
> endovascular stent graft
> pricedure of choice
