Nursing Study Notes on Clinical Skills - PDF

1 WEEK 0 - COMPULSORY CLINICAL SKILLS INJECTIONS Used to administer parenteral medications to body tissues. Three main types 1. Subcutaneous (SC) (given at 90 degrees) § Subcutaneous tissue Insulin, heparin...

1 WEEK 0 - COMPULSORY CLINICAL SKILLS INJECTIONS Used to administer parenteral medications to body tissues. Three main types 1. Subcutaneous (SC) (given at 90 degrees) § Subcutaneous tissue Insulin, heparin analgesia § More rapidly absorbed than transdermal but slower than Intramuscular § Small volumes injected Large volumes infused 2. Intramuscular (IM) (given at 45 degrees) § Antibiotics § Can take larger volumes § Absorptions rate ­ due to higher blood supply 3. Intradermal (given at 10-15 degrees) § Dermis of the skin § Less common § Allergy testing § Lowest absorption rate § Very small volumes 4. Intravenous (IV) § Antibiotics and analgesia 5. Epidural administration § Analgesia Opioid / anesthetic Needle put into epidural space Parenteral administration is faster acting Does not go through digestive system Reasons to use injections Oral route not available o NBM o Nausea o Oral surgery When drug can be destroyed by digestion o Heparin o Insulin DRUG ORDERS Check medication sheet for 1. Time 3. Dose 2. Route 4. Drug  2 Things to know Pt diagnosis Purpose of the medication Therapeutic effect Adverse effects Usual dose Related nursing implications Factors that alter drug response o Age o Weight o Psychological status ALLERGIES!!!! Drawing up medications Use a 19G drawing up needle for filter needle to get medication o Use new one on pt Vials Liquid form Remove cap and clear rubber stopper with alcohol wipe Use drawing up needle and draw up air into the syringe equal to the amount of medication needed. Set vial on bench à penetrate Keep needle above liquid and insert air (positive atm pressure) Turn syringe upright and draw meds Replace new needle Power form à do the same thing à but need to inject diluting solution Ampules Move in circle or flick to remove bubbles from neck Needle should be in the liquid when drawing up Replace needle before injection INJECTION SITES Intradermal o Inner aspect of the forearm o Blisters may appear o 5-15 degrees Subcutaneous o Location with good circulation § Anterior thigh § Abdomen § Outer aspect of the upper arm § Scapular § Ventrogluteal or dorsogluteal o Heparin à Abdomen o Insulin à thighs or abdomen o 25-27-gauge needle Intramuscular o Ventrogluteal site (the butt!) o Deltoid (forearm)  3 o Least likely for complications o No large vessels or nerves o Can be done on the thigh for younger kids o 21-23-gauge needle SIX RIGHTS OF MEDICATION ADMINISTRATION 1. Right time 2. Right drug 3. Right route 4. Right dose 5. Right patient 6. Right documentation Factors to consider when selecting injection sites Muscle mass Assess to site BMI Rotation of sites Ease of site identification Preference of patient Nurse familiarity Manufacturer recommendations VENEPUNCTURE Venepuncture is the introduction of a needle into a vein to withdraw blood for diagnostic purposes and to monitor therapeutic blood levels. Veins have 3 layers + valves Tunica intima Tunica media Tunica adventitia What veins are used? Dorsal Cephalic Axillary Median cubical Basilic Vein selection Veins are made from smooth muscles o Have a lumen and valves o Palpitations is the best way to choose o Features of good veins § Bouncy and soft § Engorged § Refill easy § Round § Well supported surrounding structures  4 o Features of bad veins § Collapsed § Thin and hard § Painful § Bruised or inflamed § Wobbly and mobile § Near infection or Oedema § Extensive scaring Figure 1 - A fistula is an abnormal connection between two § In the arm with a hollow spaces (technically, two epithelialized surfaces), such as blood vessels, intestines, or other hollow organs. Fistulas are Fistula usually caused by injury or surgery. IV running Previous mastectomy (breast removal) Lymph surgery Venepuncture steps Gather equipment o Absorbent pad o Syringe (5-10ml) o Clean gloves o Appropriate test tubes o Tourniquet o Sharps bin o Vacutainer o Alcohol wipes and gauze dressing o Needle (21-23 gauge) Introduce yourself and explain Wash hands Check à identify and label Tourniquet above location à find vein Clean site à insert tube à collect blood Undo tourniquets à remove needle Needle into sharps bin Apply pressure into site and use cotton wool Label test tubes + pathology forms à proper storage Which system to use...??? 1. Vacutainer Test tubes a. Closed system Þ Colour coded b. Less chance of injury Þ Different colors for different tests c. Bigger needle Þ Different volumes needed 2. Butterfly o Check label on tube a. Will get flashbacks Þ MUST have pt label b. Otherwise similar to vacutainer Þ Must match with pathology form c. Smaller needle 3. Needle and syringe a. Will get flashbacks b. Risk of needle stick injuries Risks during insertion Vasovagal episodes Why are veins (not arteries) used? Pain Arteries pulsate Nerve damage Veins are closer to skin so easy to see Arterial puncture Veins rarely collapse (has valves) Needle stick injury  5 How to avoid pain? Good vein selection Good technique Local anesthesia Distraction Information given to patient Complications from venepuncture INFECTION o Localized infection § Purulent discharge § erythema § Oedema § Pain § Possibly Pyrexia o Systemic infection § Low grade pyrexia § Elevated WBC o Use infection control precautions PHLEBITIS o Inflammation of the vein o Caused by insult to blood vessel wall § Impaired blood flow § Abnormal coagulation o Thrombophlebitis is the formation of a blood clot associated with phlebitis. HAEMATOMA o Caused by § “through the vein” puncture § Tourniquet too tight § Poor pressure removal § Application of tourniquet above previous puncture site § Arterial puncture o Prevention § Firm pressure over puncture site § Don’t bend arm § Remove tourniquet as soon as blood is obtained EXTRAVASATION o Accidental administration of IV infused medication into surrounding tissues o Risk factors § Fragile skin or blood vessels (old ppl) § Low muscle to subcutaneous tissue mass § Inability to report pain § Multiple previous puncture sites o Treatment à hyaluronidase CENTRA VENOUS ACCESS DEVICES (CVAD) Central venous catheter (CVC) Catheter inserted into the superior vena cava and lies near right atrium. Minimize the risk of vein inflammation and irritation.  6 Common insertion sites o Internal jugular vein o Subclavian vein o Femoral vein Indications Contraindications To monitor fluid status (CVP) Obstructed vein (clot) To administer large volumes of fluid Stenosis of vein To administer fluid/medication rapidly Severe coagulopathy Long term access Respiratory failure Multiple drug administration Contaminated site Administrate irritating medications Traumatized site Administer TPN (total parenteral nutrition) Burnt skin Difficulty obtaining other access Awake BUT Uncooperative patient Advantages Increased access ports – up to 5 lumens Reduced need for venipuncture Can be cared for in the community Types of CVCs 1. Short term a. Single lumen b. Multi-lumen (3-5 ports) c. Antimicrobial Figure 2 - Hickman line 2. Long term a. Tunneled (Hickman) i. Hickman lines are often used for chemotherapy and dialysis b. Implanted venous access ports (port-a-Cath) i. Used to draw blood and give IV fluids, drugs or for blood transfusions ii. Port is placed under skin à catheter is guided into the superior vena cava iii. Needle is inserted through skin into port for access c. Peripherally inserted central cannula (PICC) i. Positioned in large vein (arm, leg or neck) ii. Used for long term IV antibiotics, nutrition or medications PICC line Catheter inserted into basilic and cephalic vein in the cuboidal fossa or upper arm with tips sitting in the superior vena cava. Approx. 