Cardiopulmonary Notes PDF

NCM 118 – Prelim Zuñiga Medical-Surgical 3...

NCM 118 – Prelim Zuñiga Medical-Surgical 3 WEEK 1 Heart Valves CARDIOVASCULAR SYSTEM o Atrioventricular (AV) Valves Heart - closes during Systole Keywords: ❖ Bicuspid (Mitral) Valve - door between the Left Atrium and Left Heart Ventricle - time is muscle in Cardiac Emergencies - location: slightly behind the Left Sternum ❖ Tricuspid Valve note: the Heart sits in-between the Lungs - door between the Right Atrium and Right with the Left Lung being smaller to make room Ventricle - weight: ten (10) ounces o Semilunar Valves - size (adult): two (2) clenched fists - opens during Systole - size (child): one (1) clenched fist ❖ Aortic Valve Heart Layers - opens when the Left Ventricle sends oxygenated blood to the Aorta o Endocardium - inner layer ❖ Pulmonic Valve - opens when the Right Ventricle sends o Myocardium deoxygenated blood to the Pulmonary - middle layer (muscular) Artery o Pericardium Heart Arteries - outer layer (serous) o Coronary Artery ❖ Epicardium - sends oxygenated blood to the Heart - outer layer (visceral) note: adheres to the Myocardium ❖ Left Coronary Artery - protective sac that covers the Heart note: lubricates the Heart Circumflex Artery to avoid it rubbing from other organs - sends blood to the Left Atrium and Left Ventricle (side, back) Heart Anatomy Left Anterior Descending Artery (LAD) o Right Atrium - sends blood to the Septum (front) and - pumps blood to the Right Ventricle Left Ventricle (bottom) - receives deoxygenated blood from: ❖ Right Coronary Artery ❖ Superior vena cava - sends blood to the Septum (back), Left - sends blood from the upper body Ventricle (bottom), Right Ventricle, and Right Atrium ❖ Inferior vena cava - sends blood from the lower body Blood Pressure ❖ Coronary Vein Keywords: - sends blood from the Heart muscles Blood Pressure o Right Ventricle - pressure pushing against arterial walls - pumps deoxygenated blood to the: note: commonly measured in the Brachial Artery ❖ Pulmonary Artery o Preload - sends blood to the Lungs - also known as Ventricular Filling - initial stretching of the Heart muscles prior to o Left Atrium Systole (pressure at end of Diastole) - receives oxygenated blood from: o Afterload ❖ Pulmonary Veins - pressure that Heart muscles must generate to contract against Aortic Pressure o Left Ventricle - pumps oxygenated blood to the whole body o Contractility note: the Left Ventricle is slightly larger - intrinsic strength of the Heart muscles than the Right Ventricle note: affected by serum Calcium most important part of the Heart - dependent to Preload ❖ Aorta - independent from Afterload - artery that carries oxygenated blood to the whole body 1  NCM 118 – Prelim Zuñiga Medical-Surgical 3 Electrocardiogram o ST-segment - period of Complete (LR) Ventricular Keywords: Depolarization note: part of the ECG checked for diagnosis of either Ventricular Ischemia (elevated) or Hypoxia (depressed) Electrocardiogram (ECG) o T-Wave - speed: 25 mm/sec or 5 large sq./sec - known as Ventricular Repolarization - voltage: 1 mV = 10 mm or 2 large sq. note: affected by serum Potassium - every 1-mm sq. = 0.04 sec and 0.1 mV - normal PQRST: Sinus Rhythm - exhibits Positive Deflection - inverted T-Waves represent conditions affecting repolarization How Impulses Travel SA → AV → Bundle → Purkinje Node Node of His Fibers Keynotes: Sinoatrial (SA) Node is the Pacemaker of the heart generating 60 - 100 bpm Atrioventricular (AV) Node is the Secondary Pacemaker of the heart generating 40 - 60 bpm (delays impulses of the SA Node) o U-Wave Ventricles are the last line of defense of the heart generating 20 - 40 - prominent U-Waves represent conditions bpm affecting repolarization Bundle of His send impulses to either the left or right Purkinje Fibers which is then sent to either the left or right Ventricles o P-Wave - known as Atrial Depolarization from the Sinoatrial (SA) Node note: Sinoatrial (SA) Node makes P-Wave whereas the Atrioventricular (AV) Node delays impulses AV Node controls SA Node to not simultaneously make P-Wave and QRS Complex o QT Interval - time of both Ventricular Repolarization and - duration: 0.08 - 0.10 sec Depolarization - duration: 0.20 - 0.40 sec o PR Interval - time of delay of Atrioventricular (AV) Node - begins from onset of Atrial Depolarization (P- Wave) to the start of Ventricular Depolarization (QRS Complex) - duration: 0.12 - 0.20 sec o QRS Complex - known as Ventricular Depolarization from the Sinoatrial (SA) Node note: QRS Complex is made when impulses reach the Purkinje Fibers and Bundle of His CARDIOVASCULAR CONDITIONS - duration: 0.06 - 0.10 sec Hypertensive Crisis Keywords: Hypertensive Crisis - condition with blood pressure >180/120 mmHg 2  NCM 118 – Prelim Zuñiga Medical-Surgical 3 Hypertensive Emergency Predisposing Factors - situation of extreme blood pressure elevation with evidence of impending organ damage ✓ Seizure note: treatment must be given immediately ✓ Collagen Vascular Disease (e.g., SLE) ✓ Cushing’s Syndrome - must be quickly decreased to ≤140/90 mmHg - condition of overproduction of Cortisol and Aldosterone Signs of Impending Organ Damage ✓ Autonomic Dysreflexia (i.e., Spinal Cord Injury) ❖ Water Retention - abnormal overreaction to stimulation of the ❖ Dyspnea Involuntary (Autonomic) Nervous System Hypertensive Urgency ✓ Pheochromocytoma - situation of extreme blood pressure elevation without - condition of having a small benign vascular tumor at evidence of impending organ damage the Adrenal Medulla note: it leads to an irregular secretion of Epinephrine and Norepinephrine Pathophysiology CLINICAL MANIFESTATIONS Hypertensive Crisis Common Symptoms ↓ Central Nervous System Increased Blood Pressure Severe, Throbbing Headache ↓ - occurs at the nape Autoregulation Vertigo Failure - dizziness described as spinning surroundings ↓ Lightheadedness Increased Resistance Vomiting Insomnia ↓ Vasoconstriction Mood Confusion ↓ ↓ ↓ Irritability Restlessness Prothrombic Endothelial RAAS State Injury Activation Head ↓ ↓ ↓ Acute Retinopathy with Retinal Exudates - exudates are lipid residues from serous leakage due to Ischemia an impaired blood-retinal barrier note: common exudates are blood ↓ ❖ Blurred Vision Target Organ Damage ❖ Diplopia Nosebleed (Epistaxis) CAUSES / RISK FACTORS Respiratory System Precipitating Factors Orthopnea ✓ Emotional Stress (e.g., Panic Attack) - shortness of breath when lying flat ✓ Use of Stimulants - intervention: upright position (e.g., Amphetamine, Cocaine, Ecstasy, Sildenafil) - characterized with flushing, red eyes, and (↑) blood Paroxysmal Nocturnal Dyspnea (PND) pressure - shortness of breath at night that awakens patient after 2-3 hours of sleep ✓ Use of Hypertension-exacerbating Drugs - intervention: upright position (e.g., MAOI, NSAID) ✓ Uncontrolled Hypertension Exertional Dyspnea ✓ Undiagnosed Hypertension ✓ Non-compliance with Antihypertensive Drugs Cardiac System ✓ Sudden Withdrawal from Antihypertensive Drugs ✓ Pregnancy (e.g., Eclampsia) Chest Pain (Angina) ✓ Obesity Abnormal S4 Heart Sound - known as the Atrial Gallop (ta-lub-dub) note: best heard at the Apex in left side-lying position 3  NCM 118 – Prelim Zuñiga Medical-Surgical 3 - condition of late Diastolic Filling of the Ventricle ASSESSMENT and DIAGNOSIS caused by Atrial Contraction against a poor Left Ventricle (i.e., Diastolic Overload) Cardiac Troponin Test (cTN) - denotes either: - confirmatory test for Myocardial Infarction ❖ Active Ischemia ❖ (↑) Troponin I (>0.4 ng/mL) ❖ Diastolic Failure - normal: 0 - 0.4 ng/dL ❖ Stiff, Hypertrophic Ventricles Complete Blood Count (CBC) Left Ventricular Heave - indicative of Polycythemia - palpated at the Mitral Valve area - denotes: ❖ (↑) Red Blood Cell (RBC) ❖ (↑) or (↓) Hemoglobin (Hgb) ❖ Aortic Stenosis ❖ (↑) Hematocrit (Hct) ❖ (↑) Platelets Complications ❖ (↑) White Blood Cell (WBC) Intracranial Hemorrhage NORMAL VALUES Apoplexy (Stroke) Aortic Dissection BLOOD TEST - also known as Aneurysm (outpouching) MALE FEMALE Hypovolemic Shock Red Blood Cell (RBC) 4.3 - 5.9 3.5 - 5.5 - due to Abdominal Aortic Aneurysm Count x 106/μL x 106/μL Hypertension Encephalopathy White Blood Cell (WBC) 5.0 – 10.0 Count x 103/μL Central Nervous System Platelet Count 150,000 - 450,000 mm3 ❖ Decreased Level of Consciousness (LOC) ❖ Disorientation ❖ Seizure Hemoglobin Level 13.5 - 17.5 12.0 - 16.0 g/dL g/dL Head Hematocrit Level 40% - 55% 36% - 48% ❖ Papilledema - characterized by eye bulging and dilation note: occurs due to water retention Clotting / Bleeding Time Test ❖ Temporary Vision Loss ❖ (↑) Prothrombin Time (PT) ❖ (↑) Activated Partial Thromboplastin Time Body (aPTT) ❖ Hemiparesis - one-sided weakness COAGULATION TEST NORMAL VALUES Renal Failure Bleeding Time 1 - 9 minutes - intervention: indwelling catheter Clotting Time 8 - 15 minutes Genitourinary System ❖ (↓) Urine Output (20 mg/dL) - normal: 7 - 20 mg/dL Creatinine Blood Test ❖ (↑) Creatinine (>1.3 mg/dL) - normal (male): 0.7 - 1.3 mg/dL - normal (female): 0.6 - 1.1 mg/dL Complete Blood Count (CBC) - indicative of Polycythemia vera note: Polycythemia vera is a compensatory mechanism of Heart Failure due to (↓) Hemoglobin Pulmonary Artery Monitoring (PAM) / Swan-Ganz Catheterization ❖ (↑) Red Blood Cell (RBC) - route: Right-side Heart ❖ (↑) White Blood Cell (WBC) note: via Pulmonary Artery to the Inferior Vena Cava or via Subclavian / Jugular Vein to the Superior Vena Cava ❖ (↑) Hematocrit (Hct) ❖ (↓) Hemoglobin (Hgb) - assesses Hemodynamics in conditions such as: ❖ (↓) Platelets ❖ Right Ventricular Failure Arterial Blood Gas (ABG) ❖ Pulmonary Hypertension ❖ Cardiogenic Shock ❖ Hypoxemia (↓ O2 in Blood) ❖ Post-Cardiac Surgery ❖ Respiratory Alkalosis - invasive Urinalysis note: done via insertion through a Central Vein (i.e., Femoral, Subclavian, Jugular) ❖ Hematuria ❖ Proteinuria ❖ Glycosuria - if Diabetes is cause of Heart Failure ❖ (↓) Specific Gravity (7days Clinical Manifestations - cause: Anxiety, Sleep Deprivation, Hypoxemia (↑) Sensory Input, Metabolic Imbalance Central Nervous System (i.e., Respiratory Acidosis / Alkalosis) - intervention: Electrolyte Therapy, Sedative Confusion o Haloperidol (Haldol) Ophthalmic Heart Transplant Visual Halos - associated with Extracorporeal Membrane Blurring Vision (Photopsia) Oxygenation (ECMO) Yellow Colors (Xanthopsia) - procedure of replacing a failing Heart with a healthy donor Heart Cardiovascular System - reserved for patients who remain unimproved after medication and surgical treatments Bradycardia 18  NCM 118 – Prelim Zuñiga Medical-Surgical 3 Gastrointestinal System Thiazide Diuretic mnemonic: VANDA - diuretics that increase