Internal Medicine Nursing PDF

Internal Medicine Nursing Course: Internal Medicine Nursing Week: 04 1 CARDIOVASCULAR DISEASES and NURSING CARE 2  Heart Anatomy and Physiology Located slightly to the left of the midline of the chest...

Internal Medicine Nursing Course: Internal Medicine Nursing Week: 04 1 CARDIOVASCULAR DISEASES and NURSING CARE 2  Heart Anatomy and Physiology Located slightly to the left of the midline of the chest The sternum in front and the spine in the back are protected by the lungs and vertebrae on the sides. Its weight is around 350 grams  Layers of the Heart Endocardium: It is the epithelial tissue that covers the inner surface of the heart cavities and the structures within them. Myocardium: The middle layer of the heart consisting of thin muscles. Muscles enable the heart to contract Cardiac muscle has a striated muscle structure, but it works involuntarily. Myocardium is very thin in the atria and thick in the ventricles Pericardium: It is the two-layered membrane that surrounds the outer surface of the heart. The parietal pericardium is located outside and acts as a barrier against infections that may come from surrounding tissues. Visceral pericardium is the thin layer located inside and attached to the heart. The space between two pericardial leaves is the pericardial space and contains 10-12 ml of pericardial fluid.  Functional Cavities of the Heart Right atrium: It is the first part where blood is pumped. At the upper end of the right atrium is the sino-atrial node. Venous blood circulating throughout the body to the right atrium; It occurs via the superior vena cava, inferior vena cava, anterior cardiac veins, coronary sinus, and right marginal vein. Right ventricle; Vena cava superior and vena cava inferior contain venous blood coming to the right atrium and passing through the tricuspid valve. This blood is thrown into the pulmonary artery by the contraction of the right ventricle. Left atrium; Four pulmonary veins open, bringing oxygenated blood from the lung to the left atrium. Left ventricle; It is the heart cavity with the thickest wall. Arterial blood coming from the lungs via the pulmonary vein, passing through the left atrium through the mitral valve, is thrown into the aorta by the contraction of the left ventricle. HEART VALVE Atrioventricular valves tricuspid valve Mitral valve Semilunar valves pulmonary valve aortic valve  VASCULAR STRUCTURE OF THE HEART The superior vena cava brings the venous blood of the upper extremity, head and neck, and the inferior vena cava brings the venous blood of the lower extremity to the right atrium. The pulmonary artery arises from the right ventricle and carries blood to the lungs. 4 pulmonary veins coming to the left atrium The artery originating from the left ventricle is the aorta  CONDUCTION SYSTEM OF THE HEART There is a special system in the heart muscle where impulses are initiated and transmitted. This system is called the heart's stimulation and conduction system. * Sinoatrial node: Also known as the SA cardiac pacemaker. It is a special tissue in the right atrium, just on the forehead of the pericardium, where the superior vein opens into the atrium, and it produces 60-100 impulses. The stimulus from here spreads to the atrium, starting from the right atrium, and causes systole. AV node: It is a special tissue at the base of the right atrium. It receives the stimulus from the atrium, waits for it before sending it to the ventricles, and produces 40-60 impulses. Bundle of His: The stimulus from the AV node passes to the bundle of His. The bundle of His is divided into two branches: right and left. It reaches the myocardium via Purkinje fibers. HEART CYCLE The cardiac cycle consists of the contraction of the atria and ventricles, known as systole, and the relaxation of the atria and ventricles, known as diastole. One heart cycle lasts 0.8 seconds. 0.5 sec is diastole, 0.3 sec is systole The heart pumps 7500 liters of blood per day Control of heart function 1. Autoregulation: the more the heart muscle is stretched, the more it contracts (starling's law) 2. Neurohormonal control  Evaluation of Cardiac Functions General Evaluation Health perception-coping with health Nutrition, metabolic status, elimination Exercise Nursing history Sleep and rest Role perception stress situation Religious and cultural values Do you have heart disease-hypertension? Is there any surgical intervention? chest pain palpitation Arrival medical history arrhythmia heart sounds Edema claudication test results  Evaluation of Cardiac Functions AGE Arrhythmias, exercise intolerance, Gender