ADV Medsurg-EXAM 1 PDF

Tracheostomy Maintain patent airway ❖​ Monitor respiratory status ❖​ High fowler’s positon ❖​ Mechanical ventilation support of tracheostomy collar if indicated ❖​ Maintain surgical drains in neck if prese...

Tracheostomy Maintain patent airway ❖​ Monitor respiratory status ❖​ High fowler’s positon ❖​ Mechanical ventilation support of tracheostomy collar if indicated ❖​ Maintain surgical drains in neck if present ❖​ Observe for hemorrhage and elma in the neck ❖​ Vital signs - Decreased BP occurs with blood loss; increased HR may be ❖​ due to hypovolemia and pain. ❖​ Oxygenation status -Edema and increased secretion may cause shortness of breath and decreased oxygen ❖​ Patency of tracheostomy - Bleeding/edema may occur impairing patency. ❖​ Wright, nutritional innate, calorie count - Swallowing impairments impact adequate nutrition intake. ❖​ Institute aspiration precautions -At risk for aspiration due to removal of upper airway structures. ❖​ Provide means of communication ❖​ Nutritional consultation ❖​ Monitor IV fluids or parental nutrition until enteral nutrition can be admin. ❖​ Increase activity as tolerated ❖​ Reinforce method of communication ❖​ Consult speech and language pathologist ❖​ Provide stoma and laryngectomy care ​ Mechanical ventilation ❖​ Helps a patient when they cannot breathe on their own. ❖​ Airway access is provided by orotracheal intubation or tracheostomy tube. ​ Nursing Interventions ❖​ Protect airway/ visual assessment of ET tube ❖​ Assess vital signs, lung sound, respiratory status, and breathing pattern ❖​ Monitor chest for bilateral expansion ❖​ Obtain pulse ox and ABG results ❖​ Assess the need to suction ❖​ Investigate ventilator alarms (If not determined ventilate the client manually with resuscitation bag until corrected) ❖​ Provide humidification ❖​ Bedside: Ambu bag, two diff trach size, resuscitation bag, obturator Suctioning ​ Before suctioning hyperoxygenation ​ Suction for 10-15 seconds (total of 3 times) ​ Allow the patient 60 seconds of rest and oxygen between each pass ​ Perfromed when adventitious breath sounds are detected ​ When secretions are obviously present ​ All equipment must be sterile  ​ In line suction catheter use ​ Assess lung sounds and oxygen levels ​ Open suction kit, fill basin with water ​ Manual resuscitation bag (Ambu bag,two diff size trach (b/c hole can get small, so one smaller than the other) Interventions for ostomy care A colostomy is a surgically created opening on the abdomen in which the large intestine is connected for the elimination of fecal matter into an appliance specifically designed for this purpose. If the entire colon is removed, the opening is connected to the ileum of the small intestine and is called an ileostomy. If the patient has an ostomy (colostomy or ileostomy), the color and integrity need to be assessed frequently. The stoma should be reddish pink and moist. There is usually some edema initially, which subsides with time. Common locations of stomas according to ostomy location are demonstrated in Figure 58.8. The appliance is secured in place to minimize skin exposure to the stool. Slight bleeding from the stoma is not initially unusual. If the stoma begins to show signs of ischemia (dark red, purplish, or black color) or unusual bleeding, the provider should be notified immediately. The skin around the ostomy site should be inspected frequently and assessed for leakage. Leakage around the appliance into the surgical incision is a risk for infection. The ostomy will begin to function within 2 to 4 days postoperatively. It is important to note any gas being expelled from the appliance, as well as stool. The appliance needs to be emptied when there is gas or if it is one-third to one-half full of stool to decrease the risk of the appliance detaching from the skin. Stool appearance is initially liquid. The final consistency of the stool is dependent on the location of the ostomy (Fig. 58.9). The closer the ostomy is to the small intestine, the more liquid the stool. The patient with an ileostomy needs to be monitored more closely for fluid and electrolyte balance depending on the amount of drainage noted. The ostomy is described according to location and can be placed in any section of the colon or at the ileum. Stool consistency is generally described as follows: Ileostomy—liquid to semiliquid Ascending colostomy—semiliquid Transverse colostomy—semiliquid to semiformed Descending colostomy—semiformed Sigmoid colostomy—formed Self-care of the ostomy by the patient is far more successful if initial teaching is implemented before the surgery, if possible. Occasionally, a patient undergoes surgery under emergent conditions, and therefore, preoperative teaching is not possible. If the surgery is planned, the patient should have a consultation with the wound, ostomy, and continence nurse (WOCN) before surgery, who will discuss fears and concerns associated with having an ostomy. The WOCN provides educational materials that patients can review before having surgery and answer any questions. The WOCN marks the abdomen for the best possible placement of the ostomy based on the contour of the abdomen in lying, sitting, and standing positions. The WOCN also assesses the presence of any skinfolds, creases, bony prominences, and scars, as this allows for optimal placement and best fitting of an appliance after surgery. Chest Tube Monitor the amount and color of chest tube drainage. -Excessive bloody drainage may indicate a bleed within the chest. Cloudy drainage may indicate infection. Monitor the water-seal chamber. Persistent bubbling in the water-seal chamber indicates an air leak in the chest tube system. Types of surgeries for lung cancer: lobectomy to remove cancer cells localized in one lobe, a wedge resection for cancer localized in one small area of the lung, and a pneumonectomy for cancer cells spread diffusely in the lung. Position—semi-Fowler’s The semi-Fowler’s position increases oxygenation by allowing full lung expansion. Postoperative Maintain a closed chest tube system. A closed system prevents any inadvertent air leaks. NEVER CLAMP THE CHEST TUBE! Clamping the chest tube may result in increased air or fluid in the pleural space, worsening the pneumothorax, and may lead to a tension pneumothorax. Chest tube placement is indicated if a pneumo- or hemothorax occurs as the result of chest trauma. In the case of a pneumothorax, because air rises, the chest tube is placed high, usually in the second intercostal space at the midclavicular line. For a hemothorax, due to the effects of gravity, the chest tube is placed lower, between the ribs at the fifth or sixth intercostal space at the midaxillary line, to drain blood and fluid from the pleural space. Chest tube placement allows for the expulsion of air and/or fluid while allowing the lung to reexpand. The chest tube is connected to a chest-drainage system. Essential components of the chest-drainage system include a collection chamber, water seal, and suction. The collection chamber allows for the accumulation of blood and fluid. The water seal acts like a one-way valve, allowing for the removal of the air/blood over time without the introduction of air back into the pleural space. Initially, suction is applied to assist in the reexpansion of the lung. The suction is discontinued as the lung reexpands. Amount and color of drainage Drainage should be measured, marked on the chest tube collection device, and documented as determined by unit protocol. Red, free-flowing drainage in excess of 70 mL per hour (or the amount indicated by the provider) indicates hemorrhage; cloudiness may indicate an infection. The nurse should be mindful of trends of chest tube drainage. Sudden increases or decreases in chest tube drainage requires notification of the provider and potential immediate intervention. Water-seal chamber Initially, there is bubbling on expiration, indicating air removal from the pleural space. Later, after the air has escaped from the pleural space, the water level fluctuates with respiratory effort. When the pleural-wall