MedSurg I Exam: Respiratory and Cardiac

RESPIRATORY STUDY GUIDE - MED SURG ATELECTASIS - Closure or collapse of alveoli - Most common abnormality is seen on chest x-rays - Excess secretions or mucus can lead to atelectasis (impaired cough mechanism/ those confined to bed) - Patients are at high risk post-op Signs + Symptoms - Dyspnea - Cough / sputum - Difficulty breathing supine position - Patients may experience anxiety Diagnostic Findings - Crackles - Chest x-ray may show atelectasis before symptoms occur - Decreased breath sounds - Pulse ox (SPO2) may be less than 90% Nursing Interventions - Voluntary deep breathing every 2 hours - Frequent turning, high fowler's position - Incentive spirometer helps deep breathing - PEEP (positive end expiratory pressure), CPAP (continuous positive airway pressure), bronchoscopy - Thoracentesis PULMONARY TUBERCULOSIS - Infectious disease that affects lung parenchyma - Can be associated with poverty, malnutrition and overcrowding Risk factors - Airborne precaution - Spreads from person to person - Living in overcrowded areas - Those who are immunocompromised Signs + symptoms - Low grade fever, night sweats - Fatigue, weight loss - Cough, hemoptysis may occur (coughing blood) Diagnostic findings - Positive Tuberculin skin test 1 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Blood test - Sputum culture for acid fast bacilli (AFB) Medical Management - Treated with anti-TB agents for 6-12 months - INH (Isoniazid) and Rifampin(causes orange urine) are common drugs PNEUMONIA - Inflammation of lung caused by bacteria, fungi and viruses - Classified into 4 types 1. Community acquired pneumonia (CAP) 2. Healthcare associated pneumonia (HCAP) 3. Hospital acquired pneumonia (HAP) 4. Ventilator associated pneumonia (VAP) Risk factors - Travel or exposure to facilities - Influenza, covid, immunocompromised, heart failure, alcoholism. COPD Clinical manifestations - Sudden chills, rapid rising fever, bradycardia - Chest pain aggravated by deep breathing and coughing - Tachypnea of 25-45 breaths per minute Diagnostic finding - Physical examination, x-ray, blood culture - Older adults will have altered mental status from hypoxia Medical management - Hydration, fluids - Rest, self care - Supplemental oxygen / nasal cannula / face mask - Antipyretics, antitussives, decongestants, antibiotics - Pneumococcal vaccination (PCV13 & PPSV23) 1. PCV13- for adults 65+ and 19+ with weak immune systems 2. PPSV23- for 65+ and 19+ who are smokers for asthmatics ASPIRATION - Check gag reflex before you feed someone - Can happen from eating or vomit - Aspiration is common in elderly and stroke patients - Keep head of bed elevated - Check for tube placement before feeding 2 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders PLEURISY - Inflammation of both layers of pleura (parietal and visceral) - Inflamed pleural membranes rub together on respiration and cause severe, knifelike pain Clinical Manifestations - Taking a deep breath, coughing, sneezing worsen the pain - Pain usually occurs on one side - Pain may go away when breath is held Diagnostic Findings - Pleural friction rub is heard with stethoscope (a pillow decreases pain of pleural friction rub) Medical management - Analgesics - Topical applications of heat or cold provide relief PLEURAL EFFUSION - Collection of fluid in pleural space usually secondary to heart failure, TB, etc - Can be transudative effusion of exudate effusion - Transudative Effusion: results from heart failure - Exudate: occurs from inflammation from bacteria or tumors Clinical Manifestations - Fever, chills, dyspnea Diagnostic Findings - Decreased or absent breath sounds, decreased fremitus, dull sound on percussion - Can have tracheal deviation Medical Management - Thoracentesis is done to remove fluid, obtain specimen for analysis, and relieve dyspnea ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) - Can be mild, moderate, or severe - ARDS has been associated with a high mortality - Rapid onset of severe dyspnea that occurs less than 72 hours after an event - Can be from sepsis Medical Management - Intubation and mechanical ventilation - Prone position is best for oxygenation and frequent repositioning - These patients are critically ill and require close monitoring in ICU 3 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - ECMO (extracorporeal membrane oxygenation) Once a patient is on ECMO this is their last effort and most die PULMONARY EMBOLISM - A block of a artery and originates somewhere in venous system or right side of heart - Causes absent blood flow Medical Management - Ventilation perfusion imbalance (VQ mismatch) Risk factors - Trauma, immobility, pregnancy, birth control - Long care or plane ride Prevention - TPA (clot buster drug) - Heparin - prevents clot formation - Warfarin (Coumadin) (normal INR is 2-3) - Antidote for coumadin is Vitamin K CHEST TRAUMA - Flail Chest : multiple fractures in a row, ribs become displaced (inhaling = ribs expand, but flail chest = paradoxical movement) - Blunt trauma: elderly with falls, or getting into a fight - Pulmonary contusion: black and blue bruise - Penetrating trauma: knife trauma - Pneumothorax: collapsed lung, air in pleural space → treatment: chest tubes unless it is minor - Spontaneous or simple: (no trauma), occurs more in males if you get a pneumothorax you can get it again. (marfan's syndrome) - Traumatic: car accident - Subcutaneous emphysema: Air that leaks into skin tissue (crepitus, snap, crackle, back, shoulders, pop) - Hemothorax: blood in pleural space - Hemopneumothorax: blood and air in pleural space CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) - Includes emphysema and chronic bronchitis - Slow progressive respiratory disease of airflow obstruction Risk Factors - Smoking / tobacco Pathophysiology of COPD 4 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Chronic inflammation damages tissue - Scar tissue in the parenchyma decreased elastic recoil (compliance) → lungs cannot expand - Pressure on pulmonary vasculature Clinical manifestations - Chronic cough, sputum, dyspnea, weight loss - Barrel chest - Tripod position Nursing Interventions - Give COPD patient protein shakes and smaller frequent meals - CPAP to maintain positive pressures in alveoli. Medications to treat COPD - Bronchodilators, MDIs - Beta- adrenergic agonists - short and long acting; inhalers and nebulizers - Muscarinic antagonists (anticholinergics) - block neurotransmitter acetylcholine to decrease mucus production (ipratropium) Surgical Management - Bullectomy - surgical removal of dead air sacs - Lung volume reduction surgery (LVRS) - surgical removal of diseased lung to allow for expansion of remaining functional lung tissue - Lung transplant Diagnosis - Arterial blood gas - Health history - COPD patients live with higher c02 levels because they keep more in ★ Normal chest: 1:2 ★ Barrel chest: 1:1 CHRONIC BRONCHITIS - Cough and sputum production for at least 3 months for 2 full years - Causes damage to cilia, airway becomes narrow, and leads to impaired gas exchange Medical Management - Bronchodilators EMPHYSEMA - Abnormal distention of air spaces beyond the terminal less with destruction of the walls of the alveoli; hyperinflation. (Barrel chest) - Decreased alveolar surface area increases in “dead space”, impaired oxygen diffusion→ no gas exchange 5 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Increased pulmonary artery pressure may cause right- sided heart failure BRONCHIECTASIS - Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles - Hyperinflation, scarred up, lots of mucus, airway obstruction - Idiopathic causes (unknown cause) Clinical manifestations - Chronic cough - Purulent sputum in copious amounts - Clubbing of the fingernails - Postural drainage - Smoking cessation; - Bronchodilators and mucolytics ASTHMA - Chronic inflammatory disease that causes hyperresponsiveness, mucosal edema, and mucus production - Leads to cough, wheezing, chest tightness - Allergy is the biggest trigger for an asthma attack - You want to intervene early for asthma - Status asthmatics need to go on ventilators Quick Relief Medications - Beta2 adrenergic agonists, bronchodilators (albuterol, ipratropium) - Corticosteroids (reduces inflammation): prednisone and prednisolone - Magnesium IV is given in the hospital setting, it relaxes the muscle and opens airway Long Acting Medications - Corticosteroids (methylprednisolone, medrol) - Leukotriene inhibitors (montelukast) Nursing Interventions - Identify and avoid trigger - Perform peak flow monitor (measures how much they ventilate) - PULMONARY FUNCTION TEST: tests functionality of the lungs & identifies severity of asthma. ICOUGH I - incentive spirometer C - cough / deep breathing O - oral care 6 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders U - understanding G - getting out of bed H - head of bed elevation (Notes from lecture: if pt presents with one sided illness (ex: atelectasis), lay them on unaffected side to allow the affected side to work. OVERALL RESPIRATORY DRUGS: Bronchodilators: DECREASES BRONCHOSPASMS & IRRITATION 1. Short-acting beta2 agonists = albuterol RAPID* - AE: Tremors/tachycardia) 2. Cholinergic antagonists (anticholinergic meds) = ipratropium: blocks parasympathetic nervous system, allowing for INCREASED BRONCHODILATION or DECREASE PULMONARY SECRETIONS. - Watch HR, dry mouth. AE: headache, blurred vision, palpitations = toxicity 3. Methylxanthines = theophylline, requires close monitoring of blood medication levels due to the narrow therapeutic range. - AE: tachycardia, N/D 4. Long-acting beta 2 agonists (LABAs) = salmeterol (asthma attack prevention) Anti-Inflammatories: DECREASES AIRWAY INFLAMMATION 1. Glucocorticosteroids (aka corticosteroids) = fluticasone & prednisone: decreases inflammation. - Monitor for immunosuppression, fluid retention, hyperglycemia, hypok., weight gain, throat & mouth for aphthous lesions (canker sores) and poor wound healing. - Report black, tarry stools, drink fluids and take this drug w/ food. 2. Leukotriene antagonists = montelukast (long acting) 3. Mast cell stabilizers = cromolyn 4. Monoclonal antibodies = omalizumab (can cause anaphylaxis) FOR ASTHMA TAKE IN ORDER! 1. Bronchodilator 2. Anti-inflammatory agent Mucolytic agents: 1. Nebulizer treatments include acetylcysteine & dornase alfa 2. Guaifenesin is an oral agent - can also be mixed w/ dextromethorphan, as well. 7 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders CARDIOVASCULAR STUDY GUIDE GENERAL OVERVIEW OF ANATOMY Three layers: endocardium, myocardium, epicardium Four Chambers: Right atrium and right ventricle, left atrium and left ventricle - Atrioventricular valves (AV); tricuspid and mitral (bicuspid) - Semilunar valves: aortic and pulmonic Blood flow through the heart - Blood flows from right to left, deoxygenated to oxygenated - Superior & Inferior vena cava => Right Atrium => Tricuspid Valve => Right ventricle => Pulmonic Valve => Left and right Pulmonary artery => Lungs => Right & Left Pulmonary veins => left atrium => mitral (bicuspid) valve => left ventricle => aortic valve => aorta => The rest of the body Cardiac Conduction System: Electrophysiology - SA node is the pacemaker of the heart - SA node intrinsic rate 60-100 (think HEART RATE) - Electrical conduction system provides electrical stimulation for contraction Cardiac Action Potential (more heart rate) Depolarization: electrical activation of cell caused by influx of sodium into the cell while potassium exits cell - Producing electrical current to stimulate heart to contract Repolarization: (think rest). Return to the cell to resting state caused by re entry of potassium into cell while sodium exists Effective refractory period: phase in which cells are incapable of depolarizing (producing beat/electrical current) Relative refractory period: phase in which cells require stronger-than-normal stimulus to depolarize