MEDICAL-SURGICAL NURSING JOHN RICAFORT, RN OXYGENATION 1. RESP RESPIR IRAT ATOR ORY Y SY SYST STEM EM 2. CARD CARDIO IOVA VASC SCUL ULAR AR SYST SYSTEM EM 3. BLOOD BLOOD / HEMAT HEMATOPO OPOIES IESIS IS (serve (serves s as medium for transport – oxygen and nutrients) RESPIRATORY SYSTEM Gas exchange Blood pH regulation Sense of smell • • •
Upper respiratory tract sneezing reflex (nose to epiglottis) Fibrissae (nostril hair); cilia (hair-like structure) Snot (“kugang”) • •
Lower respiratory tract (below glottis) Coughing reflex •
Respiration – primary stimulant is ↑ CO2 in the blood Common manifestations of patient with respiratory problems: 1. coug cough h – car cardi dina nall sign sign 2. dyspne dyspnea a – 3 types: types: (semi(semi-fow fowler ler’s ’s – 20 to 35 degrees) a. exertional dyspnea – thru physical exertion b. orthopnea dyspnea – related to positioning supine – fluid in the blood will cause congestion best position – semi-fowler’s c. paroxysmal nocturnal dyspnea – at night 3. ches chestt pai pain n – cau cause ses: s: a. resp respir irat ator ory y prob proble lem m b. car cardiac diac pr probl oblem c. musc muscul ulos oske kele leta tall pro probl blem em evaluate type of chest pain •
•
•
•
Pertussis – characterized characterized by 5-10 consecutive coughs with a stridor or whoop at the end. • • •
♥common problem associated HERNIA tearing of tissue that will lead to hernia put abdominal support
Noisy breathing – common presentation of airway obstruction (partial airway obstruction) Loss of voice – complete airway obstruction
Goblet cells – mucous production ///////////////// - cilia ooooooooo – goblet cells CARINA – serves as an anatomical landmark for the placement of the tip of endoctracheal tube (for equal distribution of air as manifested by symmetrical lung expansion)
♥ chest Xray – to check placement position two hands at the back (lowest rib) with the thumbs toward the spinal and fingers spread to lateral side of the ribs; tghen ask patient to inhale deeply. Right bronchus – larger 2 major cells in alveoli: Type 1 – needed to combat infections • •
•
•
•
•
Type 2 – producing surfactant (↑ tension in alveoli) ♥ atelectasis – collapsed alveoli (SIDS)
HERING BREWER REFLEX – responsible for inflation and deflation process of alveoli
Right lung 3 lobes Left lung 2 lobes Beta 1 receptor – heart Beta 2 receptor – lungs 2 layers of lung: 1. visc viscer eral al (inn (inner er)) 2. pari pariet etal al (out (outer er)) must not exceed to 100 ml or cc will • cause hydrothorax or pleural effusion Diaphragm – major muscle for respiration
First nursing action for chest pain giving supplemental oxygen
4. Hemo emoptysis pH Hemoptysis base
content w/o food
start
Appearance frothy
hematemesis
With food
Non-frothy
Contra-indicated – chest physiotherapy (CPT) 5. Club Clubbi bing ng of of fing finger ers s ♥present only during CHRONIC hypoxia Schamroth method analysis – face nails • together and there should be a diamond formed in between (normal) ♥ normal degree – 160 degrees o >160 deg. – early clubbing >180 deg. – advanced clubbing o o 0 to 3 months – closed fists o 3 to 6 months – holds a bottle o 6 to 9 months – p incer grasp o 9 to 12 months – picks objects 6. fever 7. crackles 8. activity intolerance 9. seizures 10. skin flushing - ♥ due to ↑ CO2 retention (hypercapnea) causes vasodilation 11. altered altered level of consciou consciousness sness •
•
•
3 Categories for respiratory problem: Disturbances or disorders a. Restrictive Restrictiv e lung disease – atelectasis, pneumonia, PTB or chest trauma b. COPD (Chronic obstructive pulmonary disease) or CAL (chronic airflow limitation) – emphysema and bronchitis, asthma c. Pulmon Pulmonary ary vasc vascula ularr disease disease – Cor Cor pulm pulmona onale, le, pulmonary embolism RESTRICTIVE LUNG DISEASE Any process that limits to lung expansion (INSPIRATION – problem) •
COPD / CAL 1
•
•
Opposite of restrictive lung disease (EXPIRATION – problem)
o
♥ what is the appropriate fluid? 1 to 2 liters per minute can cause respiratory depression if > 2 l/min.
