NCM 112 Past Paper PDF

NCM 112: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS (ACUTE AND CHRONIC) MODULE 3M: Central Venous Pressure, Monitoring: Bone Marrow aspiration, ECG Computation and Interpretation...

NCM 112: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS (ACUTE AND CHRONIC) MODULE 3M: Central Venous Pressure, Monitoring: Bone Marrow aspiration, ECG Computation and Interpretation BSN - 3E GROUP E3 Group Members Clamares, Mary Kriszia Lou C. Dalogdog, Girl Shanhel Diapera, Claude Mykan P. Flores, John Paul T. Florida, Marie Aliyah O. Galeon, Adrianne Marie M. Facilitator: Dr. Charles Andrew M. Gabriente, RN, MD September 12, 2024 1  TABLE OF CONTENTS CLO#1: Define the key terms................................................................................................ 3 CLO#2: Discuss the importance, indications, and contraindications…………………...14 CLO#3: Locate the commonly used veins…………………………………………………….17 CLO#4: Determine the normal and abnormal results……………………………………….22 CLO#5: Elaborate on the guidelines……………………………………………………………30 CLO#6: Examine the possible complications………………………………………………...34 CLO#7: Provide nursing responsibilities before, during, and after………………………36 CLO#8: Utilize the nursing process in the care of clients………………………………….39 CLO#9: Demonstrate the beginning skills…………………………………………………….43 References………………………………………………………………………………………….67 2 CLO #1: Define the key terms for central venous pressure monitoring, bone marrow aspiration, ECG computation and interpretation (Clamares, Mary Kriszia Lou) I. Central Venous Pressure Monitoring 1.1 Central Venous Pressure It is a measurement of the pressure in the vena cava or right atrium. The pressure in the vena cava, right atrium, and right ventricle is equal at the end of the diastole; thus, the CVP also reflects the filling pressure of the right ventricle. The normal CVP is 2 to 6 mmHg. 1.2 Manometer A device used to measure pressure. It is often used to measure pressure in blood vessels, like Central venous pressure. CVP is usually recorded at the mid-axillary line where the manometer arm or transducer is level with the phlebostatic axis. 1.3 Electrocardiogram A diagnostic test that records the electrical activity of the heart over time. The electrical impulse that travels through the heart can be viewed using electrocardiography, the end product of which is an electrocardiogram. 3 1.4 Vectorcardiogram Method of recording the direction and magnitude of the electrical forces of the heart. 1.5 Echocardiogram Ultrasound imaging test that uses sound waves to produce images of the heart. It focuses on heart function, structure, and blood flow, providing critical information on conditions like heart valve problems, heart failure, and congenital heart defects. 1.6 Hypervolemia Abnormal increase in the volume of blood plasma in the body, often due to excessive fluid intake, kidney failure, or heart conditions. It can lead to shock if not properly treated. 4 1.7 Hypovolemia Decreased volume of blood plasma, often casued by dehydration, blood loss, or excessive fluid loss. It can lead to shock if not properly treated. 1.8 Phlebostatic Axis Anatomical reference point on the chest, typically at fourth intercostal space at the mid-axillary line, used to ensure proper positioning of pressure transducers when measuring hemodynamic parameters like central venous pressure. 5 II. Assisting in Bone Marrow Aspiration 1.1 Bone marrow It is a soft, gelatinous tissue that fills the cavities of the bones. It is either red or yellow, depending upon the preponderance of hematopoietic (red) or fatty (yellow tissue). 1.2 Bone marrow aspiration It is a procedure in which a small liquid sample of bone marrow is removed, usually from the pelvis and sternum. 1.3 Biopsy It is a procedure to remove cells, and tissue for examination by a medical pathologist. 6 1.4 Fibrosis It is the development of fibrous connective tissue as a reparative response to injury or damage. 1.5 Hematologist Are healthcare providers who specialize in diagnosing, treating and managing diseases that affect your blood, bone marrow and lymphatic system. 1.6 Hematoma Is an abnormal collection of blood outside of a blood vessel. It occurs when the wall of a blood vessel, artery, vein or capillary gets damaged and blood leaks into tissues where it does not belong. 7 1.7 Hematopoiesis It is the process by which the body produces blood cells and blood plasma. 1.8 Hemorrhage Is an escape of blood from a ruptured blood vessel, especially when profuse. 1.9 Myeloma It is a type of blood cancer that develops from plasma cells in the bone marrow. III. Electrocardiogram Analysis, Interpretation, and Computation 1.1 Electrocardiogram Is the actual graphical representation or record of the heart’s electrical activity produced by the electrocardiograph. It is the printed or digital output that shows the various waves and intervals of the heart’s electrical cycle. 