Cardiac Cycle - 1 cardiac cycle is 1 heart beat - Diastole = rest/relaxation = filling = low pressure - Systole = pumping/ contraction = high pressure Cardiac Output - How much blood is ejected /min - Stroke Volume (SV): amount of blood ejected with each heartbeat - 60-130 ml 8 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Preload: degree of stretch of cardiac muscle fibers at end of diastole (the amount of blood coming to the heart) - After load: resistance of ejection of blood from ventricle ( resistance to ejection of blood from the ventricles) → force that left ventricles overcomes to pump blood to rest of the body - Contractility: ability of cardiac muscle to shorten in response to electrical impulse (force generated by the contracting myocardium (muscle); direct relationship between contractility & SV→ increased by medications - digoxin, dopamine (positive inotrope, increases contractility) - positive inotrope, increases contractility → decreased hypoxemia (no oxygen = weak contraction) → decreased by medication - beta blockers (lower heart rate = less constriction) - Ejection Fraction (EF): percent of end diastolic volume ejected with each heartbeat (left ventricle) → 55-65 % normal ejection fraction (below 40% pt is in heart failure) - Cardiac Output (CO): amount of blood pumped by ventricle in liters/min CO= SV (stroke volume) x HR (Heart Rate) NOTES: - Dehydration, loss of blood volume = low preload - The more blood/ fluid coming to the heart = more preload - The less blood coming to the heart = less preload = less stroke volume = bad cardiac output - Vasodilating medications (nitroglycerin) = lowers blood pressure - More afterload/ resistance = decreased cardiac output/stroke volume Age & the CV System - Lower HR due to loss of cells from conduction system (failure of SA node = need for pacemaker) Gender Differences CV System - Female coronary arteries are narrower than man’s (less to have a blockage easier) - Females typically develop coronary artery disease (CAD) 10 years later then men due to the cardioprotective effect of estrogen ( dilated blood vessel = easier to pump blood) → until they hit menopause they are at risk Assessment of the Cardiovascular Disease - Health history - Family/ genetic history (predisposed/strong genetic history and higher chance to get if family has) - Risk factors 9 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders → Modifiable (diabetes, hypertension) ← controllable → Nonmodifiable ( coronary artery disease) ← not controllable Laboratory Tests - Cardiac biomarkers - Myoglobin, CK-MB, Troponin I & T → if elevated (heart cells damaged and release troponin) = MI! - Blood chemistry, hematology, coagulation - Brain (B-type) natriuretic peptide (BNP is elevated = heart failure) - C- reactive protein → hsCRP= hypersensitive C-reactive protein - Homocysteine: is an amino acid that damage the endothelial lining of arteries which contributes to atherosclerosis Electrocardiography - 12 - lead ECG or EKG (electrical picture of the heart) - Continuous monitoring → hardwire → telemetry- 1 lead at a time → ambulatory monitoring (wireless) Cardiac Stress Testing - Exercise stress test - test to stress the heart and monitor symptoms - Pt walks on treadmill with intensity progressing according to protocols (have to be ambulatory to walk on the treadmill) - Terminated when target HR is achieved - Pharmacologic stress testing (pts like amputees get chemical stress tests) → Vasodilating agents given to mimic exercise Endocardiography - Noninvasive ultrasound test that is used to measure the ejection fraction & examine the size, shape, and motion of cardiac structures - Transthoracic (anterior chest image of the heart) = size of chambers, measures heart valves, opening and closing, blood ejection - Transesophageal (TEE) → invasive → goes down the esophagus → posterior of the heart → checking for clots in the atria → moderate sedation (IV access, consent, NPO) 10 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders Cardiac Catheterization - Someone with an MI - A lot of nursing care - Invasive procedure used to diagnose structural and functional diseases of the heart and great vessels (need consent, pt can be NPO) → in this procedure they add a STENT which is permanent and you would need to do a angiogram (opens up the artery) → look for blockages in the coronary arteries Nursing interventions cardiac catheterization - Observe cath site for bleeding, hematoma - Assess peripheral pulses - Elevate temp, color and capillary refill of affected extremity - Screen for dysrhythmias - Maintain bed rest 2 to 6 hours (legs cannot bend at hip or knee bc it can risk bleeding) - Monitor kidney functions bc contrast is nephrotoxic - Post nursing interventions: → shortness of breath monitor → skin color → temp → may have dysrhythmias monitor → puncture site monitor for bleeding → check for pedal pulses constantly bc there was a puncture in femoral artery - ensure circulation is normal, no bleeding Hemodynamic Monitoring (cardiovascular respiratory status) - For critical patients - Pulmonary artery or Swan - Ganz catheter - Central venous pressure - fluid status → too much or too little fluid → if low = dehydrated (give fluids) → if high= fluid overload (give lasix) - Intra- arterial B/P monitoring → catheter is placed usually in radial artery Phlebostatic Axis - Transducer to patients arm lined up with this - Pt has to be supine (flat) for measurement - Right atrium - Vertical line 4th intercostal space, right sternal border 11 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders CORONARY ATHEROSCLEROSIS - Heart to pump and perfuse to the rest of the body - Atherosclerosis: is the abnormal accumulation of lipid (fat) deposits and fibrous tissue within arterial walls and lumen. ( too calcified = no heart STENT) - In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce blood flow to the myocardium - Cardiovascular disease is the leading cause of death in the US