o
•
MEDULLA OBLONGATA – respiratory center VENTURI MASK – most appropriate O2 device for COPD / CAL most accurate O2 concentration •
•
next option NASAL CANNULA
•
♥ most common complication Cor pulmonale (enlargement of Right ventricle)
PULMONARY VASCULAR DISORDER disturbances in the vascular compartment of the pulmonary area
2. PNEUMONIA • • •
•
•
RESTRICTIVE LUNG DISORDERS – 3 conditions: 1. ↓ lung capacity 2. ↓ elasticity or recoil 3. ↑ work of breathing 1. ATELECTASIS collapsed of previously inflated lung tissue 2 types: 1. Primary atelectasis common to newborn (premature) – common problem is surfactant 2. secondary atelectasis due to compression and obstruction • •
•
•
COMPRESSION Pneumothorax Hemothorax Pneumohemothorax hydrothorax • •
•
•
OBSTRUCTION
aspiration
N. dx: Impaired Gas Exchange Manifestations: Dyspnea o o Chest pain o SOB Hypoxia o o Asymmetrical lung expansion o ↓ breath sound on affected lung o signs of shock Dx test: o Chest Xray – confirmatory test o ABG – ↓ pH, ↑ PCO2, ↑ partial COs and a ↓ O2 Respiratory acidosis and hypoxia o Pulse oximetry - ↓ O2 saturation (N: 95-100%) o ♥93% - O2 supplement (first nursing action) Management: O2 supplement / therapy o o Semi-fowler’s (to promote lung expansion) o Treat underlying cause (ex. Hemathorax – chest tube insertion)
Put patient in a mechanical ventilation to correct atelectasis, hypoxia and acidosis ♥ continuously monitor cardiopulmonary and neurostatus (because of hypoxia)
refers to inflammation, infection of lung tissue IP – 2 to 3 days 2 types: (causative agents) o bacterial pneumonia streptococcus diplococcus o viral pneumonia H. influenzae Pathognomonic signs: o Strep./diplo. Pneu. – RUSTY PURULENT SPUTUM Staphylococcal pneu. – YELLOW o BLOODY streak sputum Microplasmal pneu.- NONo PRODUCTIVE COUGH progressing to mucoid Klebsiella pneu. – RED GELATINOUS o sputum Types of pneumonia: o LOBAR P. – site: either left or right lung o LOBULAR P. – entire lung; also called bronchopneumonia Classification of pneumonia – 4: o Community acqd. Pneumonia (CAP) o Hospital acqd. Pneumonia (HAP) also called nosocomial pneumonia o Aspiration pneumonia o Pneumonia for immuno-compromise
CAP – most common Strepto / diplococcal Rainy days • •
HAP – staphylococcal Acquired after 48 hours after admission or discharge •
Aspiration pneumonia – due to reflex of gastric content into respiratory area Children and old people Neuro – problem, stroke, neuromuscular problem (myasthenia gravis) Elevate HOB (20-35 deg.) • •
•
Pneumonia for immuno-compromised Patient with HIV, DM Pneumocystic Carinii pneumonia (PCP) – fungal or protozoal infection (cause) P.S. – Non-productive cough Drug of choice (DOC) – BACTRIM • (Trimethoprim-sulfamethorazole) antiprotozoal effect • •
•
Dx Test: Chest Xray – confirmatory test (common result: consolidation of lung tissue) Sputum exam •
•
2
•
Throat culture
Manifestations / SS of pneumonia: 1. productive cough 2. chest pain 3. hemoptysis 4. dyspnea 5. crackles 6. fever (infection) 7. anorexia 8. ↑ fremitus vibration – movement of air (ask patient to say 99 and feel for the vibration – start up downwards – diminishing fremitus) 9. egophony – distortion of “e” sound to “a” sound (ask patient to say e, and you will hear a sound during auscultation) 10. whispered pectoriloque – sound can be heard clearly because sound travels faster in solid – (+) pneumonia an audible whispered 1-2-3 (instruct patient to whisper 123) normal: not clear Management: 1. O2 supplement (dyspnea) 2. semi-fowler’s position 3. ↑ oral fluid intake (OFI) 4. give nutritious food 5. adequate rest 6. give antibiotic – DOC: penicillin or erythromycin 7. turn patient to sides q 2 hours – prevent pulling of secretions on the lower lobe, which can cause dyspnea (prevent hypostatic pneumonia) ♥ position to promote ventilation: RIGHT LUNG pneumonia – unaffected o side (left) Ventilation – good lung down o •
