Med-Surg Unit 1 1 Medical-Surgical – Adult Unit 1 Respiratory – Adult Unit 1 Week 1 – 9/7/18 CASE STUDY REPORT - RESPIRATORY Patient 1: 72 y.o M came in with COPD, he is still a current smoker, 25ppy, 2L nasal cannula 89% , he does uses 2L nasal cannula O2 at home, sometimes tachy when exerting like 105, but last EKG showed normal sinus rhythm, at 6am he had his meds, he is sitting up in bed having breakfast, last night he had chest x- ray - showed consolidation, ID team just rounded on him and wrote some orders so check that and report. Q: Is he having SOB, vital signs WNL Patient 2: 32 y.o M, sitting up in bed, wearing clothes to be discharged, CC smoke inhalation, fire in apartment, originally on 2L NC, had productive cough but now he is on RA, if you look at his nose his nasal hairs are synchs, he inhaled smoke, sputum has soot in it, no burns, voice is hoarse, really ready to go home but he is coughing a lot, but pulse ox is 91%, he had been on 98% on 2L, pulmonary is going to come round on him Q: Any chest pain à “some discomfort,” A&O x 3, O2 stat going from higher to lower is concerning, productive cough is concerning #1 - POTENTIALLY THE MOST DANGEROUS PATIENT à COULD DIE FIRST Patient 3: 86 y.o F, came from a SNIF (skilled nursing facility), gone in for hip replacement for 10 days, but here today on pulmonology for SOB and has a possible PE, admitted to our unit 3 days ago, a little disoriented when first came in now A&O x 3, has heparin drip, last PTT with morning labs, and d-dimer was elevated at admission. Q: What was the PTT à in WNL, drew it again to see if WNL, is she ambulatory or bedrest à bed rest, needs bedpan. #2 – PRIORITY Patient 4: 45 y.o M, quadriplegic, around C7, from a motor vehicle injury year ago, here today, new admit, CC chest pain and productive cough to rule out pneumonia, 38 Celsius, last CBC elevated WBC – 13,000, neutrophils to the left elevated, O2 is 98% on RA, chest pain when breathing in (pleuritic pain) lungs diminished on the bases, chest x-ray ordered, not ventilated,
Transcript
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Medical-Surgical – Adult Unit 1 Respiratory – Adult Unit 1
Week 1 – 9/7/18 CASE STUDY REPORT - RESPIRATORY Patient 1: 72 y.o M came in with COPD, he is still a current smoker, 25ppy, 2L nasal cannula 89% , he does uses 2L nasal cannula O2 at home, sometimes tachy when exerting like 105, but last EKG showed normal sinus rhythm, at 6am he had his meds, he is sitting up in bed having breakfast, last night he had chest x-ray - showed consolidation, ID team just rounded on him and wrote some orders so check that and report. Q: Is he having SOB, vital signs WNL Patient 2: 32 y.o M, sitting up in bed, wearing clothes to be discharged, CC smoke inhalation, fire in apartment, originally on 2L NC, had productive cough but now he is on RA, if you look at his nose his nasal hairs are synchs, he inhaled smoke, sputum has soot in it, no burns, voice is hoarse, really ready to go home but he is coughing a lot, but pulse ox is 91%, he had been on 98% on 2L, pulmonary is going to come round on him Q: Any chest pain à “some discomfort,” A&O x 3, O2 stat going from higher to lower is concerning, productive cough is concerning #1 - POTENTIALLY THE MOST DANGEROUS PATIENT à COULD DIE FIRST Patient 3: 86 y.o F, came from a SNIF (skilled nursing facility), gone in for hip replacement for 10 days, but here today on pulmonology for SOB and has a possible PE, admitted to our unit 3 days ago, a little disoriented when first came in now A&O x 3, has heparin drip, last PTT with morning labs, and d-dimer was elevated at admission. Q: What was the PTT à in WNL, drew it again to see if WNL, is she ambulatory or bedrest à bed rest, needs bedpan. #2 – PRIORITY Patient 4: 45 y.o M, quadriplegic, around C7, from a motor vehicle injury year ago, here today, new admit, CC chest pain and productive cough to rule out pneumonia, 38 Celsius, last CBC elevated WBC – 13,000, neutrophils to the left elevated, O2 is 98% on RA, chest pain when breathing in (pleuritic pain) lungs diminished on the bases, chest x-ray ordered, not ventilated,
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OBSTRUCTIVE VS. RESTRICTIVE PULMONARY DX
Ø Obstructive: COPD (chronic bronchitis + emphysema) & asthma o Increased residual volume = air trapping o COPD à struggle with EXPIRATION o Can become barrel chested o Air gets trapped o CO2 increases & can become HYPERCAPNIC
Ø Restrictive: Pulmonary fibrosis (scarring of the lungs) o Decreased inspiratory capacity o Cause: often occupational exposure, could also be effect of radiation therapy
§ Amiodarone à used for A.fib but could have serious side-effects of lungs § Lupus…mostly idiopathic § Chemotherapy can cause scaring of the lungs
o Can take anti-fibrotic agents & steroids to decrease inflammation, but no cure, help patients with cough suppression
o Much less common o Pulmonary fibrosis can occur in jobs like miners, or labor workers in chemical
plants o Issue is about INSPIRATION o Lungs are very stiff, don’t open nicely o Not curable, but we treat symptoms
v Question A client with COPD is being discharged from the hospital. Which statement by the client indicates further teaching is necessary?