55cm long Single or multi-lumen Figure 3 - PICC line Can be in-situ for more than 12 months Complication from PICC lines During insertion o Pneumothorax and/or Hemothorax o Air embolus o Arterial cannulation o Arrhythmia o Cardiac injury o Incorrect positioning o Nerve injury o Bleeding  7 After insertion o Extravasation o Thrombosis o Infection Pt must have CXR after insertion! o Hemorrhage o Sepsis o Subcutaneous emphysema Central venous pressure (CVP) The pressure within the right atrium or superior vena cava Guides in fluid balance measurement Can be used to estimate circulating blood volume Assist in monitoring circulating (Pump) failure Normal value – 0-8mmHg Elevated CVP Right ventricular failure Volume overload Tricuspid valve stenosis Constrictive pericarditis Pulmonary hypertension Cardiac tamponade Right ventricular infarction Decreased CVP Dehydration Shock o Hypovolemic o Septic o Anaphylactic o Neurogenic General nursing care for PICC lines Dressing changes Check tubing connections regularly Catheter site should be cleaned and All infusions must run via a pump redressed 24/24 post insertion Flush ports that are not in use Regular changes weekly Ensure intact dressings Record catheter length weekly Palpate around catheter site If TPN à change line regularly Assess for signs of infection Assess entire arm with PICC line Use sterile technique Assess site for infection or hemorrhage Flushing PICC lines Always use pulsatile (stop/start) motion to flush o Create turbulence in lumen o Remove debris o Avoid blockage of the catheter Clean positive pressure bung with alcohol swabs three times and allow to dry before use. On accessing PICC line, flush with normal saline (NS) 10ml to determine patency  8 Investigate blockages (could be from clamps, tubing or positioning) Use non-touch technique ALWAYS wear gloves Flush before and after drug administration with 10ml NS. After blood sampling flush with 20ml NS. Flush weekly when not in use, with (+) pressure bung. Follow hospital protocol. PCA AND EPIDURALS PCA Pt able to control analgesia requirements Administration is via IV Locked fusion pump with release button Delivers a present bolus dose of opioids Aim of PCAs, o Improve pt satisfaction o Improve comfort o Allow mobility o Allow effective chest wall expansion Advantages o Reduce nursing workload o Remove bias o Allow accurate evaluation of analgesia o Effective on opioid dependent patients o Can use for patients over 6 years of age Disadvantages o Inadequate analgesia (pt might be in real pain but might be locked out) o Adverse effects of opioids o Can only be given to alert and responsible patients Contraindications o Cognitive impairment o Limited understanding and confusion o Physically unable to push button o Patient refusal Loading dose à dose administered prior to PCA commencing Demand (bolus) dose à dose released by pt when the button is pressed Background infusion à continuous present dose Lockout period à pre-programmed time when no bolus dose is given (even when button is pressed) Dose limit à total cumulative dose for certain time (about 4 hours) Nursing assessment Sedation score o S = sleeping o 0 = none o 1 = sometimes drowsy but easy to arouse o 2 = frequently drowsy but easy to arouse o 3 = somnolent and hard to arouse Assess respiration rate, BP and HR  9 Pain score Functional activity score o A = no limitation o B = mild limitation o C = severe limitation Infusion pump observations o Infusion rate o Total demands and whether that number of demands are good or bad? o Total amount of drug infused Complications Respiratory depression Pain If apneic – CODE BLUE Respiratory depression Arouse pt and deep breath Urinary retention Turn off pump Reached dose limit Administer Oxygen Sedation Administer Naloxone Severe itching Inform NIC or MET call Seizures Nausea and vomiting EPIDURAL Regional anesthesia Catheter in epidural space Can use opioid or local anesthetics Results in anesthesia or analgesia Advantages Post-op pain management Rapid onset Need smaller doses Figure 4 - A dermatome is an area of skin that Can deliver by syringe or volumetric pump is mainly supplied by a single spinal nerve. Effective below level of block Works from about 3-4 dermatomes higher than insertion site Complications Pt consent Coagulopathy or warfarin haematoma Hypotension Sepsis Spinal injury / surgery / CNS illness Alcohol or drug intoxication Inadequate analgesia Restricted to bed Respiratory depression Sedation or apnoea High blocks Urinary retention Epidural haematoma  10 Headaches Spinal cord compression o Leg weakness o Severe back pain Dermatome assessment C8 à little finger numb à high block o Might cause respiratory depression T4 à block near nipple line à might impair cardiac function Check dermatomes every 6hrs or PRN o If pt complaints of pain o Prior to top ups o 20-30 min post epidural bolus o 20-30 min post rate change o If complications are suspected Nursing assessment BP, HR and RR Sedation score Pain score IV access Urine output Adjust analgesia ALTERED FLUID, ACID-BASE AND ELECTROLYTE IMBALANCES Body fluid distribution Intracellular (ICF) – inside cells Extracellular (ESF) – outside cells o Interstitial fluids § Found in spaces between cells o Intravascular fluid § Found in blood vessels Plasma o Transcellular fluids § Urine § Sweat § Digestive secretions § CSF § Plural secretions Figure 5 - Electrolyte and serum normal values  11 Fluid deficit and excess Fluid deficit Fluid excess Heart rate Decreased systolic Increased Pulse amplitude Increased Increased respirations Normal Moist crackles & wheezes Jugular vein flat Distended Oedema Rare Dependent Skin Turgor Loose, poor turgor Taut Urine output Low and concentrated May be low or normal Weight loss Gain RASS System Renin Angiotensin Aldosterone System Maintains intravascular fluid balance and blood pressure ADH system ADH is produced by the posterior pituitary gland and regulates water retention from the kidneys. BP and blood volume decrease and osmolality increase Osmoreceptors in hypothalamus stimulate PPG Release ADH ADH increase distal tubul permiability increased water abosorption  12 Fluid volume deficit FVD is a decrease in intracellular, interstitial and/or intra-cellar fluid in the body. FVD can be caused by, Excessive blood loss Insufficient fluid intake Regulatory mechanism failure Fluid shifts Dehydration à loss of water only Pathophysiology Common causes of FVD Excessive loss of GIT fluid from, o Vomiting o Oral trauma o Diarrhea o Sweating o Gastrointestinal suctioning o Hemorrhage o Intestinal fistulas o Chronic abuse of laxative and o Diuretic therapy – water or sodium enemas o Unable to swallow fluids