3. TUBERCULOSIS Highly infectious respiratory infection caused by tubercle bacilli 3 common (most common – microbacterium tuberculosis) •
•
• •
•
75 Filipinos die everyday (PTB) 1993 – Global emergency (WHO declared PTB outbreak) manifestations: o fatigue, malaise, anorexia, weight loss (early signs) chronic cough (productive) - > 2 weeks o o night sweats o hemoptysis (advanced state) low grade fever (afternoon) o
Best sputum specimen – contains bronchial secretions and mucous (not saliva) Best time for PPD after 72 hours (exposure) induration of <4 mm – negative 5-9 mm – doubtful result (give INH for 6 to 12 months) o <35 y/o – INH – 6 to 12 mos o >35 y/o – INH – 6 to 9 mos. (risk of drug induced hepatitis) 10 mm – (+) for exposure • •
•
•
tuberculin skin testing – if immunocompromised - > 4 months
Multi-drug therapy – prevention of emergence of drug resistance 4. Chest trauma 1. accident (common cause) nonpenetrating / blunt – flail chest o (chest is still intact) penetrating – break in the chest wall o integrity (stab wound, gunshot) hemothorax, pneumothorax, hemopneumothorax and tension pneumothorax (cause mediastinal shift) Flail chest multiple rib fracture or rib fracture adjacent to each other Hemothorax lower lobe Pneumothorax upper lobe tension pneumothorax injury that resulted to a one-way valve increasing tension in the lungs. Chest tube purpose: to DRAIN (valsalva maneuver not allowed) 2. for insertion or removal of chest tube (instruct patient to do valsalva maneuver) 3. DRAIN air (pneumothorax) – site: 2nd or 3rd ICS 4. Insertion – 7th or 8th ICS 5. After insertion: NR o Check site Check V/S o o Position: semi-fowler’s position (promotes lung expansion)
Unaffected side (to drain) ↓ pressure – affected side 6. check for tidalling or oscillation – refers to fluctuation of fluid o needle is out – it there is no tidalling inspiration – fluid falls or goes down o o expiration – fluid rises 7. ♥nursing alerts o keep bottle below the heart o clamp the tube as close to the patient’s body o don’t clamp the tube for long period of time – can cause tension pneumothorax o don’t milk the tube – will create suction site and can cause trauma to the tissue o chest drainage – clamp or forceps should be at the bedside (to clamp tube incase bottle will break) o extra bottle with water should also be at the bedside 20 cms. High submerge tube to the water, which will o act as seal o interpretation: intermittent bubbling – indicates that the lungs have re-expanded continuous bubbling – indicates leakage COPD / CAL problem: EXPIRATION 1. EMPHYSEMA (irreversible) – PINK PUFFER 3
•
• • • •
• •
Most appropriate device: VENTURI MASK 1 to 2 liters / min. O2 saturation – 95 to 100% Loss of lung elasticity (alveoli wall) Common cause: smoking (n. mgt.: cessation of smoking) Exposure to chemicals – asbestos Deficiency of anti-trypsin (protein that will neutralize trypsin)
Pathologic changes in emphysema: 1. Loss of lung elasticity 2. Formation of bulla / bullae (air sac) – because alveoli wall due to loss of elasticity will not deflate properly causing air sac 3. Hyperinflation of lung tissue - 2˚ to loss of elasticity (affects inflation / deflation) Common result in Xray – “barrel chest” (↑ anterior-posterior diameter than transverse diameter •