a. “I’ll eat six small meals a day”
b. “I’ll get a flu shot every winter”
c. “I’ll walk every morning before breakfast”
d. “I’ll call my health care provider if I get cold symptoms”
Answer: C à COPD patients have a more productive cough in the mornings D à cannot take lightly someone with a fever or a cold who has COPD, can change into pneumonia or something else very fast
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CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Ø What’s included in pulmonary rehabilitation? o Breathing technique
• Pursed lipped breathing • Take short breath in (3 seconds), long deep breath out (7 seconds) • Slows down RR • Increases resistances in little airways, which helps to keep them open and prevent
them from collapsing in • Controlled breathing • Longer exhale • “smelling a rose, blowing out birthday candles” • Diaphragmatic breathing • Putting hand on stomach to watch it rise & fall • CDB à mucous • Incentive spirometer à used only if worried about atelectasis • Chest PT à vest that shakes them, only for emphysema (a lot of mucous)
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REVIEW OF INTERVENTIONS FOR SOB (SHORTNESS OF BREATH)
Ø Position them, HOB, sit them down Ø Oxygen Ø Breathing Ø Medication à bronchodilator
Ø Alternate activity with rest, but encourage activity as tolerated Ø Stress reduction Ø CDB as ordered, not IS Ø Pulse oximetry >90%
o Recognize hypoxemia & hypercapnia Ø Clear airways before eating Ø Partial Oxygen Norm
o pO2 normal = 80-100mmHg o COPD normal = 60-80mmHg
Ø 5-6 small meals Ø COPD expends more calories Ø COPD pt. keep O2 low b/c that is their breathing drive Ø Chart 21-4 for pursed lip breathing
o 3/7 o Prolong exhalation & increase airway pressure to open airway during exhalation
to reduce trapped air o Can perform nasotracheal suction if pt cannot expectorate own mucus
v Question: Which statement by the nurse best describes the purpose of diaphragmatic breathing exercises for a client with COPD?
A. It dilates the bronchioles B. It decreases vital capacity C. It increases residual volume D. It decreases alveolar ventilation
Answer: D à decreases RR and then decreases residual volume, Residual volume is what is left over, COPD patients already have too much residual,
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NORMAL CHEST VS. BARREL-SHAPED
CHANGES IN ALVEOLAR STRUCTURE
PATHOPHYSIOLOGY OF CHRONIC BRONCHITIS
Fluid restriction only if the patient has comorbidity like CHF or fluid retention.
v Question: A nurse is caring for a client with emphysema. Which nursing interventions are appropriate? Select all that apply.
A. Reduce fluid intake to less than 2500 mL/day B. Teach diaphragmatic, pursed-lip breathing C. Administer low-flow oxygen D. Keep the client in a supine position as much as possible E. Encourage alternating activity with rest periodically F. Teach the family use of postural drainage and chest physiotherapy
Answer: B, C à can do low flow nasal cannula, E, F
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COPD
Ø But majority of COPD patients have both & therefore have a combination of chronic bronchitis & emphysema symptoms
ASTHMA
Ø What are the anticipated: o Lung sounds
§ Trouble getting air in & out § Wheezing in inspiratory and expiratory
o Treatments § Importance of explaining the use of long-acting inhaler vs. quick-relief
inhaler § Trouble with managing b/c of overuse of inhaler or rescue inhalers, can
make them desensitized, should not be more than twice a week, long-term inhalers
MEDICATIONS FOR OBSTRUCTIVE PULMONARY DISORDERS
Ø Bronchodilators o B2-adrenergic agonist
§ Albuterol (Proventil) o Anticholinergic agent
§ Ipratropium bromide (Atrovent) o Methylxanthines
Ø Used for biopsy Ø Topical anesthesia à numb back of throat or nose Ø Pre-procedure: Conscious sedation & topical anesthesia Ø Post-procedure: What is expected?
o Drinking/eating o Hoarseness o Bleeding o Fever à persistent fever o NANDA: risk for aspiration (after operation)
v Question: A client is scheduled to have a series of pulmonary function tests (PFTs). For which med should the nurse anticipate an order to withhold six hours prior to the test? A. Azithromycin B. Robitussin C. Albuterol D. Cefaclor
Answer: C à hold albuterol because it will give you a false positive
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VENTILATOR SETTINGS
Ø O2 (fraction of inspired oxygen) à 40-50% commonly, adjust based on ABG & SpO2 o Check ABG’s
§ We want to stabilize them and then slowly take them off of the vent § CO2 could be going up or down § ABG’s will show us hyperoxygenation, that you cannot see on pulse ox.
Ø PEEP (positive end expiratory pressure) à 5-10 cmH20 o Blowing in to keep alveoli open
Ø RR à normal (+/- for acid-base imbalance) Ø Tidal volume (VT) à weight-based Ø All pts. on vents get ABG’s
Look at the bottom numbers PEEP: 18 (high) Keep bringing levels down to see what they can handle
v Question: A client returns to the nursing unit after a bronchoscopy and is expectorating pink-tinged sputum. What is the most appropriate nursing action?