bradycardia, fatigue, postural hypotension with age. High risk of MI in men, high risk of heart Cardiac risk factors disease in post-menopausal women Apical pulse is difficult to detect, heart family history rate increases up to 100, angina with coronary arteriosclerosis advanced age Gender race Hypertension Smoking hyperlipidemia Obesity DM physical inactivity  Evaluation of cardiac functions skin appearance skin turgor Temperature, color (cardiogenic shock) general view ecchymosis, cyanosis Facial expression, anxiety, stress and state of Skin color may be pale due to anemia. Nails, lips, consciousness oral mucosa are observed Peripheral and central cyanosis is best observed in the oral mucosa, tongue, extremities, nose, lips, and earlobes.  in BP measurement Measurement in sitting or lying position Smoking-alcohol (-) until 30 minutes ago rest 5 minutes ago Suitability of the cuff (length 30cm, width Factors affecting BP measurement Blood pressure 12-14cm) Increased peripheral resistance Normal value is 100/60-140/90 mmHg in Calibration Loss of vascular wall elasticity adults Clothes should not pinch the arm Heart pumping too much blood to the Proper placement of the cuff aorta The patient's position is comfortable Shoulder-elbow at heart level Correct placement of the stethoscope No consecutive measurements  Pulse Pressure It is the difference between systolic and diastolic pressure Normal value is 30-40 mmHg It increases in anxiety and anxiety, in bradycardia, when vascular resistance decreases, in old age, atherosclerosis, hypertension When stroke volume decreases, it decreases Common Symptoms symptom Things to ask Comment Dyspnea (Breathing Distress) Did it start suddenly or gradually It is normal for healthy people to increase? experience dyspnea due to In which activity and for how long excessive physical activity. does respiratory distress occur? It is abnormal for dyspnea to When did it start and is it occur at rest or during light permanent or temporary? activity. Is it affected by the position? In paroxysmal nocturnal dyspnea Does it wake you up at night? (PND), classically, the person wakes up with air hunger after Is there respiratory distress during sleeping, gets out of bed and ADL? opens the windows to get fresh What are the factors that increase air. and decrease It is a symptom of heart failure.. Because when you lie on your back, the intrathoracic blood volume increases and the failing heart cannot adapt to this increased load. Common Symptoms palpitation Fast irregular heartbeats Tiredness Edema Pain Major finding Pain location and distribution (substernal, precardial, jaw, back...) Feature (feeling of pressure, crushing, burning, stinging, burning heart….) Starting type, duration, frequency Initiating and stimulating factors (resting, sleeping, activity, eating, exercise, emotional…) Pain rating scale Common Symptoms SYMPTOM THİNGS TO ASK COMMENT When did it started ? How long did it continue? Chest pain; It may be due to heart, lung, musculoskeletal or Have you had this type of pain GI origin, and this must be ruled before? out. How often has it happened?? Location of the pain, does it Chest Pain radiate elsewhere? Character of pain? What is the event that starts the pain? Angina is an important cardiac finding and must be classified!! Symptoms accompanying pain… Did you take medication when the pain started?  SYMPTOM THİNGS TO ASK COMMENT Cough When did it started ? Hemoptysis is the discharge What time of day does it of light red blood with happen? sputum. Hemoptysis usually Does it produce phlegm? indicates pulmonary disease but may be seen in Does it have a phlegm- cardiogenic pulmonary colored smell? edema. Is the activity related to position (lying on your back), anxiety related to Morning cough is common speech? in smokers. What activities (sitting, walking and exercise) increase or decrease it? Does it go away with rest or medication?  PHYSICAL ASSESSMENT Evaluation of Jugular Vein Fullness The neck veins are examined to determine right atrial pressure (central venous pressure) and to observe changes in venous waveforms. Normal venous pressure is around 5-9 cm H2O. Situations where JVB increases 1) Primary or functional RV (Right Heart) failure, 2) Tricuspid valve disease (TD/TR), 3) Increased intrapericardial / intrapleural pressure 4) Constrictive pericarditis 5) Physiological conditions such as exercise, anxiety and pregnancy.  