for men and women of all racial groups (strong genetic predisposition) - Coronary artery disease (CAD) is the most prevalent cardiovascular disease in adults Clinical Manifestations - Symptoms are caused by myocardial ischemia (inadequate tissue oxygenation) - Angina pectoris (most common manifestation) - chest pain from myocardial ischemia - Other symptoms: epigastric distress, pain that radiates to jaw or left arm, SOB, atypical symptoms in women (present fatigue) - MI, Heart failure or chronic heart failure, and sudden cardiac death = ischemia can lead to Risk Factors for CAD - Modifiable risk factors: Hyperlipidemia, tobacco use, HTN, metabolic syndrome, obesity, physical inactivity and diabetes - Unmodifiable risk factors: family history, age, increasing age, gender (men > women until postmenopausal), race (african american > caucasian) - Elevated LDL: primary target for cholesterol - lowering medication; “bad cholesterol” - Metabolic syndrome: cluster of metabolic abnormalities that together increase CVD risk including insulin resistance (hyperglycemia) , obesity, dyslipidemia, and HTN → (high risk) Prevention of CAD - Control cholesterol - Watch diet - Exercise - Insulin (glucose) - Low salt 12 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Control diabetes “hyperglycemia fosters dyslipidemia” - Fatty acid + glucose = increase deposition of fats - Harmful effects of tobacco (damage lining of vessels) - Increase oxidation LDL => damage endothelium => platelet adhesion => thrombus - Smoke inhalation increases CO which binds more readily with Hgb => decreases available oxygen - As we age = vessels stiffen and lose elasticity = higher pressure = left ventricle works harder ANGINA PECTORIS - A syndrome characterized by episodes or paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow (ischemia) - these patients have known atherosclerotic disease - Stable angina: predictable/ consistent pattern of pain on exertion that is relieved by rest and/ or nitroglycerin (goes away with rest) - Unstable angina: unpredictable/ increasing frequency of symptoms (chest pain, sob, etc) not relieved with rest or nitroglycerin (more symptoms, unpredictable) - Intractable angina: severely incapacitating chest pain (severe, seek medical help) - Prinzmetal's (Variant) angina: pain at rest, reversible ST- segment elevation on EKG, vasospasm → nothing physically blocking artery but angina symptoms present the same, meds to prevent/ treat spasms - Silent ischemia: objective evidence of ischemia (EKG changes, failed stress test) but no pain (usually in diabetic patients, no pain) Assessment and Findings for Angina Clinical Manifestations - May be described as tightness, choking, or a heavy sensation → Levine’s sign - clenched fist over chest (angina, chest pain) - Anxiety frequently accompanies the pain - Other symptoms may occur: dyspnea or shortness of breath, dizziness, nausea, and vomiting, and diaphoresis - Unstable angina is characterized by increased frequency and severity and is not relieved by rest and NTG. Requires medical intervention bc heart is not getting enough oxygen!! Treatment - Treatment seeks to decrease myocardial oxygen demand and increase oxygen supply 13 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Medications - Reduce and control risk factors - pt education - Reperfusion therapy may also be done (do with STENT, bypass surgery) (opening arteries so the heart gets oxygen) → oxygen needs an order Medications: MONAB(MI/ACS) /TASS (S-T Seg Elevation) Drugs for MI/ACS (CORRECT ORDER DURING SITUATION ONAM): Morphine Oxygen Nitroglycerin - Vasodilator (3x, q5 min) Aspirin (antiplatelet) - prevents worsening of clots Beta Blockers - (drugs that end with -olol) decreases HR, BP, contractility Drugs for S-T Seg. Elevation: Thrombolytics Anticoagulants - blood thinner Stool Softeners - prevents strains and risk for vagal response Sedatives Collaborative Problems #1 - ALL COMPLICATIONS - ACS, MI, or both - Dysrhythmias and cardiac arrest - Heart failure - Cardiogenic shock Nursing Interventions - Treat Angina - Priority - ABC (Airway, breathing, circulation) - Patient is to stop all activity and sit or rest in bed (semi- fowler's positioning) - stop and rest - Someone who has angina still give supplemental oxygen even if O2 saturation is okay Nursing Intervention: Patient Teaching #1 - Nitroglycerin - Can also give morphine if the pt has pain - Avoid exercising in extreme temperatures (cold constricts vessels) - Stop using tobacco products (nicotine increases HR and BP) - Diet low in fat and high in fiber (bulks stool, prevents spokes of sugar) → diabetics, cardiac pts 14 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders ★ THINK MONA FOR MEDS - M=morphine - O= oxygen - N= nitroglycerin - A= aspirin (ASA) ★ CORRECT ORDER IS: ALWAYS GIVE OXYGEN FIRST - O= oxygen - N= nitroglycerin - A= aspirin - M= morphine ACUTE CORONARY SYNDROME (ACS) AND MYOCARDIAL INFARCTION (MI) - Emergent situation (need medical situation) - ACS is more severe - MI is the plaque buildup in artery ● Plaque (atheroma) rupture → impeded blood flow ● Thrombus formation (clot) → impeded blood flow ● MI can evolve (can get worse) → impeded blood flow - ACS includes unstable angina UA MI: - NSTEMI: non - ST elevation MI; elevated cardiac biomarkers without EKG changes; may be less damage to myocardium - STEMI: ST elevation MI; evidence of acute MI in 2 contiguous leads on 12 lead EKG; significant damage to myocardium Ischemia, Injury, and Infarction - Ischemia: insufficient tissue oxygenation; changes in T wave; Reversible (tissue in the cells lack oxygen) - Injury: persistent oxygen deficiency; ST segment abnormalities; Reversible - Infarction: tissue necrosis (death, dead muscle cells); ST segment abnormalities; pathological Q wave; Irreversible (MI) Nursing process: The Care of the Patient With ACS - Assessment - Chest pain ● Occurs suddenly and continues despite rest and medication ● Other signs and symptoms: SOB, ℅ indigestion; nausea; anxiety; cool, pale skin; increased HR, RR - ECG changes - Lab studies ● Cardiac enzymes - creatine kinase myocardial band (CK-MB) → Diagnostic for MI 15 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders ● Troponin I (positive for an MI, labs to do) → peeks early ● LDH- lactate dehydrogenase Nursing Process: The Care of the Patient With ACS - Diagnosis - Coronary pain = acute - Acute pain related to increased myocardial oxygen demand and decreased myocardial oxygen supply - Risk for decreased cardiac tissue perfusion related to reduced coronary perfusion - Risk for imbalanced fluid volume Nursing Management: ACS/MI - Oxygen and medication therapy - MONA - morphine, oxygen, nitrates, aspirin - Physical rest in bed with head of bed elevated - Relief of pain helps decrease workload of heart - Monitor I&O and tissue perfusion - Report changes in patients condition Invasive Coronary Artery Procedures: PCI (Percutaneous Coronary Interventions): open coronary arteries due to CAD (due to atherosclerosis). OVERVIEW: CAD → Myocardial Ischema → MI (angina symptoms) - Atherectomy: shaver/laser to remove/shave plaque within vessels - Stent: placement of a mesh-wire device to hold artery open and prev. restenosis. - Bare metal - Drug eluting stents (DES) Percutaneous (through skin) Transluminal (through lumen) Coronary Angioplasty (PTCA) - balloon to open artery and more room for STENT. Coronary Artery Bypass Graft (CABG): - Coronary artery bypass graft (CABG) → Invasive surgical procedure (OPEN HEART) that aims to restore vascularization of the myocardium with the replacement of vessels from: saphenous vein, radial artery, mammary artery, synthetic artery graft. Cardiopulmonary Bypass System - Blood warmed up → oxygenated → back to body → stop and restart to heart (can lead to dysrhythmias so they keep a pacing wire - Go to ICU after surgery 24-48 hours - Ventilator (within 24 hours) - Central venous line 16 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Swans games catheter - Mid- sternal chest tube for drainage - Assess circulation - Head to toe assessment Nursing Management: Patient requiring Invasive Cardiac Interventions - Maintain adequate tissue perfusion (monitor perfusion) → check hourly urine output - Maintain body temperature (keep normothermic) - Provide pt education - ABC’s (airway, breathing, circulation) HEART FAILURE & PULMONARY EDEMA (>400 pg/mL = HF) CHF: - HF occurs due to the heart muscle unable to pump effectively → inadequate CO, myocardial hypertrophy & pulmonary systemic congestion. - HF is due to acute/chronic cardiopulmonary problem: systemic HTN/MI/Pulmonary hypertension/dysrhythmias/valvular heart disease/pericarditis/cardiomyopathy. LHF (LUNGS): dyspnea/orthopnea (nocturnal dyspnea), fatigue, displaced apical pulse (hypertrophy), S3 heart sound, pulmonary congestion (cough), bibasilar crackles, frothy sputum (can be blood tinged), AMS, manifestations of organ failure (oliguria), nocturia. RHF (BODY): JVD, DVT, ascending dependent edema, legs, ankles, sacrum, abdominal distention (ascities), fatigue, weakness, nausea/anorexia, polyuria at rest (nocturnal), liver enlargement (hepatomegaly) & tenderness, & weight gain. PULMONARY EDEMA: - Accumulation of fluid in alveoli & interstitial spaces of lung that can → severe HF. Medications: - Diuretics (first line): furosemide (do not administer faster than 20 mg/min or else ototoxicity)/bumetanide/thiazide → decreases preload - Potassium sparing diuretic: spironolactone VALVULAR DISEASE - HTN can lead into valvular disease. ● Valvular heart disease describes an abnormality or dysfunction of any of the heart’s four valves: the mitral and aortic valves (left side), the tricuspid, and pulmonic valves (right side). Tricuspid valve dysfunction occurs secondary to endocarditis or IV illicit drug use and is rare. 17 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders ● Valve dysfunction reduces the efficiency of the heart as a pump and reduces stroke volume. Over time, there might be remodeling of the heart itself (hypertrophy) and heart failure. ● With age, fibrotic thickening occurs in the mitral and aortic valves. The aorta is stiffer in older adult clients, increasing systolic blood pressure and stress on the mitral valve. Regurgitation: The valve does not properly close, and blood back flows through the valve. Can be MITRAL and/or AORTIC. Stenosis: The valve does not open completely, and blood flow through the valve is reduced (narrow path). PULMONIC, MITRAL, AND AORTIC. Valve Prolapse: The stretching of an atrioventricular valve leaflet turbulent blood flow) (not enough blood ejected, into the atrium during systole - Mitral and aortic is on the left side (most issues occur) - Murmur: turbulent blood flow through the heart - Bruit: turbulent blood flow everywhere else (peripheral) → auscultating - Thrill: palpating = of the blood flow Infective endocarditis: - Can happen due to invasive procedures (prosthetic valves), or structural defects - IV drug abuse as a cause - Indwelling catheters, body piercings - HIGH MORTALITY RATE - 14-22% of patients die in hospital, 40% die within a year Rheumatic endocarditis: - Rheumatic fever - untreated strep throat - School aged children risk - Chronic - Group A beta hemolytic streptococcal pharyngitis - Affects mitral valve Pericarditis: - Inflammation, no infection - Can worsen to cardiac tamponade ●Risk Factors: - Hypertension - Rheumatic fever (mitral stenosis and insufficiency) - Infective endocarditis - Congenital malformations - Marfan syndrome (connective tissue disorder that affects the heart and other areas of the body) 18 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - In older adult clients, the predominant causes of valvular heart disease are degenerative calcification and atherosclerosis, and papillary muscle dysfunction Mitral Valve Prolapse (MVP) - Twice as many women as men (more common in women) - Inherited (genetics