A. Notify provider as soon as possible B. Take client’s VS & notify provider C. Auscultate client’s lung fields for possible pulmonary edema D. Educate client this is expected and continue to monitor
Answer: D à some bleeding is expected in the beginning Pink-tinged sputum à blood in sputum
Also: after any procedure that goes through throat, what is another consideration? v Question: Two hours after sub mucous resection, a client’s nostril’s are packed. Which
assessment would alert the nurse to active bleeding at the surgical site? A. Frequent swallowing B. Dry mucous membranes C. Decrease in urinary output (UO) D. Elevated temperature
Also: (1) careful blowing nose, will cause increased inflammation & (2) position correctly post-op Answer: A à could indicate that blood is trickling down their throat
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VENTILATOR MODES
Controlled Modes Supported Modes Combo Modes o Volume or
pressure control o Mechanical
breaths
o Spontaneous o CPAP o Pt initiated
breaths
o Often seen as intermediate step: is it time to extubate?
o SIMV (Synchronized intermittent mandatory ventilation)
o Pt is doing some breathing on their own, and if they miss a breath the machine will do it for them
o Intermediate step before we take someone off the vent
Question: If pt is hypercapnic, what change might you make to vent setting? Answer: Too much CO2, hypercapnic, want to blow-off CO2, Increase RR VENTILATOR ALARMS
Ø Don’t silence vent alarms! Assess the patient, not the alarm Ø Endotracheal tube goes in trachea and needs to sit above the bifurcation of bronchioles
o Look for bilateral rise of chest
HIGH PRESSURE LOW PRESSURE o Some sort of blockage o Coughing o Biting tube o Fighting ventilator o Secretions in airway o Water in circuit o Kink in tubing
o System is open, air is not going to the patient
o Low is more SERIOUS o Disconnection of system (circuit or
airway leaks) o Disconnection from patient
(extubation)
Ø Make sure that the ambu bag is besides the bed, just in case something happens.
Ø Need to move it daily, to be careful for skin breakdown
Ø Check the markings, it will say a measurement, you have to make sure it is still in that measurement (24 on the lip on right/left side)
Ø Properly sedate the patient so they do not bite
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NURSING INTERVENTION FOR ET TUBE & VENT
Ø Keep ambubag for resuscitation at bedside Ø Preventing ventilator-associated pneumonia (VAP):
1. HOB 30-45 2. Oral care with chlorhexidine 3. Prevent PUD (peptic ulcer disease)
o Helps prevent pneumonia too 4. Sedation vacation
NURSING INTERVENTION FOR TRACH
Ø If awake: o Teach pt how to communicate needs o Provide writing tablet
Ø If restrained: o Provide appropriate call light
Ø Hyperoxygenate before suctioning Ø Clean area couple times a shift, full trach care once a day
v Question: The nurse is caring for a client who has been intubated. What is the nurse’s priority intervention? A. Use lubricant on the lips every eight hours B. Provide oral care twice a day C. Suction the oral cavity twice a day D. Reposition the endotracheal (ET) tube every 24 hours
Answer: D à skin breakdown can happen right away, C would be correct if it said down the ET tube, B&C are very similar, oral care does require attention but not priority, You do lubricate lips but it’s not a priority v Question: A client is admitted to the hospital with respiratory failure. He is intubated in
the ED, placed on 100% FiO2, and is coughing up copious secretions. What is the nurse’s most appropriate action? A. Request a chest X-ray B. Infuse the ordered antibiotic C. Suction the client D. Obtain the ordered arterial blood gas (ABG’s)
Answer: C à priority is to suction patient and clear airway
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ENHANCING GAS EXCHANGE & EFFECTIVE AIRWAY CLEARANCE INTERVENTIONS
Ø Administer bronchodilator as prescribed…add to this Ø Smoking cessation Ø Educate & encourage diaphragmatic breathing & effective coughing (consider activities) Ø Monitor ABGs and other indicators of hypoxia. Note trends Ø Balance pain management with judicious use of analgesics
o Some analgesics can decrease respiratory rate Ø Adequate hydrate patient Ø Auscultate lung sounds at least every 2 to 4 hours. Ø Measures to clear airway: suctioning, CPT, position changes, promote mobility Ø Administer oxygenation (caution) & humidification Ø Educate on reporting early signs of infection…next step?
