Care of Clients With Problems in Oxygenation (Part 2)

8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)

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CARE OF CLIENTS WITHPROBLEMS IN

OXYGENATION(P ART 2)

Jotham C. Marfil, RN


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D IAGNOSTIC TESTS


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CK-MB (CREATININE KINASE,MYOCAR D IAL MUSCLE)

An elevation in value indicates myocardialdamage

An elevation occurs within 4 to 6 hoursand peaks 18 to 24 hours following anacute ischemic attack

Normal value is 0% to 5% of total; totalCK is 26 to 174 units/L


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L ACTATE D EHY D ROGENASE (L D H)

E levations in LDH levels occur 24 hoursfollowing myocardial infarction and peakin 48 to 72 hours

Normally, LDH1 is lower than LDH2;when the serum concentration of LDH1 ishigher than LDH2, the pattern is

indicated as flipped, signifyingmyocardial necrosis

140 to 280 IU/L


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TROPONIN

Is composed of troponin C, cardiactroponin I, and cardiac troponin T

Has a high affinity for myocardial injury;it rises within 3 hours and persists for upto 7 days

Troponin I lower than 0.6ng/mLTroponin T 0 to 0.2ng/mL


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C OMPLETE BLOO D COUNT

RBC decreases in rheumatic heart diseaseand infective endocarditis and increasesin conditions characterized by inadequatetissue oxygenation

The WBC increases in infectious andinflammatory diseases of the heart andafter MI to dispose necrotic tissueresulting from infarction


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E levated hematocrit level can result from

vascular volume depletion

Decreases in hematocrit and hemoglobinlevels can indicate pneumonia


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S ERUM LIPI D S

The lipid profile measures serumcholesterol, triglyceride, and lipoproteinlevels

Is used to assess the risk of developingcoronary artery disease

Serum cholesterol lower than 200mg/dLLDL lower than 130mg/dLHDL 30 to 70 mg/dL


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B- TYPE NATRIURETIC PEPTI D E (BNP)

Is released in response to atrial andventricular stretch; it serves as a markerfor congestive heart failure

Should be lower than 100pg/mL

The higher the level, the more severe thecongestive heart failure


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ELECTROCAR D IOGRAPHY

Noninvasive test that records theelectrical activity of the heart and isuseful for detecting cardiac dysrhythmias,location and extent of MI, and cardiachypertrophy and for evaluation of theeffectiveness of medications


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INT E RV E NTIONS

Determine the clients ability to lie still;advise the client to lie still, breathenormally, and refrain from talking duringthe test

Reassure the client that an electrical shockwill not occur

Document any cardiac medications theclient is taking


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E CHOCAR D IOGRAPHY

Noninvasive procedure based on theprinciples of ultrasound and evaluatesstructural and functional changes in theheart

Heart chamber size is measured, ejection

fraction is calculated, and flow gradientacross the valve is determined


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E XERCISE TESTING (STRESS TEST )

Noninvasive test that studies the heartduring activity and detects and evaluatescoronary artery disease

Treadmill testing is the most commonlyused mode of stress testing


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INT E RV E NTIONS

Obtain an informed consent if required

Provide adequate rest the night before theprocedure

Instruct the client to eat a light meal 1 to

2 hours before the procedure

Instruct the client to avoid smoking,alcohol and caffeine before the procedure


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Instruct client to wear nonconstrictive,

comfortable clothing and supportiverubber-soled shoes for the exercise stresstest

Instruct the client to notify the physicianif any chest pain, dizziness, or shortnessof breath occurs during the procedure

Instruct client to avoid taking a hot bathor shower for at least 1 to 2 hours afterthe procedure


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D IGITAL SUBTRACTION ANGIOGRAPHY

This test combines x-ray techniques and acomputerized subtraction technique withfluoroscopy for visualization of thecardiovascular system

A contrast media (dye) is injected


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INT E RV E NTIONS

Assess for allergies to seafood, iodine, orradiopaque dyes. Premedicate client withantihistamines or corticosteroids to

prevent a reaction

Obtain informed consent

Monitor vital signs

Assess injection site for bleeding ordiscomfort


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M AGNETIC RESONANCE IMAGING

Noninvasive diagnostic test that producesan image of the heart or great vesselsthrough interaction of magnetic fields,

radio waves, and atomic nuclei

Provides information on chamber size andthickness, valve and ventricular function,and blood flow through the great vesselsand coronary arteries


