Untitled

Chapter 24 - Management of Patients with Structural, Infectious, and Inflammatory Cardiac Disorders

Left Ventricular Hypertrophy

• Information regarding the pathophysiology, symptoms, and assessment techniques

Aortic Stenosis:

• Pathophysiology: Narrowing over time obstructs left ventricular outflow, leading to LV hypertrophy, pulmonary congestion, and heart failure.
• Risk Factors:
  • High LDL and low HDL cholesterol levels.
  • Smoking, older age due to degeneration, with those over 86 at higher risk, diabetes mellitus, and stimulant use.
• Symptoms: Asymptomatic presentation is possible.
  • Can include dyspnea on exertion and fatigue, pulmonary congestion, orthopnea, paroxysmal nocturnal dyspnea (PND), and pulmonary edema.
  • Presence of loud aortic murmurs and S4 sounds, dizziness, syncope, and angina due to high O2 demand with insufficient coronary blood flow.

S/S of Heart Failure

• Ascites, JVD, peripheral edema, capillary refill assessment, pulse grading, and skin temperature.
• Auscultation may reveal murmurs, clicks, rubs, and extra heart sounds such as S3 and S4.
• Crackles may be heard during lung auscultation.
• Monitor for dysrhythmias such as Afib and Aflutter.
• Assess rhythm frequently and watch for decreased cardiac output.
• Urine output, daily weights, I&Os fluid restriction, O2 saturation, BNP, BUN, creatinine, and electrolytes need to be monitored.
• Education of the patient on elevating head via pillows, medication adherence, the disease itself, its progression and treatment plans is key.
• Treatments include internal cardiac defibrillators that sense VTACH/VFIB and deliver shocks, and Holter monitors for heart rhythm recording.

Mitral Valve Regurgitation:

• Info on the pathophysiology, symptoms, and assessment of this condition.
• Pathophysiology: Blood flows backwards, directly affecting cardiac output.
  • The left atrium hypertrophies and pulmonary congestion occurs.
  • This may lead to right-sided heart failure (Cor Pulmonale), RV hypertrophy and dilation.
• Symptoms: Many patients are asymptomatic, but the condition can become serious after an MI
  • Severe acute congestive heart failure may require ECMO or balloon pumps
  • Fatigue, weakness, dyspnea, palpitations, SOB, and high-pitched murmurs.
• Assessment:
  • Evaluated via ECHO with other management similar to heart failure.
• Afterload Reduction: Using ACEs and ARBs to reduce cardiac stress.
• CCBs: Block skeletal and cardiac muscle excitation, to slow heart rate.
  • These are effective for patients prone to tachycardia.
• Beta Blockers: Utilized for rate control to assist heart filling and blood output.
• Activity restrictions may be necessary.
• Valve replacement may be a surgical intervention.

Valve Replacement Surgery / TAVR

• Suitable for patients at high risk for open-heart surgery or those with congenital pediatric issues or elderly with comorbidities.
• Valve Types:
  • Mechanical Valves: More durable than tissue with an audible click.
    • For younger patients and has risk of thromboembolic complications needing anticoagulant therapy.
  • Tissue Valves: Not as durable, may require replacement.
    • Heterografts (from animals like pigs or cows), homografts (from cadavers), and autografts.
• Teaching:
  • Patients will likely need to take warfarin anticoagulant therapy for the rest of their life.
• Education:
  • Anticoagulant therapy, prevention for infective endocarditis and need for regular echocardiograms.

Endocarditis

• Involves risk factors, management strategies, and potential complications.
• Risk Factors:
  • Poor dental health, IV drug use.
• Management:
  • Frequent neurovascular assessments.
  • Prevention, antibiotic prophylaxis (monitor for sepsis), and good oral hygiene.
  • Hospitalized patients need to adhere to the agreed-upon plan including diet and surgery
• Medical Management:
  • Long-term IV antibiotics administered via PICC line for 6-8 weeks in the hospital, monitoring temperature, etc.
  • Valve replacement may be necessary.
• Nursing Management:
  • Monitoring patients HR and temperature, administering medications, encouraging fluid intake, planning rest periods evaluating heart sounds, and watching for embolism or heart failure signs.
• Complications:
• Heart valve damage, heart failure, myocardial abscess, stroke, meningitis, seizures, kidney damage, spleen enlargement, joint pain and swelling, skin lesions, pneumonia, sepsis, multi-organ failure.

Myocarditis

• Information includes management and education.
• Management:
  • Treating the cause with antibiotics for bacterial infections or symptom management for viral infections.
  • Bed rest and restricted activity.
• Nursing Management:
  • Monitoring vital signs, watching for S/S complications, and using anti-embolism stockings with passive ROM.
• Education:
  • Recognizing symptoms such as chest pain, respiratory distress, lethargy, medication schedules, activity restrictions, and balanced diets with fruits, vegetables, whole grains, lean proteins, and healthy fats.