CHEST TUBES
Ø Indication o Air à pneumothorax o Fluid à blood, water, pus, lymph, parietal space (pleural effusion) o Fluid à mediastinal (s/p heart surgery)
Ø Mark your output at least each shift change Ø Keep below level of chest Ø Suction Ø Clamp the tube, whenever you will unhook the tube, cus it is a closed system, clamp
using blue clip
Attached to pt
Fluid accumulations
Mark a line & initial
Clamp
Bubbling
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CT TROUBLESHOOTING
Ø Normal o A little bit of rise and fall is normal
Ø Check for air leak in water chamber (bubbling) o Need to call provider
Ø SubQ emphysema https://youtu.be/H036SlCqUYo o Risk after thoracentesis o If air gets in the chest cavity o Catch it early à feel the skin around the tube, it will feel like rice crispies
Ø What do you do if it falls out? o If the pt. is moving around a lot, it’s possible that it can slip out, sometimes its ok
if it was ready to come out, let the provider know o If it was really early on, they will need one inserted o Cover it with an occlusive covering with petroleum gauze o Tension pneumothorax, they may allow air to come out sometimes
Ø Output: when do we worry? o When there is a dramatic change, if there is too much or too little
§ If the pt. was laying on the tube and compressing it and all of a sudden all this fluid starts to come in, then we don’t know how much fluid was backed up around heart or lungs
Ø When is it time to take it out? ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
Ø Nonspecific pulmonary response to a variety of pulmonary and nonpulmonary insults to the lung
Ø Characterized by interstitial infiltrates, alveolar hemorrhage, atelectasis, decreased compliance, and refractory hypoxemia
o All this fluid leaks into the lungs Ø Refractory hypoxemia
o Even when you give them O2, you can’t get the SpO2 up o SpO2 and partial pressure, they work together o If you can’t overcome, then you have to do mechanical intubation o Put them on mechanical intervention
Ø Mortality around 40% Ø Causes:
o Main: shock o Delayed: Smoke inhalation, near drowning
§ Inflammation is the reason there is destruction of the tissue, which could put them in respiratory failure
§ Carbon monoxide poisoning Ø Treatment:
o Prone position à lay on stomach to make the front of the lungs perfuse more with the help of gravity
o “White lung” – white on the x-ray
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PLEURAL EFFUSION & THORACENTESIS
PNEUMOTHORAX
Ø Trauma or injury Ø Pneumocystis pneumonia Ø Sometimes it can be done from surgery Ø Some young white-men, can get spontaneous pneumothorax Ø Note
o Tracheal deviation o Uneven chest rise & fall
Hemothorax Or Empyema
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CYSTIC FIBROSIS
Ø Autosomal Recessive, most lethal genetic dx among US white o Can’t be with someone who also has a recessive disorder because you will
definitely pass it down to offspring Ø Carriers unaffected
Air rushed in to the pleural cavity which is supposed to be a closed cavity but b/c there was some sort of air it allows it to mix, there is too much high pressure of air in the space, need to bring it back to -4mmHg
Spontaneous Pneumothorax
v Question: The assessment of a client on the first day after thoracotomy shows a temperature of 100 degrees F (37.8 deg C), HR 96 bpm, BP 136/86 mmHg, and shallow respirations at 24 breaths/min with rhonchi at the bases. The client reports incisional pain. Which nursing action is most important?
A. Medicate the client for pain B. Help the client get out of bed C. Give ibuprofen as ordered to reduce the fever D. Encourage the client to cough and deep breath
Answer: A à make sure to medicate them before you make them do deep breathing, B à you don’t always have to go medically to treat a fever D à trying to prevent atelectasis
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Ø >30,000 in US Ø “salty kiss”…sweat test (Cl > 60meq/L)
o Imbalance with salt (Na) metabolism o Accumulation of chlorine that leads to malfunction
Ø Projection: 10 yrs from now, 70% of people with CF will be adults Ø Main infectious organisms: MDR Psuedomonas, MRSA, NTM Ø Top 2 nursing interventions: (postural drainage)
1. Mucous is what is killing them, tenacious (hard 2. Infection, they may take prophylaxis to reduce infection risk
PULMONARY EMBOLISM
• Name • DVT + PE = VTE • Deep vein thrombosis, pulmonary embolism,
• Who’s at risk?
Ø Vest that shakes you to shake the mucous out
Ø They can drown in their own mucous
Ø Surgery Ø Smoking Ø Hyperlipidemia Ø Foreign object
(pacemaker, central line)
Ø Bedbound patients Ø A.Fib
Ø Pregnant women Ø OCP Ø Clotting disorder Ø Elderly
Ø If no anticoag…IVC filter (inferior vena cava) Ø Surgery
Heparin (IV) Coumadin/Warfarin (ORAL) Lab o PTT
¯ Low = increase heparin blood is thinner, longer to clot High = ¯ decrease heparin blood is thinner, longer to clot o Really High PTT, 95ms long time
to clot, blood thinner = HOLD heparin drip
o aPTT
PT/INR Normal = 1.0 Therapeutic INR = 2-3
Antagonist Protamine Sulfate Vitamin K
Prevention Ø Massage: light, not deep Ø Compression: stockings,
ted-hoes, SCEDS (prevents pooling of blood)
Ø Movement: encourage movement, ambulation
Ø Positioning of legs: be careful with crossing your legs (airplanes)
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Review: Thursday 5-7pm 9/13/18 Exam will have 2 ABG’s
v Question: Which client is at highest risk for developing respiratory alkalosis? A. A client in labor B. A client with diabetes C. A client with renal failure D. An immediate postoperative client