8 1.2 Electrocardiograph Is the actual machine or device used to record the electrical activity of the heart. It includes the hardware and software needed to capture and display the heart’s electrical signals. 1.3 Electrophysiology Is a test performed to assess the heart’s electrical system or activity and is used to diagnose abnormal heartbeats or arrhythmia. 9 1.4 Electrodes Is a medical device that converts ionic current energy into electrical current in the body. 1.5 Lead Is used to detect electrical activity from different areas of the heart muscle. 1.6 SA node It represents a cluster of myocytes with pacemaker activity. It generates electrical impulses that set the rhythm and rate of the heart. 1.7 Excitability Ability to respond to a stimulus, depolarization and repolarization, communication with adjacent cells, and propagation of the electrical activity. 10 1.8 Automaticity Ability of the cardiac cells to initiate an electrical impulse. 1.9 Depolarization Process by which cardiac muscle cells change from a more negatively charged to a more positively charged intracellular state. 1.10 Bradycardia Is a condition where your heart beats slowly, fewer than 60 beats per minute. 11 1.11 Tachycardia Is a heart rate of more than 100 beats per minute at rest. 1.12 Rhythm Regular, repeated pattern of movement or sound. 12 1.13 Arrhythmia/dysrhythmia Is a disorder of the heart that affects the rate or rhythm at which the heart beats. It is known for its abnormal heartbeats which change from the normal sequence of electrical impulses. 1.14 Cardiac arrest Is caused by a dangerous abnormal heart rhythm which happens when the electrical system in the heart isn’t working properly. 13 CLO #2: Discuss the importance, indications and contraindications in central venous pressure monitoring, bone marrow aspiration and ECG computation and interpretation. (Dalogdog, Girl Shanhel) Central Venous Pressure Monitoring Importance Central venous pressure (CVP) measures the blood pressure inside of your right atrium, or in some cases vena cava. This makes it a common device to measure hemodynamic status, right heart function and intravascular volume in intensive care units (ICUs), surgical theaters or emergency department (EDs). Furthermore, when a patient is anesthetized or has had surgery, CVP monitoring can help to identify fluid overload or incipient heart failure. Indications Contraindications Post-operative Fluid Management Distorted local anatomy (eg, from Hypovolemic shock. vascular injury, prior surgery, or Specific medical condition that previous irradiation) includes central lines for Patients having cardiovascular intravenous access. disorders Burns or trauma requiring rapid Infection at the insertion site fluid resuscitation. Coagulopathy or Bleeding Total parenteral nutrition (TPN) Disorders Monitoring of central venous pressure (CVP) Bone Marrow Aspiration Importance This is an important diagnostic procedure, which removes a tiny sample of bone marrow for examination. The test shed some light on the bone marrow's general condition and operation. This is the organ responsible for creating blood cells. It can uncover problems in the production of red blood cells, white blood cells, or platelets. For instance, it may find out that you have one of several different kinds of blood disease-leukemia, lymphoma, multiple myeloma and aplastic anemia. It tracks the response of bone marrow to treatment and is therefore useful in assessing what percentage of patients is actually helped by new therapies. 14  Indications Contraindications To diagnose blood disorders such Severe Hemophilia as anemia, leukemia, lymphoma, Severe Disseminated multiple myeloma, Intravascular Coagulation (DIC) myelodysplastic syndromes and Infection at the aspiration site to diagnose infectious diseases Patient refusal or lack of such as tuberculosis and fungal informed consent infections To assess the effectiveness of chemotherapy or radiation therapy To monitor the recovery of the transplanted bone marrow Evaluation of thrombocytopenia and leukopenia ECG Computation and Interpretation Importance The ECG is the cardinal test for the interpretation of cardiac rhythm, conduction system abnormalities, and the detection of myocardial ischemia. It presents great value in the evaluation of other types of cardiac abnormalities, including valvular heart disease, cardiomyopathy, pericarditis, and hypertensive disease. It is through the understanding of the ECG findings that patients can make informed decisions about their heart health. Indications Contraindications Symptom-Based Indications There are no absolute contraindications Chest pain: To differentiate for an electrocardiogram. The relative between