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INT E RV E NTIONS

E valuate client for the presence of pacemaker or other implanted items thatpresent a contraindication to the test

E nsure client has removed all metallicobjects such as watch, jewelry, clothingwith metal fasteners, and metal hairfasteners

Inform client that she or he mayexperience claustrophobia while inscanner


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SICKLE CELL ANEMIA


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Constitutes a group of diseases termedhemoglobinopathies, in which hemoglobin A is partly or completely replaced byabnormal sickle hemoglobin S

Caused by inheritance of a gene for astructurally abnormal portion of thehemoglobin chain

Hemoglobin S is sensitive to changes in theoxygen content of the RBC


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Insufficient oxygen causes the cells to

assume a sickle cell shape and the cellsbecome rigid and clumped together,obstructing capillary blood flow

Situations that precipitate sickling includefever and emotional or physical stress; anycondition that increases the need for oxygenor alters the transport of oxygen can resultin sickle cell crisis


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At risk are those having parents

heterozygous for hemoglobin S or being of African American descent

Sickle cell crises are acute exacerbations of the disease, which vary considerably inseverity and frequency ; these include vaso-occlusive crisis, splenic sequestration, andaplastic crisis


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V ASO -O CCLUSIV E CRISIS

Caused by stasis of blood with lumping of the cells in the microcirculation, ischemia,and infarction

Fever, painful swelling of the hands, feet,and joints, and abdominal pain


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S PL E NIC S EQ U E STRATION

Caused by the pooling and clumping of blood in the spleen (hypersplenism).

Profound anemia, hypovolemia, and shock


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A PLASTIC CRISIS

Caused by the diminished production andincreased destruction of RBC, triggered byviral infection or the depletion of folic acid

Profound anemia and pallor


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INT E RV E NTIONS

Maintain adequate hydration and bloodflow with IV administered NSS and withoral fluids

Administer oxygen and blood products asprescribed

Administer analgesics as prescribed(ATC)

Administration of meperidine (Demerol) isavoided


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Assist the child to assume a comfortable

position so that the child keeps theextremities extended to promote venousreturn

E levate the bed of the head 30 degrees,avoid putting strain on painful joints, anddo not raise the knee gatch of the bed

E ncourage consumption of high-calorie,high protein diet, with folic acidsupplementation


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Administer antibiotics as prescribed toprevent infection

Monitor for signs of complications,including increasing anemia, decreased

perfusion, and shock

Instruct the child and parents about theearly signs and symptoms of crisis and themeasures to prevent crisis


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IRON D EFICIENCY ANEMIA


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Iron stores are depleted, resulting in adecreased supply of iron for themanufacture of hemoglobin in RBC

Commonly results from blood loss,increased metabolic demands, syndromes of GI malabsorption and dietary inadequacy


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S IGNS AND S YMPTOMS

Pallor

Weakness and fatigue

Irritability


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INT E RV E NTIONS

Increase the oral intake of iron

Instruct the child and parents in foodchoices that are high in iron

Administer iron supplements as

prescribed

Give iron supplements between meals formaximum absorption


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Give iron supplements with a multivitaminor fruit juice because vitamin C increases

absorption

Do not give iron supplements with milk orantacids because these items decrease

absorption

Teach the child and parents that a liquidiron preparation stains the teeth andshould be taken through a straw

Inform parents/client on side effects(constipation, black stools, foul aftertaste)


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HEMOPHILIA


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Refers to a group of bleeding disorders

resulting from a deficiency of specificcoagulation proteins

Factor VIII deficiency (hemophilia A orclassic hemophilia)

Factor IX deficiency (hemophilia B or

Christmas disease)

Result as an X-linked recessive disorder


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Most frequently transmitted by the union

of an unaffected male with a trait-carrierfemale; however, it can result from theunion between an affected male and anormal or carrier female


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S IGNS AND SYMPTOMS

Abnormal bleeding in response to trauma orsurgery (usually detected after circumcision)

E pistaxis

Joint bleeding causing pain, tenderness,swelling and limited ROM

Tendency to bruise easily

Platelet test is normal; clotting factorfunction may be abnormal


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INT E RV E NTIONS

Monitor for bleeding and maintainbleeding precautions

Prepare to administer replacement factorsas prescribed

Monitor for joint pain; immobilize the

affected extremity if joint pain occurs

Assess neurological status (child is at riskfor intracranial hemorrhage)


