Exam #2 101A

Cardiovascular

What is the assessment of the cardiac system

-inspection (chest symmetry, skin color)

-palpation (lumps or masses)

-auscultation (breaths sounds, apical pulse

-pt Hx (risk factors, symptoms)

What are the auscultation points

-aortic

-pulmonary

-erb’s point

-tricuspid

-mitral (apex)

Stroke volume

-60 to 70 mL of blood into aorta with each contraction

-stroke vl X HR = cardiac output

What effects a pulse

-fever, pain, hypoxia, anxiety, exercise, and cardiac disease

-does not normally change with age, but dysrhythmias are common in elderly

Arrhythmias

-a period of normal rhythm broken by periods of irregularity or skipped beats

what is the pulse score system

-absent → 0

-palpable, but thready and weak -→ 1+

-normal, easily identified → 2+

-increased pulse → +3

-full bounding → 4+

Blood pressure

-changes with agin (d/t hardening of the arteries)

-systolic pressure ( arterial)

-diastolic pressure ( in between contracts)

What is the leading cause of stroke in elderly

hypertension

BP affected by cardiac output

-increased BP with increase in circulation output

-if blood volume decrease beyond vascular bed ability to compensate, BP may decrease

-causes: vasoconstriction and vasodilation alter BP to compensate

Hypertension: essential/ primary

-no identifiable medical cause

-90 to 95 % of cases

Hypertension: secondary

-underlying causes (kidney disease, sleep apnea, pregnancy complications)

-5 to 10 %. of cases

What is considers an elevated BP

(systolic) 120 to 120 / 80 (diastolic)

What is considers stage 1 hypertension

(systolic) 130 to 130 / 80-89 (diastolic)

What is considered stage 2 hypertension

(systolic) 140 or higher / 90 or higher (diastolic)

what is considers a severe hypertension and hypertensive emergency (with s/sx)

(systolic) higher than 180 / higher than 120

Hypertension - ASSESSMENT

-may be no symptoms, pt could have HA or dizziness

-Anginal pain (Chest pain d/t reduced blood flow)

-intermittent claudication ( leg pain during exercise and subsides with rest)

-retinal hemorrhages and exudates

-poluria, nocuturia and diminished ability of kidneys to concentrate during

-dyspnea upon exertion

-edema of the extremities

Hypertension - PATIENT HISTORY

-age of onset

-family Hx and Hx of renal or CV disease

-dyspnea, fatigue, weakness, anginal pain, swelling of feet or nocturia

-sudden weight loss/ gain

-recent severe HA or drenching sweats

-activity level, alcohol intake, diet and personality type

Hypertension - PHYSICAL EXAM

-Bp taken in different locations (both arms, lying down, standing)

-Ophthalmoscopic ( can deter damage of blood vessels through eyes damaged by hypertension)

-auscultation of heart & aorta, EKG readings

-palpation of partiers in neck, wrist, femoral areas and feet

-neuro exam for s/sc of cerebral thrombosis or hemorrhage

Hypertension- LAB STUDIES

-UA and cultures (renal disease)

-CBC and ESR (inflammation or infection)

-Na, K , Cl, CO2 ( primary aldosteronism aka elevated plasam/ low renin activity)

-blood urea nitrogen (BUN) and creatine - kidney disease

Ejection fraction (EF): % of blood ejected from heart during systole

-normal is 50-70 %

-as EF decrease with HF, tissue perfusion diminishes

-decreases EF causes backup of blood into pulmonary vessels

-too much blood and increase pressure in pulmonary vessels can cause pulmonary edema

Mean arterial pressure (MAP)

-Systolic blood pressure (SBP) +2 x Diastolic blood pressure (DBP) divided by 3

-if value is greater than 60, adequate profusion and <60 is not

CARDIAC ENZYMES: expected range for Creatine Kinase MB isoenzyme

0% of total CK

CARDIAC ENZYME: expected range for Troponin T

<0.1 ng/mL

CARDIAC ENZYMES: expected range for Myoglobi

<90 mcg/L

CARDIAC ENZYMES: expected range for Troponin I

<0.03 ng/mL

Low density lipidprotein (LDL) :LIPID PROFILE

-expected range of <130 mg/dL

-purpose: bad cholesterol, carriers from liver to body cells

High density lipidprotein (HDL) : LIPID PROFILE

-expected range for males is >46 mg/dL

-expected range for female is >55 mg/dL

-good cholesterol, helps keep heart healthy by caring extra cholesterol from body back to liver

LIPID PROFILE: total cholesterol

-expected range of <200 mg/d;