There is air trapped inside – Hyperresonance during percussion 4. small air trappings and collapse Hypercapnea - ↑ CO2 •
•
PINK PUFFER – associated with smoking ↑ CO2 retention (pink) – loss of lung elasticity no cyanosis dyspnea ineffective cough hyperresonance on chest percussion • orthopneic barrel chest exertional dyspnea loss of lung elasticity impaired gas exchange ↑ CO2 retention vasodilation blood will congest resulting to pinkish d iscoloration •
• • •
• • •
Dx Test: CXR – reveals barrel chest history of smoking •
ABG – respiratory acidosis and hypoxia (↓ pH, ↑ PCO2, ↑ partial COs and a ↓ O2) Pulmonary function test – INCENTIVE SPIROMETER (measures total lung capacity) o done to enhance deep inspiration Incentive Spirometer: Tidal volume N: 500 ml Residual vol. N: 1200 ml Inspiratory reserve volume N: 3,000-3,300 ml Expiratory Reserve volume N: 1000-1200 ml Tidal volume – amount of air that enters and leaves the lungs Residual volume – amount of air present inside the lungs after a Normal expiration Inspiratory Reserve volume – amount of air that can be forcibly inspired after a normal inspiration (↓ IRV – emphysema) Expiratory Reserve volume – amount of air that can be expired (emphysema - ↓ ER) 3 types of emphysema:
1.
Pon lobular emphysema – upper lobe (most common) 2. centro lobular emphysema – central lobe 3. paraseptal distal acinar emphysema – distal lower lobe Management: 1. cessation of smoking 2. O2 supplement – 1 to 2 liters/min. 3. position: semi-fowler’s 4. antibiotics – affect coughing reflex, which makes a patient at risk to infection 5. diuretics Lobectomy – removal of a lobe position: (post) affected side Pneumonectomy – removal of a lung (entire) position: (post) semi-fowler’s BRONCHITIS (reversible) – BLUE BLOATERS inflammation of the bronchus termed as smoker’s coughs N. Dx: Ineffective Airway Clearance Color: dusky to cyanotic •
•
• • • •
• • • • •
Recurrent cough and ↑ sputum production Hypoxia Hypercapnea Acidosis Edematous
Management: 1. avoidance of irritating substances 2. cessation of smoking 3. ↓ physical stimuli ( to ↓ O2 demand) 4. Drugs: a. Anti-inflammatory (corticosteroids) i. Don’t take corticos-teroids for long period of time – cause immune suppression, Cushing syndrome ii. Watch for S/S of immune suppression iii. Don’t stop corticosteroids abruptly b. Bronchodilator – salbutamol, theophylline, aminoptylline (N: theophylline level – 10 to 20) i. Signs of theophylline toxicity 1. tremors 2. palpitations 3. nausea 4. headache 5. dizziness c. antibiotics – prevent secondary infection ASTHMA is a hypersensitivity reaction characterized by abnormal breath sounds secondary to histamine release effects of histamine: o cause vasodilation o cause bronchoconstriction o ↑ mucous production o bronchospasm N. Dx: Ineffective Airway Clearance Wheezes – expiration (expiratory wheezes – P.S.) Hypersensitivity •
•
• •
•
4
• • • •
• • • • • • •
↑ occurrence in males onset before 12 y/o retractions hypoxemia o tachycardia o ↑ restlessness o tachypnea familial cough cough ↑ mucus SOB Expiratory wheezed (P.S.) ↑ CO2 retention prolonged expiration
2. 3. 4. 5.
dyspnea SOB tachycardia signs of shock
Dx Test: 1. CXR 2. ECG 3. ABG 4. Pulmonary angiography – confirmatory test (invasive) N. priority – check peripheral pulses (popliteal, dorsalis pedis, posterior pedialis) Damage of femoral line – diminish peripheral pulses •
•
2 major types of ASTHMA: 1.