disruption is healed, the water fluctuation may no longer be present. At that point, the patient should be evaluated for chest-tube removal. Continuous bubbling in the water-seal chamber is an indication of an air leak. Subcutaneous emphysema Subcutaneous emphysema produces a crackling feeling under the skin on palpation. It is not painful to the patient but may become uncomfortable if excessive. It is indicative of air from a chest injury escaping into the subcutaneous space, indicating potential chest trauma. Subcutaneous emphysema may also be a clinical indication that a chest tube is not positioned appropriately or has migrated. Subcutaneous emphysema of the head and neck could be life-threatening because the airway could be compromised. Maintain a closed system. Tape all connections and secure the chest tube to the chest wall. -These measures are important to prevent inadvertent tube removal or disruption of the system’s integrity. Keep the collection apparatus below the level of the chest; keep tubing free from kinks or loops. Pleural fluid drains into the collection apparatus by gravity flow as well as low-level suction. Kinks or loops can interfere with drainage. NEVER CLAMP THE CHEST TUBE! Clamping the chest tube may result in increased air or fluid collection in the pleural space, worsening the pneumo- or hemothorax, and may result in a tension pneumothorax. When the chest tube is removed, immediately apply a sterile occlusive petroleum jelly dressing. An occlusive dressing prevents air from reentering the pleural space through the chest wound. Need bedside: Oxygen, sterile water, enclosed hemostat clamps, Occlusive dressing, suction source Report bright red blood collection chamber greater then two hours. Sudden ceasing of drainage, and disconnection of chest tube Tidaling good, continuous bubbles bad, add water to suction chamber as it evaporates, place chest tube in a bottle of sterile water if cracked to disconnect, Tell patient to take deep breaths during removal Flail Chest ❖​ Flail chest (blunt chest trauma associated with accidents) - Loose segment of the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall. WHEN YOU BREATH IN THE CHEST CAVES IN WHEN YOU BREATH OUT THE CHEST GOES OUT. ➔​ SIGNS/SYMPTOMS: Tachypnea/shortness of breath, impaired gas exchange, paradoxical respirations, severe chest pain, diminished breath sounds, hypotension/tachycardia ➔​ DIAGNOSED - Chest x-ray (elevates skeletal features of the chest and integrity of lungs), chest CT, laboratory studies: ABGs, Serum lactate, CBC, Ultrasound (FAST)(Used for quick assessments to rule out cardiac tamponade (blood in pericardium) in emergency situations.) ➔​ INTERVENTIONS: Maintain airway (prepare for intubation and mechanical ventilation), maintain breathing (Fowler’s position, oxygen, and bedrest to reduce oxygen demand), circulation (IV fluids/blood component administration as indicated), pain control ➔​ SURGICAL MANAGEMENT (indicated for unstable chest wall) - Operative stabilization, thoracotomy (damaged organs or major vessels), thrombectomy ➔​ COMPLICATIONS: Tension pneumothorax/Cardiac tamponade (Beck’s triad: Muffled, distant heart sounds, hypotension, neck vein distension) (emergent pericardiocentesis) ➔​ PATIENT EDUCATION: Use of pain medication (does not reduce respiratory effort), cough and deep breath, encourage early ambulation, incentive spirometer, splint while coughing, motor vehicle safety. Dysrhythmias  ​ Asystole- CPR,Epi, Assess two leads ​ A-Fib- Blood thinner ​ V-Fib- Shock, D-fib ​ A-Flutter- Blood thinner ​ V-Tach- Shock ​ SVT- Adenosine (fast push short half life. Temporary stop heart) ​ Torsades de Pointes- Give Mag Prioritization /delegation -​ Always remember ABC -​ The AP/UAP(assistive personnel) can’t TEACH!! Infective endocarditis ​ Inflammation of the inner lining of the heart and valves ​ Risk factors: Immunodeficiency, IV drug abusers, Valve replacement/repair with prosthetic materials, Surgery/invasive procedures ​ The exact prevalence of infective endocarditis (IE) is unknown; however, it is estimated that approximately 47,000 cases occur each year, and the number of cases has steadily risen since 2000. Most cases of IE involve native valves, affecting mostly the mitral or aortic valve, but the disorder can affect any valve. Of all the heart valves, the pulmonic valve is the least affected. Infective endocarditis can be classified as right or left endocarditis, referring to the affected valve. Individuals who abuse IV drugs tend to have right-sided or tricuspid valve infections. Individuals who abuse non-IV drugs tend to have left-sided or mitral valve endocarditis. It can also be classified as native valve versus prosthetic valve endocarditis. –S/S ​ Signs of infection -Fever -Anorexia/weight loss -Fatigue -Change in behavior ​ Oslers nodes ​ Janeway lesions ​ Splinter hemorrhage ​ Murmur ​ Clinical manifestations of IE include red, painful nodes in the pads of the fingers and toes—Osler’s nodes—and red, painless spots on the palms and soles, called Janeway lesions. Splinter hemorrhages, tiny blood clots that run vertically under nails, may also be present. Most patients have a heart murmur and can experience heart failure (HF), arrhythmias, weight loss, or night sweats. A murmur is the sound heard when there is turbulent blood flow across a heart valve. Other symptoms are similar to those of any infectious process, which include: ​ Fever  ​ Fatigue ​ Confusion (in older adults) –Diagnosis Medical Management ​ Labs -Blood cultures (two sets from different sites) -WBC Count ​ Transesophageal echocardiogram (TEE) ​ IV antibiotic therapy -Standard duration is 4-6 weeks -Client discharged on IV therapy ​ Surgical management -Valve repair or replacement ​ Tests used to confirm the diagnosis of IE are blood cultures, two sets from different sites, and transthoracic echocardiogram (TTE) or transesophageal echocardiogram (TEE) (NPO). Echocardiography can identify valve dysfunction, vegetative growth, abscesses, and changes in heart size and pumping ability that can occur with IE. An elevated white blood cell count may also be indicative of infection. ​ Medication management consists primarily of IV antibiotic therapy. The increasing trend of microbial resistance has led to the use of combination therapy. The standard duration of treatment is 4 to 6 weeks but may be longer for prosthetic valves. Patients are often discharged to home on IV antimicrobial therapy. Shorter duration is recommended for some combination therapies. Oral antimicrobial agents might be used as a preventive measure in patients who are at increased risk for IE, but these are rarely used as initial treatment. Repeated blood cultures may be obtained until results are negative, indicative of adequate bactericidal effects. ​ The choice of antimicrobial agents is complex and based on the organism cultured and the sensitivity report, right-sided versus left-sided IE, native versus prosthetic valve involvement, patient comorbidity, and other factors. Infectious disease specialists are often consulted. Penicillin G, ceftriaxone, vancomycin, nafcillin, and gentamicin may be considered in various combinations for the treatment of IE. Supportive treatment for the common complications of IE, especially HF, is also indicated to optimize cardiac output and tissue perfusion. ​ The surgical treatment options for IE include valve repair or replacement. Surgery can remove infected tissue and reduce mortality and complications, but it also has significant risks. The timing of surgery is controversial, with a lack of definitive evidence to support practice. Early surgery is recommended for cases in which antimicrobial therapy has been ineffective in controlling the infection or when complications such as embolic events or heart failure are observed –Nursing Assessment ​ Auscultate breath and heart sounds -Crackles may be a sign of heart failure related to valve dysfunction. -A new or worsening murmur may occur due to valve damage. ​ Vital signs  -– Fever is indicative of ongoing acute infection. Hypotension, tachycardia, tachypnea, and