Hypovolemia Caused by excessive loss extracellular fluid Decreased blood circulating volume Electrolytes are loss along with fluids causing an isotonic fluid volume deficit Water and electrolytes lost à serum sodium ion concentration remain same à other electrolyte concentrations drop à fluids drawn into vascular space à intercellular fluids depleted à hypovolemia à sympathetic NS stimulated à (1) Thirst à (2) ADH and aldosterone released à sodium and water retention increased in kidneys à blood volume increase Third spacing Shift of fluid from vascular space into an area where it is unavailable to support normal physiological processes. Abdomen Bowel Pleural or peritoneal space In soft tissue water trauma Nursing care Diagnostic tests 1. Serum electrolytes a. Isotonic FD = sodium level normal b. Water loss à Na­ c. Potassium ¯ 2. Serum osmolality a. Isotonic fluid loss from water loss b. Water loss à osmolality ­ c. In Isotonic FD à normal 3. Hb and hematocrit a. Intravascular volume ­ therefore hematocrit ­  13 4. Urine specific gravity and osmolality a. Kidneys conserve water, therefore both ­ 5. Haemodynamic pressure a. Arterial and venous pressure ¯ Sodium imbalance Imbalance Possible causes Manifestations Hyponatremia Excess sodium loss Anorexia, N&V, diarrhea Serum sodium < 135mEq/L Water gain *** Headaches Critical level > 120mEq/L Excessive hypotonic solutions Altered LOC Cirrhosis, renal failure, heart disease *** Muscle cramps and tremors Seizure and coma Hypernatremia Diarrhoea Dry mucus membranes Serum sodium >145mEq/L Diabetes insipidus Restless Critical level < 250mEq/L Oral electrolyte solutions Weakness Excessive IV fluids Thirst Hyperosmolar tube feeding formulas Increased body temperature Inability to obtain water Altered mental status Altered thirst sensation Decreased LOC Inability to respond to thirst Muscle sweating Profuse sweating Seizures Hyponatremia Diagnosis Serum Na and osmolality o Decreased in hyponatremia § Na < 135mEq/L § Osmolality < 275mOsm/kg 24-hour urine specimen o More Na – water gain o Less Na – Diarrhea and vomiting Medications Sodium containing fluids o PO, NG or IV Isotonic ringer solution Isotonic saline (0.9% NaCl) Critical pt à IV 3% or 5% NaCl Hypo – too much à loop diuretics Nursing care Fluid balance charts Use IV control devices Fluid restrictions Monitor serum electrolytes and osmolality Assess neurological changes Assess muscle strength and tone  14 Hypernatremia Serum sodium level more than 145mEq/L Serum osmolality more than 295mOsm/kg Water deprivation test o Diabetes insipidus § No change in urine osmolality and gravity Medications Oral and IV water replacements o 0.45% NaCl or 5% Dextrose Diuretics Nursing care Monitor and maintain water replacements Monitor neurological functions Safety precautions Orient to place, person and time Potassium imbalance Imbalance Causes Manifestations Hypokalaemia Excess GI loss (vomit & diarrhoea) Cardiovascular Serum level < 3.5mEq/L Renal losses (diuretics) Arrhythmias Critical level < 2.5mEq/L Inadequate intake ECG changes Shift into cells – alkalosis Gastrointestinal N&V Anorexia Decreased bowel sounds Ileus Musculoskeletal Muscle weakness Leg cramps Hyperkalaemia Renal failure Cardiovascular Serum level > 5.0mEq/L Potassium sparing diuretics Tall T waves widened QRS Critical level > 6.5mEq/L Adrenal deficiency Arrhythmias Excess potassium intake Cardiac arrest Aged blood Gastrointestinal Shift into cells – acidosis N&V Abdominal cramping Diarrhea Neuromuscular Muscle weakness Paraesthesia Flaccid paralysis  15 Diagnosis Serum K o Hypo – less than 3.5mEq/L o Hyper – more than 5mEq/L o ABG § Hypo – increased pH o Renal function studies § Serum urea and creatinine o ECG Medications Hypo o Oral and parenteral supplements Hyper o Moderate to severe § Calcium gluconate (IV) o Diuretics à frusemide o Sodium polystyrene sulphate (GI or rectal) Nursing care Check serum K levels regularly Monitor vital signs (orthostatic) If on digitalis – check for toxicity Diluted IV potassium Skeletal muscle strength and tone Check RR and depth Fluid balance charts Monitor for fluid volume excess Acid- Base balance Buffer systems Buffers are substances that prevent major changes in pH by removing or releasing hydrogen ions pH à normal range is 7.35-7.45 Measure of the hydrogen ion concentration 7.45 = alkalosis HCO3- Normal range = 22-26 mEq/L PaCO2 à partial pressure of CO2 in the arterial blood Normal range = 35-45 mmHg 45 mmHg = hypercapnia PaO2 à partial pressure of oxygen in the arterial blood Normal range = 80-100 mmHg  16 Metabolic acidosis Low pH and low bicarbonate Risk factors o Acute lactic acidosis o Renal failure o Type 1 diabetes o Diarrhea, GI suction or fistula Diagnosis o ABG § pH ¯ and HCO3- ¯ o serum electrolytes § Mg ¯ and K ­ o ECG o BGL – renal function Medications o Give bicarbonate § If severe give IV § If chronic give oral o Diabetes § Give insulin § Fluid replacement Nursing care o Check vital signs regularly o Heart and lung sounds o Fluid replacement o Check for Oedema o Track urine output o Weigh regularly o ECG o Diuretics o Capillary refill time o Assess neurological function o ABG o Falls risk!!! Metabolic alkalosis High pH and high bicarbonate Caused by o Loss of acid o Excess bicarbonate Metabolic alkalosis à high pH à lungs try to bring it back to normal à slow down RR à CO2 retained à PCO2 gets ­ Risk factors o Hospitalization o Hypokalemia o Alkaline solution treatment Diagnosis o ABG § pH ­ and bicarbonate ­ o serum electrolytes § K ¯ and Cl¯ § Urine pH low § ECG Medications o Restoring normal fluid volume § NaCl and KCl solutions given  17 o Severe cases § Diluted HCl or Ammonium Cl- Nursing care o RR, depth and effort o Daily weight o Oxygen saturation o IV medications and fluids o Skin colour (central cyanosis???) o Monitor serum electrolytes o Mental status and LOC o ABG o Fowler or semi-fowler position for o Osmolality easy breathing o Oxygen therapy Respiratory acidosis Excessive dissolved carbon dioxide or carbonic acid Low pH and PaCO2 ­ Risk factors o Acute or chronic lung disease o COPD o Excessive narcotic analgesia o Airway obstructions o Neuromuscular disease Diagnosis o ABG à pH¯ and PaCO2 ­ o If chronic à HOC3- is ­ o Serum electrolytes § Cl ¯ o Pulmonary function test Medications o Bronchodilators o Antibiotics o Reduce risk of excessive analgesia § Naloxone Nursing care o Respiratory status o Lung sounds o ABG results o Deep breathing o Fowler and semi fowler o Increase fluid intake o Oxygen therapy o Drainage Respiratory alkalosis High pH and low PaCO2 Caused by hyperventilation à low CO2 Risks factors - Anxiety with hyperventilation o Mechanical ventilation Diagnosis o ABG - High pH and low PaCO2 o Chronic – serum bicarb ¯ Medications - Sedative or Anti-anxiety Nursing care o Assess respirations o Subjective data - Why is pt anxious? o Breath into paper bag  18 PHARMACOLOGY BASICS Pharmacology is the study of the biological effects of chemicals. Nurses responsibilities, Administration of drugs Assessing adverse effects Intervening to make the drug regime more tolerable for pt Providing pt education about drugs Monitoring and prevention of medication errors. Generic drugs à chemicals that are produced by companies that are solely involved