Answer: A – fast breathing, breathing off CO2, B – DM ketoacidosis, C – metabolic acidosis, D – postoperative breathing too slow maybe too much pain meds, respiratory acidosis by holding in them v Question: Which intervention should a nurse perform for a client with acute respiratory
alkalosis? A. Give one ampule of bicarbonate as orders B. Give oxygen at 3L NC C. Reposition patient in high-fowler D. Have client breath into paper bag
Answer: D – help slow down breathing, increase CO2, A – is for acidosis generally for metabolic acidosis
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Cardiovascular – Adult Unit 1 Week 2 – 9/10/18 CASE STUDY REPORT - CARDIOVASCULAR Patient 1: 76 y.o M CC for CHF exacerbation, present previous night to ED, dyspneic, coughing up sputum, pink and frothy, showing 3+ pitting edema in lower extremities, is up on the cardiac unit, 4L NC, 90% SpO2, EKG normal sinus, 2lb weight gain in past 4 days. Diagnosis: pulmonary edema, issue with fluid overload, probably go on a Lasix drip, a diuretic, order chest x-ray, ECHO (ultrasound for heart) Question: Strict I & O, breaths sounds à bilateral crackles, change in weight à daily weights, check potassium levels PRIORITY – ABC’s (airway, breathing, circulation) Patient 2: MI patient, 80 y.o M presents with MI workout (rule out MI), troponin levels (breakdown of cardiac tissues) want to see cardiac enzyme levels, increased in troponins, normal sinus, tachy 110 cus of pain, he’s on morphine, presented with pain, aspirin, intervention could be give O2, 2L NC, cath lab à already went and came back, did they place a stent?, bleeding at the site? Check femoral access site Question: EKG (ST elevation), troponin levels, Patient 3: 55 y.o M, s/p 5 days post op CABG, mediastinal chest tube, minimal scant emphysema near site, cardiac team aware, DM type 2, on insulin sliding scale, has purulent drainage from saphenous vein graph site, low grade fever Question: Sent culture, output drainage of chest tube, planning to removal chest tube, known allergies for antibiotics, fever à sepsis, WBC, EKG Patient 4: 33 y.o F, sudden onset of sharp chest pain, + pleuritic pain (pain in inspiration), pain radiating to back, pericarditis pain à unique by having positional pain, by sitting forward, heart sound associated with pericarditis à friction rub, temp 102 F, back packing past 3 months, elevated WBC, C – reactive protein would be elevated (CRP), treating with antibiotics, inflammation treated with steroids, pain is ibuprofen Question: fever, risk factor, CBSC’s Risk factor: can end up pericardial effusion, can lead to cardiac tamponade Big picture: If I tell you that the patient in room 5 is a cardiac patient & nothing else, how would you assess them?
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Admission assessment vs subsequent assessments o Full head-to-toes o Focused assessment
Inspect o Incision sites o Heaving o Breathing o Edema o Skin à pallor o JVD à fluid overload
Auscultation o Heart sounds o Lung sounds o Bowel Sounds
Palpation o Pulses o Edema 1+ à 4+ o Capillary refill <3sec
HEART FAILURE
Ø Number one death in USA à cardiac disease/heart failure
Stroke Volume: ejection per beat Cardiac Volume: ejection per minute Ejection Fraction: amount of how much leaves the heart to how much went in, percentage HEMODYNAMICS
Ø Cardiac Output (CO) = SV X HR o Use an ECHO to figure out
Ø Stroke Volume (SV) = mL per beat Ø Preload & Afterload = preload à volume, check by CVP (central venous pressure),
afterload à pressure, BP, resistance
v Question: “The amount of blood the ventricles eject each minute” is known as: A. Afterload B. Stroke Volume (SV) C. Cardiac Output (CO) D. Preload E. Heart Rate (HR) F. End-Diastolic Volume (EDV) G. Ejection Fraction (EF)
Answer: C - per minute
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Ø Ejection Fraction o Should be higher around 60 o <40 % ejection fraction = heart failure o Dilated cardiomyopathy à enlarged heart
Upside down heart Measure amount of blood at the end of filling at the end of diastole, and volume after contraction of systole. SV = EDV – ESV (Filling – ejections) Amount that left the heart in one beat = 46 mL 46mL/ 147mL = 0.31 (ejection fraction) Ejection fraction = SV/EDV
o More symptomatic Left Sided Heart Failure Right Sided Heart Failure
o Paroxysmal nocturnal dyspnea –
difficulty breathing at night o Orthopnea – positional breathing
difficulty, trouble breathing laying down à sleep with a lot of pillows, some sleep sitting up
o Pulmonary edema
o Right sided heart failure : backing up of
blood on its way to the heart, systemic backup
o Accumulation: lower extremities, abdominal (ascites), lungs
o Might say, it “started as right-sided, or left-sided”
Ø But…the main cause of right-side HF is progressive left-sided HF, so patients tend to
look like a mix of the two, as shown here Ø Most common med: angiotensin Ø receptor-neprilysin inhibitor (ARNI) (Entresto) Ø Neprilysin inhibitor: sacubitril Ø ARB: valsartan Ø Also: ACE-I, BB; not Ca channel block
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DIAGNOSING HEART FAILURE
Ø ECHO to determine ejection fraction Ø Draw labs, especially to check BNP (brain naturistic peptide) Ø Classic syndrome of associated symptoms Ø Vital signs:
o Tachycardia § Can’t get proper perfusion
o Tachypnea § Can’t get proper perfusion à could also be anxiety
o Hypotension r/t treatment Ø CANNOT CURE HEART FAILURE à CAN ONLY HELP SYMPTOMS Ø L-VAD
ICU Additions
ART line – arterial line
MAP is average of blood pressure MAP = 2 DBP + SBP / 3 Normal = < 65 MAP: mean arterial pressure, Normal ~ 70-100mmHg, titrate >65 CVP: central venous pressure, norm varies by units & positioning ~2-8 mmHg High CVP means too much fluid BV most important for maintaining circulation