low SpO2 can be signs of sepsis or heart failure. ​ Neurologic function -Neurological changes or deficits in pupils, grips, foot pushes, facial droop, and speech may be signs of CNS embolization. ​ Skin assessment -Cyanosis or pallor, delayed capillary refill, and decreased peripheral pulses may indicate peripheral embolization. Edema could be a sign of heart failure related to valve dysfunction. -Osler’s nodes, Janeway lesions, and splinter hemorrhages are indicative of IE. ​ Health history -History of drug use -Invasive procedures -Implanted devices or cardiac devices -Valve replacement surgery ​ Monitor for complications -Monitor diagnostic test results. Repeated culture reports are used to evaluate the effective treatment of IE. White blood cell (WBC) counts can indicate responsiveness to infection. Echocardiograms can evaluate the size of vegetation and valve function and can be used to predict the risk of complications. –Complications ​ Embolic events ​ Transient ischemic attack or stroke ​ Pulmonary emboli ​ Heart failure ​ Dysrhythmia ​ Embolic events are the major complication of IE and occur in 22% to 50% of cases. Embolization occurs when fragments of vegetation break free from the valve and travel to other parts of the body through the bloodstream. Embolic events are often a complication of left-sided IE and are rarely seen in right-sided IE. The emboli can travel randomly to any organ or tissue, resulting in obstructed blood flow and potential spreading of infection. Emboli from left-sided IE typically travel to the central nervous system (65%) but can also affect the kidneys, spleen, bowel, and extremities. Emboli traveling to the central nervous system (CNS) cause transient ischemic attacks or strokes. Right-sided IE is associated with pulmonary emboli. ​ Heart failure and dysrhythmias can also occur due to valvular dysfunction and abscesses in the conduction system. Strokes, heart failure, and dysrhythmias can be a part of the presenting symptoms of IE because they compel patients to seek treatment.  ​ Mitral valve vegetation in infective endocarditis –Nursing Diagnosis ​ Infection r/t an invading organism secondary to IE ​ Oneffective tissue perfusion r/t emboli ​ Decreased cardiac output r/t valve dysfunction, altered rhythm, and/or altered stroke volume –Nursing Interventions and Patient Education ​ Nursing interventions -Admin antibiotics as prescribed -Encourage activity and antieembolism stockings as prescribed ​ Patient Education -Importance of oral hygiene at least twice a day -Importance of skin laceration care to prevent infection -Use of prophylactic antibiotics prior to invasive procedures (1.e dental procedures) -Need for complete IV antibiotic admin via PICC line at home (maintain aseptic technique) -Report to the HCP signs of infection, heart failure, or embolism ​ Administer antibiotics as prescribed – Treatment for IE is long-term IV antibiotic treatment. ​ Maintain IV access for antibiotic administrations – Intravenous access is essential for antibiotic administration. Long-term venous access, such as a peripherally inserted central catheter (PICC), may be considered. ​ Administer heart failure medications as needed – Heart failure treatment optimizes cardiac output and tissue perfusion. ​ Provide social support during prolonged hospitalization – Social isolation due to hospitalization may contribute to depression, anxiety, and anger. ​ Refer patient to addiction counseling services if drug use has caused the disease – Stopping recreational IV drug use may help limit the recurrence of IE and lead to a better quality of life. ​ Good oral hygiene utilizing a soft toothbrush – Bleeding gums provide a portal of entry for bacteria into the bloodstream. Poor dental hygiene may increase the recurrence of IE.  ​ Inform the healthcare provider about IE history prior to any dental or invasive procedure – Prophylactic antibiotics may be prescribed to decrease the risk of IE. ​ Completion of prolonged antibiotic regimen – Completing the full course of antibiotics is critical to eradicating the infection and preventing recurrence and complications. Pulmonary edema The chest x-ray reveals the increased alveolar fluid as bilateral infiltrates. Pulmonary edema (fluid in the lungs) causes shortness of breath and the inability to breathe while lying flat and can be life-threatening. You would see pulmonary edema in Myocardial infarction, Coronary Artery Disease, ARDS, Chest Trauma, Heart valve problems. Symptoms would be SOB, wheezing, chest pain/tightness, fatigue, and swelling in the legs. Mitral valve stenosis A click is high-pitched sound heard early in diastole and is typically caused by mitral valve stenosis. Stenosis is stiffening and thickening of the valve leaflets, caused by calcium deposits or scarring , narrow the opening and obstruct flow. ST-segment elevation STEMI- Total occlusion of coronary artery- requires emergency intervention! Positive cardiac enzymes (Elevation= Acute injury). Emergency PCI and Thrombolytics would be needed. Angina ​ Agina is chest pain resulting from Myocardial ischemia ​ Temporary imbalance between the coronary artery's ability to supply oxygen and cardiac muscles' demand for oxygen ​ Ischemia limited in duration (does not cause permanent damage to myocardial tissue) ​ The goal of treatment for angina is to provide relief from the acute attack, restore myocardial oxygen demand, and to prevent complications such as a heart attack –Types of Angina- Stable Angina ​ Stable angina (Predictable) ​ Usually will subside with rest and/ or Nitroglycerin (up to 3 tabs SL q 5 min) -If unrelieved after Nitroglycerin call 911 (home)/MD (healthcare setting) -Make sure the patient is sitting when taking medication –Unstable Angina ​ Unstable angina (unpredictable) -characterized by increasing frequency and severity, not relieved by rest and NTG -Required medical intervention ​ New-onset angina -Pts that experience angina for the first time after exertion/increases demands on heart ​ Variant (Prinzmetals) angina -CP (chest pain) d/t coronary artery spasm -Typically occurs at rest -More common in men than women -Smoking is the number 1 risk factor ​ Pre-infarction angina -CP that occurs days to weeks BEFORE an MI –S/S  ​ Chest tightness pressure ​ Chest pain- retrosternal pain -May radiate to neck, jaw, shoulders ​ Indigestion ​ Dizziness ​ Pallor ​ Diaphoresis ​ N/V ​ Based upon the clinical manifestations, what priority nursing assessments will be performed for a client with unstable angina? ​ ►12 lead ECG ​ ►Continuous cardiac monitoring ​ ►Assessment of cardiac status ​ ►Assessment of pain –Nursing Intervention ​ Goal: Decrease myocardial oxygen demand and increase oxygen supply ​ Medications -Nirto (short and long-acting) -Beta-blockers (-LOL) Metoprolol (lopressor), Atenolol (Tenormin), Carvedilol (Coreg), Satalol (Betapoce) -CCB (Diltiazem (Cardizem) -Aspirin -Anticoagulants Enoxaparin (Lovenox), heparin, bivalirudin (Angiomax), ticagrelor (Brilinta) ​ Oxygen ​ Bedrest ​ Establish IV access ​ Reduce and control risk factors –NITRO SL admin Patient Education ​ When you begin to feel chest pain, sit down, place SL tablet in your mouth, under your tongue (Do not chew crush, or swallow) ​ If pain is unrelieved with the first tablet, take another tablet 5 minutes later ​ If pain is unrelieved with the second tablet, take another tablet 5 minutes later ​ If pain is unrelieved with the third tablet call 911 immediately, do not drive to the hospital ​ Common side effects include headache, dizziness, and drop in BP (hence sitting position) DASH diet A Dietary Approaches to Stop Hypertension (DASH) diet high in fruits, vegetables, and low-fat dairy products has been shown to lower elevated pressures ARDS  ❖​ Occurs as a complication of some other condition. ❖​ Interstitial edema causes compression and obliteration of the terminal airways. ❖​ RISK FACTORS: Sepsis (most common cause), severe trauma, aspiration, cardiopulmonary bypass, pneumonectomy, pulmonary embolism, and drug/alcohol overdose, massive transfusion, cigar smoking, PE, Covid ❖​ Direct