Pericarditis

• Info includes risk factors, symptoms, and assessment.
• Risk Factors:
  • It can be primary or secondary with multiple causes.
  • Bacterial, viral, or internal heart disease.
  • It can be acute, chronic, or recurring, with complications.
• Inflammation: Leads to pericardial effusion or cardiac tamponade of Beck's Triad.
  • Fluid accumulates, causing a friction rub.
• Symptoms: Maybe asymptomatic, chest pain and friction rub, and Beck's triad.
  • Muffled heart sounds, JVD, or widening pulse pressures, pulsus paradoxus, and hallmark slam dunk.
• Assessment: Diagnosis is based on vitals, the S/S, echo, and EKG with global ST elevation.

Cardiac Tamponade

• Patho: Reduced diastolic filling of the right ventricle due to pressure from the adjacent expanding pericardial sac
  • Results in backup of fluid into the veins draining into the heart
  • Treatment: Requires a needle or small tube for fluid drainage (pericardiocentesis).

DVT

• Includes risk factors and prevention Information.
• Risk factors: being over 60 years old, lack of movement, injury or surgery, pregnancy, birth control pills, being overweight, smoking, cancer, heart failure, IBD, history of PE, genetics
• Prevention: Includes lifestyle changes to move more, exercise, quit smoking and medications.

Chapter 22: Management of Patients with Arrhythmias and Conduction Problems

Normal Sinus Rhythm

• 60-100 bpm characterized by a present and normal P-wave.
• Origination from the sinus node and has a narrow QRS complex of under 0.12 seconds.
• PR Interval range is 0.12-0.20 seconds.

Sinus Tachycardia

• More than 100 bpm.
• Causes: Physiological and psychological stress, medications, stimulants/drugs.
• Management: Vagal maneuvers, adenosine, IV beta-blockers or calcium channel blockers if adenosine is not effective.
• Try synchronized cardioversion if symptomatic.

Atrial Fibrillation

• Common arrhythmia associated with aging.
• Risk Factors: Increasing age, hypertension, diabetes, obesity, valvular heart disease, Obstructive Sleep Apnea, alcohol abuse, hyperthyroidism, MI, and Smoking.
• Assessment: History, physical examination, S/S, Blood tests, chest x ray, and exercise stress test.
• Medical Management: Warfarin, HR control medications (beta-blocker, or non-dihydropyridine calcium channel blocker) and amiodarone.

Atrial Flutter

• Conduction defect in the atrium causing a rapid atrial impulse at a rate between 250 and 400 bpm.
• Faster atrial rate than AV node can conduct leads to an irregular heartbeat.
  • Results: Inefficient blood pumping and symptoms like chest pain, low blood pressure, and shortness of breath.
• Ventrical Rate: 75-150 bpm - Rhythm is regular, QRS is normal.
• P wave is saw toothed shaped, cannot determine PR.
• Management: Is symptomatic and involves a vagal maneuver/adenosine trial.

Supraventricular Tachycardia (SVT)

• An atrial rate is 150-250 bpm and ventricular rate is also 150-250 bpm
• P waves are not discernible and PR-i measurements cannot be made.

Premature Ventricular Contractions

• Complex occurs when an electrical impulse starts in the atrium.
  • Impulse is before the next normal impulse of the sinus node with an irregular rhythm.
  • Management: No treatment needed, avoid stimulants such as caffeine, and replace K+.

Medications

Adenosine

• Class V antiarrhythmic, blocks the AV node temporarily
• Used to treat supraventricular tachycardias (SVT), such as PSVT and is administered via rapid IV push, followed by a saline flush.

Atropine

• Anticholinergic that blocks the effects of the vagus nerve on the heart.
  • Increases heart rate and conduction in bradycardia or heart block admin IV situatuionally.

Magnesium

• Electrolyte that regulates heart electrical activity
• Action: used for torsades de pointes and arrhythmias, administered IV or orally.

Diltiazem:

• Calcium channel blocker slows AV conduction, used for atrial fibrillation and SVT via oral or IV administration.

Metoprolol

• Beta-blocker that reduces heart rate
• Used for atrial fibrillation, angina, and heart failure and is administered orally or IV.

Digoxin

• Cardiac glycoside that increases contraction force - Class: Cardiac glycoside and is administered orally or IV via heart failure and atrial fibrillation administration.