in manufacturing medications. OTC drugs à Over the counter medications that are available without prescriptions for self-treatment. OTC drugs mask signs and symptoms of underlying disease, making diagnosis difficult. Taking these drugs with prescription meds can result in drug interactions and interfere with drug therapies. Not taking these drugs as directed can result in overdoses. Pharmacodynamics is the science of dealing with interactions between living organisms and foreign chemicals. Drug actions 1. Replace or act as a substitute for missing chemicals 2. To increase or stimulate certain cellular activities 3. To depress or slow down cellular activities 4. To interfere with the functioning of the foreign cells Receptor cells à receptor cells react to certain chemicals. The better the fit à more pronounced the reaction. Enzymes à break down chemicals à open receptor cells. Pharmacokinetics Onset of drug action Drug half life Timing of peak effect Duration of drug effect Metabolism and biotransformation of drugs Site of excretion Chemical concentration à The amount of drugs needed to cause a therapeutic effect Loading dose à A higher dose that is usually used for treatment Dynamic equilibrium à The actual concentration that a drug reaches in the body Dynamic equilibrium is affected by, Absorption Biotransformation Distribution Excretion  19 Absorption Affected by route of administration Oral medications are affected by food in the stomach First pass effect o Medications metabolized in the liver before going into the rest of the body Distribution Protein binding Blood-brain barrier Placenta Breast milk Biotransformation Mostly happens in the liver Breaks down medications Prevents medication adverse effects Excretion Mostly done by kidneys Half life Half-life is the time it takes for the amount of drugs in the body to decrease to ½ of the peak level Half-life is affected by absorption, distribution, biotransformation and excretion of drugs. Factors affecting drug effects Weight Physiological factors Immunological factors Age Pathological factors Psychology Gender Genetics Environment Drug tolerance Cumulative effects Drug – drug interactions Can occur anytime when 2 or more drugs are taken together. Can occur at, Site of absorption Excretion Distribution Site of action Biotransformation Adverse drug effects Drugs may have other effects on the body besides the therapeutic effect. Reasons, The person can be sensitive to the drugs being given. The drugs’ action on the body cause other responses Person is taking too much or too little of the drugs Dermatological reactions Rashes and hives o Abnormalities in skin, redness and blisters o Might have to discontinue medications Stomatitis o Inflammation of mucus membranes à might need frequent mouth care  20 Drug induced tissue and organ damage Superinfections o Destruction of the normal flora of the body o Fever, diarrhea, vaginal discharge o Interventions § Mouth and skin care § Antifungal meds § Stop drug use Body dyscrasia o Bone marrow suppression o Fever, chills and weakness o Interventions § Blood clots § Protective isolation Toxicity Assessment Interventions Liver Fever, nausea, jaundice, Discontinue meds change in colour of urine and stool, elevated liver enzymes. Kidney Change in urinary Notify doctor pattern, elevated BUN Change dose and creatinine Stop meds Sensory effects Ocular toxicity o Assessment = visual changes o Monitor vitals when giving such meds Auditory damage o Damage to 8th cranial nerve o Monitor for hearing loss o If hearing loss found, discontinue meds and notify doctor Neurological effects CNS effects Extrapyramidal symptoms (EPS), o Altered LOC also known as extrapyramidal side o Prevent injuries and falls! effects (EPSE), are drug-induced Atropine – like (anticholinergic) effects movement disorders that o Dry mouth, urinary retention and blurred vision include acute and tardive symptoms. These symptoms o Mouth care include dystonia (continuous o Ask to void before giving meds spasms and muscle Parkinson’s like syndrome contractions), akathisia (motor o Muscle tremors and changes in gait restlessness), parkinsonism (charac o Discontinue meds teristic symptoms such as Neuroleptic malignant syndrome rigidity), bradykinesia (slowness of o Extrapyramidal symptoms movement), tremor, and tardive o Discontinue meds dyskinesia (irregular, jerky movements).  21 Teratogenicity Teratogenic drugs: A teratogen is an agent that can disturb the development of the embryo or fetus. Teratogens halt the pregnancy or produce a congenital malformation (a birth defect). Advise parents on possible side effects Weigh out benefits vs. risks  22 RESPIRAPTORY SYSTEM CHEST DRAINAGE Pleural drainage Thoracic cavity is a closed space Negative pressure keeps the lungs inflated When the cavity is damaged, the pressure becomes (+) and lungs collapse o Chest tubes establish (-) pressure by removing air or fluid Uses à after cardiac surgery à prevent tamponade Chest drains there are 3 chambers o collection chamber o water seal chamber o suction control chamber types of fluids inside can be o blood o serosanguineous o pleural fluid water chamber should NOT have bubbles (leak!) water level should go up and down as pt breath (swing is okay) The level of water is what determines the (-) suction NOT the value on the suction regulator! Assessment steps for ICCs Check the dressing No dependent loops No striping or milking Check the drainage rate Check for bubbles Check water level in water and suction chambers Adjust bubbles – gentle bubbling Check vacuumed unit ICC documentation Respiratory assessment Amount of suction Amount of drainage Chest drain chart Swing Bubbles Pain relief Pt education Progress notes  23 CHEST X-RAY Assess for technical quality! Then check for ABCDEF … A = airways B = bones and soft tissue C = cardiac silhouette (mediastinum) D = diaphragm (gastric bubble) E = effusions (pleura) F = fields (lung fields) Also check for lines, tubes, devices and past surgeries. VENTILATORY DISORDERS Acute bronchitis Bronchitis is the inflammation of the bronchi. (inflammation of the larger airways of the lungs) Causes o Smoking o Impaired immunity Infectious bronchitis is commonly caused by bacteria and virus that damage the mucosa Inflammatory bronchitis is caused by inhalation of toxic gases or chemicals. o The inflammatory response to infection or tissue damage from inhaled substances cause § Capillary dilation § Oedema of mucosal lining This leads to excessive mucus formation Capillary epithelium damaged Immune responses of leukocytes and macrophages inhibited by the bacterial activity o High risk of infection Mucosal irritation, mucus and coughs o Bronchospasms Acute bronchitis evidenced when a non-productive cough becomes productive. Manifestations Productive cough Fever Paroxysms – sudden recurrence /attacks General malaise Pleuritic pain Diagnosis History and clinical presentation Chest X ray Treatments Symptom relief Increase fluid intake Antibiotics Paracetamol Codeine (cough) Bronchodilators  24 Nursing care Increased fluid intake OTC analgesia Cough precautions Look out for medication overdose! Reduce stress Pneumonia The inflammation of the lung parenchyma (respiratory bronchioles and alveoli). Can be infectious