predisposition) - Rarely symptomatic but maybe fatigue, dizzy, palpitations (avoid caffeine/smoking), dyspnea (mostly dyspnea bc of turbulent blood flow) - “Mitral click” → more severe - No prophylactic antibiotics (dental work → bacteria lands on valves) - Avoid smoking (increases BP & HR) and caffeine (increases HR) Mitral Regurgitation - Left side of heart (rejects blood from lungs) - S/S of lung congestion, heart failure - Lung congestion => CHF S/S (blood regurgitation = decreased cardiac output Findings: - Systolic murmur at the apex - S3 sounds - Fatigue and weakness - Atrial fibrillation - Dyspnea on exertion - Orthopnea - Atypical chest pain - Palpitations - Jugular venous distention - Pitting edema - Possible diminished lung sounds - PND (Paroxysmal nocturnal dyspnea) - Hepatomegaly Mitral Stenosis - Valve won't open - Mitral valve doesn't open = less blood into ventricle = decreased cardiac output = pulmonary conjunction - Narrowing or obstruction of flow of blood from left atrium to left ventricle Findings: - Apical diastolic murmur - Dyspnea on exertion - Orthopnea 19 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Atrial fibrillation - Palpitations - Fatigue - Jugular venous distention - Pitting edema - Hemoptysis - Dry cough - PND (Paroxysmal nocturnal dyspnea) - Hepatomegaly Aortic Regurgitation - Backflow of blood into left ventricle from aorta during diastole left ventricle hypertrophy Causes: - Syphilis (STI), untreated, latent (simple blood test to check for syphilis (antibiotics to treat) - Aneurysm (vessel walls become weak) - Blunt chest trauma (has to be very severe → car accident or motorcycle accident) Findings: - Diastolic murmur - Sinus tachycardia - Exertional dyspnea - Orthopnea - Palpitations - Fatigue - Nocturnal angina with diaphoresis - Widened pulse pressure - Bounding arterial pulse on palpation (Corrigan’s pulse) - Elevated systolic and diminished diastolic pressures - PND (Paroxysmal nocturnal dyspnea) Aortic Stenosis - Seen a lot in elderly patients - Most common valve disorder - Narrowing (less blood) or obstruction of blood flow between left ventricle and aorta = decrease cardiac output Findings: - Systolic murmur - Dyspnea on exertion - S4 sounds 20 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Angina - Syncope on exertion - Fatigue - Orthopnea - PND (Paroxysmal nocturnal dyspnea) - Narrowed pulse pressure Causes: - Degenerative calcifications (most elderly) - S4 (heard before S1) - TAVR - transcatheter aortic valve replacement (elderly pts 80+ is the better one to do for severe aortic stenosis) - SAVR - surgical aortic valve replacement Signs and symptoms Valvular Heart Disorders - SOB (dyspnea on exertion) - Fatigue - Cough (pulmonary congestion) - Orthopnea - Dizziness, syncope (fainting) - Decreased cardiac output Diagnostic Procedures - Chest x-ray shows chamber enlargement (with stenosis and insufficiencies) and pulmonary congestion (with aortic stenosis). - 12-lead electrocardiogram (ECG) shows chamber hypertrophy. - Echocardiogram shows chamber size, hypertrophy, specific valve dysfunction, ejection function, and amount of regurgitant flow. - Transesophageal echocardiography (TEE) provides visualization of the mitral and aortic valves; can be used intraoperatively during valve replacement and repair. - Exercise tolerance testing/stress echocardiography is used to assess the impact of the valve problem on cardiac functioning during stress. - Radionuclide studies determine ejection fraction during activity and rest. - Angiography is used to evaluate the coronary arteries and the degree of atherosclerosis. Cardiac catheterization might be used as a diagnostic tool in valvular disease. Nursing Care - Check daily weight to monitor for heart failure - Assess heart rhythm (can be irregular or bradycardic, assess for murmur). - Administer oxygen and medications. - Assess hemodynamic monitoring. Maintain fluid and sodium restrictions. 21 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Assist the client to conserve energy. General Cardiac Medications: Diuretics: used to treat heart failure by removing excessive extracellular fluid. - Loop diuretics, such as furosemide - Thiazide diuretics, such as hydrochlorothiazide - Potassium-sparing diuretics, such as spironolactone Nursing Actions - Administer furosemide IV slowly over 1 to 2 minutes (prevent risk of ototoxicity) - Monitor for hypokalemia with loop and thiazide diuretics and administer potassium supplements as indicated. - Client Education: If taking loop or thiazide diuretics, ingest foods (dried fruits, nuts, spinach, citrus fruits, bananas and potatoes) and beverages that are high in potassium to decrease the risk of developing hypokalemia. Afterload-reducing agents - Afterload-reducing agents help the heart pump more easily by altering the resistance to contraction. - Angiotensin-converting enzyme (ACE) inhibitors (enalapril, captopril, lisinopril) - Angiotensin-receptor blockers (losartan, valsartan) TAKE IF AE: COUGH is present while on ACE inhibitors. - Beta-blockers: metoprolol, carvedilol - Calcium-channel blockers: felodipine, nifedipine, amlodipine - Vasodilators, such as hydralazine Nursing Actions: Monitor clients taking ACE inhibitors for initial dose hypotension. - Inotropic agents, such as digoxin, are used to increase contractility and thereby improve cardiac output. If self-administering digoxin: - Count pulse for 1 min before taking the medication. If the pulse rate is irregular or the pulse rate is outside of the limitations set by the provider (usually less than 60/min or greater than 100/min), the hold the dose and contact the provider. - Take the dose of digoxin at the same time every day. - Do not take digoxin at the same time as antacids. Separate the two medications by at least 2 hr. - Report manifestations of toxicity, including fatigue, muscle weakness, confusion, visual changes, and loss of appetite. Anticoagulants: - Anticoagulation therapy is used for clients