cardiac and non-cardiac contraindications to its use include: causes of chest discomfort. Patient refusal Palpitations: To identify Allergy to the adhesive used to arrhythmias or other heart affix the leads rhythm disturbances. Shortness of breath: To assess for heart failure, pulmonary embolism, or arrhythmias. Dizziness or syncope: To evaluate 15  potential cardiac causes like arrhythmias or heart block. Diagnostic Indications Suspected heart disease: To identify coronary artery disease, myocardial infarction, or cardiomyopathy. Arrhythmia detection: To diagnose and classify different types of arrhythmias. Electrolyte imbalances: To detect abnormalities like hyperkalemia or hypokalemia. Drug toxicity: To assess the effects of certain medications on heart function. Preoperative evaluation: To assess cardiac risk before surgery. Follow-up of known heart conditions: To monitor disease progression and treatment efficacy. Monitoring Indications Continuous monitoring: For patients with unstable cardiac conditions or those at risk for arrhythmias. Exercise stress testing: To evaluate heart function during exertion. Post-operative monitoring: To detect potential cardiac complications after surgery. 16 CLO #3: locate the commonly used veins in CVP insertion, bone marrow aspiration landmarks and their corresponding positions, and ECG lead placement (Diapera, Claude Mykan) Common Veins in CVP Insertion Typically helps the client receive drugs, fluids, or blood for emergency or long-term treatment. It also helps with blood draws Internal Jugular Vein: Located in the neck, accessed through the triangle formed by the sternocleidomastoid muscle and the clavicle. Subclavian Vein: Found beneath the clavicle, accessed approximately 2-3 cm inferior to the midpoint of the clavicle. Femoral Vein: Located in the groin, accessed about 1-3 cm below the inguinal ligament and 0.5-1 cm medial to the femoral artery pulsation. 17  Basilic and Cephalic Veins: Often used for peripherally inserted central catheters (PICC lines) in the arm Bone Marrow Aspiration A procedure used to obtain a sample of bone marrow for diagnostic purposes. This procedure is essential for diagnosing various hematologic disorders, including leukemias, lymphomas, and other blood-related diseases. 18  Posterior Superior Iliac Crest: This is the preferred site due to its accessibility of a large marrow reservoir, safety as there are less blood vessels nor nerves in the area, and lower risk of complications. Anterior Superior Iliac Crest: This site is an alternative when the posterior site is not accessible due to conditions like obesity or infection. However, it is less preferred because of the denser cortical bone, which can make sampling more difficult and inflicts pain to the client Sternum (Aspirate Only): Intended for clients who are immobile or have undergone radiation therapy and is a contraindication if the client has disorders regarding bone resorption Tibia (Aspirate Only): Indicated towards infants younger than one year and is avoided due to the method can cause bone fractures ECG Lead Placement 19 20  Lead I: Lateral view, positive deflection from left arm to right arm. Lead II: Inferior view, strong positive deflection from left leg to right arm, commonly used for monitoring. Lead III: Inferior view, positive deflection from left leg to left arm. 21 CLO #4: Determine the normal and abnormal readings and implication of CVP monitoring, normal and abnormal results of bone marrow aspiration, and ECG waves and complexes in relation to the events that occur during electrical conductions of the heart. CVP Monitoring Normal readings Abnormal readings Significance - Reading between > 6mmHg - CVP increase can 2-6mmHg - Elevated right be an indicator of ventricular preload heart failure due to - Hypervolemia decreased (excess bodily fluid contractions, circulation) dysrhythmias, and - Right sided heart abnormalities in failure the valve. - Hypovolemia or 0.20 seconds in first degree heart block. duration. If the PR interval is less than 12 seconds it could indicate the presence of an accessory pathway between the atria and ventricles or AV nodal junctional rhythm. QT Interval QT Interval A QT interval that exceeds 0.32-0.40 seconds Less than 0.32 or normal ranges could be in duration if heart greater than 0.40 an rate is 65-95 bpm. seconds in duration if indicator for ventricular heart rate is 65-95 arrhythmia, syncope, and bpm. death. A QT interval that goes below normal ranges could be an indicator for a congenital heart defect which may later lead to atrial fibrillation. Absence of U waves The presence of U waves U waves are normally may indicate absent during an hypokalemia, ECG analysis in individuals hypertension, or heart without complications. If disease. this wave shows up in a cardiogram, then it could be an indicator of other potential diseases such as hypokalemia. 