Decreased Cardiac Output:

• Causes: Heart failure, arrhythmias, MI, valvular disease, cardiomyopathy, hypovolemia, sepsis, cardiac tamponade.
• Symptoms: Fatigue, dizziness, shortness of breath, hypotension, chest pain, pale/cool skin, edema, confusion.
• Assessment:
  • Check vitals for low blood pressure, irregular heart rate and tachypnea.
  • Check JVD, skin edema and lung crackles.
  • Check heart sounds for murmurs, gallops, elevated BNP, electrolyte imbalances.
  • Perform an ECG for arrhythmias, echocardiogram for heart function, and chest X-ray for pulmonary edema.

Cardioversion

• Designed to treat tachyarrhythmias.
• Deliveres a synchronized shock during the QRS complex to restore normal rhythm with conscious sedation.

Defibrillation

• Immediate: Used for emergent situations of with ventricular fibrillation and Pulseless Ventricular Tachycardia
  • Delivers unsynchronized shock at any point in the cardiac cycle without sedation.

Code Blue / BLS

• Assess ABCD's quickly, call a Code Blue, start CPR, push hard and fast.
  • Interventions are directed towards the underlying cause once known

Medical Code "H's"

• Hypoxia: Administer oxygen or improve ventilation.
• Hypovolemia: Administer IV fluids or blood for hemorrhage.
• Hydrogen Ion (Acidosis): Administer sodium bicarbonate
• Hypothermia: Rewarm the patient gradually,
• Hypokalemia: treat patients with Potassium replacement
• Hyperkalemia: treat using Calcium chloride or calcium gluconate, sodium bicarbonate, insulin/glucose, dialysis
• Hypoglycemia: Administer dextrose or glucose.

Medical Code T's

• Tablets/Drug Overdose: Administer antidotes, or treat with activated charcoal.
• Tamponade: Use pericardiocentesis to remove fluid.
• Tension Pneumothorax: Use needle decompression or chest tube

Medical Code Embolisms

• Thrombosis (Pulmonary): Administer Thrombolytics or embolectomy for pulmonary embolism.
• Thrombosis (Coronary): Percutaneous intervention or thrombolytics for a myocardial infarction.

Pacemakers

• Used to treat advanced HF, pulse impulse formation, symptomatic AV, or ventricular conduction.
• Transcutaneous: Used for symptomatic bradycardia or heart block via electrodes to stimulate the heart.
  • If impulses do not stimulate the heart, reposition electrodes, adjust settings, and correct electrolyte imbalances.
  • Follow-up with regular checkups.

Permanent Pacer Education

• Restrict activity on that side of the implantation.
• Avoid heavy lifting or electromagnetic interference.
• Watch for dizziness, fainting, swelling, or infection at the pacemaker site. Keep the site clean.

Implanted Cardioverter-Defibrillator

• Detects and terminates life-threatening tachycardia or fibrillation. Ventricular arrhythmias post-cardiac arrest are indications. The ICD detects arrhythmias delivers shocks and is programmed to restore normal rhythms.

Chapter 28 - Assessment of Hematological Function and Treatment Modalities

Blood Transfusions

• Focus: Nursing assessments prior, symptoms/types of transfusion reactions, nursing interventions in the reaction.
• Nursing Assessments Prior to Transfusions:
  • Check blood count, patient history for allergies or transfusion reactions.
  • Physical assessment is preformed to gain a baseline.
  • Have IV access: at LEAST a 20g.

Nursing Responsibilities

Before a blood transfusion make patient is informed and a consent form is signed. Type and screen is only valid for only 72.

• Take baseline vital signs prior to beginning with monitoring.
• Start administration of blood up to 2 mL/min for the first 15 minutes

Symptoms/Types of Transfusion Reactions:

• Febrile Non-Hemolytic Reaction is most common. Often occurs when the patient has had a previous reaction.
  • Symptoms- Chills, fever, anxiety.
• Acute Hemolytic Reaction: Most dangerous and result in death.
  • Antibodies combine with the antigens of the red blood cells that are being delivered which causes fever, chills, low back pain chest pain and dyspnea
  • Administer benadryl, corticosteroid or tylenol
• Allergic Reaction: presents with itching and hives
• Transfusion associated circulatory overload (Hypervolemia as a result of blood being transfused too fast) S/S fluid overload: Dyspnea, orthopnea, tachycardia, HTN, sudden onset anxiety, JVD, lung congestion, crackles, pulmonary edema also known as TACO. This complication appears up to 6 hrs after transfusion. Diurectics are often administered per unit of blood as a precaution- Check High HF, CKD & MI patients
• Bacterial rare and can happen anytime during procedure TRALI. Delayed Hemolytic Reaction can occur within 14 days after transfusion. With TRALI patient will need aggressive support for 6 hours.

Nursing Interventions for Transfusion Reaction

• (ORDER): Stop the infusion, assess and take vitals, call physician, notify the blood bank, obtain urine sample. Other Steps:
• VS monitoring, lung sounds, heart sounds and questions.