EKG line
SpO2 line
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Classes of Medications Example Meds Notes Beta Blockers o Metoprolol (Lopressor)
o Propranlol (Inderal)
o Lower BP o Lower HR o Be careful when you give a med
for more than one reason, when it has two actions, make sure pt can handle both actions
Statins o Lipitor o Cholesterol lowering meds Thiazide Diuretics o Hydrochlorothiazide , HCTZ
(Microzide)
o One of the first diuretics we turn to à well tolerated
Loop Diuretics o Furosemide (Lasix)
o *Potassium wasting à hypocalemia
K+ Sparing Diuretics o Spirinolactone (Aldactone) o * Hypercalemia ACE – I (pril) o Enalapril (Vasotec)
o Lisinopril (Prinivil, Zestril)
o Work well to inhibit RAAS à increase pressure, by keeping fluid and sodium in, for CHF pt want to inhibit RAAS
ARBs o Losartan o Valsartan (Diovan) or
sacubritirl and valsartan (Entresto)
o Entresto is a mix with valsartan sacubitiril that helps neprilysin inhibitor à sacubitril, has diuresis effect help stimulate
Ca2+ Channel Blocker o Amlodipine (Norvasc) o Verapamil (Calan, Verelan) o Diltiazem (Cardizem, Tiazac) o Nifedipine (Procardia)
o Help with blood pressure o Help decrease workload on
heart o Vasodilation o Do not use them in heart failure
à not effective for HF Cardiac glycoside o Digoxin o Potassium can be too low
o Vision changes Vasodilators (Nitrate)
o Isosorbide mononitrate (Imdur)
o Nitroglycerin (Nitrobid)
Thrombolytics o Tissue plasminogen activator, tPA (Alteplase)
o Known difference between blood thinning agents
o Dissolves clot but concern is bleeding out
o tPA used in stroke a lot
Anti - Coagulants o Warfarin (Coumadin) o Enoxaparin (Lovenox) o Heparin
o Oral à slow clotting time o Injection at home
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o Dabigatran (Pradaxa) o Replace coumadin à does not need as much INR monitoring
Anti - Platelets o Aspirin o Clopidogrel (Plavix)
Anti – Arrhythmic o Amiodarone o Adenosine (Adenocard) o Atropine o Digoxin o Lidocaine
o Known the difference of these three
o When given as an IV
Inotropic Agent o Dopamine o Digoxin o Dobutamine o Norepinephrine (Levophed)
o More in intensive care units o Used in shock
ELDERLY
Ø HR slower Ø CO goes down with age naturally
REVIEW OF DYSRHYTHMIAS Sinus Bradycardia
Ø Primary Actions:
o Are they symptomatic? o Fatigue o Dizziness o Deceased BP
Ø Medication: ATROPINE o Transcutaneous pacing IF atropine is not working
§ External pacemaker • Take pads from cardia machine and make their heart rhythm for
them
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V. Fib (ventricular fibrillation)
Ø Primary Actions: o Call a code o Shock
Ø Medication: EPI o 1 mL EPI
3rd Degree Heart Block
Ø Primary Action: o Call a code o Transcutaneous pacing o Shock o Can only last minutes at this state o Atria and ventricles are not talking to each other o Ventricles are not full when they pump
Ø Medications: ATROPINE Normal Sinus Rhythm with PVC
Ø Primary Actions: o Check patient, pt leads o Check electrolytes – K+ o Check to see if there is an increase
o Check vital signs if there is cardiac output issues
o Concerning if HR going up and BP going down
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V. Tach (Ventricular Tachycardia)
Ø Primary Action: o Check the pt o If they stay in v tac they will cardiac arrest o Cardioversion o Code
A.Fib (Atrial Fibrillation)
Ø Primary Action: o One of the most common o Will be on the exam o Is it normal hr or are the tachy o Uncontrolled a fib vs. controlled a fib o Palpitation o Is this acute or chronic
Ø Medications: AMIODARONE o Amiodarone o Cardioversion
Ø Last step if medicine is not working, for treating A.fib o Surgery à ABLATION (MAZE) ‘
Ø Patient goes home with chronic a.fib, they are able to maintain it, they will maybe go on oral amiodarone, they may throw a clot, the atria are fibrillating and they can pool up and throw a clot, A. FIB NEED TO BE ANTI-COAGULATED (Warfarin) à have to go back to INR (1.0 for non-anticoag pts, 2-3 is therapeutic INR)
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Supraventricular Tachycardia (SVT)
Ø Fast heart rate Ø NO P-wave Ø Watching the monitor after giving adenosine Ø Super-fast half-life, so push with a flush
https://youtu.be/8fpJXPSC7w8
PACEMAKER
Ø Look for pacer-spike to see pacemaker Ø Keep incision clean and dry for 48 hours but leave steri strips on for week, will fall off by
self Ø Avoid vigorous arm movements or lifting first 4-6 weeks (on side with device) because
can pull wires out of place Ø Don’t drive for 1 week Ø Avoid large electromagnetic field: microwave & cell ok, but generally airport security is
not Ø Check incision for signs of infection Ø No MRI, (but there are new MRIs that are ok) Ø “Failure to capture”
o No ventricular beat following o Pacer spike but no subsequent spike after it
Ø Failure to sense o No pace or spike
Ø Pacer spike, no ventricular beat
Awake Synch Consent Medicate
Code Cardiac Arrest Asynch Synch
Shock Same machine
Cardioversion Defibrillation
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o Pace-maker will not kick in if they are moving and they are at 80 o Pace-maker is a safety net so they do not drop lower o Risk for blood clots o No showering for like 5 days when first put in, need to do sponge bath, keep it
dry, keep strips on o Can’t lift arm above shoulder
§ Could dislodge the pacemaker wirers § Encourage movement however still § Let them know if there is any electromagnetic field
TRANSCUTANEOUS PACING
Ø What is it?