-purpose: heart disease screening

LIPID PROFILE: Triglycerides

-expected range for males is 40- 160 mg/dL

-expected range for females is 35-135 dg/mL

-asses pts r/f heart disease

Electrocardiogram (EKG and ECG)

-continuous monitoring of the heat’s electrical activity

-can detect NSR ad dysrhythmias

-application: placement of lead and the importance of proper placement

ELECTROLYTES: Na

controls fluids levels and aids nerve and muscle function

ELECTROLYTES: K

supports, heart, nerve/muscle functions

ELECTROLYTES: Ca

helps blood vessels contract and expand to stabilize BP

ELECTROLYTES: Cl

helps maintain healthy blood levels, BP and body fluids

ELECTROLYTES: Mg

-supports never/ muscle function

-too little = arrhythmia

-too much= possible cardiac arrest

ELECTROLYTES: Phosphate

supports skeletal system, nerve/ muscle for optima cardiac performance

ELECTROLYTES: Bicarbonate

maintain acid base balance in blood, essential for heart enzyme and muscle function

ECHOCARDIOGRAPHY: Transthoracic echocardiogram, TTE

-indication: cardiomyopathy, HF, angina, myocardial infarction

-consideration: noninvasive, occasionally asked to hold breath, review test results and plan for follow up

ECHOCARDIOGRAPHY: Transesphageal echocardiography, TEE

-indications: HF, valvular heart disease, atrial or ventricular thrombi

- monitoring LOC changes and return of gag reflux

ECG stress test

-treadmill, records hearts electrical activity

-V/S monitored every 3 min on treadmill

-until reaching or nearing maximum heart rate

-requires consent form

STOP TEST: chest pain, sever fatigue, dyspnea

Chemical stress test

-for pt who cannot exercise, Pt must lay on back

-continuous 12 lead ECG

-NPO during test, can lead to mild nausea, HA may also occur

HEMODYNAMIC MONITORING: purpose and test

-determines pressure flow and oxygenation

-tests: via pulmonary artery catheter, called right heart catherization

-could be d/t dehydration/ age = low valve

HEMODYNAMIC MONITORING: procedure and complications

-procedure: special cathartic, infusion system, transducer and monitor —> catheter placed by provider

-complications: infection/ sepsis and embolism (blood clot)

HEMODYNAMIC MONITORING: nursing implications

-system must be calibrated

-reading taken then data can be calculated

Cardiomegaly

-enlarged heart, can be short term or chronic

-risk factors: family Hx, alcohol/substance abuse, tobacco use, HTN, Hx of Mi, sedentary lifestyle

-increased r/t HF or stroke and d/t thickening of walls

-s/sx: dizziness, edema, fatigue, SOB

CARDIOMYOPATHY: overview and major problems exhibited

-group of ideas affection structure/function of heart

-heat enlarged and becomes an inefficient pump

-3 major types: dilated, hypertonic, restrictive

-major problems exhibited: HF and dysthymias

CARDIOMYOPATHY: S/Sx, Dx, and Tx

-dyspnea, activity intolerance, angina ( chest discomfort), dizziness, HTN and palpitations

-Dx: Hx, CXR, cardiac catheterization, echocardiography, ECG, MRI CT

-Tx: digoxin, antihypertensives, diuretics, anti arrhythmic, and anticoagulants

Heart failure: Overview and 4 classes

-occurs when the heart muscle is unable to pump effectively, heart in unable to maintain adequate circulation to meet tissue needs

CLASS I : no signs with activity

CLASS II: S/Sx with normal exertion

CLASS III: S/Sx with minimal exertion

CLASS IV: manifestation at rest

Heart failure: Dx

-Dx: abnormal heart sounds and rates, increase venous pressure, distended neck veins, prolonged circulation time, decrease in cardiac output, presence of albuminuria, increase BUN

Heart failure: nursing management

-monitor SOB, dyspnea, V/S, I&O’s (retention= weight gain) and hemodynamic pressure, administer O2

-maintain dietary restrictions

-provide emotional support

-medications

Heart failure: complications

-acute pulmonary edema

-cardiogenic shock

-pericardial tamponade (fluid in pericardial sac, the space surrounding the heart)

Left sides HF: S/Sx

-dyspnea or orthopnea

-paroxysmal nocturnal dyspnea (waking up w /SOB)

-cheyne stoke respirations

-pleural effusion and pulmonary edema

-cough and cardiac asthma

-decreased renal function, edema and wt gain

-cerebral anoxia (lack of 02 to the brain)

-fatigue and muscular weakness

Left sided HF (back up in pulmonary veins) : RISK FACTORS

-hypertension

-CAD (coronary artery disease), angina, MI

-valvular disease (mitral and aortic)