or not infectious. Infectious à bacteria, virus or protozoa Non-infectious o Aspiration of gastric contents o Inhalation of toxic substances There are many ways of getting this disease o Hospital acquired o Healthcare associated o Community acquired o Opportunistic infections “Streptococcus pneumoniae” Found in upper respiratory tract Spread by droplet contamination Infection results from aspiration of resident bacteria In lower respiratory tract, these organisms cause exudate and Oedema Respiratory bronchi and alveoli fill with serous exudate, RBC, Fibrin and bacteria à consolidation Lower lobes are mostly affected à because of gravity Consolidation of the large portion of lung lobe à lobar pneumonia Patchy consolidation involving several lobes à bronchopneumonia  25 Manifestations Bacterial pneumonia o Rapid onset chills o Fever o Productive cough (purulent sputum) o Pleuritic pain o Limited breath sounds o Fine crackles / pleural rub o Dyspnea o Cyanosis Bronchopneumonia o Fever o Cough o Scattered crackles o Dyspnea (less common) o Tachypnea Complications Lung Abscess o Local area of lung necrosis o Pus formation o Weight loss and night sweats o Foul smelling sputum Emphysema o Accumulation of purulent exudate in pleural cavity o Need chest X ray or CT o Thoracentesis à to remove exudate o Bacterial infection in the exudate can cause endocarditis, peritonitis or meningitis Viral pneumonia More common in children Secondary to bacterial pneumonia Herpes and measles virus can cause this Mild disease Seen in older people and pts with chronic conditions too Community epidemics Headache, fever, fatigue, malaise, muscle aches and dry cough Aspiration pneumonia Aspiration of gastric contents Emergency surgery, obstetric surgery, impaired swallowing Depressed cough and gag reflexes Common in old people Gastric contents (acidic) may cause inflammation, edema and respiratory failure Take precautions for old people Diagnosis of pneumonia Chest XR Sputum gram stain  26 Sputum culture and sensitivity o When this test comes out negative à try serology testing FBC à elevated WBC Pulse oximetry à oxygen would be less than 95% ABG à less oxygen below 75-80mmHg) Fiber optic bronchoscopy Medications Broad spectrum antibiotics Bronchodilators o Salbutamol o Ventolin o Atrovent Mucolytic agents (breaks up mucus) o Acetylcysteine Pleural effusions Pleural space contains 10-20ml of serous fluid. PE is a collection of excess fluid in the pleural space. Can be caused by, Systemic disorders o Heart failure o Liver and kidney disease o Rheumatoid arthritis Local disorders o Pneumonia o Cancer o Trauma Excess fluid can be, Transudate – high capillary pressure Exudate – high capillary permeability Manifestations Dyspnea Pleuritic pain Limited chest movements Diminished breath sounds Nursing care Support respiratory function Treatments o Maintain oxygen stats Thoracentesis (draw out with needle) Impaired gas exchange Treat underlying condition o Oxygen therapy Repeated drainage Activity tolerance Thoracotomy surgery (rare) Teaching home care Parenteral antibiotics Install irritant (talc) Water seal chest tube drainage  27 Pneumothorax Accumulation of air in the pleural space. Spontaneous pneumothorax Air filled blister on the lung surface rupture and air fills the pleural space Can be primary or secondary o Primary § smokers § Mostly effect tall, slender 18-40yo men § Cause is unknown A secondary spontaneous pneu § High altitude flying mothorax (SSP) is defined as § Rapid decompression in scuba diving a pneumothorax that occurs as a o Secondary complication of underlying § More serious lung disease. In § Overdistension and rupture of alveoli contrast, primary spontaneous p § Older people neumothorax occurs without a § Underlying Lung diseases – COPD precipitating event in the Manifestations absence of clinical lung disease. o Depend on size, extent and disease o Pleuritic chest pain o Shortness of breath o RR­ and HR ­ o Asymmetric chest wall movement o Absent lung sounds on affected side o Hypoxemia Traumatic pneumothorax Blunt, penetrating chest trauma Open pneumothorax Penetrating chest trauma Stabbing, gunshot Air move freely between pleural space and atmosphere Rapid lung collapse Hypoventilation Closed pneumothorax Motor accidents Falls CPR Ruptured trachea or bronchus Ruptured esophagus Iatrogenic pneumothorax Puncture or laceration of visceral pleura Central line placement Thoracentesis Bronchoscopy or biopsy  28 Manifestations Pain Diminished lung sounds Dyspnea Asymmetric chest movements Tachypnea Hemothorax Tachycardia Tension pneumothorax When injury to chest wall or lungs allows air to come into the pleural space but prevents it from escaping back out. This causes the lungs to collapse à the pressure goes into the mediastinum, opposite lung or other organs. This is a MEDICAL EMERGANCY!!! Manifestations Severely impaired ventilation Impaired venous return to heart Other pneumothorax symptoms Hypotension Distended neck veins Displaced trachea (to the unaffected side) Shock Nursing care Vital signs and respiratory status Chest tubes Fowlers or semi-fowlers position for ease Rest of breathing Drainage Oxygen therapy Haemothorax Blood in the pleural space Chest trauma, surgery, diagnostic procedures Tumors, pulmonary infarction, infection Manifestations Diminished lung sounds Symptoms similar to pneumothorax and PE  29 Treatments Thoracentesis – put a needle in and get the stuff out Thoracotomy - surgical opening à put a drain tube Chest tube drainage Blood transfusion Nursing care Maintain respiratory function Maintain cardiac output Impaired gas exchange Fluid deficits No smoking GAS EXCHANGE DISORDERS Asthma Chronic inflammatory disorder. A condition in which a person's airways become inflamed, narrow and swell and produce extra mucus, which makes it difficult to breathe. Wheezing, breathlessness, chest tightness and coughing often seen. Risk factors o Allergies o Workplace exposure o Genetics o Infections o Exercise o Stress o Pollution o Cold air Manifestations o Dyspnea o Wheezing o Tachypnea o Cough o Tachycardia o Anxiety o Chest tightness o Lung crackles Status asmaticus is the prolonged, severe asthma that does not respond to routine treatment. Endotracheal intubation Mechanical ventilation Aggressive drugs  30 Stimulus Chemical mediator release Inflammatory Bronchospasm cell activation Increased Mucus Epithelial airway Oedema production damage resistance increase Increased Acute asthma Airway airway Obstruction attack limitations resistance Acute asthma Acute asthma Acute asthma attack attack attack Diagnosis Respiratory function test Nursing care o Residual volume ­ Skin colour and temperature o Vital capacity ¯ Level of consciousness Bronchial provocation test Cyanosis ABG Assess ABG results o might should hypoxemia Oxygen therapy o low PaO2 and low PaCO2 Fowlers or semi-fowlers position o mild respiratory alkalosis Nebulizer o pH ­ Chest physiotherapy skin testing for allergies Increase fluid intake Provide endotracheal suctioning Medications Vital signs bronchodilators Medications on time! leukotriene receptor agonists Reduce stress and anxiety adrenergic stimulants Pt education anticholinergic drugs Asthma management plan methylxanthines  31 Mild to moderate