AUSCULTATİON The diaphragm part of the stethoscope picks up high-frequency sounds, and the bell part picks up low-frequency sounds. Auscultation is performed with the patient supine in the left lateral position, sitting and leaning forward; because some sounds are heard well in this position. During auscultation, attention should be paid to heart rate and rhythm, normal heart sounds, additional heart sounds, if any, and whether the sounds are affected by respiration. HEART SOUNDS NORMAL HEART SOUNDS Tricuspid and mitral valve closing sound It is best heard in the mitral area. S1 “Lub” Mitral Area: Left 5th ICA, clavicular midline It is a full, low-frequency sound. It is louder than the S2 sound. Aortic and pulmonic valve closing sound It is best heard in the aortic area. S2 “dub” Aortic Area: Right 2nd ICA, next to the sternum It is a short and sharp sound  KALP SESLERİ ANORMAL KALP SESLERİ Gallop S3 “lub-dud-dee” S4 “dee-lub-dub” Quadruple gallop ventricular gallop Atrial gallop Having both S3 and S4 It is heard in the early period It is heard in the late period together of diastole. (fast filling) of diastole. In this case, all 4 heart It is best heard from the It is best heard from the sounds may not be apex. apex. distinguishable from each It occurs as a result of the Hypertension other. vibration of the covers. Ventricular Hypertrophy Advanced Heart Failure It can be considered normal MI in children and adults up to Aortic or Pulmonary Stenosis the age of 30. Pulmonary Embolism Early sign of heart failure VSD (Ventricular Septal Defect) Murmurs Abnormal sound created by blood flow as it passes through the valves WHILE LISTENING TO MY MURM! POINTS TO If heard in diastole: MAKE Tricuspid or mitral stenosis Is the murmur in systole? in diastole? If heard in systole: Aortic or pulmonic valve insufficiency The point where it is most dense Tricuspid or mitral insufficiency heard between S2 and S1. Stenosis in the aortic or Where does the sound travel? pulmonic valve It is heard between S1 and Quality and tone of voice S2.  Peripheral Vascular Circulation Examination Size and symmetry of Skin color and structure of nail beds capillary refill test the extremities temperature capillary refill test varicose rash ulcer homans sign Edema examination examination  DIAGNOSTIC TESTS AND APPLICATIONS Cardiac Enzymes and Isoenzymes Plasma cardiac enzyme diagnosis is part of the diagnostic profile associated with acute MI, which includes ECG, symptoms, and health history. Enzymes are released after injury to the cell membrane. Many enzymes are not associated with specific organ damage. Some isoenzymes are released only in cases of myocardial cell damage in cases of permanent hypoxia that occurs in infarction or trauma.  Serum Electrolytes Sodium, potassium, Serum potassium The first symptoms of calcium and magnesium concentration level is hypermagnesemia are ions play vital roles in cell effective in myocardial lethargy and decreased depolarization and depression and neuromuscular activity. repolarization. ventricular irritability. Hypomagnesemia Hypokalemia and Calcium is necessary for prolongs the QT interval Serum sodium hyperkalemia can both coagulability and on the ECG and paves the concentration reflects lead to ventricular neuromuscular activity. way for life-threatening fluid balance. fibrillation or cardiac arrhythmias. In general, hyponatremia arrest. indicates fluid excess and. hypernatremia indicates. fluid deficit.  Lipid and Lipoprotein Coagulation Tests The risk of coronary artery disease increases Coagulation tests are routinely performed with an increase in the LDL/HDL ratio or the before invasive procedures such as total cholesterol (LDL+HDL)/HDL ratio. catheterization, electrophysiology testing, and coronary or cardiac surgery. In lipid panels, total cholesterol, triglycerides LDL, HDL and VLDL are measured, how long Measuring partial thromboplastin time (PTT) does the patient have to wait 12 hours before and partially activated thromboplastin (aPTT) measurement? time determines interactive activity.. In the patient receiving heparin, the PTT or aPTT value should be 1.5-2.5 times the basal value.. Hematological Studies Low hemoglobin (Hb) and hematocrit (Hct) levels increase angina attacks in patients with coronary artery disease. Chest X-Ray A chest x-ray is the most important part of evaluating the heart; It provides important information about the heart, lungs and large vessels.  Long Term Ambulatory ECG Recording Ambulatory ECG (Holter monitoring) is a widely used, non-invasive method that evaluates heart rhythms and conduction disorders by monitoring them over a long period of time and detects short-term temporary electrical activity disorders.  