injury: Damage or disruption of the respiratory system. Indirect injury: Occurs outside the respiratory system but has deleterious effects on the lungs. ❖​ SIGNS/SYMPTOM: Dyspnea/tachypnea, restlessness, overwhelming hypoxemia (despite high concentration of delivered oxygen), tachycardia, decreased mentation, and deteriorating ABG levels (Resp Alkalosis). NONCARDIOGENIC PULMONARY EDEMA. ❖​ Diagnosis: Chest x-ray (identify infiltrates:ground glass appearance, snow screen effect, and whiteout effect), Lab testing (ABG level, CBC, sputum, blood, & urine cultures), CO increase attempt to increase blood flow through lungs ❖​ Nursing interventions (Treat cause) - Oxygenation and ventilation,start with supplemental oxygen, intubation andmechanical ventilation if progresses- Positive end-expiratory pressure (opens collapsed alveoli, but High levels of PEEP can compromise venous return), clearance of secretions, ECMO, medication administration, patient position (proning/best tolerated), infection protection/prevention ❖​ Medications: antibiotics, neuromuscular blockade, hydration, and nutrition ❖​ Complications: Barotrauma (Stiffening of the lungs and a loss of compliance), renal failure, multisystem organ dysfunction syndrome, and ventilator associated pneumonia (fever, leukocytosis, increased respiratory, and purulent secretions)(preventative care: suctioning and regular mouth care. ❖​ Nursing interventions: Teach disease process/encourage family visitation Mitral Valve replacement –Surgical Management ​ Valve replacement ​ Valve repair ​ Surgical intervention to repair or replace diseased valves is often indicated and is based on the degree of valve dysfunction, symptom severity, and surgical risk. For patients needing valve replacement, open-heart surgery with a mechanical or bioprosthetic valve remains the standard approach. In these surgeries, patients undergo general anesthesia and are placed on cardiopulmonary bypass, and the diseased valves are replaced through a sternal incision or multiple smaller chest incisions. For patients with comorbidities, this comes with an increased risk of operative mortality; thus, fewer of these patients undergo surgical intervention. A more recent treatment option for aortic valve replacement is prosthetic valves that allow a transcatheter approach to valve replacement. In this procedure, called a transcatheter aortic valve replacement (TAVR),  a new valve is deployed through a catheter that is peripherally inserted and guided to the heart. The TAVR procedure is recommended particularly for intermediate- and high-operative-risk patients with aortic stenosis. Transcatheter mitral valve replacement is an emerging technology that is being studied and may be considered for patients who have severe regurgitation and symptoms with high surgical risk. ​ Overall, there is growing evidence that when possible, valvular repair yields better outcomes than replacement. Reparative surgery includes balloon valvuloplasty, commissurotomy, and mitral valve annuloplasty. Balloon valvuloplasty is a transcatheter procedure to repair stenosed valves. It involves inserting a balloon catheter through an appropriate vessel and advancing it to the heart. The balloon is inflated in the affected valve to enlarge the opening. Commissurotomy is a surgical procedure done to incise fused leaflets, widening the valve opening. Valve annuloplasty is a reconstructive procedure to repair the ring (annulus) that attaches and supports the valve leaflets. For patients with severe mitral valve regurgitation, a new procedure that partially clips the bulging leaflets together to reduce regurgitation and improve symptoms is being evaluated. –Valvuloplasty ​ Repair rather than replacement ​ Functions longer than prosthetic valves ​ Does not require lifelong anticoagulation ​ Types: -Commissurotomy -Balloon valvuloplasty -Annuloplasty -Leaflet repair -Chordoplasty –Valve Replacement ​ Used when valvuloplasty is not a viable option ​ Surgery is open versus closed or balloon ​ Types of valves -Mechanical valves -More durable -Less prone to infection versus tissue -Risk of thromboembolism -Bioprosthetic valves -Less durable (requires more frequent replacement) -Less likely to clot than mechanical valves –Patient Education Valve replacement surgery ​ Anticoagulant education including diet change and safety implications related to the risk of bleeding for mechanical replacement -Warfarin prescribed ​ Antibiotic prophylaxis prior to certain procedures to prevent infectious valvular disease -i.e dental procedures  ​ Avoid heavy lifting ​ Obtain and wear a medical alert bracelet ​ Medication teaching – Understanding and adhering to the medication treatment plan are essential for effective medication treatment. ​ Consider prophylactic antimicrobials for dental procedures only for patients at high risk – Prevent (re)occurrence of infectious valvular disease ​ Strict adherence to anticoagulation regimen if prosthetic valve – Prevent thrombotic/embolic events (i.e., stroke) ​ Anticoagulation precautions: avoid activities/sports that have a high risk for injury, report any injuries or falls to your provider, report anticoagulant use prior to any procedure, take care with shaving (electric razor preferred), take care with flossing to avoid bleeding, and limit alcohol consumption – Avoid activities/actions that increase bleeding risk. ​ Maintain consistent intake of green leafy vegetables if taking warfarin – Green leafy vegetables impair the effectiveness of the anticoagulant warfarin. Pericarditis ​ Acute or chronic inflammation of the pericardium -Pain management ​ ​ Pericarditis, inflammation of the pericardium, is diagnosed in about 5% of emergency room patients with chest pain not related to ischemia. About 80% of cases are idiopathic (unknown etiology) or are presumed to occur after a viral infection. Acute pericarditis is common following MI, occurring in about 15% to 20% of post-MI patients. The true prevalence of pericarditis is difficult to determine because persons with mild cases (subclinical) do not seek treatment. Some studies show that pericarditis occurs more in men and young and middle-aged persons. Recurrence is common, with 20% to 30% of persons having an additional episode. Pericarditis can be categorized as infectious (viral, bacterial, fungal, or parasitic), noninfectious (auto-immune, neoplastic, metabolic, trauma, and drug-related), and idiopathic. Pericarditis can also be described as acute, chronic, or recurrent. The prognosis is generally good, with an in-hospital mortality rate of 1.1%. –S/S ​ Signs of infection -Fever and chills  -Malaise -Elevated WBC ​ Pleuritic chest pain -Exacerbated by breathing, coughing, swallowing, and supine position -Relived by leaning forward ​ ECG changes ​ Auscultation of friction rub ​ The most common clinical manifestation of pericarditis is pleuritic chest pain. This occurs in 85% to 90% of cases and can be differentiated from MI chest pain because it tends to be relieved by sitting up and leaning forward. Friction rubs, and scratchy sounds that occur with each heartbeat may be auscultated in 30% of cases. Box 30.1 describes how to assess for a friction rub. Other clinical manifestations include: ​ New or worsening pericardial effusion (60%) ​ ECG changes: diffuse ST-segment elevations or PR depression (60%) ​ Fever –Nursing Assessment ​ Vital signs -Hypotension, tachycardia, tachypnea, and pulsus paradoxus are indicative of cardiac tamponade, which is due to an excessive or sudden buildup of pericardial effusion. Fever is indicative of an ongoing infection. ​ Pain -Chest pain that is relieved by sitting up and leaning forward distinguishes pericarditis pain from the pain associated with MI. ​ Auscultate heart sounds -A friction rub is a common finding in pericarditis. Muffled heart tones may indicate pericardial effusion or cardiac tamponade. ​ ECG -ST elevation or PR depression in all or most leads can be associated with pericarditis. –Diagnosis ​ ECG ​ Chect x-ray ​ Echocardiogram ​ Cardiac CT scan ​ MRI ​ Tests used to diagnose pericarditis include