attack Severe attack Life-threatening attack Give salbutamol 4-12 puffs via Give salbutamol 12 puffs via Give salbutamol 2x5mg nebules pMDI and spacer pMDI and spacer via continuous nebulisation driven by oxygen. Repeat every 20-30 min for the If pt is unable to breathe through first hour if needed. (sooner if the spacer, give 5mg nebule via Maintain oxygen saturations needed to relieve nebuliser. breathlessness) Adult: 92% or higher Start oxygen therapy if oxygen Children: 95% or higher saturation is below 95%. Arrange immediate transfer to Adults: 92%-95% higher level care. Children: 95% or higher When dyspnoea improves, Repeat salbutamol as needed. consider changing to salbutamol Give at least every 20 min for the via pMDI plus spacer or first hour. intermittent nebuliser (doses as for severe acute asthma) CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term for a group of progressive lung conditions including: Emphysema, Chronic bronchitis and Chronic asthma which causes chronic airflow obstructions. Risk factors – middle aged and smokers Chronic bronchitis Disorder of excessive bronchial mucus secretion. Chronic bronchitis specifically refers to chronic cough and daily mucus production for at least three months of two or more consecutive years. Manifestations Vasodilation Recurrent infections Right sided heart Congestion Hypoxemia failure Oedema Hypercapnia Distended neck veins Impaired ciliary action Hypertension Enlarged liver and Goblet cells increase in Productive cough heart size and number Cyanosis Wheezing lung sounds Thick tenacious mucus Emphysema Destruction of the alveoli walls, with resulting enlargement of air spaces. Surface area of the lungs are reduced Common to chronic bronchitis and Elastic recoil ¯ therefore passive expiration air volume ¯ emphysema Manifestations Productive cough Dyspnea Dyspnea Barrell chest Exercise intolerance Thin body Smokers cough (in the morning)  32 Tachypneic Tripod position Use accessary muscles to breath Diminished lung sounds Prolonged expiration Diagnosis Respiratory function test Ventilation – perfusion scanning Serum a1 – antitrypin levels ABG Pulse oximetry Exhaled carbon dioxide levels FBC CXR Medications Antibiotics Bronchodilators Corticosteroids Oxygen therapy Nursing care Assess respiratory status o Rate, pattern, cough etc. Monitor ABG Daily weight Increase fluid intake (2000-2500ml) Fowlers and semi-fowlers Coughing and deep breathing exercises Sputum removal – self removal or suction Rest Administer expectorant and bronchodilators Oxygen therapy Diet and nutrition Quit smoking TRACHEOSTOMY CARE A Tracheostomy is the formation of an opening into the trachea. 2nd and 3rd rings of cartilage Used for Providing long term mechanical ventilation on cases of neuro-muscular disease Facilitate weaning of mechanical ventilation (COPD) Bypass obstruction (larynx cancer) Maintain open airway (coma)  33 Temporary trachy Upper and lower airways still connected if removed. Permanent trachy No connection if removed Potential short-term complications Subcutaneous emphysema Tube dislodgement Potential long-term complications Thinning of trachea (trachemalacia) Development of tissue granulation Narrowing of airway Once removed, opening might not close on its own Dysphagia Tracheal ischemia and necrosis Fenestrated tube Cuffed tracheostomy tube Hole in the outer cannula Allow speaking Contain 3 parts Used in weaning process 1. Outer cannula (inflatable cuff, plot tube) 2. Inner cannula 3. Obturator More suitable for long term ventilation. Pts should have effective cough and gag reflex to pervert aspiration. Nursing care Find out when and why the trachy was inserted before taking over patient! Size and type of tube Check for, o Hypoxia o Infection o Pain Auscultate breath sounds Examine tube and stoma site o Redness o Bleeding o Purulent discharge Help thin and mobilize secretions o Frequent repositioning o Deep breath and cough exercise o Chest physiotherapy o Oral and parenteral hydration o Supplemental humidification  34 DRUGS ACTING ON THE LOWER RESPIRATORY TRACT Preventative and treatment measure for COPD Reduce environmental exposure to irritants Stop smoking Filter allergens from the air Avoid exposure to known irritants and allergens Open the conducting airways through muscular bronchodilation Drug type Actions Indications & Pharmacokinetics Adverse effects Drug-drug Contraindications interactions Drugs that affect the Lower respiratory tract Xanthines Direct effect on Indications Narrow Related to Many drugs the smooth Symptomatic therapeutic theophylline interact (Aminophylline) muscles of the relief or margin. levels in the xanthines. respiratory prevention of Quickly absorbed blood. system, both in bronchial asthma by the GI tract. Nicotine the bronchi and and for reversal of Metabolized in GI upsets increase blood vessels. bronchospasm the liver. Nausea metabolism. associated with Excreted by urine. Irritability COPD Tachycardia Contraindications Seizures GI problems Brain damage Coronary disease Even death Respiratory dysfunction Renal and hepatic disease Alcoholism Hyperthyroidism Sympathomimetics Beta2 selective Indications Rapidly Sympathomimetic General adrenergic agonist Acute asthma distributed after stimulation. anaesthetics (Adrenaline) attacks. injection. Bronchospasm in Transformed in CNS stimulation acute or chronic the liver to asthma. metabolites that GI upsets Prevention of are excreted in Arrhythmias exercise induced urine. Hypertension asthma. Bronchospasm Contraindications Sweating Depends of the Pallor severity of Flushing underlying condition Anticholinergic Blocks vagally Indications Onset of action is Related to bronchodilators medicated Maintenance of 15min when anticholinergic - reflexes by bronchospasm inhaled. effect of the drug. (Ipratropium) antagonising the associated with action of COPD Peaks in 1-2 Dizziness acetylcholine hours. Headache Fatigue Nervousness Dry mouth  35 Contraindications Duration of Sore throat Any condition that action is 3-4 Palpitations would be hours. Urinary retention aggravated by cholinergic drugs. Inhaled steroids Decrease the Indications Well absorbed inflammatory Prevention and from respiratory Sore throat (Budesonide) response of the treatment of tract. Hoarseness - airway. asthma. Coughing Treating chronic Metabolised in Dry mouth steroid dependent natural systems, bronchial asthma. mostly within the Pharyngeal or Contraindications liver and excreted laryngeal fungal Not used for in urine. infections. emergency during an acute attack or status asthmatics. Pregnancy or breastfeeding. Leukotriene receptor Selectively and Indications Rapidly absorbed Headache Propranolol agonists competitively Prophylaxis and from the GI tract, Dizziness Theophylline block or chronic treatment extensively Myalgia Warfarin (Zafirlukast) antagonise of bronchial metabolised in Nausea receptors for the asthma in adults the live and Diarrhoea Calcium production of and in individuals primarily Abdominal pain channel leukotriene. younger than 12 excreted in Vomiting blockers years of age. faeces. Contraindications Cyclosporine Hepatic and renal Elevated liver Aspirin impairment. enzyme Pregnancy or concentration breastfeeding. Generalized pain Mast cell stabilisers