Fundamentals of Nursing: Human Health and Function PDF

Fundamentals of Nursing: Human Health and Function Cardiac Function  Assessment Normal Pattern Identification – Assess activity tolerance Can he tolerate a reasonable level of physical exertion? Can he perform a normal range of ADLs – Does he have...

Fundamentals of Nursing: Human Health and Function Cardiac Function  Assessment Normal Pattern Identification – Assess activity tolerance Can he tolerate a reasonable level of physical exertion? Can he perform a normal range of ADLs – Does he have chest pain with activity? If yes, always warrants a full investigation 2  Assessment Normal Cardiovascular Function – Structure of the Cardiovascular System Heart Blood Vessels – Function of the Cardiovascular System Heart Blood Vessels Blood 3  Assessment (cont’d) Lifespan Considerations – Newborn and Infant Rate – 130 to 160 bpm & irregular NB ˂ 100 bpm in NB – alarm! As baby matures rate slows & is more rhythmic Infancy – 80 to 150 bpm B/P not routinely assessed during infancy Lowest during NB – systolic ~ 40 mm Hg 4  Assessment (cont’d) – Toddler and Preschooler By end of toddler period 70 to 110 bpm resting HR B/P measured annually after 3y/o Use appropriate size cuff Accurate reading If ˃ 95th percentile will need follow-up 5 evaluation for with pedi cardiologist  Assessment (cont’d) – Child and Adolescent Heart ↑ size & rate ↓ B/P changes – more gradual Boys – slightly higher B/P & lower HR than girls By 19 y/o both have stabilized at adult values Optimum time to develop a healthy lifestyle Eating & exercise habits 6  Assessment (cont’d) – Adult and Older Adult Changes in CV system may lead to ↓ activity tolerance & ↓ endurance Natural changes that occur Lifestyle factors that contribute to the process of calcification, fatty degeneration, and diminished elasticity of the blood vessels. B/P tends to ↑ as we grow older due to above mentioned factors Heart rate ↑ due to added workload of pumping blood through resistant vessels. 7  Assessment (cont’d) Cultural Considerations – Genetics & lifestyle factors influence incidence of CV disease – Health beliefs vary among cultures Gender Differences – Important for nurse to have knowledge of differences 8  Assessment (cont’d) Risk Identification – Ask about past CV conditions Any functional deficits as a result? – Any non-modifiable risk factors? – Any modifiable risk factors? – Assess dietary intake – Assess medications he is taking 9  Assessment (cont’d) Factors Affecting Cardiovascular Function – Cigarette Smoking-major cause of peripheral vascular disease – High Blood Pressure-Most common manifestation of altered blood flow & causes further dysfunction – Nutrition-Healthy diet low in fats, cholesterol, salt, sugar & high fiber helps fight CV disease 10  Assessment (cont’d) – Sedentary Lifestyle – Diabetes – Obesity – Medical & Family History – Medications & Drug Use 11  Assessment (cont’d) – Stress Coping responses can help identify areas of risk – Personality Types “Type A”-Hard driving, competitive “Type B”-Easy going, relaxed, more cooperatively orientated “Type D”-Distressed-negative & lack of involvement in close social relationships & situations. – Community Factors-Contribute to poor public health along with disease within the population 12  Assessment (cont’d) Dysfunction Identification – Chest Pain Syncope? Fainting spells/temporary loss of consciousness – Gender Differences Men-Chest pain/Pressure/Squeezing Women-Seep issues, lethargy, nausea, back/stomach pain – Stroke Screening NIH Stroke Scale 13  Assessment (cont’d) Manifestations of Altered CV Function – Changes in Vital Signs Blood Pressure Pulse Character Heart Rate Respiration – Changes in the Skin Rubor Cyanosis 14  Assessment (cont’d) – Decreased Cardiac Output Muscle Damage Ischemia Valve Dysfunction Conduction Problems Dysrhythmia (arrhythmia) 15  Assessment (cont’d) – Altered Blood Flow Alterations in the Blood Arterial Dysfunction Capillary Dysfunction Venous Dysfunction 16  Assessment (cont’d) – Decreased Tissue Perfusion Pain-commonly occurs with ischemia. Angina- chest pain with decreased coronary blood flow. Intermittent claudication-limb pain caused by poor blood flow. Organ Dysfunction and Failure- Leads to damage that can be permanent