INTRINSIC ASTHMA – non-allergic (ex. Stress, infection, sudden change in weather) 2. EXTRINSIC ASTHMA – allergic asthma attack a. IgE – mediated b. Common cause: DUST Management: 1. O2 supplement 2. position: semi-fowler’s 3. stay with patient 4. ↓ physical stimuli – to decrease oxygen demand 5. Drugs: a. Bronchodilators b. Corticosteroids c. Antii-histamine (♥ S/E – drowsiness discourage driving and avoid operating machineries) 6. Avoidance of allergens PULMONARY VASCULAR DISORDER 1. Cor Pulmonale – refers to enlargement of Right ventricle (R ventricle hypertrophy) Common cause: COPD •
•
COPD narrowing of pulmonary vessels ↑ resistance of blood flow to the lungs ↑ functional demand of heart (R ventricle) to pump blood compensation (hypertrophy)
Manifestation of Cor Pulmonale Right sided heart failure Management – treat respiratory problem PULMONARY EMBOLISM Refers to occlusion in one or more pulmonary veins Blood clot (♥ don’t forget – patients with oral contraceptives - ↑ risk of clotting formation) Origin: LOWER extremities Cholesterol Amniotic fluid Air (fatal: 10 cc) •
•
• • • •
•
Best position: (air embolism) head lower than the body and on left side-lying (air normally goes up) left side lying so air bubbles won’t go on right side
Manifestations: 1. acute chest pain
Management: 1. O2 supplement 2. Semi-fowler’s (20 to 35 degrees) 3. mechanical ventilation 4. ↓ physical stimuli 5. drugs: a. analgesic – Morphine Sulfate b. anti-coagulant – aspirin, heparin (PTT, antidote: protamine sulfate), coumadin/warfarin (PT, antidote: Vit. K) c. thrombolytics – dissolves clot (streptokinase, TPA) 6. Surgery – removal of clot (embolectomy) N. Dx for pulmonary embolism Alteration in Impaired Tissue Perfusion • •
BLEEDING TENDENCIES 1. DISSEMINATED INTRAVASCULAR COAGULATION Common cause: SEPTICEMIA, ABRUPTIO PLACENTA Management – blood transfusion (platelet concentrate) 2. HEMOPHILIA A bleeding disorder due to chromosomal problem (male) Carrier – women Asymptomatic Earliest manifestation – bleeding of the umbilicus or during circumcision Ratio and proportion •
•
•
• • •
•
P.S. of hemophilia – HEMARTHROSIS (bleeding in the joints) Earliest manifestation – reluctance to move a body part (pediatric) – pad the joints and extremities because there is bleeding with active hemarthrosis – CBR 2 types of hemophilia: o A – CLOTTING FACTOR VIII (antihemolytic factor) o B – clotting factor IX (Christmas factor) – also called Christmas Disease Dx Test – Partial Thromboplastin Time (PTT) • Cryoprecipitate administer plasma (to supply the needed clotting factors) •
•
• •
•
5
•
Yellow discoloration of skin (pooling of plasma due to too much plasma)
3. THROMBOCYTOPENIA • •
•
•
•
An ↑ in platelet (N: 150000-450000 mm3) Due to exposure to agents or drugs a. Alcohol b. Chemotherapy drugs – cause bone marrow suppression c. Radiation exposure d. Viral exposure – ex. Dengue, ebola virus (ebola Zaire – causative agent) e. Thrombolytics – anti-coagulants f. Chloramphenicol g. Corticosteroids – bone marrow suppression h. Phenobarbital i. Penicillin Platelet count that can lead to bleeding < 50,000 mm3 Management – blood transfusion (platelet concentrate) Nursing alerts (for bleeding disorders) a. No invasive procedure b. Avoid astering, no anti-coagulant, no thrombolytics c. Avoid extreme temperatures d. Observe safe administration / transfusion of blood e. No drugs that are psychophlegics (drugs that can cause paralysis in the ocular muscles) – can cause bleeding of the eyes f. Pad extremities and joints of patients