Works at the Indications Absorption is isoprenaline cellular level to Treatment of largely from the Cough (Sodium inhibit the release chronic bronchial respiratory tract. Runny nose cromoglicate) of histamines and asthma. Normally inhaled Throat irritation inhibits the Exercise induced – more puffs Unpleasant taste release of SRSA. asthma. more absorption. Headache Allergic rhinitis. Drugs that affect the upper respiratory tract Antitussives Block the cough Indications Drying effect in reflex by acting on Control non- Rapidly absorbed the mucus - (Dextromethorphan) the medullary productive cough membrane. cough centre Metabolised in the liver CNS adverse Excreted in urine. effects. Contraindications GI upset People who need to cough to maintain airway. Head injury and impaired CNS.  36 Hypersensitivity or history of narcotic addiction. Topical nasal Sympathomimetic Indications Generally, not Local stinging and Cyclopropane decongestants Relieve the absorbed burning. Affects discomfort of systemically. halothane (Ephedrine) sympathetic NS to nasal congestion Rebound cause that accompanies Any portion of congestion. vasodilation. the common cold, these medication sinusitis and that is absorbed Sympathomimetic Causing less allergic rhinitis. in metabolised in Effect. inflammation of Contraindications the liver and the nasal Lesions and excreted in urine. membrane. erosions in the mucus membrane. Any condition that can be exacerbated by sympathetic activity. Oral decongestants Shrink the nasal Indications Well absorbed Rebound OTC products mucus membrane Promotion of and widely congestion that contain by stimulating the drainage of the distributed in the Pseudo- alpha-adrenergic sinuses and body. Sympathetic Ephedrine. receptors in the improving air effect nasal mucus flow. Metabolised in Taking membrane Contraindications the liver and together can Any condition that excreted in urine. cause serious might be side effects. exacerbated by sympathetic activity. Topical nasal steroid Exact mechanism Indications Generally, not Local burning decongestant is not known. Seasonal allergic absorbed Irritation - rhinitis. systemically. Stinging Inflammation Dry mucosa after the removal Headache of nasal polyps. Contraindications Suppression of Acute infection healing can occur Active infection in a person who Avoid exposure to has had nasal airborne surgery or trauma infections. Antihistamines Selectively block Indications Well absorbed Drowsiness Vary based the effect of Seasonal and Sedation on drug. (Diphenhydramine) histamine at the perennial allergic Metabolised in receptor sites, rhinitis. the liver decreasing the Allergic allergic reaction. congestivitis. Excreted in urine Uncomplicated and faeces. urticaria Angio-oedema  37 Contraindications Pregnancy or breastfeeding. Renal and hepatic impairment. History of arrhythmias. Expectorants Enhances the Indications Rapidly absorbed. GI symptoms output of Symptomatic Headache - (Guaifenesin) respiratory tract relief from Metabolism and Dizziness fluids by reducing respiratory excretion have Mild rash the adhesiveness conditions not been and surface characterised by reported. Prolonged use tension of these dry, non- may be masking a fluids, allowing productive cough. serious easier movement underlying of the less viscous condition. secretions. Mucolytics Work to break Indications Nebulisation or GI upset down mucus in People who have direct inhalation Stomatitis - (Acetylcysteine) order to aid the difficulty coughing into the trachea Rhinorrhoea high-risk out secretions. Bronchospasm respiratory patient People who Rash in coughing up develop thick tenacious atelectasis mucus. People undergoing diagnostic bronchoscopy. Post-op patients. People in tracheostomies. Caution Acute bronchospasm Peptic ulcer Oesophageal varices  38 CARDIOVASCULAR SYSTEM NURSING CARE FOR PATIENTS WITH CORONARY HEART DISEASE Development of Atherosclerosis Progressive disease – The buildup of fats, cholesterols and other substances in and on artery walls. Stages o Fatty streak § Liquid filled smooth muscle cells o Fibrous plaque § Protrudes into arterial lumen o Complicated lesion § Atheroma à consists of lipids, fibrous tissue, collagen, calcium, cellular debris and capillaries. Collateral circulation LDL – carry cholesterol into peripheral tissues Very LDL – carry triglycerides to muscle and fat cell HDL – attract cholesterol and return it from peripheral tissues to the liver Myocardial ischemia Profusion can be affected by, Occlusion Thrombosis Spasm of already narrowed vessels Drop of BP Normal autoregulatory mechanisms fail Risk factors for coronary heart disease Non-modifiable o Age (men over 45 and women over 55) o Gender o Heredity Modifiable o Smoking o Obesity o Physical inactivity o Atherogenic diet o Hormones in women Pathophysiological o Hyperlipidemia o Hypertension o Diabetes mellites o Menopause o Thrombolytic factors  39 Diagnosis of risk factors Lab testing o Total serum cholesterol o Lipid profile o C-reactive protein (CRP) Ankle – brachial BP index (ABI) Exercise ECG testing Electron beam computed tomography (EBCT) Myocardial perfusion imaging (scintigraph) Management of risk factors Quit smoking Dietary advice Exercise Management of hypertension Medications o Lipid lowering o Aspirin o ACE inhibitors Angina Chest pain resulting from reduced coronary blood flow (could be from myocardial ischemia) May be due to, Partial obstruction of arteries Coronary artery spasm Thrombus Precipitating factors Relieving factors Manifestations Exercise Rest Chest pain (tight and heavy) Dyspnea Stress Repositioning Pallor Emotion GTN Tachycardia Cold Diagnosis ECG Stress testing Nuclear medicine studies Echocardiogram Coronary angiography Medications Nitrates o Dilate veins and arteries o Reduce myocardial work Aspirin o Reduce oxygen demand Reduce risk of platelet o Reduce preload and afterload aggregation Calcium channel blockers Reduce thrombus formation o Reduce myocardial oxygen demand o myocardial blood supply o Increase myocardial oxygen supply  40 Nursing care Assess heath history Physical assessment Medications Oxygen therapy Rest and exercise Quit smoking Psychological responses Acute coronary syndrome Coronary blood flow is acutely reduced and not immediately reversible. Manifestations Chest pain Pallor Dyspnea Tachycardia Sympathetic NS stimulation Hypotension Diaphoresis N & V and diarrhea Diagnosis ECG Cardiac muscle troponin Creatinine kinase Medications Thrombolytics Antiplatelet drugs Nitrates Beta blockers Acute myocardial infarction (AMI) Necrosis (death) of myocardial cells LIFE THREATNING!!! If circulation of the affected myocardium is not promptly restored à loss of functional myocardium affects the hearts ability to maintain an effective cardiac output à leads to cardiogenic shock and death. Myocardial infarction occurs when blood flow to a portion of the cardiac muscle is completely blocked, resulting in prolonged tissue ischemia and irreversible cell damage. Manifestations Chest pain Cool molted skin Tachycardia Diminished peripheral pulses Tachypnea Hypotension or hypertension Dyspnea Palpitations SOB Arrhythmias N&V Signs of left sided heart failure Anxiety Decreased level of consciousness Diaphoresis  41 Complications of AMI