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Control joint bleeding by immobilization,elevation, and the application of ice; inaddition, apply pressure (15 minutes) forsuperficial bleeding

Instruct parents how to control bleeding

Instruct the parents on activities to beavoided by the child, emphasizing

avoidance of contact sports and the needfor protective devices while learning towalk


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KAWASAKI D ISEASE


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Is known as mucocutaneous lymph node

syndrome and is an acute systemicinflammatory illness

The cause is unknown but may be associatedwith an infection from an organism or toxin

Cardiac involvement is the most serious

complication; aneurysms can develop


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S IGNS AND SYMPTOMS

Fever

Conjunctival hyperemia

Red throat acute stage

Swollen hands, rash,and enlargement of thecervical lymph nodes


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Crackling lipsand fissures

Desquamation of theskin on the tips of thefingers and toes

subacute stageJoint pain

Cardiac manifestations

Thrombocytosis


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Irritability may last up for up to 2 monthsafter the onset of symptoms

Peeling of the hands and feet may occur

Pain in the joints may persist for severalweeks

Stiffness in the morning, after naps, and incold temperatures may occur


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INT E RV E NTIONS

Monitor temperatures frequently (refer if 101F or higher)

Assess heart sounds, rate, and rhythm

Assess extremities for edema, redness, anddesquamation

E xamine eyes for conjunctivitis

Monitor mucous membranes forinflammation


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Monitor strict intake and output

Administer soft foods and liquids that areneither too hot nor too cold

Weigh the child daily

Provide passive range of motion exercises tofacilitate joint movement

Administer ASA as prescribed


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Administer immune globulin intravenouslyas prescribed to reduce the duration of thefever and the incidence of coronary arterylesions and aneurysms


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CORONARY ARTERYD ISEASE


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Narrowing or obstruction of one or morecoronary arteries as a result of atherosclerosis, which is an accumulation of lipid-containing plaque in the arteries

Causes decreased perfusion of myocardialtissue and inadequate myocardial oxygensupply

Symptoms occur when the coronary arteryis occluded to the point that inadequateblood supply to the muscle occurs causingischemia


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Coronary artery narrowing is significant if

the lumen diameter of the left main arteryis reduced at least 50%, or if any majorbranch is reduced at least 75%

The goal of treatment is to alteratherosclerotic progression

Cardiac catheterization provides the mostdefinitive source for diagnosis


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S IGNS AND SYMPTOMS

Chest pain

Palpitations

Dyspnea

Syncope

Cough or hemoptysis

E xcess fatigue


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When blood flow is reduced and ischemiaoccurs, ST segment depression, T waveinversion, or both is noted; ST segmentreturns to normal when the blood flowreturns

With infarction, cell injury results in STsegment elevation, followed by T waveinversion and an abnormal Q wave

Blood lipid levels may be elevated


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INT E RV E NTIONS

Instruct the client regarding the purposeof diagnostic medical and surgicalprocedures and pre procedure and postprocedure expectations

Assist the client to identify risk factorsthat can be modified

Assist the client to set goals to promotelifestyle changes to reduce the impact of risk factors


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Instruct the client regarding a low-calorie,low sodium, low cholesterol, and low fatdiet with an increase in dietary fiber

Stress to the client that dietary changes

are maintained for life

Provide community resources to the clientregarding exercise, smoking cessation,and stress reduction as prescribed


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S URGICAL PROC E DUR E S

PTCA to compress the plaque against thewalls of the artery and dilate the vessel

Laser angioplasty to vaporize the plaque

Atherectomy to remove the plaque fromartery

Coronary artery bypass grafting toimprove blood flow to the myocardialtissue at risk for ischemia or infarction


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ANGINA


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Chest pain resulting from myocardial

ischemia caused by inadequatemyocardial blood and oxygen supply

Caused by an imbalance between oxygensupply and demand

Causes include obstruction of coronaryblood flow resulting from atherosclerosis,coronary artery spasm, or conditionsincreasing myocardial oxygenconsumption


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P ATT E RNS OF ANGINA

Stable Anginay Also called exertional angina

y

Occurs with activities that involve exertionor emotional stress; relieved with rest ornitroglycerin

y

Usually has a stable pattern of onset,duration, severity and relieving factors


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U nstable Anginay

Also called preinfarction angina

y Occurs with an unpredictable degree of exertion or emotion and increases in

occurrence, duration, and severity over time

y Pain may not be relieved with nitroglycerin


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I ntractable Angina is a chronic,incapacitating angina unresponsive tointerventions