ECG, chest x-ray, echocardiogram (transthoracic or transesophageal), cardiac CT scan, and MRI. The hallmark ECG changes include widespread ST-segment elevation or PR-segment depression. ​ The finding of cardiomegaly and clear lung fields on chest x-ray may indicate a pericardial effusion (fluid buildup in the pericardial sac) and might be supportive of the pericarditis diagnosis. Pericardial effusion might also be evident on an echocardiogram, CT scan, or MRI. ​ Laboratory tests include serial cardiac biomarkers to rule out MI. Positive blood cultures, a complete blood count with a high WBC count, and positive inflammatory markers such  as C-reactive protein or sedimentation rates may indicate the presence of infection or inflammation, leading to the diagnosis of pericarditis when combined with the associated clinical manifestations. –Nursing Interventions ​ Keep the head of the bed elevated -High fowlers and leaning forward for pain relief ​ Admin meds as ordered -Meds to decrease inflammation (NSAID, ASA, Corticosteroids -Pain medication -Antibiotic for infection Oxygen ​ Monitor complications -Pericardial effusions -Cardiac tamponade (Prepare the client for pericardiocentesis) ​ Keep the head of the bed elevated – Pericardial effusion exerts pressure on surrounding organs, resulting in orthopnea (shortness of breath when lying down) and dyspnea. Raising the head of the bed relieves shortness of breath. Pain is also relieved by sitting in an upright position. ​ Administer NSAIDs or ASA and colchicine medications as prescribed – Pain relating to pericarditis is associated with inflammation, so control is largely managed with anti-inflammatories. Steroids are added if necessary. ​ Provide emotional support – Anxiety can occur because of the fear that the pain is from a heart attack. –Critical Thinking The nurse is caring for a client with pericarditis. Which symptoms, if observed by the client would indicate that cardiac tamponade may be developing? ►Beck’s triad ►Hypotension ►Muffled heart sounds ►JVD ​ A complication of pericarditis is pericardial effusion. This is an accumulation of fluid in the pericardial space exceeding the typical 20 to 60 mL. Pericardial effusion is diagnosed by the use of chest X-rays, echocardiography, and ECG. Depending on the volume and clinical presentation, draining of the excess fluid, also known as pericardiocentesis, may be indicated. In a pericardiocentesis procedure, ultrasound guides needle insertion through the chest wall to aspirate the excess fluid. ​ Depending on the etiology, pericardial fluid may accumulate slowly (i.e., neoplastic), allowing the pericardium to stretch to accommodate the increased volume. Clinical symptoms in these cases gradually progress. In contrast, rapidly growing effusions overwhelm the stretching capacity of the pericardium, resulting in acute decompensation. If not treated emergently, the increased volume of fluid within the pericardial space can exert pressure on the heart, resulting in cardiac tamponade. In cardiac tamponade, the excessive fluid in the pericardial sac compresses the cardiac structures and dramatically decreases cardiac output. Common signs of pericardial tamponade include dyspnea, tachycardia, pulsus paradoxus, JVD, an enlarged heart,  and muffled heart tones. Pulsus paradoxus is an abnormal drop in systolic blood pressure during inspiration. Beck’s triad is the classic finding of hypotension, muffled heart sounds, and JVD but is only present in 10% to 40% of cases of tamponade. Emergent pericardiocentesis is indicated in this clinical presentation. Surgical management of pericardial effusions and cardiac tamponade may include a pericardial window, in which a window or fistula is created to drain excess fluid from the pericardial space. Cardiac biomarkers Cardiac biomarkers: troponin- ​ Troponin levels (a protein released into the bloodstream when there is cardiac muscle damage) rise when the heart sustains an acute injury. Troponin can help differentiate between angina and MI pain. ​ Specific cardiac biomarkers are used to rule out MI. Troponin (a protein released into the bloodstream when there is cardiac muscle damage) levels rise when myocardial injury occurs. It is the most accurate and commonly used biomarker to identify when ischemia has led to tissue damage. This biomarker begins to rise two-three hours after damage occurs and continues to rise over the next 12-48 hours. It is measured every 6 hours after admission to the hospital to evaluate evolving ischemia. This is known as serial cardiac biomarker testing. Laboratory tests diagnostic for CAD ​ -Troponin ​ -Creatine kinase (CK) ​ -CK-MB ​ -Myoglobin Chest trauma ​ Introduction ❖​ BLUNT CHEST TRAUMA (object hits chest or chest hits object) - Declaration injury: body movement suddenly stops but internal organs remain in motion and collide with the chest wall. Acceleration injury: Body so abruptly set in motion (rear-end collisions) or body is hit by a rapidly moving object. ❖​ PENETRATING TRAUMA (sharp objects enter chest) - Gunshot wound into the lateral right chest is superficial. Gunshot in the middle of the left chest is life threatening. ​ Assess for signs of respiratory distress ❖​ Dyspnea ❖​ Decreased chest expansion ❖​ Tracheal deviation ❖​ Decreased breath sounds ❖​ Decreased O2 saturation ❖​ Cyanosis ​ Assess for signs of cardiovascular compromise  ❖​ Rappid, thready pulse ❖​ Decreased BP Distended neck veins ❖​ Muffled heart sounds ❖​ Chest pain ​ Initial Interventions ❖​ Ensure patent airway ❖​ Admin O2 (>90%) ❖​ Establish IV access with two large-bore catheters. Begin fluid resuscitation as needed. ❖​ Remove clothing (assess injury) ❖​ Cover sucking chest wound with nonporous dressing taped on 3 sides. ❖​ Stabilize impaled objects ❖​ Assess for other significant injuries ❖​ Stabilize flail rib segment ❖​ Place in semi-Fowler's position or to comfort ❖​ Prepare for emergency needle decompression or chest tube placement as indicated. ❖​ Need for potential intubation ❖​ Ongoing monitoring ➔​ Vital signs ➔​ Level of consciousness ➔​ O2 Sat ➔​ Cardiac rhythm ➔​ Respiratory status ➔​ Urinary output ➔​ Need for potential intubation ​ Types of chest trauma: ❖​ Rib fractures (direct blunt chest trauma) - Noted on chest x-ray ➔​ SIGNS/SYMPTOMS: Pain/tenderness (increases with inspiration) at site of injury, shallow respirations, splints chest, ecchymosis, chest wall deformity, crepitus. ➔​ INTERVENTIONS: NO STRAPPING OR BINDING CHEST, Fowler’s position, breathing exercises, splinting, pain control (ribs reunite spontaneously) ➔​ PATIENT EDUCATION: Pain medication use, Importance of cough/deep breathing, ambulation, splinting when coughing, motor vehicle safety. ❖​ Pneumothorax (Atmospheric air enters pleural cavity) - Positive pressure in cavity causing the lung to collapse. ➔​ Spontaneous (pneumonia) ➔​ Traumatic blunt (closed) - Rib fracture that lacerate the lung ➔​ Traumatic penetrating (open) - Stab or gunshot wound ➔​ Tension pneumothorax - Buildup of positive pressure in the pleural space. Mediastinum shifts towards the unaffected side,  compromising the ‘good’ lung, further compromising oxygenation. Occurs with mechanical ventilation and resuscitative efforts. Also occurs if chest tubes are clamped or become blocked in a patient with a pneumothorax. ➔​ SIGNS/SYMPTOMS: Absent breath sounds on the affected side, decreased chest expansion, dyspnea/tachypnea, sharp chest pain, SQ emphysema (damaged air sacs), sucking sound with open chest wound, mediastinal shift with tension pneumothorax. ➔​ INTERVENTIONS: Place in Fowler’s position, admin oxygen as needed, prepare for chest tube placement (remains in place till chest expands fully), maintain hemodynamic stability, open pneumothorax emergency management (apply non porous) dressing over an open chest wound)- stopping the flow of air is a life saving measures, tension pneumothorax emergency management (prepare for urgent needle decompression for tension pneumothorax then chest tube placement)- reduce pressure in the lungs is a life saving measure Drug CalculationX -​ Previous dosage exam is