CARDIAC DISTURBANCES CARDIO-VASCULAR – a system that circulates blood around the body Heart 3 layers: Pericardium (outermost) Myocardium (thickest layer) Endocardium (innermost) 4 chambers – Right and left atrial and ventricles valve – to prevent regurgitation or reflux AV valve Right tricuspid Left mitral SEMILUNAR valve Pulmonary SL valve Aortic SL valve LUBB DUBB – sounds due to valvular closure (Lubb – S1, closure of AV valve; Dubb – S2, closure of SL valve) •
•
•
•
Pacemaker – SA node (conductive system) – recorded in ECG SA node – AV node – Bundle of His – Right and Left Branches – Purkinje Fiber ECG electrical activities will be presented by waves P wave – atrial depolarization QRS wave – atrial repolarization & ventricular depolarization
T wave – ventricular repolarization
DEPOLARIZATION – stimulated stage / phase REPOLARIZATION – resting stage / phase
BASIC ECG INTERPRETATION Normal rate 60 – 100 bpm N P-R 0.12 – 0.20 seconds N QRS 0.08 – 0.12 seconds One small box = 1 mm One big box = 5 mm Normal sinus rhythm: 300, 150, 100, 75, 60, 50 look for R wave that falls in the dark line R wave >100 –tachycardia R wave < 100 – bradycardia 1. Standard ECG – composed of 12 leads 2. Holter Test – also called ambulatory ECG 3. Stress Test 12 leads – divided into 2 divisions, which shows different angles of the heart: 1. chest a. V1 and V2 – Right side of heart b. V3 and V4 – Septum c. V5 and V6 – left side 2. limb a. I b. II – most important lead and most stable (where dysrhythmia is checked) c. III d. AVR e. AVL f. AVE ♥Nursing alerts: 1. Can’t cause electrocution 2. No metals in the body 3. Breath normally and lie still 4. Holter test report electrical activity of the heart for 24 hours a. ♥ Don’t forget to instruct patient to jot down the activities during reporting period b. ♥advise to do usual ADLS – No variations c. ♥ Don’t moist / wet the apparatus d. ♥Don’t operate machineries / appliances – will affect the result of the test STRESS TEST – evaluate cardiac function once the patient is subjected to physical exertion ♥diet – light diet meal (crackers and soup) attire – proper footwear (rubber shoes) Don’t leave the patient alone Check the V/S before, during and after the test Stop the test when the patient complaints cardiopulmonary manifestations (ex. Dyspnea) DISTURBANCES: 1. INFECTION – RHEUMATIC HEART DISEASE RHD i. Complication or se sequelae of frequent and untreated GABS infection (sore throat) ii. Common: 5 to 15 y/o iii. Auto-immune problem iv. Target: connective tissue (muscles, joints, bones and blood) 6
v. Manifestations (Major symptoms – JONES criteria) 1. carditis – inflammation of 3 layers of the heart 2. valvular defect – mitral valve 3. chorea – St. Vitus dance a. refers to abnormal jerking movement b. upper extremities, face – usually at night c. loud music – aggravates d. self-limiting (3 mos.) 4. Rashes on abdominal area going to peripheral parts – erythema marginatum 5. subcutaneous nodules (self-limiting – requires no treatment) 6. Polyarthritis – inflammation of 2 or more joints a. Put some bed cradle vi. 1. 2. 3. 4.