Ø When would we use it?
Ø Patient considerations:
v Question: The home care nurse visits a patient with a new permanent pacemaker implanted in the area below the left clavicle. It is most important for the nurse to respond to which of the following?
A. “It will be good to be back under my electric blanket again when I sleep” B. “I just got out of shower, my incision looks clean” C. “My spouse signed up for a CPR class” D. “I’m doing my arm exercises”
Answer: B v Question: Nurse instructs outpatient about cardiac stress test. Which is best?
A. “Will assess overall physical function” B. “Determine amount of workload heart can tolerate” C. “Determine adequacy of peripheral circulation” D. “Enable provider to evaluate cardiac output”
Answer: v Question: The nurse teaches the client with angina prior to discharge. It is most important for the
client to report which behavior? A. Pain following sexual activity B. A headache after taking nitroglycerin C. A change in the character of the pain D. Pain after eating a large meal
Answer: C – nitroglycerin is sublingual, teach pt. to take it as soon as they feel chest pain, sit-down, stop activity, wait 5 mins if it doesn’t work take another one, can take it up to 3x
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LABS FOR CVD
Ø Cardiac Enzymes o CK, CK-MB o Myoglobin o Troponin T and I
o Indicator of atherosclerosis; aa that interferes with the elasticity of endothelial layer in BV, foods rich in B vitamins (esp folic acid) lower homocysteine levels
Ø Stenosis vs Regurgitation (aka insufficiency) *know valve names o May have both o Mitral may also prolapse o Which do you think tends to be more severe?
§ Stenosis • Aortic stenosis à can’t get blood flow properly in aorta and rest of
body • Decreased cardiac output
Ø Role of infective endocarditis o Rheumatic fever o Gingivitis o Treatment depends on severity o Symptoms similar for both: DOE, fatigue, pulmonary congestion, murmur o Mechanical or tissue valve
Ø Considerations… o Battery life o No swimming, shower? Other restrictions? o Reduced life span o Dressing @ driveline exit site o “Bridge to transplant” vs “destination therapy” (2/3 NYP are dest.) o Risks: pump thrombosis (anticoag)
How will an LVAD alter your physical assessment?
1. Pulse 2. BP 3. Heart sounds
Living by a pack How to assess MAP in an LVAD patient: https://youtu.be/kctHfE6MIHE ECMO: Extracorporeal membrane oxygenation - For respiratory failure or cardiac arrest Destination therapy à live with it
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PERIPHERAL CIRCULATION
Differentiate between peripheral arterial and venous disease Peripheral Arterial Disease
(PAD) also known as Arterial Insufficiency
Peripheral Venous Disease (PVD) also known as Venous Insufficiency
Overall color of legs Pallor, dependent rubor Brown discoloration
Further skin assessment Ulcer, gangrene Hardness
Temperature of legs Cooler Warm
Pedal pulses Diminished ¯ In tact
Pain Intermittent claudication Dull aches
Edema None Lots
Drainage (exudate) No Yes, lots
Case Smoking
Valvular insufficiency, obesity
Notes Don’t put legs up Don’t confuse with cellulitis
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ABDOMINAL AORTIC ANEURYSM
Ø Differentiate between Ø Most common in: male + smoker + Caucasian + > 65yo + family history Ø Often asymptomatic until rupture Ø 90% mortality with rupture Ø 80% of rupture bleed is retroperitoneal Ø Imaging q3-6m for >5cm Ø May cause pulsation near navel
RAYNAUD’S PHENOMENON
Ø Issue: COLD Ø Poor circulation to finger tips Ø Primary OR associated with other autoimmune disease (e.g. scleroderma, lupus…) Ø What would we like treatment to do?
o Vasodilate o Nifedipine o Feels like pins & needles à numbness/tingling
v Question: Which patient is at highest risk for venous thromboembolism (VTE)?