and can lead to organ failure Cognitive Dysfunction-The brain is very sensitive to decreased blood flow. 17  Assessment (Cont’d) Physical Assessment – Inspection – Palpation – Auscultation 18  Assessment (Cont’d) – Diagnostic Tests and Procedures Laboratory Studies CBC Cardiac biomarkers (cardiac enzymes) Kidney function studies Lipoprotein levels 19  Assessment (Cont’d) Diagnostic Procedures Radiography Electrocardiography Exercise Testing Echocardiography 20  Assessment (Cont’d) Blood Flow Studies Cardiac Catheterization Angiography Electrophysiology 21  Nursing Diagnoses NANDA-I – Decreased Cardiac Output – Ineffective Tissue Perfusion Other significant problem – not exclusive CV problem – Activity Intolerance 22 Outcome Identification and Planning Look at all of assessment – What is his level of cardiac dysfunction? – What are his needs/problems/diagnosis? Ex. Healthy? Has an acute problem? Has a Chronic Problem? Has a Terminal Problem? Plan what nursing interventions will help him 23  Implementation Health Promotion – Modifying Risk Factors Help patient understand causes of CV disease – Preventing Venous Stasis Education Avoid Constriction Help ↓ risk of clot formation Encourage venous return 24  Implementation (Cont’d) Assisting with Leg Exercises Teach before surgery – prevent post- op complications All with impaired mobility Also good when will be on a long flight Applying Antiembolism Stockings Strong elastic material – varying degrees of compression at different areas of leg Must fit properly 25  Implementation (cont’d) Using Pneumatic Compression Devices Sequential Compression Devices (SCDs) Impulse Foot Pump Foot sleeve with rigid base – inflated & deflated with air Anticoagulation Prophylaxis Anticoagulation drugs to prevent DVT or pulmonary embolism 26  Implementation (cont’d) Nursing Interventions for Altered CV Function – Patient Teaching Teach warning signs of ↓ CO or ↓ perfusion Teach how to promote blood flow, reduce edema, promote skin integrity & avoid fatigue – Medications Explain each clearly Stress importance of taking as ordered 27  Implementation (cont’d) – Edema Reduction Elevation of Limbs Uses gravity to assist venous return and helps decrease venous pressure Avoid constriction while elevating and do not elevate hospital bed at knees Reducing Sodium Intake Daily sodium intake ˂ 2.5 g/day is typical if on fluid retention Fluid Restriction I&O; daily weight to monitor 28  Implementation (Cont’d) – Positioning Hypotensive patient Elevate legs 20 to 30 degrees along with specific treatment Dependent placement of hands/feet with poor perfusion 29  Implementation (cont’d) – Pain Management Chest Pain Acute – stop all activity, rest, sitting comfortably Document – duration, activity during onset, V/S during episode Report to MD In hospital – stat 12-lead EKG Start O₂, maintain bed rest, sublingual nitroglycerin & assess B/P 5min after 30 Implementation (cont’d) At home New pain not relieved by 1 dose of nitroglycerin – call 911 Chronic angina – activity management Nurse – Don’t schedule activities right after meals If ordered, give nitroglycerin before performing any activity that previously caused pain 31  Implementation (cont’d) Claudication and Peripheral Ischemic Pain New – notify MD Avoid activities that exceed individual tolerance & plan rest periods Heating pad – avoid burns – Increased Activity Begin slowly, progress gradually Outpatient Cardiac Rehabilitation 32  Implementation (cont’d) – Energy Conservation Most important measure – regular rest Breathlessness or ↑ HR for > 10 min. – go slower Rest undisturbed 1 hr. after meals Immediately stop any activity that produces fatigue, breathlessness, pressure, or pain – Cardiopulmonary Resuscitation 33  Implementation (cont’d) Home and Community Care – Cardiac Rehabilitation Rest is essential – activity important Continuing rehab program – prescribed by MD Common concerns Impact on sexual function Fear of cardiac episode during sex – Emergencies 34  Evaluation Based on Outcome Criteria – Did interventions work/help? – Do we need to change to another implementation or nursing action? – If goal met, do we need to revisit it at a later time, or are we done with this problem? – Are their other problems we identified during our interventions? 35