who have a mechanical valve replacement, atrial fibrillation, or severe left ventricle dysfunction to reduce the risk of thrombus. - Monitor for manifestations of a stroke, such as neurological changes. - Monitor PT and INR. 22 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Monitor for manifestations of bleeding, such as bruising. ●Nursing Actions: Post-surgery care is similar to coronary artery bypass surgery (care for sternal incision, activity limited for 6 weeks, report fever). ●Percutaneous balloon valvuloplasty: This procedure can open aortic or mitral valves affected by stenosis. A catheter is inserted through the femoral artery and advanced to the heart. A balloon is inflated at the stenotic lesion to open the fused commissures and improve leaflet mobility. ●Valve replacement: This procedure replaces damaged heart valves with mechanical, xenografts (from other species), allografts (from cadavers), or autografts (formed from the client’s pulmonic valve and a portion of the pulmonary artery). It is often done with an open-heart approach, although minimally invasive surgery is also performed in some instances. •Mechanical valves require lifelong anticoagulant therapy. ●Tissue valves need to be replaced every 7 to 10 years. Nursing Actions - Monitor insertion site for bleeding - Monitor for manifestations of emboli Miscellaneous surgical management - Other surgeries used in the treatment of valvular disorders include chordae tendineae reconstruction, commissurotomy (relieve stenosis on leaflets), annuloplasty ring insertion (correct dilatation of valve annulus by narrowing the opening), and leaflet repair. - Medical management is appropriate for many older adult clients; surgery is indicated when manifestations interfere with daily activities. The goal of surgery can be to improve the quality of life rather than to prolong life. PERIPHERAL VASCULAR DISEASE (PVD) Assessment of the Vascular System: Intermittent Claudication: leg pain/cramping Physical Pain: - Skin (cool, pale, pallor, rubor, loss of hair, brittle nails, dry or scaling skin, atrophy, and ulcerations) - Peripheral Pulses - Co-morbidities DM, HTN, Risk Factors: same as HTN, CAD 23 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders PAD: narrowing of the peripheral arteries, or hardening of the arteries, most commonly in the legs. A build up of plaque restricts blood flow and causes leg pain, usually during physical activity. The walls of the arteries become stiff and cannot dilate to allow greater blood flow when needed. Foot elevated: Pallor, venous gluttering Foot dependent: rubor Diagnostics: - Doppler ultrasound flow studies - Ankle-brachial index (ABI) - Exercise testing - Duplex ultrasonography - Computed tomography scanning - Angiography and magnetic resonance angiography - Contrast phlebography (venography) - Lymphoscintigraphy Goals of the peripheral Circulatory System: 1. Increase arterial blood supply - Discourage use of nicotine 2. Decrease venous congestion - Positioning strategies body part below the level of the heart 3. Promote vasodilation, prevent vascular compression: - Exercise program and activities: walking, graded isometric exercises. Consult primary provider before engaging in an exercise routine. 4. Relieve ischemic pain: - Rest/activity - Stress reduction 5. Maintain tissue integrity: - Temperature; effects of heat & cold Peripheral Arterial Disorders: Arteriosclerosis: - Hardening of the arteries - Diffuse process whereby the muscle fibers and the endothelial lining of the walls of small arteries and arterioles become thickened Atherosclerosis: - A form of arteriosclerosis affecting the intima of large and medium-sized arteries 24 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery Other Arterial conditions: Atheromas or plaques, Peripheral artery disease, Upper extremity arterial disease, Aortoiliac disease, Aneurysms (thoracic, abdominal, other), Aortic dissection, Arterial embolism and arterial thrombosis, Raynaud’s phenomenon and other acrosyndromes Signs of PAD: Symptoms that may be a sign of PAD - Leg muscle tiredness, heaviness, or cramping - Toes or feet that are discolored, blue or look pale - Leg pain or foot pain that disturbs sleep - Wounds or sores on legs or feet that heal slowly or do not heal at all - Leg muscle tiredness, heaviness, or cramping Risk Factors: - Diabetes - Smoking - HTN - Age over 50 - High cholesterol - Chronic kidney disease Hallmark Symptom: - Intermittent claudication described as aching, cramping, numbness, tingling, or inducing fatigue or weakness - Occurs with some degree of exercise or activity - Relieved with rest - Pain is associated with critical ischemia of the distal extremity and is described as persistent, aching, or dull/boring (rest pain) - Ischemic rest pain is usually worse at night and often wakes the patient Common Sites of Atherosclerotic Obstruction: - Abdominal Aorta: causing potentially hemorrhage hypovolemic shock - Coronary & Carotid Arteries: causing potentially a heart attack (ACS) or stroke - Popliteal Artery: causing potentially the loss of the limb Management and Treatment for PAD: 25 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Antithrombotic medication: ASA, Clopidogrel, Phosphodiesterase III inhibitor and Statins May also be on vasodilators - Cilostazol - Revascularization: Balloon angioplasty, Stent placements - Bypass surgery: fem-pop bypass ANEURYSMS Localized sac or dilation formed at a weak point in the wall of the artery - Classified by its shape or form - Most common forms of aneurysms are saccular and fusiform - Saccular aneurysm projects from only one side of the vessel - When an entire arterial segment becomes dilated, a fusiform aneurysm develops Risk factors: - Atherosclerosis - Males - Uncontrolled HTN - Tobacco use - Hyperlipidemia - Genetic predisposition - Blunt force trauma - Older adults Expected findings: initially, clients are often asymptomatic. Cerebral: headache, dizziness, loss of