what is going to be on this exam!!! Spirometry ​ The incentive spirometer (Fig. 7.12) is a handheld respiratory device designed to assist the patient in deep-breathing exercises and encourage the patient to breathe slowly and deeply to allow lung expansion and to prevent or reverse atelectasis. When taking a slow, deep breath in and holding it, the alveoli expand, reducing the risk for collapse and assisting with oxygenation ​ The incentive spirometer is ordered by the healthcare provider for patients who have had a surgical procedure and patients diagnosed with chronic breathing problems or pulmonary issues. Patients ordered bedrest or patients with an extended hospital stay associated with decreased or limited mobility may benefit from the use of an incentive spirometer to reduce the possibility of developing atelectasis, which increases the risk for pneumonia. ​ Encourage the patient to use this device 5 to 10 times per hour while awake. Set the incentive spirometer goals on the basis of the patient’s individual performance. For surgical patients, teaching and setting of incentive spirometer goals are best if completed preoperatively because postoperative pain or sedation may impair respiratory effort. Repeated use of the incentive spirometer can improve lung expansion and assist in removing secretions from the airways ​ Explain the correct use and indication for incentive spirometry. ​ Assist the patient to a sitting position (semi-Fowler’s) if no contraindications are noted. (This allows for optimal lung expansion during this breathing exercise.) ​ Instruct the patient to exhale completely.  ​ Instruct the patient to place the mouthpiece in the mouth and place the lips tightly around the mouthpiece. (This allows for a good seal around the mouthpiece.) ​ Instruct the patient to take in a slow, smooth, deep breath, like inhaling through a straw. When the patient has reached maximal inspiration and cannot inhale any more, instruct the patient to hold their breath for approximately 3 seconds. Then have the patient exhale smoothly and slowly. (This allows for good expansion of the alveoli to prevent or treat atelectasis.) ​ Encourage the patient to use the device 5–10 times per hour while awake or as directed by the healthcare provider. ​ Have the patient rest a few seconds between exercises and cough after each session. (This repeated exercise improves lung expansion and promotes airway clearance of the secretions.) ​ Keep the incentive spirometer at the bedside within the patient’s reach. ​ Document exercises and effectiveness in the patient’s healthcare record. Urine output NO PEE PEE NO BP BP!!!!!!!!!! Oxygen demand ​ Hypoxia and increased oxygen demand due to tachycardia may lead to dysrhythmias. ​ Dysrhythmias may cause an imbalance in myocardial oxygen demand and supply, potentially resulting in chest pain. ​ Ischemia develops when there is an imbalance between supply and demand of oxygen-rich blood to the heart tissue, resulting in insufficient oxygen to meet the demands of the myocardial tissue. Infarction, or cell death, occurs when that imbalance is severe or prolonged, which causes irreversible damage. The primary patient complaint is chest pain, also called angina. Angina is classified into two categories, stable and unstable angina. ​ Physical activity increases the oxygen demand. Increased fatigue and dyspnea may be signs of worsening heart failure. Chest pain/Myocardial Infarction ​ An acute onset of myocardial ischemia that results in myocardial death if definitive interventions do not occur promptly ​ Dynamic process that does not occur instantly but evolves over several hours ​ Unstable angina can be grouped into here ​ Big difference is that STEMI means complete occlusion of a coronary artery vs. NSTEMI and unstable angina which is not complete occlusion. ​ Unstable angina will not have positive cardiac enzymes, NSTEMI and STEMI will ​ NSTEMI will have elevated cardiac biomarkers but no definite ECG evidence of acute MI = less damage to the myocardium. –Risk Factors ​ Atherosclerosis  ​ Coronary Artery Disease ​ Elevated cholesterol levels ​ Smoking ​ Type 2 diabetes ​ Obesity ​ Inactivity ​ HTN –Assessment on admission –Diagnosis ​ Elevated cardiac enzymes -Troponin -Creatine kinase (CK) -CK-MB -Myoglobin ​ ECG Changes -STEMI-ST segment elevation MI -Total occlusion of coronary artery-requires EMERGENCY INTERVENTION -NSTEMI-non-ST-elevation MI -Partially occluded vessel ​ Cardiac catheterization -Determines the extent and location of obstruction of the coronary arteries ​ Laboratory tests used to diagnose an MI include troponin, creatine kinase (CK), and CK-MB, and myoglobin. Creatine kinase is a general marker of cellular injury. It is released from cells in the brain, skeletal muscle, and cardiac tissue after muscle damage has occurred. ​ Diagnostic testing for MI can be performed through invasive and noninvasive tests. These tests include ECG, echocardiogram (echo), stress testing, and coronary angiography. An ECG has become the gold standard for diagnosis of MI. ​ STEMI -Traditional manifestation -↑ Cardiac enzymes -ST- segment changes -Elevation = acute injury -Emergent PCI  -Thrombolytic if Ø PCI -Totally occluded artery ​ NSTEMI -Common in women -↑ Cardiac enzymes -May have “normal” EKG -In RARE cases patients can have ST-segment inversion. This will be reversible with nitroglycerin -Stabilizes w/ medications -Elective PCI in the AM -Partially occluded artery —Nursing Assessment ​ V/S and Pulse ox - Tachycardia with a borderline low BP and decreased oxygen saturation is a sign of inadequate CO and oxygen delivery ​ Characteristics of pain -including location, radiation, duration, intensity, precipitating or alleviating factors; use a 1 to 10 pain scale — Chest pain is an indication of MI. Continued or changing pain characteristics can be indicative of a worsening condition. ​ ECG -ST-segment depression is indicative of ischemia. ST-segment elevation is indicative of injury. If present, a Q wave is diagnostic for MI. ​ Restlessness -Restlessness may be found in the early stages, but progression to severe anxiety and a sense of doom is a late-stage symptom. ​ Skin color and temp, peripheral pulses, diaphoresis -Decreased pulses and cold, clammy, pale skin are signs of inadequate tissue perfusion and inadequate CO. Activation of the sympathetic system with low CO will stimulate diaphoresis. ​ Urine output -Decreased or absent urine output is a sign of decreased renal perfusion related to decreased CO. ​ Labs -Assess troponin and CK, CK/MB levels — Troponin is a protein released from damaged cardiac muscle. It elevates within 4 hours and can stay elevated for days. CK/MB, the CK isoenzyme marker specific to cardiac tissue, is released from the cells with cardiac  muscle damage. Increased levels can be seen at 3 hours and remain elevated for as long as 36 hours. When admitting a patient with a non–ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a.Obtain the blood pressure. b.Attach the cardiac monitor.-Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible. c.Assess the peripheral pulses Auscultate lung sounds —Nursing Diagnosis ​ Decreased CO (cardiac output) r/t poor cardiac contractility secondary to MI ​ Pain r/t inadequate blood supply by the heart —Signs of decreased CO ​ Changes in behavior/ decreased LOC ​ Hypotension ​ Thready pulse ​ Hypoxia ​ Low urine output —Nursing Interventions ​ Admin Oxygen — Oxygen consumption and demand increases; therefore, oxygen supply should be increased. ​ Insert two large-bore IVs -IV access is essential for medication delivery and fluid resuscitation. ​ Admin meds as ordered -Aspirin and heparin: prevent new clot formation. -Nitroglycerin: dilates the coronary arteries, increasing blood flow and decreasing pain. -Morphine: a narcotic given for pain relief if nitroglycerin is not effective. -Beta-blockers: decrease the sympathetic response to an MI, decreasing cardiac workload and oxygen consumption. -Fibrinolytic: dissolves clots. ​ Continuous ECG monitoring: Electrocardiogram monitoring is essential to evaluate the evolution of the MI and the effectiveness of treatment and to monitor for dangerous dysrhythmias that can occur. ​ Bed rest: The patient may require bed rest as well as emotional rest to decrease oxygen and cardiac demands. —Chest Pain Protocol ​ Rapid assessment -Pain location/ type. Rating -12 Lead EKG done within 10 min  -Cardiac biomarkers (Troponin, Creatine Kinase (CK-MM. CK-MB. CK-BB), Myoglonin) ​ Bedrest ​ MONA -Morphine -Oxygen -Nitro -ASA 162-325 mg ​ Prepare for Percutaneous Coronary intervention (PCI) if indicated-Door to balloon within 90 min -Fibriniltyic therapy if no PCI available in 120 min -Should be initiated within 30 minutes of hospital arrival ​ MONA is not considered standard for all MIs anymore, but is an important acronym for nursing students to know. ​ Immediately upon arrival to the hospital, the patient should receive oxygen, sublingual (SL) nitroglycerin, aspirin, and then pain medication such as morphine sulfate if pain is not relieved by the SL nitroglycerin. Oxygen is recommended for all patients with a suspected MI and specifically for patients in respiratory distress if the arterial saturation is less than 90% or for patients with a high risk of hypoxia. Nitroglycerin dilates the coronary arteries, increasing blood flow to the heart in an attempt to limit myocardial muscle damage and control pain. One tablet may be given sublingually every 5 minutes for a maximum of three doses as long as the patient maintains an adequate BP. If pain is not controlled with three doses, IV nitroglycerin will be started. Aspirin is given to help prevent platelets from enlarging the existing clot or new clots from forming. Morphine sulfate can be given to control pain; however, in contrast to nitroglycerin, which relieves pain and dilates the coronaries, morphine can mask pain symptoms while not improving coronary blood flow, thus potentially worsening an MI. Research has found a higher risk of death in patients who received morphine thus as noted previously, it is recommended only when pain is not relieved by nitroglycerin. Additional medications include the initiation of beta-blocker therapy to decrease the sympathetic nervous system response, thus decreasing myocardial workload and myocardial oxygen consumption. Also, heparin sodium infusion (heparin) is started to help prevent new clot formation. ​ It has been demonstrated that patients who undergo emergency revascularization by PCI or fibrinolytic therapy within 6 hours have significantly higher survival. The overall mortality when revascularization occurs in less than 6 hours is 38%. When rapid revascularization is not attempted, mortality rates approach 70%. ​ Percutaneous coronary intervention is the most preferred method for opening blocked blood vessels that cause MI. During PCI, a catheter with a small balloon on its tip is inserted into an artery and advanced under fluoroscopy up to the left side of the heart and coronary arteries. The balloon is inflated and deflated to open the lumen of the blocked artery. It should be done within 90 minutes of arrival to the hospital: door to balloon—90 minutes. Once the lumen is open, a stent may be advanced to the location to hold the artery open and maintain adequate blood flow (Fig. 32.10). The radial or femoral artery is typically used for this procedure. Any catheter placement into a  blood vessel is associated with a risk of bleeding. If the femoral approach is used, the patient will need to lie flat without bending the leg for 2 to 6 hours to allow the artery to heal. In some cases, even with prolonged immobility, internal bleeding can occur and can be severe enough to require blood transfusions or surgery to repair the femoral artery. The radial artery has become the preferred site for catheterization because the risk for internal bleeding is eliminated and any external bleeding can be easily compressed. Once the catheter is removed from the radial artery, a compression device is placed around the wrist to apply pressure on the artery, and there is no requirement for the patient to remain immobile. ​ Fibrinolytics are medications that accomplish revascularization through fibrinolysis of the existing clot. They should be administered within 30 minutes of arrival to the hospital. Success of fibrinolytic therapy is defined as ECG demonstration of ST-segment reduction greater than 50% at 90 minutes. Fibrinolytics should be considered if not contraindicated and immediate PCI is not available. Contraindications include recent surgery or bleeding, presence of a peptic ulcer, uncontrolled hypertension, pregnancy, and noncompressible vascular punctures. The major complication of fibrinolytic therapy is bleeding, specifically an increased risk for intracranial hemorrhage. —Evidence-Based Practice ​ Beta Blocker within 24 hours of admission ​ ACE inhibitor within 24 hours of admission -Lisinopril; (Zestril), Losartan (Cozaar) -ARB if unable to tolerate ACE -losartan (Cozaar), vaslsartan (Diovan) ​ Continued ASA dose ​ Platelet Inhibitor -Clopidogrel (Plavix) ​ Statin therapy ​ Smoking cessation —Invasive Procedures ​ Cardiac catheterization with Percutaneous transluminal coronary angioplasty (PTCA): An invasive nonsurgical technique in which 1 or more arteries are dilated with a balloon catheter to open the vessel lumen and improve arterial blood flow ​ ​ Coronary artery bypass graft (CABG) —Nursing Care Pre PCTA  ​ Informed consent ​ Assess for allergies to seafood, iodine, or dyes Cardiac catheterization injects contrast dye to visualize blockage ​ Assess renal function (Its important that the client has appropriate renal function prior to performing a cardiac catheterization in order for the client to excrete the contrast dye) ​ NPO ​ Prep the insertion site by shaving and cleaning with an antiseptic solution Radial or femoral artery used for procedure ​ IV access —Nursing Care Post PTCA ​ Asses cardiac function -Cardiac rhythm -Vital signs -Chest pain should not be present ​ Protect and monitor the incision site -Pressure dressing or device -Monitor for bleeding -Monitor pulses distal to insertion site -Avoid flexion at the insertion site ​ Bedrest ​ Encourage fluid intake for the excretion of dye —Potential Complications Post PCTA ​ Bleeding ​ Hematoma ​ Arrthymia ​ Thrombus Formation —Coronary Artery Bypass Grafting (CABG) ​ The occluded coronary arteries are bypassed with the client's own venous or arterial blood vessels -Vessels used may include: Saphenous vein, Mammary artery ​ CABG is performed when the client does not respond to medical management or the vessels are severely occluded —Preop Nursing Interventions  ​ Patient education regarding expectations post-surgery -Chest incision -Arm or leg incision -Chest tubes -Foley catheter placement -ET intubation and mechanical ventilation ​ Educate the patient on postop pain and how to splint the chest incision ​ Educate the patient on the need to: Use incentive spirometry, cough and deep breath, and perform leg exercises and increase activity as tolerated —Postop Nursing Assessment ​ Airway ​ Breathing -Mechanical ventilation -Chest tubes -Lung sounds and continous oxygen sat monitoring ​ Cardiovascular -HR, rhythm, auscultation -Continuous ECG monitoring ​ Hemodynamic monitoring ​ Peripheral vascular status ​ Fluid and electrolytes ​ LOC ​ Incisions ​ Body temp ​ Renal fucntion ​ Pain —Hemodynamic Monitoring ​ Invasive hemodynamic monitoring is important to allow early identification and treatment of complex medical problems ​ Measures central venous pressure and pulmonary artery pressures ​ Monitoring systems include -Arterial catheter -Central venous catheter -Pulmonary artery catheter ​ Invasive hemodynamic monitoring is important to allow early identification and treatment of the complex medical problems of the critically ill patients. Physical examination can provide only a limited assessment of the patient’s hemodynamic status. Advanced hemodynamic monitoring enables the nurse to assess for the presence of shock and cardiac and pulmonary abnormalities, as well as complications following myocardial infarction (MI). With the use of advanced monitoring systems, the nurse can evaluate the patient’s immediate response to treatments including inotropic medications and mechanical support. Important concepts to understand when discussing hemodynamic monitoring include cardiac output, oxygen delivery, oxygen utilization, and oxygen consumption.  ​ Central Venous Pressure (CVP) -Measure pressure in the vena cava or right atrium -Reflects filling pressure of right ventricle (preload) -Normal 2-6 mmHg -↑ pressures = elevated right ventricular preload (hypervolemia/R-sided HF) -↓ pressures = low right ventricular preload (hypovolemia -Pulmonary Artery Catheter -Monitor pulmonary wedge pressures and left ventricular preload -Immediately deflate the balloon after reading is obtained -Normal 8-12 mmHg ​ Hemodynamic monitoring systems include arterial, central venous, and pulmonary artery (PA or Swan-Ganz) catheters. When correctly assembled and attached to a monitor, these systems provide pressure readings that correspond to BP, right atrial (RA) or central venous pressure (CVP), and pulmonary artery pressures. The readings are displayed as waveforms on the monitor. The system consists of transduced catheters attached to noncompressible pressure tubing and a pressurized normal saline flush bag to prevent backup of blood. The bag is pressurized to 300 mm Hg for the arterial catheter and 150 mm Hg for the central venous and PA catheters. Evidence has demonstrated flush bags only need to be pressurized, not heparinized; therefore, most institutions have changed their policies to reflect this standard. —Postop Nursing Interventions ​ maintain airway and prevent hypoxia ​ maintain hemodynamic stability ​ fluids and medications as ordered ​ Chest pain should not occur after surgery ​ maintain body temperature ​ monitor drains and provide wound care ​ administer pain medication ​ pulmonary hygiene ​ early mobility or ambulation ​ administer pain medication ​ Maintain tight BP control — Hypotension may result in graft collapse; hypertension may result in bleeding. ​ Administer fluids and medications (vasodilators, vasoconstrictors, inotropes, and diuretics) as ordered — Maintains hemodynamic stability ​ Rewarm patient slowly with warm fluids, blankets, or air flow devices. Prevent shivering — Rapid rewarming may cause dysrhythmias and/or hypotension due to vasodilation. Shivering increases oxygen needs. ​ Administer pain medication and continuous sedation medications — Maintains effective sedation and analgesia to decrease anxiety and pain which may potentially increase cardiac workload. ​ Pulmonary hygiene while intubated: Reposition frequently, suction as needed. Oral care every 4 hours.  ​ Pulmonary hygiene after extubation; Incentive spirometry (IS), cough and deep breathing (C&DB) every 1 to 2 hours while awake, encourage chest splinting when coughing— Helps with weaning toward extubation, oral care helps prevent ventilator-associated pneumonia, IS and C&BD reduces the risk of hospital-acquired pneumonia, improves oxygenation. ​ Plan for and initiate early mobility or ambulation — Reduces complications related to immobility: deep venous thrombosis, pneumonia, constipation, skin breakdown ​ Wound care: Initial dressing to be removed or changed by provider, then change daily or as needed — Helps prevent wound infection and promotes healing –MI Medication Management at discharge ​ ASA every day ​ Clopidogrel-minimum of 6 months ​ Statins ​ ACE/ARBS if indicated ​ Beta-blockers ​ Calcium Channel blockers –Patient Teaching ​ Smoking cessation ​ Diet control ​ Physical activity ​ Resuming sexual activity ​ BP, Blood glucose control ​ Cardiac medications ​ Educate on symptoms that require the pt to seek help Warfarin Anticoagulant Vitamin K antagonist (VKA) Warfarin (Coumadin) Inhibits clot formation –Indicated Rhythm: ​ AF ​ AFL Monitor signs and symptoms of bleeding (bleeding precautions). Monitor renal function. Monitor INR. Be prepared to administer vitamin K as an antidote. Warfarin (Coumadin) Works in the liver to inhibit synthesis of four vitamin K–dependent clotting factors Bleeding Close monitoring required with laboratory values; PT/INR Therapeutic levels monitored by INR Takes 3–4 days to achieve therapeutic anticoagulation  Medication usually taken 3–6 months after deep vein thrombosis (DVT) Vitamin K is the antidote for warfarin Diet and lifestyle teaching are essential –Essential teaching points for patients on warfarin: ​ Immediately report blood in sputum, emesis, stool, or urine. ​ Take the medication at the same time every day. ​ Never skip a dose of the medication. ​ Have laboratory values (international normalized ratio [INR]) checked on a regular basis. ​ Ensure that laboratory levels are safe to continue current dosage or change dosage. ​ Limit intake or maintain a consistent intake of green leafy vegetables that contain vitamin K (kale, spinach, collard greens, broccoli, okra, cabbage) that may counteract the action of warfarin. ​ Consult with your care provider before taking aspirin or Plavix in addition to warfarin. ​ Limit any physical activities that will increase bleeding risk such as contact sports. ​ Use an electric razor when shaving. ​ Use a soft toothbrush. Pulmonary embolism ​ Intro: ❖​ Thrombus forms (commonly in a deep vein) lodges into the branch of a pulmonary artery. ❖​ More than 40% of patients diagnosed with PE also have diagnosed with DVT. ❖​ 3rd most common cause of death in patients who are hospitalized for other reasons. ❖​ Treatment is aimed at prevention through risk factor recognition and elimination. ​ Risk Factors: ❖​ Presence of DVT ❖​ Prolonged immobility (most common cause) ❖​ Virchow’s triad of venous stasis, vessel wall damage, and hypercoagulability (major predisposing factors of DVT) ❖​ History of VTE (venous thromboembolism) ❖​ Obesity ❖​ Smoking ❖​ Chronic heart disease ❖​ Fracture (hip/leg) ❖​ Hip or Knee replacement ❖​ Major surgery/trauma ❖​ Spinal cord injury ❖​ Malignancy ​ Signs and Symptoms: (PE results in high ventilation/low-perfusion scenario- a high V/Q mismatch) ❖​ Respiratory ➔​ Dyspnea (1st indication) ➔​ Tachypnea (1st indication) ➔​ Feeling of impending doom ➔​ Hypoxemia ❖​ Cardiac ➔​ Chest pain (1st indication) ➔​ Distended neck veins ➔​ Hypotension ​ Pulmonary embolism should be suspected in any POST OP PATIENT especially from LONG BONE SURGERIES with a NEW ONSET OF SHORTNESS OF BREATH. ​ If pulmonary infarction (death of lung tissue) occurs due to hypoxia of pulmonary tissue, patient may have hemoptysis (bloody sputum). ​ Diagnosis ❖​ Spiral CT with contrast (most commonly used to diagnose) ❖​ Ventilation-perfusion (V/Q) scan (“High probability” indication of V/Q mismatch) ❖​ Laboratory studies ➔​ Plasma D-dimer level (specific indicator) - Level increases as the body removes clots. Positive D-dimer indicates the presence of clots but requires further testing. 1st TEST DONE with patients of acute PE. ➔​ ABGs ❖​ EKG for chest pain ( 1st initial test to rule out myocardial infarction) ​ Damage to the myocardium is represented by new Q waves and right bundle branch blocks. ​ A CHEST X-RAY is done preliminarily to rule out other causes of respiratory distress. ​ Definitive study: ANGIOGRAPHY (visualization of pulmonary vasculature) EXPOSES PATIENT TO MORE RADIATION. USED ON STABLE PATIENTS. ​ B-TYPE NATRIURETIC PEPTIDE may be elevated. (Released by overstretched ventricles under physiological stress)(100< heart failure) ​ TROPONIN I and TROPONIN T may rise. ​ Nursing Interventions ❖​ Elevate the head of bed - Allows dropping of diaphragm, less work of breathing, and better oxygenation. ❖​ Admin IV Fluids - Decreases blood viscosity (resistance to flow). Caution in with right ventricular overload. ❖​ Admin IV Oxygen ❖​ Admin anticoagulants as ordered ❖​ Admin inotropic agents if ordered - Increases cardiac contractility to augment cardiac output in hemodynamically unstable patients. ❖​ Admin thrombolytic meds ig ordered - Dissolves clots in hemodynamically unstable patients  ❖​ Admin norepinephrine or vasopressin if ordered - Maintain systolic blood pressure of