A. A 50-year-old postoperative patient B. A 25-year-old patient with a central venous catheter in place to treat septicemia C. A 71-year-old otherwise healthy older adult D. A pregnant 30-year-old woman due in 2 weeks
Answer:
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HYPERTENSION
BP Category SBP DBP Normal <120 mm Hg and <80 mm Hg Elevated 120–129 mm Hg and <80 mm Hg Hypertension
Stage 1 130–139 mm Hg or 80–89 mm Hg Stage 2 ≥140 mm Hg or ≥90 mm Hg
BP indicates (based on an average of ≥2 careful readings obtained on ≥2 occasions
MANIFESTATIONS OF HYPERTENSION
Ø Usually no symptoms other than elevated blood pressure
Ø Symptoms seen related to organ damage are seen late and are serious
o Severe HA o Retinal and other eye changes o Bloody nose (epistaxis) o Renal damage o Myocardial infarction o Stroke
SHOCK
Ø Shock o Condition in which tissue perfusion is inadequate to deliver oxygen, nutrients to
support vital organs, cellular function o Affects all body systems
Type of Shock Hypovolemic shock state resulting from decreased intravascular volume due to fluid loss
Ex: blood loss
Cardiogenic shock state resulting from impairment or failure of myocardium Ex: heart attack
Septic circulatory shock state resulting from overwhelming infection causing relative hypovolemia Ex: infection
Neurogenic shock state resulting from loss of sympathetic tone causing relative hypovolemia
Anaphylactic circulatory shock state resulting from severe allergic reaction producing overwhelming systemic vasodilation, relative hypovolemia Ex: allergic rxn
Primary or Essential No known cause (idiopathic)
Secondary Identifiable cause (e.g. renal or endocrine dx)
Hypertensive urgency
No evidence of organ damage
Hypertensive emergency
Must be lowered immediately to prevent organ damage
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COMPENSATORY MECHANISMS IN SHOCK
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Ø Shock à extremely low BP Ø SNS causes vasoconstriction, increased HR (rapid thread pulse), increased heart
contractility o This maintains BP & CO
Ø Body shunts blood from skin, kidneys, GI tract, resulting in cool, clammy skin, hypoactive bowel sounds, decreased urine output
Ø Perfusion of tissues is inadequate o Hypoxia causes cells to perform anaerobic metabolism o Causes buildup of lactic acid à measure LACTATE LEVEL o Which causes acid-base imbalance of metabolic acidosis o Which leads to compensatory increase in bicarbonate o Which may lead to acid-base imbalance of alkalosis
Ø Confusion may occur (agitation, anxiety, restlessness, sense of impending doom] Ø Decrease urinary output Ø Cool skin Ø Mechanisms that regulate BP can no longer compensate, BP and MAP decrease Ø All organs suffer from hypoperfusion Ø Vasoconstriction continues further compromising cellular perfusion
o Thready or absent pulses PROGRESSIVE OR DECOMPENSATED STAGE OF SHOCK
Ø Mental status further deteriorates from decreased cerebral perfusion (will become unresponsive
Ø Mechanisms that regulate BP can no longer compensate, BP and MAP decrease < 75 Ø All organs suffer from hypoperfusion Ø Vasoconstriction continues further compromising cellular perfusion
o Thready or absent pulses Ø Mental status further deteriorates from decreased cerebral perfusion (will become
unresponsive Ø Lungs begin to fail, decreased pulmonary blood flow causes further hypoxemia, carbon
Ø Inadequate perfusion of heart leads to dysrhythmias, ischemia Ø As MAP falls below 70, GFR cannot be maintained
o Oliguria o Acute renal failure may occur
Ø Liver function, GI function, hematological function all affected Ø Disseminated intravascular coagulation (DIC) may occur as cause or complication of
shock
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ACUTE DIC
Ø Massive systemic activation & consumption of coagulation proteins o Damaged endothelial cells activate the coagulation cascade
Ø Most common with infectious disease (therefore _________ shock) Ø Look for spontaneous bleeding @ venipuncture sites Ø COULD CLOT AND BLEED OUT AT THE SAME TIME Ø Look for petechiae, purpura, may turn into necrosis’
o Petechiae à mini clots, looks like holes Ø Routine labs:
o Platelets § Use up all of the proteins and platelets § Drop ¯
o PT and aPTT § increase § Longer to clot § Blood is thinner
IRREVERSIBLE STAGE SHOCK At this point, organ damage so severe that patient does not respond to treatment and cannot survive
Ø BP remains low Ø Renal, liver function fail Ø Anaerobic metabolism worsens acidosis Ø Multiple organ dysfunction progresses to complete organ failure Ø Judgment that shock is irreversible only made in retrospect
MULTIPLE ORGAN DYSFUNCTION SYNDROME
Ø Presence of altered function of two or more organs in acutely ill patient such that interventions are necessary to support continued organ function
Ø High mortality rate: 75% Ø Treatment
o Controlling initiating event o Promoting adequate organ perfusion o Providing nutritional support
Ø What do you do when a patient is entering shock? o Fluid
Ø Keep blood pressure up Ø Fluid replacement
o Crystalloid, colloid solutions § Colloid – albumin
o Complications of fluid administration Ø Vasoactive medication therapy Ø Nutritional support (hyper vs hypoglycemia)
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SURVIVING SEPSIS CAMPAIGN
1. Measure lactate 2. Obtain blood cultures 3. Administer broad spectrum abx 4. Administer crystalloid for hypotension & lactate > 4 mmol/L 5. Administer vasopressor to keep MAP > 65 mmHg
** need to decide when to act, may not be in the same order as given** VASOACTIVE MEDICATIONS (PRESSORS)
Ø Used when fluid therapy alone does not maintain MAP Ø Support hemodynamic status; stimulate SNS Ø Check vital signs frequently; continuous monitoring of vital signs every 15 minutes or
more often Ø Give through central line if possible Ø Dosages usually titrated to patient response Ø First line: norepinephrine (Levophed)
o Caution: only give this if they have proper fluid in them o Levophed constricts to perfuse the blood o Put them on some fluid
v Question: When caring for a patient in hypovolemic shock who is receiving large volumes of IV isotonic fluids, the nurse should monitor for symptoms of: A. Hyperthermia B. Pain C. Pulmonary edema D. Tachycardia