Minor symptoms: fever chest pain frequent sore throat ↑ ASO titer (anti-streptolysin-O) a. if >333 – indicates GABS infection
Diagnosing RHD criteria: 1 major symptom (+) 2 minor symptoms 2 major symptoms (+) 1 minor symptom Dx test – no specific test: throat culture serum / blood analysis - ↑ ASO titer ↑ ESR 2 dimensional echocardiography o mitral valve Management: 1. give aspirin 2. corticosteroids 3. drug of choice (DOC) penicillin drug 4. treatment for active RHD (3 to 6 years) compliance of patients to meds – problem
LSHF – S/S; 1. paroxysmal nocturnal dyspnea 2. elevated pulmonary capillary wedge pressure (PCWP) 3. cough 4. crackles 5. wheezes 6. blood-tinged sputum 7. restlessness 8. confusion 9. orthopnea 10. tachycardia 11. exertional dyspnea 12. cyanosis Management: ↑ force of contraction without increasing HR U – Upright position (prevent pulmonary congestion – Cause dyspnea) N – Nitrates will be given – vasodilator of BVs L – Lasix – loop diuretics (remove congested fluids) O – O2 (congestion – altered tissue perfusion) A – Aminophylline (bronchodilator– prevents dyspnea) D – Digoxin (DOC) - ↑ force of contractions without Increasing HR F – Fluid restriction (1,000 – 1,300 ml/day) A – Afterload decrease (↓ O2 consumption) BetaBlocker, Ace inhibitors S – Sodium restriction T – Test for ABG and K(+)
↑K(+) = H+ retention acidosis (Hyperkalemia - ↓pH) ↓K(+) = H+ elimination alkalosis (Hypokalemia-↑pH)
2. CONGESTIVE HEART FAILURE (CHF) Inability of the heart to pump properly Types of CHF: i. RSHF – systemic ii. LSHF – pulmonary
S/S of RSHF: 1. fatigue 2. ↑ peripheral venous pressure 3. ascites 4. enlarged liver and spleen
distended jugular veins anorexia and complaints of GI distress swelling in hands and fingers dependent edema
↑ urine fluid loss K (+) excretion Hypokalemia hydrogen (H+) elimination ↑pH alkalosis
♥RHD 1. Take antibiotic prior to dental work-up or surgery – prophylaxis 2. Stress importance of good oral hygiene 3. Compliance to treatment regimen 4. Regular physical exam (annual 2D echo) 5. provide comfort – put some bed cradle
RSHF – blood will accumulate in systemic LSHF – pulmonary manifestations
5. 6. 7. 8.
DIGOXIN – effective: ↑ urine output (↑GFR) ♥check for HR and B/P don’t give if HR <50bpm or <90/60(B/P)
♥check for digoxin level N: 0.5 – 2.0 g/dl i. 2.0 – digitalis toxicity – S/S 1. bradycardia 2. hypotension 3. dizziness 4. nausea and vomiting 5. visual disturbances (yellow to yellow-green halos around the light ii. antidote: DIGIBIND – or Digoxin Immune Fab 3. CORONARY ARTERY DISEASE (CAD) Affects normal perfusion of blood from heart i. Atherosclerosis ii. Arteriosclerosis iii. Angina pectoris iv. MI Improve perfusion
1) Atherosclerosis (fatty deposition) – form of arteriosclerosis ↑ cholesterol level
7
an abnormal accumulation of lipid, or fatty substances and fibrous tissues in the vessel wall cholesterol: o HDL – good cholesterol LCL – bad cholesterol (Hard to metabolize – most abundant) Triglycerides LDL (low density level) – deposited in the tunica intima (inner lining of the BV) WBC and macrophages will modify LDL, so HDL can remove it (might cause injury – fibrous formation) o Thick capsule – can impede circulation of the blood o Thin capsule – can result to rupture (aneurysm) or emboli to be released to the blood stream (injured tunica intima) – releases fibrous tissue 2) Arteriosclerosis – hardening of the blood vessel wall (secondary to aging process) Risk factors for CAD: 1. NON-MODIFIABLE: Family history of CAD Increasing age Gender (male) Race (African American) 2. MODIFIABLE: High B/P (↑s chances of atherosclerosis) Cigarette smoking (nicotine will promote accelerated atherosclerosis) High blood cholesterol level DM Lack of estrogen in women Physical inactivity Obesity