ECG is taken during exercise. The heart rate is increased by having the patient walk on a rotating belt or pedal a stationary bicycle. Meanwhile, the ECG records taken from the patient are analyzed on the computer. At the same time, changes in blood pressure and pulse with exercise, and whether the patient has complaints such as chest pain and shortness of breath are also recorded.  This test; To check whether there is stenosis in the coronary vessels and to determine the severity, if any, In determining the risk in AMI patients, In monitoring treatment results, To investigate the degree of blood pressure increase with exertion, In measuring effort capacity, In the diagnosis of rhythm disorders that occur with effort, It plays an important role in the evaluation of chest pain.  Echocardiography (ECHO) It is an imaging method based on the principle of ultrasound. In traditional ECHO, before the procedure, the nurse informs the patient about the test and explains that the procedure is painless. The process involves moving the receiver over the chest area and viewing the images obtained with sound waves on the screen. Oral off for 6 hours before the procedure. An IV catheter is inserted. In TEE, local anesthesia is applied to the throat. ECG and vital signs are monitored throughout the procedure. is done. The patient's symptoms throughout the procedure should be noted. And after the procedure, the mouth should be closed for 4 hours.  Heart Catheterization Cardiac catheterization is the technique of sending a soft catheter inserted through a vein or artery to the heart. By sending the catheter to the heart, the pressures of the heart chambers or their associated vessels can be measured. The oxygen saturation of the blood is determined; The anatomy and functions of the coronary arteries can be examined by administering radiopaque substances to the heart cavities (angiocardiography) and by administering these cavities to the coronary arteries (coronary angiography). Additionally, structural changes in the coronary arteries can be evaluated (coronary ultrasonography and angioscopy), biopsy and electrophysiological examination can be performed with the help of special tools placed at the tip of the catheters.  Responsibilities of the Nurse in Cardiac Catheterization ELECTROCARDIOGRAPHY Electrocardiography is based on recording the electrical activities that occur during the functioning of the heart through electrodes placed in different parts of the body. ECG can be recorded with 12, 15 or 18 leads. With standard 12-lead ECG, dysrhythmias, conduction arrhythmias, heart wall expansion and cardiac ischemia or infarction, high or low calcium and potassium levels and some treatment effects can be identified.. Locations of Electrodes for Chest Leads CARDIOVASCULAR SYSTEM DISEASES HEART FAILURE  Description It is a disease in which filling and/or emptying is impaired due to structural or functional disorder and the blood cannot pump adequately. Heart failure; It is a structural and functional disorder that causes the heart to fail to provide enough oxygen to the tissues to meet their metabolic needs, despite normal or increased filling pressures. HEART FAILURE CLASSIFICATION According to the First, according to By onset of According to the amount of cardiac the impaired symptoms: ventricle involved: output: ventricular function: Acute- High flow- Left-Right Systolic- Chronic Low flow heart failure Diastolic Epidemiology Prevalence: 2-3% 20% at ages 70-80 5% of those admitted to hospital acutely, This patient group occupies 10% of patient beds 1-2% of the country's budget is spent on this disease In Turkey, the prevalence is 3.2% (HAPPY study-2009) in men The prevalence of hypertension, CAD, diabetes and obesity is above the average of industrialized countries  Etiology Acute MI Arrhythmia Message Disorders Uncontrolled HT Anemia Irregular Drug Use Acute Renal Failure İnfection Excessive Salt And Fluid İntake Pregnancy  Signs and symptoms Dyspnea: Exercise dyspnea, orthopnea, PND Fluid retention: Edema in the lower extremities, ascites, symptoms accompanying liver congestion (nausea, abdominal pain), abdominal distention Decreased exercise tolerance (fatigue, weakness) Anorexia, cachexia Memory impairment, sleep disturbance, confusion (in the elderly)  Signs and symptoms Clinical feature symptom Finding Peripheral edema, Shortness of breath peripheral edema congestion Fatigue, weakness JVB increase Anorexia Pulmonary edema, Hepatomegaly, ascites pulmonary edema Severe dyspnea at rest fluid retention Cachexia rales in the lung Effusion, Tachycardia, Tachypnea cardiogenic shock confusion Inadequate peripheral perfusion Weakness SBP