P reinfarction Anginay

Associated with acute coronary insufficiency

y Lasts longer than 15 minutes

y Symptom of worsening cardiac ischemia

y Occurs after an MI, when residual ischemiamay cause episodes of angina


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S IGNS AND SYMPTOMS

Pain

Dyspnea

Pallor

Sweating

Palpitations and tachycardia


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Dizziness and faintness

Hypertension

Digestive disturbances


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INT E RV E NTIONS

Assess pain

Provide bed rest

Administer oxygen at 3L/min by nasalcannula as prescribed

Administer nitroglycerin as prescribed

Obtain a 12-lead E CG


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Provide a continuous cardiac monitoring

Assist the client in identifying angina-precipitating events

Instruct client to stop activity and rest if chest pain occurs and to take nitroglycerinas prescribed

Instruct client to seek medical attention if pain persists


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Assist client to identify risk factors thatcan be modified

Provide dietary instructions

Provide community resources to the clientregarding exercise, smoking cessation,and stress reduction


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MYOCAR D IAL INFARCTION


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Occurs when myocardial tissue is abruptlyand severely deprived of oxygen

Ischemia can lead to necrosis of myocardial tissue if blood flow is notrestored

Infarction does not occur instantly butevolves over several hours

Obvious physical changes do not occur inthe heart until 6 hours after theinfarction, when the infarcted areasappears blue and swollen


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Not all clients experience the classic

symptoms of an MI

Women may experience atypicaldiscomfort , shortness of breath, or fatigue

An older client may experience shortnessof breath, pulmonary edema, dizziness,altered mental status, or a dysrhythmia


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S IGNS AND SYMPTOMS

Pain

Nausea and vomiting

Diaphoresis

Dyspnea

Dysrhythmias


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Feelings of fear and anxiety

Pallor

Cyanosis

Coolness of extremities


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INT E RV E NTIONS

Obtain a description of the chestdiscomfort

Assess vital signs

Assess cardiovascular status

Place client in a semi-Fowlers position

Administer oxygen at 2 to 4L/min by nasalcannula as prescribed


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E stablish an IV access route

Administer nitroglycerin as prescribed

Administer morphine sulphate as

prescribed to relieve chest discomfort

Obtain a 12-lead E CG

Monitor thrombolytic therapy, which maybe prescribed for the first 6 hours of thecoronary event


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Administer beta blockers as prescribed

Assess distal peripheral pulses and skintemperature

Monitor intake and output

Assess RR and breath sounds for signs of heartfailure

Monitor BP closely

Provide reassurance to the client and family


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Maintain bed rest for the first 24 to 36hours as prescribed

Allow the client to stand to void or use a bedside commode if prescribed

Provide ROM exercises

E ncourage client to verbalize feelingregarding the MI


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RAYNAU D S D ISEASE


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Vasospasms of the arterioles and arteriesof the upper and lower extremities

Vasospasms cause constriction of thecutaneous vessels

Attacks are intermittent and occur withexposure to cold or stress

Affects primarily fingers, toes, ears, andcheeks


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S IGNS AND SYMPTOMS

Blanching of the extremity, followed bycyanosis during constriction

Reddened tissue when the vasospasm isrelieved

Numbness, tingling, swelling, and a coldtemperature at the affected body part


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INT E RV E NTIONS

Monitor pulses

Administer vasodilators as prescribed

Assist the client to identify and avoidprecipitating factors such as cold andstress

Instruct the client to avoid smoking


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Instruct the client to wear warm clothing,

socks and gloves in cold weather

Advise client to avoid injuries to fingersand hands


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BUERGER S D ISEASE


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Thromboangiitis obliterans

An occlusive disease of the median andsmall arteries and veins

The distal upper and lower limbs areaffected most commonly


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S IGNS AND SYMPTOMS

Intermittent claudication

Ischemic pain occurring in the digits whileat rest

Aching pain that is more severe at night

Cool, numb, or tingling sensation

Diminished distal pulses


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INT E RV E NTIONS

Instruct the client to stop smoking

Monitor pulses

Instruct the client to avoid injury to theupper and lower extremities

Administer vasodilators as prescribed

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Care of Clients With Problems in Oxygenation (Part 2)

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