PRELIM: 2ND QUIZ Flashcards
The common causes of both top 1 and top 2 are
arterial blockage or arteriosclerosis, smoking
This sudden increase in the mortality rate is the target of the DOH campaign: “ Healthy Lifestyle to the Max.”
HEART DISEASE
Common illnesses which may require treatment in Intensive Care Unit
HEART DISEASE
VASCULAR DISEASE
RENAL DISEASE
Most Common cause of cardiovascular disability and death.
Coronary Heart Disease
A client with chest pain and shortness of breathing arrived in ER. You are about to perform a physical assessment on this patient. Data obtained in the nursing history of relevance to heart disease MUST include?
D. Drowning feeling at night
Modifiable Risk Factors
Hyperlipidemia- enhances atherosclerosis
Diabetes Mellitus
Obesity- result to increase cardiac workload
Personality type or behavioral factors
Contraceptive pills
This is information patients give concerning how they feel, what symptoms they are experiencing, their fears, and concerns.
Subjective Data
Nurse Lea is assessing a client who is previously diagnosed with Myocardial Ischemia, it is most important to ask which of the following?
A. “ What medications are you currently taking?”
is an ISCHEMIA
Lack of blood supply due to occlusion of coronary artery and its branches
MYOCARDIAL INFARCTION
MYOCARDIAL INFARCTION Most case are due to
ATHEROSCLEROSIS (90%)
Other causes- spasm, embolism,trauma ( 5%)
Decreased tissue perfusion and oxygenation may cause
anaerobic metabolism causes production of lactic acid
Nurse assess PQRST
in chest pain
P-rovoke
Q- uality
R- egion/ R-adiation
S- everity
T- iming
(dark red = most typical area,
light red = other possible areas).
Rough diagram of pain zones in myocardial infarction
DM- differences in pain threshold, autonomic neuropathy and psychological factors
After heart transplantation.
Silent MI
CARDIOVASCULAR ASSESSMENT
EBRILE IF:
Cardiovascular infection,
Heightened cardiac workload,
MI , Acute Pericarditis,
Ineffective Endocarditis
IF.. Assessing BP for the 1st time, take measurements in both arms
ALERT: a difference of more than 10mmhg in both arms may indicate
THORACIC OUTLET SYNDROME
difference between systolic and diastolic pressure normal: 40 mmHg
Pulse Pressure
Rising pulse pressure is seen with
Increased stroke volume
Declined Peripheral vascular resistance
Mitral or Aortic stenosis
Constricted peripheral vessels
Declined stroke volume
Diminishing pulse pressure is seen with
ESPIRATION EVALUATION
Observe for EUPNEA
Note for
Tachypnea with low cardiac output
Dyspnea
Cheyne Stokes
Shallow Breathing
ubjective feeling (inability to get enough air)
Dyspnea
Dyspnea on exertion is due to increased
O2 myocardial demand.
related to blood pooling in the pulmonary bed; suspect Pulmonary Edema
Orthopnea
Any sudden or acute dyspnea may be a sign of
Pulmonary Embolism
Myocrdial Infarction- sputum is none specific but any changes in
patient’s secretion may signifies infection
Mucoid and foamy sputum can be a sign of
CHF
Pink-tinged frothy appearance may signal
Pulmonary Edema
Whitish,
viral infection
Change in color other than the above mentioned may signify
Bacterial infection.
Awareness of rapid or irregular heartbeat
Autonomic Nervous System and Adrenal Glands response (stress)
Palpitations
Transient loss of consciousness
Due to decreased cerebral tissue perfusion
Syncope
no pitting edema
0
mild pitting edema, 2mm depression that disappears rapidly
+1
moderate pitting edema, 4mm depression that disappears 10-15 sec
+2
moderately severe pitting edema, 6mm depression that may last for more than 1 minute
+3
severe pitting edema, 8 mm depression that may last for more than 2 minutes
+4
Types of edema
CHF or Renal Failure
Bilateral edema
Types of edema caused by Vascular or Lymphatic obstruction
Unilateral edema
Types of edema caused by inflammatory
Non pitting edema
Types of edema caused by HP and COP derangement
Pitting edema
Abnormal Findings
Skin Color-
Cyanosis, pallor, jaundice, ugular vein distention Skin Temperature- cool, moist or clammy
most often noted in heart and lung diseases that cause a lower than normal amount of oxygen in the blood
Clubbing
Pathophysiology
CLUBBING OF FINGERS
Blood vessel dilation in distal circulation
↓
Hypertrophy of the nail beds
↓
CLUBBING OF FINGERS
used to monitor dehydration and the amount of blood flow to tissue.