consciousness. Neurologic deficits from pressure on surrounding part of the brain Abdominal: abdominal, back, or groin pain Rupture: severe blood loss, death. Abdominal aortic aneurysm (AAA): most common, related to atherosclerosis - Constant gnawing feeling in abdomen - Low back pain (due to pressure on lumbar nerves by aneurysm) - Pulsating abdominal mass (do not palpate; can cause rupture) - Bruit over the area of the aneurysm - Elevated BP (unless in cardiac tamponade or rupture of aneurysm) Thoracic aortic aneurysm: - Severe back pain (most common) - Hoarseness, cough, shortness of breath, and difficulty swallowing 26 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Decrease in urinary output (secondary to hypovolemic shock) - Nodule above suprasternal area - Report of pressure in substernal/tracheal area Aortic dissections: Often associated with Marfan syndrome - Sudden onset of “tearing,” “ripping,” and “stabbing” abdominal or back pain - Hypovolemic shock - Diaphoresis, nausea, vomiting, faintness, apprehension - Decreased or absent peripheral pulses - Neurologic deficits - Hypotension and tachycardia (initial) - Oliguria Diagnostic procedures: - XRAY - Computed tomography (CT) and ultrasonography - Transesophogeal echocardiography (TEE) Nursing Care: Priority intervention is to maintaing client’s BP within expected range. Elevated blood pressure can result in rupture. - VS every 15 min until stable, then every hour. Monitor for increased BP. - Administer antihypertensives (ARBs, beta blockers, diuretics, calcium blockers), analgesics, as prescribed (may require IV administration) - Assess onset, quality, duration, and severity - Monitor ABGs, SaO2, electrolytes, and CBC findings - Insert indwelling urinary catheter if prescribed - Administer O2 as prescribed - Obtain and maintain IV access Procedures: 1. Aneurysmectomy (open-aneurysm resection/repair) of abdominal and thoracic aneurysms - Excision of the aneurysm and the placement of a synthetic graft (elective or emergency). This procedure is not frequently performed. - Elective: manages large AAA or thoracic aneurysms - Emergency: rupturing aneurysm 2. Endovascular repair/stent grafts: 27 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Procedure is more commonly performed to repair aneurysms. Procedure involves the percutaneous insertion of endothelial stent grafts for aneurysm repair, which avoids abdominal thoracic incisions and shortens the postoperative recovery period. Gerontologic Changes: Aging produces changes in the walls of the blood vessels that affect the transport of oxygen and nutrients to the tissues Changes cause vessels to stiffen and results in: - Increased peripheral resistance - Impaired blood flow - Increased left ventricular workload Raynaud’s Disease: - Intermittent arterial Vaso occlusion, usually of the fingertips or toes - Raynaud’s disease: primary or idiopathic - Raynaud’s syndrome: associated with other underlying disease such as scleroderma - Manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning pain - Episodes brought on by a trigger such as cold or stress - Occurs most frequently in young women - Protect from cold and other triggers. Avoid injury to hands and fingers Venous Disorders: - Venous thromboembolism (VTE): DVT and PE DVT: blood clot (i.e. thrombus) develops in a large, deep vein of the limbs (common in lower limbs) - Can lead to PE Caused by VIRCHOW’S TRIAD - Hypercoagulability - Blood stasis - Vessel injury Symptoms: - throbbing/cramping pain - redness & swelling (i.e. edema) - hard/sore veins - larger calf diameter 28 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders Diagnosis: - Medical history and physical exam - WELLS Score - High probability -> ultrasound - Low probability -> D-DIMER blood test. Protein released when blood clot breaks down. - Preventative measures: - Determine Risk - Early ambulation and leg exercises - Graduated compression stockings - Intermittent pneumatic compression devices - Subcutaneous heparin or LMWH - Lifestyle changes; Weight loss; Smoking cessation - Regular exercise - Chronic venous insufficiency: - Assess for pain, peripheral pulses, edema, signs of infection, color, temperature, and nutritional status. - Treatment depends on the type of ulcer - If infected: Oral antibiotics (anti-infective) - Compression therapy – Wound care - Varicose veins (bulging veins) - Leg ulcers: leg swelling, skin color and texture changes, venous ulcers Prevention and Care of Patients with Venous Insufficiency: Avoid: - activities that cause venous stasis such as wearing socks that are too tight at the top or that leave marks on the skin - crossing the legs at the thighs, and sitting or standing for long periods Elevate - legs 3 to 6 inches higher than heart level – - wear graduated compression stockings Encourage - walking 30 minutes each day if there are no contraindications - Overweight patients to begin weight reduction plans Lymphatic Disorders: Primary: congenital | Secondary: acquired obstruction 29 Medical Surgical I Exam I: Pulmonic/Cardiac Systemic Disorders - Lymphangitis: inflammation or infection of the lymphatic channels (cellulitis) - Lymphadenitis: inflammation or infection of the lymph nodes - Lymphedema: tissue swelling related to obstruction of lymphatic flow Clinical Judgement Model Exercise: Recognize cues: - c/o throbbing leg pain (4-7/10), worse after walking down the hall, uses walker, pale colored skin on calves and ankles, elevated on pillow Prioritize Hypothesis: - Peripheral Arterial Disease, poor oxygen to the peripheral tissues Take Action: - Exercise regimen, don’t cross legs, anticoagulants/anti platelets. Dependent/elevation positioning. Analyze Cues: - History of smoking, weak to absent pedal pulses, states -skin becomes red after walking Generate solutions: - Lessen pain, promote o2 to tissue, prevent complications (wounds, infection) Evaluate Outcomes: - Pain <4, skin pink, warm, adequate circulation, no wounds/infections