Nursing care Arrhythmias Rapid assessment and early diagnosis Pump failure Relieve chest pain Cardiogenic shock Reduce extent of myocardial damage Infarct extension Maintain cardiovascular stability Structural defects Decrease cardiac workload Pericarditis Prevent complications Psychological responses Medications Aspirin Analgesia Thrombolytic therapy Antiarrhythmics Beta-blockers Cardiac arrhythmias A disturbance or irregularity in the electrical system of the heart. Affects cardiac performance. Supraventricular rhythms arise above the ventricles. Ventricular rhythms originate in the ventricles and may be fatal if left untreated. Treatment Synchronized cardioversion o Delivers direct electrical current synchronized with the person’s heart rhythm Defibrillation o An emergency procedure that delivers direct current without regard to the cardiac cycle. Pacemaker therapy Implantable cardiovascular defibrillators Cardiac mapping Catheter ablation Sudden cardiac death Unexpected death occurring within one hour of the onset of cardiovascular symptoms. Usually due to left ventricular dysfunction Cardiac arrest is the sudden collapse, loss of consciousness and cessation of effective circulation that proceeds biological death. BLS and ALS à 2-4 min of arrest Causes Coronary heart disease PE Myocardial hypertrophy Cerebral hemorrhage Cardiomyopathy Chocking Valve disorders Electrical shock Aneurysm Acid-base imbalances Cardiac drug toxicity  42 Nursing care Treat the person, not the monitor!!! MET call Start BLS Assess effectiveness of interventions Defibrillators o Ventricular defibrillation o Pulseless ventricular tachycardia Advanced cardiac life support HYPERTENSION Blood pressure Defined as the pressure exerted by the blood against the arterial walls. HPT à prolonged excess pressure Primary HPT – no identified cause Secondary HPT – identified cause Four systems affect the blood pressure 1. Nervous Cardiovascular 2. 3. Renal 4. Endocrine Risk factors Family History Stress Insulin resistance Age Mineral intake Alcohol Race Obesity Blood pressure The pressure of the blood in the circulatory system, often measured for diagnosis since it is closely related to the force and rate of the heartbeat and the diameter and elasticity of the arterial walls. Mean arterial pressure The mean arterial pressure is an average blood pressure in an individual during a single cardiac cycle. Pulse pressure Pulse pressure is the difference between the systolic and diastolic blood pressure. It represents the force that the heart generates each time it contracts. Cardiac output The amount of blood pumped by the heart per minute. Necessarily, the cardiac output is the product of the heart rate, which is the number of beats per minute, and the stroke volume, which is amount pumped per beat. CO = HR X SV.  43 Lifestyle modifications Not at goal BP (>140/90). (>130/80 for pts with diabetes or CKD Initial drug chocies Without compelling With compelling indications indications Stage I Stage II Antihypertensives, Diuretics, ACE, BB, SBP = 140-159 SBP > 160 CCB and ARB DBP = 90-99 DBP > 100 Two drugs combo of No Diuretics, ACE, ARB, BB Diuretics + ACE, ARB, and CCB BB or CCB change ? No No Change meds and change ? change ? contract specialisits Change meds and Change meds and contract specialisits contract specialisits Heart failure Heart failure is the pathological process in which the systole and/or diastole function of the heart is impaired and as a result, cardiac output decreases and is unable to meet metabolic demands of the body. Causes Myocardial damage o MI o Cardiomyopathy o Myocarditis Metabolic disturbances o Ischemia and hypoxia o Beriberi Overload of myocardium o Pressure overload § HPT, aortic stenosis o Volume overload § Mitral regurgitation Restriction of cardiac dilation – pericardial effusion  44 Precipitating factors Infection (lungs) Arrhythmia (tachy, brady or AF) Excessive physical activity Pregnancy and delivery Anemia Inappropriate drugs Medication non-compliance Excess fluid intake Thyrotoxicosis Left ventricular failure Pulmonary congestion + low cardiac output Symptoms Exhausted dyspnea Cardiac Orthopnea o Enlarged LV Proximal nocturnal dyspnea o Gallop rhythm Acute pulmonary edema o Systolic murmur in apex Cough Pulmonary - Dry rales or moist crackles Fatigue Right ventricular failure GIT issues Hepatomegaly Renal issues Ascites Hepatic area pain Oedema Dyspnea Pleural fluids Hepatojugular reflux Heart failure lab tests Brain natriuretic peptide (BNP) -à >100pg/ml if Heart failure Stages of HF A = asymptomatic, no heart damage, have risk factors Symptoms of heart failure B = asymptomatic but signs of structural heart damage F = fatigue C = have symptoms and heart damage A = Activities limited D = End stage disease C = chest congestion E = Edema (ankle swelling) Treatments S = SOB Treat underlying causes Treat precipitating causes Improve life style Rest Limit salt intake Manage water intake Lessen cardiac load Diuretics  45 Medications ACE inhibitors Asymptomatic LV Beta Blockers dysfunction Mild to moderate Digoxin HF Moderate to severe CHF Diuretics Spironolactone The donkey Analogy Digitalis Like a carrot in front of donkey Acute heart failure Severe dyspnea Pink frothy sputum Cyanosis Orthopnea Moist rales and wheezing Treatments Body position Oxygen Morphine Diuretics Vasodilators Digitalis Aminophylline  46 Rhythm strip interpretation Figure 6 - Normal sinus rhythm Figure 7 - Sinus Tachycardia (Rate 100-160) Figure 8 - Bradycardia (less than 60bpm) Figure 9 - Premature ventricular contraction/depolarization Figure 10 - Atrial flutter (Regular or irregular beat, no P's, looks like saw tooth  47 Figure 11 - Atrial fibrillation (irregular, no P's) Figure 12 - Ventricular Tachycardia ( 20 or PaCO2 < 32 mmHg WBC < 4000 or >12000 HR > 90 bpm Sepsis à SIRS + known cause Severe sepsis à Sepsis + organ hypoperfusion Septic shock à Sepsis + shock refractory to fluid resuscitation Treatment for sepsis Early recognition Antibiotics Fluid restriction Source removal Diagnosis History (medical Hx) and physical exam Vitals (BP¯, tachy and do they have SIRS?) Lactate (this is byproduct of anaerobic respiration so more lactate means less organ perfusion) Central venous oxygenation Procalcitonin (bacteremia à procalcitonin ­) Antibiotics STAT does Then start appropriate type – start as narrow spectrum as possible Fluid resuscitation CVP – 8-12mmHg à give crystalloids and colloids MAP > 65mmHg à give crystalloids and colloids ScVO2 > 70% à RBC transfusion Medications Vasopressors o If unable to achieve adequate tissue perfusion with fluid resuscitation § Norepinephrine § Epinephrine § Vasopressin Be careful of … Be aware of giving the pt too much fluids o Keep checking oxygen stats  74 o Chest x ray Control BGL à try to keep below 10 mmol/L Corticosteroids of nothing else is working! If the patient is persistently sick, Try to change type of antibiotics Examine alternate source of infection NEUROGENIC SHOCK Neurogenic shock is the result of an imbalance between the parasympathetic and sympathetic stimulation of vascular muscles. This ceases missive vasodilation The vasodilation causes decreased preload or relative hypovolemia o Decreased cardiac output Causes Spinal cord injury (above T5)