CAPILLARY REFILL
defined as the time taken for color to return to an
external capillary bed after pressure is applied to cause blanching.
n newborn infants, capillary refill time can be measured by pressing on the _____________ for five seconds with a finger or thumb.
Sternum
INSPECTION OF CHEST- exposed the anterior chest wall
NURSE assess for the presence of the following findings
Pulsations
Symmetry of movement
Retractions
Heave- strong outward thrust of the chest wall
CHEST IRREGULARITIES THAT INHIBITS CHEST EXPANSION
Barrel Chest
Pectus Excavatum- depressed sternum
Pectus Carinatum– protruding sternum
Affected patients tend to have lung volumes that are mildly decreased but within the normal range and they are often associated with
mild air-trapping.
The deformity may be classified as either “chicken breast” (chondrogladiolar) or
“Pouter pigeon breast”
PECTUS CARINATUM
Cardiovascular Normal Findings
Normal Heart rate – 60-100
Rhythm – regular or irregular
HEART SOUNDS- S1 AND S2- normal heart sounds
S3- “ Protodiastolic Gallop” or “Ventricular Gallop” lab-dub-ta
S4-” Presystolic gallop” Ta-lab-dub- or “ atrial gallop” which is pathologic.
A sound heard over an artery or vascular channel, reflecting turbulence of flow. Most commonly, a bruit is caused by abnormal narrowing of an artery.
BRUIT
A vibration caused by the movement of fluid felt by the NURSE on palpation.
THRILL
Created by turbulence in a fluid column passing through an incompetent valve, or from a vessel of smaller caliber to a larger vessel
THRILL
Nurse Mabel assessed bruit over the ABDOMINAL AORTA, aware that this is life threatening signals AORTIC ANEURYSM. What is the nursing action at this point?
Avoid deep palpation to prevent aneurysm to rupture
During assessment palpated carotid bruit may signal
( TIA or CVA).
KILLIP CLASSIFICATION OF AMI WITH EXPECTED MORTALITY RATE
NO SIGNS OF PULMONARY OR VENOUS CONGESTION
EXPECTED HOSPITAL MORTALITY
0-5%
CLASS 1
KILLIP CLASSIFICATION OF AMI WITH EXPECTED MORTALITY RATE
MODERATE HF OR PRESENCE OF BIBASAL RALES
EXPECTED HOSPITAL MORTALITY
10-20%
CLASS 2
KILLIP CLASSIFICATION OF AMI WITH EXPECTED MORTALITY RATE
SEVERE HF, RALES ≥ 50% of THE LUNG FIELD
EXPECTED HOSPITAL MORTALITY
35-45 %
CLASS 3
SHOCK WITH SYSTOLIC BP
≤ 90MMHG
EXPECTED HOSPITAL MORTALITY
85-95%
CLASS IV
indicating ischemia in ECG
T wave inversion
injury and the acuteness of MI
S-T segment elevation
Abnormal Q wave
indicaating tissue death
Myocardial infarct in ECG
ST elevation
In order for a patient to be diagnosed with a myocardial infarction, they must have at least two of the following three criteria
Clinical history of chest discomfort consistent with ischemia, such as crushing chest pain
An elevation of cardiac markers in blood (Troponin-I, CK-MB, Myoglobin)
Characteristic changes on electrocardiographic tracings taken serially
cardiac markers: CK-MB at what hours
0-20 hours
Cardiac markers: Myoglobin
first mins