Normal cholesterol: N total serum cholesterol – 150 to 240 mg/dl N HDL – 29 to 77 mg/dl N LDL – 60 to 160 mg/dl Triglycerides – 10 to 190 mg/dl Desired level of LDL: If one (1) risk factor or no risk factors – 160 mg/dl 2 or more risk factors - <130 mg/dl Dx: CAD <100 mg/dl o If not corrected – result to angina pectoris (AP) ♥If not corrected – result to Angina Pectoris (AP)
AP refers to chest pain/discomfort o Cause: Myocardial ischemia (inability of the coronary arteries to supply blood to the heart) Inverted T wave – ischemia normal
abnormal
Drugs – decongestants (can cause constriction of the blood vessels o Types of AP: Stable angina Unstable angina Variant angina Intractable or refractory angina Silent angina Ludwig’s angina
Stable angina – when under stress (tired) – arteriosclerosis (common cause) Unstable angina – may lead to MI (also called preinfarction angina) – even at rest (atherosclerosis – cause) Variant angina – or nocturnal angina (at night only) or Prinzmetal angina (vasospasm – cause) Intractable or Refractory angina – will not respond to Drug (severe pain); vasocompression – cause Silent angina – asymptomatic (ECG – inverted T wave But no pain) Ludwig’s angina – drug-induced AP
Manifestations of AP: 1. chest pain - <15 mins. To 30 mins. 2. nitroglycerin or rest – pain will disappear 3. radiating pain – chest to left arm 4. Levine sign – grasping outer chest Classifications I II
III IV
Activity Evoking
Prolonged exertion Walking more than 2 blocks Walking < 2 blocks Minimal activity or at rest
Limits to Activity None Slight
Marked severe
Management for AP: 1. Supplemental O2 2. Position: semi-fowler’s (lung expansion promotion – improve perfusion) 3. ↓ physical stimuli (↓ O2 demand) 4. drugs: a. aspirin – anti-coagulant (prevents formation of new clot) b. nitroglycerin or nitrates – vasodilation to improve flow and perfusion o comes in several packages: o tablet – must be stored in a dark, d ry place and tightly cupped container must be taken sublingually (burning sensation – effective) light-headedness and nausea are expected taken 1 tablet at a time at 5 mins. Interval for 3 tablets ♥ same with spray (3 doses at 5 mins. Interval)
Factors that affect AP (which will lead to myocardial ischemia) Atherosclerosis Arteriosclerosis Vasospasm Vasocompression
discard nitroglycerin after 6 months - potency (4th month – patency starts to ↓)
o
o o
spray patch Nursing alerts: 8
Don’t touch medicated surface – cause hypotension Place the patch on a non-hairy spot (shaved site) – shave along the hair growth to prevent skin breakdown Anterior chest (site of patch) – intermittent R & L o Parenteral – don’t give rapid infusion
MYOCARDIAL INFARCTION (MI) o Coronary occlusion or “heart attack” o Causes: same with AP Chest pain is >15 – 30 mins. o o Levine sign o Radiating pain o Manifestations: o D – dyspnea o A – anxiety o N – N/V o C – crushing substernal pain o E – elevated temperature o P – pallor o A – arrhythmia o D – diaphoresis o Lactic acid can cause chest pain o Cardiac enzymes ↑ (activation of pyrogenes - ↑s temperature) – due to injury o LDH o CPK Rises 4 to 8 hours after attack Peak of CPK – ½ to 1 ½ da ys Normalizes 3 to 4 days after o Troponin T & I – most reliable (-) Normal rises: immediately peak: 4 to 24 hours normalizes: 1-3 weeks after o Lactic dehydrogenase 100 to 190 in/liter rises: 12 to 24 hours after peak: 2 to 6 days after Management of MI: M – Morphine sulfate (narcotic analgesic) O – O2 (improve tissue perfusion) A – Aspirin and Ace inhibitors (anti-coagulant; ↓ afterload) N – Nitroglycerin/nitrates (vasodilator) S – streptokinase (thrombolytic – dissolves a clot) best time: within 3 hours after the attack o
pathological Q wave or very large Q wave
N. Dx (MI) – alteration in comfort and pain Ace inhibitors – “pril” captopril Streptokinase – substance derived (bacteria) N. alerts:♥ o best given within 3 hours after attack o don’t give to active streptococcal infection patients o don’t give to immunocompromise – cause septic shock o don’t give to patients with thrombocytopenia - ↓ platelet can cause bleeding
9