Bone Marrow Biopsy

• Provides insight into indications, risks, and education.
• Confirms blood disorder once additional information is acquired. You would position patient, informed signed ensure material availabity. Make sure to do a complete time out.
• Assessment of the patient and communication is required.
• Monitor for breathing and if pain present medicate but dont sedate. Indications:
• Hematolgic disorders: unexplained anemia, leukopenia (low WBC), or thrombocytopenia (low platelets.)
• Cancer Diagnosis & Staging: Leukemia, lymphoma, multiple myeloma, and metastatic cancers affecting the bone marrow.
• Suspected fungal, bacterial, tuberculosis infections.
• Assess iron stores in overload
• Risks & complications: Pain or discomfort, bleeding or hematoma, infection swelling.
• • Patient can only feel pain during needle insertion**- monitor VS monitor and make sure there is minimal bleeding
• Educate prior and during procedure.

Chapter 29 - Management of Patients with Nonmalignant Hematologic Disorders

Anemia

• Results from iron deficiency, this includes risk factors, assessments, management, education. Risk: Ulcers, IBD, grastrist excess menstrual bleeding, pregnancy causes iron loss, anemia and leads to dizziness as well as a smooth red tongue.
• Management and Education: Promote healthy diet iron foods, vitamin C and supplements. If issues arise contact provider

Vitamin B12 deficiency

• Causes/Risk Factors: 1. Malabsorption Disorders: Celiac, Crohn's, tropical sprue.
  • Medications (PPIs), Deficiency and Lack Of Intrinsic Factor is autoimmune which impairs vitamin B12 uptake. Assessments:
• Symptoms: Fatigue, weakness, pale skin, or Shortness of breath dizziness , Neurological Symptoms, Gastrointestinal Symptoms, Anemia Symptoms which are low B12 levels
  • Management/Education: Vitamin B12 replacment, and safe for fall risks patients, Educate medication!

Folic acid deficiency

• Risk Factors:
  • Deficiency to folate that leads to legumes or fortified grains.
  • Alcholism from alcohol use can impart to loss. Preganancy- Malapsoprtion disorders. Fatigue, weakness, paleness from anmeia.
  • GI symptom
  • Neuro less common but is possible to co exist to B12.
• Treatment*
• Folate pills leafy greens vitamin c
• Also treatment for alcoholism

Aplastic

• Decrease in or damage to stem cells in the bone marrow with causes and risk factors. 1. Idiopathic 2. Medications/Toxin 3 Viral 4. Autoimmune 5. Genetic 6. Radiation pregnancy.
  • Assessments include anemia such as low white cell count, platelets bleeding and are found through BONE marrow biopsy
• Treatment*
• Stem cell replacment to replce bone marrow _ Drugs to suppress bones marrow

Immune Thrombocytopenic Purpura (ITP)

• Pathophysiology: Autoimmune disorder destroys platelets (ITP) occurs in women and young kids with unknown cause.
  • Medcal Management: To maintence safe plact count, use suppreressive agents and nurse monitor.

Sickle Cell Disease

• Genetic disease of sickle cell gene abnormal
• RBC are rigit fragile and impair oxygen transportation ( common issues fatigue, pain damage)

Hemophilia

• Patients with clotting disorders need to be more cautious due to bleeding.
• Prevent cuts by using soft toothbrushes to minimize
• Monitor blood loss.

Neutropenia and Precautions

• Healthcare providers should be aware due to low immune and cancer treatment. In order to avoid infection healthcare providers should preform strict hand washing!
• Provide a limit visitors avoid crowed.

Disseminated Intravascular Coagulation (DIC)

• Inflammatory system to widespread of clotting factors
• Manage Underlying cause improve oxygenated support circulation adn give platelets also nurses stay to be ontop of sepsis

Chapter 30 - Management of Patients with Hematologic Neoplasms

Myelodysplastic Syndrome

• Treatment focused on impriving qualitiy of life, decreasing, frequent chelation therapy, and fatigue due to risk.
  • Also to educate patient a bout chronic risk disease

Acute Myeloid Leukemia (AML)

• Treatment is focused on defect in the cells in the bone marrow, diagnosis is any one the age of 45 due to CBC
• Signs include fever infection , weakness, decrease
• Bone marry bioposy show hallmark and leads to death Complication Infection prone

Acute Lymphocytic Leukemia (ALL)

• Treatment:
  • Maintening the body and Genetic to CFS. Chemo, Complex, genetic testiing and consolidatrion

Hodgkin / Non-Hodgkin Lymphoma

• Early Symptoms
• B: symptoms is drenching
• All organs are valuable to invasion

Multiple Myeloma

• Manage there is no cure: however there control to function chemono use immuno to help malignant plasma and bones
  • Manage pain (important), kidney work!
  • Also no lifting use braces