25 Complications correlated with the events that occur during the electrical conductions of the heart Sinus Node Arrhythmias Sinus Bradycardia It is when the heart beats slower than normal, typically less than 60 bpm. May indicate that the heart is not pumping enough blood. Sinus Tachycardia It is when the heart beats faster than normal, usually over 100bpm. May be a response to anemia or stimulants like caffeine. Sinus Arrhythmia The variation of heart rate often changes with breathing. HR increases when you inhale and vice-versa. Atrial Arrhythmias Premature Atrial Complex An extra heartbeat originates in the atria before the normal heartbeat. Appears as an early P-wave followed by a normal QRS complex which disrupts regular heart rhythm. Atrial Fibrillation An irregular and often rapid heart rhythm that occurs when the atria quiver instead of contracting effectively. Manifests as a chaotic baseline wherein the heart rate varies widely. Wolf Parkinson White Syndrome A congenital condition where an extra electrical pathway in the heart causes tachycardic episodes. It is identified by a short PR interval and a delta wave on the ECG, indicating that electrical signals bypass the normal pathway. 26  Atrial Flutter A type of fast heart rhythm that occurs when the atria contract in a rapid, organized manner. It is characterized by a "sawtooth" pattern of P waves (often referred to as "F-waves") on the ECG, typically at a rate of 240-340 beats per minute. Junctional Arrhythmias Premature Junctional Complex An early heartbeat that originates from the junction (area near the atrioventricular node) instead of the sinoatrial (SA) node. Occurs due to stress, caffeine, or heart disease. It usually appears as an early QRS complex with an inverted P wave (if visible) or no P wave at all. Junctional Rhythm Occurs when the heart's natural pacemaker (the SA node) fails, and the heart relies on the junctional area to set the rhythm. The heart rate is usually between 40-60 beats per minute. P waves may be absent or inverted, and the QRS complexes are typically narrow. Nonparoxysmal Junctional Tachycardia Tachycardia originating from the junctional area and is not characterized by sudden episodes (nonparoxysmal) The heart rate is typically above 100 beats per minute, with narrow QRS complexes. P waves may be absent, inverted, or retrograde (appearing after the QRS complex). Atrioventricular Nodal Reentry Tachycardia A type of tachycardia that is caused by a reentry circuit involving the atrioventricular (AV) node. The heart rate is usually between 150-250 beats per minute. The rhythm is regular, and P waves may be present or absent, often appearing after the QRS complex. 27 Ventricular Arrhythmias Premature Ventricular Complex An extra heartbeat that originates from the ventricles (lower chambers) of the heart, occurring earlier than expected. It has a wide QRS complex and is often followed by a compensatory pause. They can occur in isolation or patterns like bigeminy (every other beat). Ventricular Tachycardia A rapid heart rhythm originating from the ventricles, usually over 100 beats per minute. It has a wide QRS complex and is regular. Can be sustained (more than 30s) or nonsustained (less than 30s) Ventricular Fibrillation A chaotic, disorganized heart rhythm originating from the ventricles. It will show on the ECG a quivering, irregular pattern. Idioventricular rhythm A slow ventricular rhythm, usually less than 40 beats per minute. Has a wide QRS complex and is regular. 28 CLO #5: Elaborate on the guidelines of central venous pressure monitoring, bone marrow aspiration and ECG computation and interpretation. (Galeon, Adrianne Marie) I. Central Venous Pressure Monitoring A. With Electronic Transducer System 1. Position patient supine with head-of-bed 0-60° elevation 2. Check the level of the transducer with the phlebostatic axis. 3. During the first assessment of shift, zero transducer to air. 4. Assess waveform for dampness. 5. Maintain tight luer-lock connections and non vented caps on stopcocks of pressure tubing. 6. Record CVP pressure from the monitor. B. With Water Manometer 1. Position patient supine with head-of-bed 0-60° elevation. 2. Turn the stopcock of the water manometer off to the patient and fill the water manometer up to 20 cm H20. 3. Align 0 (zero) of water Manometer with phlebostatic axis. 4. Turn the stopcock of the water manometer off to IV solution bag. 5. Encourage the patient to take some normal breaths while the water descends the water Manometer to the resting pressure. 6. Read the water meniscus (bottom of water level) during the end expiration of the patient's respiratory cycle. 