-previous heart attack

Right sided HF: S/Sx

-liver enlargement and abdominal pain

-anorexia, nausea and bloating

-dependent edema (early sign) , coolness of extremities

-anxiety and fear

-weight gain

Right sided HF: RISK FACTORS

-left sided HF (d/t overworking)

-right ventricular MI

-pulmonary problems

Advanced heart failure: S/Sx and SHOCK SYNDROME

-S/Sx: weight loss and (involuntary weight loss, muscle wasting and fatigue)

-stupor pallor (unresponsive but aroused by stimuli, critical emergency)

-Rapid, thready pulse

-cool sweats, restlessness, profound HYPOTENSION

Advanced HF: RISK FACTORS

-increased metabolic needs

-septicemia (fever)

-anemia

-hypothyroidism

Pulmonary edema: OVERVIEW

-cardiogenic factors most common cause

-complication of various heart and lung diseases

-noncardiac pulmonary edema

-neurogenic pulmonary edema

-older adults consideration

Pulmonary edema: S/Sx

-anxiety and confusion

-inability to sleep

-persistent cough w. pink frothy sputum

-tachypnea, hypoxemia, cyanosis (late stage) , tachycardia

Pulmonary edema: RISK FACTORS

-acute MI and acute respiratory failure, fluid volume overload

-HTN, valvular heart disease

-postpneumonectomy, post evacuation of pleural effusion

-left sided HF, high altitude exposure

-trauma, sepsis, med toxicity

Pulmonary edema: HEALTH PROMOTION AND PREVENTION

-remain physically active

-consume low sodium diet

-refrain from tobacco use (irritation of lungs, vasoconstricts)

Pulmonary edema: NURSING MANAGEMENT

-high Fowles

-high flow 02, monitor V/S, I&o’s, check labs and diagnostics

-administer med

Valve Diseases: 1. stenosis and 2. regurgitation

1.narrowed opening hinder blood flow (causes the heart to work harder through a smaller opening)

2.blood flows backwards (blood leaks back into atrium)

commonly affected valves: MITRAL AND AORTIC

S/Sx and health promotion/ disease prevention for VALVE DISEASE

-late progression, murmur with turbulent blood flow, left sided valve damage

-Prevent and Tx of bacterial infections, low sodium diet, fluid restrictions

-control chronic illness, increase activity to exercise to boot HDL level

RISK FACTORS for Valve diseases

-HTN, rheumatic fever (inflammatory disease)

-infective endocarditis (bacteria on heart tissue)

-congenital malformation

-marfan syndrome (skeletal changes in limbs and digits)

Infective endocarditis (bacterial) : ETIOLOGY

-infection of the endocardial surface of the heart, may be caused by bacteria, viruses, or fungi

-can affect heart valves, walls, or septal defect in heart

Infective endocarditis (bacterial): PATHOPHYSIOLOGY AND S/SX, DX, TX

-inflamed tissues of heart become rough and swollen

-low grade fever

-blood culture will be +

-antibiotics (doens’t work for viral infection)

Dysrhythmias: COMMON ONES

-A fiberaltion

-V tach

-V fiberaltion

-heart block

Integumentary (SKIN): ASSESSMENT

-Hx of infections disorders

-potential skin trauma

-chronic diseases →diabetes

-Hx of allergic reactions, seasonal

-inspection → skin lesions via location, size, color

Integumentary (SKIN): PLAN/IMPLEMENTATION

-diagnostic test via skin biopsy or skin culture

-monitor mood d/t precautions/isolations which can affect physiological needs

Integumentary (SKIN): NURSING INTERVENTIONS

-nutrition → helps with healing wounds

-apply dressing → varies on given order (open wet, closed wet)

-promote rest and administer medications as needed

Integumentary (SKIN): EVALUATIONS

-preform appropriate skin care

-adjust to socialization problems of skin disorders

Inspection/ Palpation for Skin Assessment

-adequate lighting

-assess turgor

-palpate temp of skin

-inspect for edema, lesions, wounds

Cellulitis

-dermis and subcutaneous tissue infection

-usually d/t staphylococcus

S/Sx: erythematous (redness), swollen, painful

Cellulitis: Dx/ Tx/ Management

-Hx and exam

-draining any lesions, de bride ent if necrotic

-healing affect areas, preventing reoccurrence

-dry absorbed dressing

Contact dermatitis

-avoid exposure to harsh chemicals

-r/f: exposure to allergies & irritants, stress genetics, cause not always known (idiopathic)

Contact dermatitis: Tx and Pt education

-good skin lubrication

-control of inflammation and itching

-corticosteroids, antihistamines, immunosuppressants

PT education: steroids are bad for a long term use

Steven John’s Syndrome:

-allergic reaction d/t infection, med or idiopathic

S/sx: lesions have irregular borders and may have blisters, necrotic centers

To: discontinue the drug (if d/t med) , fluid/ nutrition, and wound care

(If not treated, systemic / sepsis = organ failure

Herpes: Simplex (Cold sores)

-blisters, vary depending on specific type (oral or genital)

Dx: history and physical examination

Tx: topical and oral acyclovir, valtrex

Herpes Zosters (Shingles)

S/sx: aching/ discomfort along nerve pathway followed by appearance of vesicles

Tx: symptomatic treatment, antibiotics, systemic corticosteroids

Management: cold compress, rest, adequate nutrients, deep muscle relaxation

*pregnant/ if pt hasn’t had chickenpox (or self) = higher risk

Fungi Infections

-Tinea pedis = athletes foot

-Tinea cruis= jocks itch

-Moniliasis = thrush, attack on mucous membrane of mouth

Pediculosis and Scabies

S/Sx: severe itching leading to excoriation

Dx: body inspection and examination of skin scraping

Tx/Nursing management: prescription of drugs/ liver function, fine tooth comb, contact isolation and preventing reinfestation

Integumentary Diagnostic Procedures: WOODS LIGHT EXAM

-light skin tones, hypopigmentation

-UV light to show skin infections, lesions

DIASCOPY: glass slide to test for blanching, painless

Integumentary Diagnostic Procedures: REMOVAL OF SAMPLE TISSURE

-confirms, r/o malignancy

-local anesthesia

-punch, shave, or excision

-potential Dx and maybe a skin lesion

-informed consent, educate pt of potential scurrying, several days for results

Integumentary Diagnostic Procedures: SKIN AND CULTURE

-sample of purulent draining from lesion/ wound

-done before starting antimicrobial therapy

-preliminary results in 24-48 hrs, final resuts in 72 hrs

Skin and Pressure injuries

-caused by localized interference with circulation, may blanch or appear pale under pressure , upon pressure release reactive hyperemia occurs

Assessment guidelines: Braden scale, inspect pressure areas during repositioning, reassess skin every 24 (frequently on shift)

Skin and Pressure injuries: RF & Prevention

RF: immobility, incontience, diaphoresis, poor neutrinos, decrease mental awareness

-turn and reposition pt regularly

-use support surfaces, maintain hygiene, ensure adequate nutrition

*malnourished pt are more prone to tissure breakdown

Stages of pressure injuries

-stage 1: intact reddened skin, does no blanch

-stage 2: skin loss involving derm, may look like blister or shallow crater. Surrounding skin is warm

-stage 3: fullness skin loss, damage to muscle or supporting structures, deep crater

-stage 4: excessive tissue necrosis or muscle or supporting structures. May appear dry and black

Signs of infection

-strong odor, color change to dark red or brown

-texture change, exudate and purulent drainage

-sloughing of graft

Wound care

-assess wound characteristics and follow wound care order

-manage pain

-encourage mobility

-educate pt. On wound hygiene, s/sx of infection/worsening med adherence, nutrition, lifestyle

Foundation and assessment: Mobility, Comfort & Pain

-gait: coordination, balance

-alignment: position of joints, muscle, tendons, ligaments

-symmetry and muscle mass

-muscle tone

Range of motion

-determines full extent of joint movement across 3 planers →Sagittal, transverse, frontal

Active: pt can preform independently

Passive: pt cannot actively move by themselves, rna move it form then = prevents stiffness

Musculoskeletal Diagnostic Procedures: NUCLEAR SCANS

-bone scans: evaluate entire skeletal system

-gallium and thallium: may require sedation

Indications: for pt with bone pain

Musculoskeletal Diagnostic Procedures: DUAL ENERGY X RAY ABSORPTIOMETRY

(DEXA)

-measure bone density and uses two beams of radiation

-pt. Receives “score”, no contrast

-removed metal, f/u with provider

Payne Martin Classification system: SKIN TEARS

-category 1: without tissue loss

-category 2: with partial tissue loss

-category 3: with complete tissue loss in which epidermal flap is missing

Protocol: cleanse wound, absorb exudate, keep wound bed moist and reduce pain/ discomfort

Risk factors for skin tears

-dry skin with dehydration

-imparted sensory perception and mobility

-taking multiple medications

-prolonged use of corticosteroids (stop the production of collagen)

-presence of renal disease, congestive HF, or stroke impairment

How does sleep help recovery

-muscle recovery and repair

-energy restoration

-inflammation reduction

-cognitive function

-pain management

-emotional well being

-hormonal balance

Functions of the skin

-protection, sensation, temperature regulation, & excretion and secretion