7. As soon as a pressure is read, turn the stopcok or the water manometer off to the water column and flush the IV tubing of any blood backed up in the tubing. Leave the stopcock in the off position to the Manometer when not in use. II. Bone Marrow Aspiration A. Before the procedure 1. Explain procedure and obtain informed consent. 2. Ensure that the patient is fasting for at least 6 hours before the procedure. 3. Place the patient in a comfortable position, usually lying on their side or abdomen. 29  4. Prepare skin over the aspiration site. 5. A mild sedative should be given an hour before the test. 6. Check the patient if they are on any anti-coagulation drugs (e.g. aspirin, warfarin, clopidogrel), ensuring that they have been omitted. 7. Patients should have a full blood count and clotting screen taken prior to the procedure. B. CT-Guided Approach 1. Place a radiopaque grid on the patient’s skin over the iliac crest to guide needle entry. 2. If not using CT, palpate anatomical landmarks for needle placement. C. Needle Placement 1. For the posterior iliac crest, mark the site about three fingerbreadths from the midline and two fingerbreadths below the posterior iliac crest. 2. Angle the needle towards the anterior superior iliac spine. 3. Make an indentation or pen mark on the patient’s skin at the chosen entry site. D. Preparation 1. Wear proper protective equipment: sterile mask, gown, and gloves. 2. Open and organize the procedure tray on the sterile table. 3. Prep and drape the chosen site in a sterile manner. 4. Use 1% to 2% lidocaine solution with a 23-gauge needle for local anesthesia, ensuring broad anesthesia of the periosteum. E. Needle Insertion 1. Use a sterile needle and a 10-20 mL syringe to puncture the skin, subcutaneous tissue, and bone to reach the bone marrow cavity – making a small incision at the skin entry site after anesthesia. 2. Select and advance the bone marrow needle toward the bone. 30  3. For CT-guided procedures, scan the region of interest in the axial plane to determine needle trajectory, adjusting as necessary. 4. Advance the needle to the periosteum with proper angulation, using imaging as needed. F. Bone Marrow Aspiration 1. Hold the needle with the stylet in place and advance into the bone using a gentle clockwise-counterclockwise motion. 2. Once the bone marrow cavity is entered, remove the stylet. 3. Attach a 2 mL syringe to the needle and obtain the aspirate. 4. An assistant should prepare the sample on slides or in the proper tube. G. Post-Aspiration 1. Reinsert the stylet if a new site is needed after an unsuccessful attempt. 2. After obtaining proper samples, reinsert the stylet and remove the needle. III. ECG Analysis and Interpretation A. General guidelines 1. All recording and other nearby electrical equipment should be properly grounded. Make sure that the electrodes are properly attached. 2. Follow certain hospital protocols in reading and interpreting ECG results and know their normals. 3. The electrode should be changed periodically before the adhesive performance decreases. 4. Setting the alarms appropriately for each patient is important to avoid needless alarm notification. 5. Note current cardiac drug therapy on the test request form and pertinent information, such as chest pain and pacemaker presence. 6. Monitor the patient for seizure and maintain seizure precautions. 31 B. Assess ventricular (RR intervals) and atrial (PP intervals) rate and rhythm 1. P-waves should precede every QRS complex and the P-wave should be positive in lead II. 2. Note the common findings for the sinus rhythm: a) Heart rate: 50-100 beats per minute b) P-waves precedes every QRS complex c) The P-wave is positive in lead II d) The PR interval is constant C. Assess P-wave morphology and PR interval 1. P-wave is always positive in lead II (actually always positive in leads II, III, and aVF). 2. P-wave duration should be 0.03s and/or amplitude >25% of R-wave amplitude in the same lead, in at least 2 anatomically contiguous leads.) E. Assess the ST segment (morphology, depression, elevation) 1. The ST segment should be flat and isoelectric (at the level with the baseline). It may be slightly upsloping at the transition with the T-wave. 2. ST segment deviation (elevation and depression) is measured in the J point. F. Assess T-wave morphology 1. Should be concordant with the QRS complex. Should be positive in most leads. 32  2. T-wave progression should be normal in chest leads. 3. In limb leads the amplitude is highest in lead II, and in the chest leads the amplitude is highest in V2-V3. G. Assess QTc interval and U wave. 1. Note the following: a) QTc duration men: 10,000/m demonstrate a about the procedure, addressing the coping techniques, m³) due to minimized risk patient’s concerns. and exhibits stable infection risk of infection 2. Teach the patient relaxation techniques, vital signs (HR post-proced following the such as deep breathing and guided