serum Calcium via inhibition of urinary Calcium excretion Vomiting Anorexia o Metolazone (Zaroxolyn) Nausea o Hydrochlorothiazide (Hytaz, Diuzid) Diarrhea - side effect: Photosensitivity Abdominal Disturbances Aldosterone Antagonist Diuretic Antihypertensive Therapy - complication: Hyperkalemia, Hyponatremia Vasodilator o Spironolactone (Aldactone) - MOA: (↓) Afterload, (↓) Blood Pressure - excretes salt and water - side effect: Hypotension - retains potassium o Hydralazine (Aprezine, Apresoline) NURSING DIAGNOSIS o Isosorbide Dinitrate (Dilatrate) Actual Physiologic Calcium Channel Blocker (CCB) - ends in -dipine Excess Fluid Volume - MOA: Vasodilation - main physiologic nursing diagnosis - avoid: Grapefruit Juice note: Grapefruit Juice exacerbates drug effect Impaired Gas Exchange o Nicardipine (Cardene) Potential Physiologic Beta-Blocker Agent Risk for Decreased Cardiac Output - ends in -olol Risk for Impaired Skin Integrity - goal: improves Exercise Quality - MOA: (↓) Afterload, Vasodilation Actual Behavioral - side effect: Dizziness, Bradycardia, Hypotension - antidote: Glucagon Defensive Coping - main behavioral nursing diagnosis o Carvedilol (Coreg) o Bisoprolol (Zebeta, Cardicor) Fear o Metoprolol (Lopressor) Potential Behavioral Angiotensin-converting Enzyme (ACE) Inhibitor - ends in -pril are Oral ACE Risk for Disturbed Thought Process - ends in -prilat are IV ACE Risk for Noncompliance with Fluid Restriction - MOA: (↓) Afterload, (↓) Blood Pressure - side effect: Dry Cough, Hyperkalemia, Hypotension Cardiac Tamponade - indication: delays progression of Heart Failure, relieves symptoms of Heart Failure Keywords: o Enalapril (Enalaprilat, Vasotec) Cardiac Tamponade o Lisinopril (Prinivil) - condition of rapid (unchecked) (↑) in blood pressure leading to fluid accumulation in the Pericardial Sac Angiotensin-Receptor Blocker (ARB) note: the Pericardial Sac can stretch up to 1-2 L - ends in -sartan - side effect: Hyperkalemia, Hypotension - even a small amount of fluid accumulation (50-100 mL) - indication: delays progression of Heart Failure, can cause serious Cardiac Tamponade relieves symptoms of Heart Failure note: normal Pericardial Fluid Volume is 15-50 mL o Losartan (Vasotec) CAUSES / RISK FACTORS o Valsartan (Diovan) Predisposing Factors Adjuvant Therapy goal: relieves symptoms of severe Heart Failure ✓ Idiopathic (e.g., Dressler’s Syndrome) - Dressler’s Syndrome occurs as post-MI effect Loop Diuretic - diuretics that decrease serum Calcium via promotion ✓ Pleural Effusion (e.g., Tuberculosis) of urinary Calcium excretion - rarely in Acute Rheumatic Fever - short-acting medication - side effect: Blurred Vision, ✓ Hemorrhage r/t Traumatic Cause Orthostatic Hypotension - e.g., Gunshot Wound, Stab Wound (at Chest) o Furosemide (Lasix, Furosan) ✓ Hemorrhage r/t Nontraumatic Cause - side effect: Hearing Loss - e.g., Anticoagulant Therapy 19  NCM 118 – Prelim Zuñiga Medical-Surgical 3 ✓ Pericarditis (either Viral or Post-irradiation) ASSESSMENT and DIAGNOSIS - COVID-19 results to Pericarditis - Radiation Therapy via Central Line (i.e., Subclavian, Chest X-Ray Jugular) results to Pericarditis - Cardiomegaly is evident - widened Mediastinum is evident ✓ Drug Reaction o Daunorubicin (Chemotherapy for Leukemia) o Procainamide (Antiarrhythmic for SVT) o Penicillin (Antibiotic for Group A Streptococcus) o Isoniazid (TB Drug) o Hydralazine (Vasodilator) o Minoxidil (Topical Vasodilator for Bald Spots) ✓ Chronic Renal Failure - Dialysis via Central Line (i.e., Subclavian, Jugular) Electrocardiogram (ECG) results to Pericarditis - used to rule out Acute Pericarditis - Sinus Tachycardia is evident ✓ Connective Tissue Disorder (e.g., SLE, Scleroderma) - evidenced by: ✓ Acute Myocardial Infarction (MI) ❖ ST-segment Elevation CLINICAL MANIFESTATIONS ❖ Low-amplitude QRS Complex ❖ Alternating QRS Complex (Electrical Alternans) Beck’s Triad mnemonic: 3D Echocardiography - swinging motion is evident o Decreased Arterial Blood Pressure (Hypotension) - compression from Pericardial Effusion of Right o Distended Jugular Vein Atrium and Right Ventricle is evident o Distant (Muffled) Heart Sound - results to soft S1 and S2 sound Central Venous Pressure (CVP) - occurs due to insulation of fluid-filled Pericardium - pressure of the Superior Vena Cava or Right Atrium - provides baseline on body volume and right Early Manifestations ventricular action symptoms occur during Pericardial Effusion - normal: 0 - 8 mmHg | 3 - 8 cm H2O - Hypovolemia: 8 mmHg - impaired Capillary Pressure MEDICAL MANAGEMENT Sharp Chest Pain - increased when Supine or upon Inspiration Pericardiocentesis - aspiration of excess fluid on the Pericardial Cavity Dull Chest Pain note: fluid is sent for laboratory testing of Tumor Cells, Bacterial Culture, and Differential Blood Count Dysphagia Dyspnea with Crackles - position: Sitting / Semi-Fowler’s Position - occurs due to increased Right Ventricular Filling - may be done either: Hoarseness ❖ Apical Pedal Edema ❖ Substernal - occurs due to increased Left Ventricular Filling ❖ Parasternal Cardiomegaly Hepatomegaly Late Manifestations symptoms occur during Cardiac Tamponade Cardiogenic Shock Pulsus Parodoxus - exaggerated drop in blood pressure of >10 mmHg upon Inspiration Pericardiotomy note: due to increased Left Ventricular Filling - also known as Pericardial Window - procedure of opening the Pericardial Sac via General - measured via Radial Pulse wherein palpation causes Anesthesia decrease in strength and rate NURSING DIAGNOSIS Other Manifestations Actual Physiologic Restlessness Anxiety Decreased Cardiac Output - main physiologic nursing diagnosis 20  NCM 118 – Prelim Zuñiga Medical-Surgical 3 Impaired Gas Exchange o Type II Epithelial Cells - produces Lung Surfactant (lipid coating Alveoli) Potential Physiologic - allows: Risk for Decreased Organ Perfusion ❖ Uniform Expansion (during Inspiration) Risk for Ineffective Tissue Perfusion ❖ Prevent Alveolar Collapse (during Expiration) Actual Behavioral Perfusion Lungs Anxiety - s - main behavioral nursing diagnosis Upper Airway Ineffective Coping o Nose Potential Behavioral ❖ Nasal Cavity Risk for Powerlessness ❖ Nasal Conchae Risk for Situational Low Self-esteem ❖ Nasal Vestibule WEEK 2 o Paranasal Sinus RESPIRATORY SYSTEM ❖ Frontal Respiration ❖ Sphenoid Keywords: o Larynx Respiration ❖ Epiglottis - gas exchange between atmospheric air (O2) and blood ❖ Thyroid Cartilage ❖ Cricoid Cartilage Types of Respiration Lower Airway o Internal Respiration - involuntary process o Trachea - Breathing is not involved - occurs only in the cells ❖ Carina note: it can occur in the absence of Oxygen o Right Lung o External Respiration - both voluntary and involuntary process Lobes of the Right Lung - Breathing is involved - occurs in the cells and environment ❖ Superior Lobe note: it cannot occur in the absence of Oxygen Middle Lobe - ❖ ❖ Inferior Lobe Types of External Respiration o Left Lung ❖ Ventilation - houses the Lung Apex ❖ Pulmonary Perfusion - blood flow right side to left side of the Heart Lobes of the Left Lung through Pulmonary Circulation ❖ Superior Lobe ❖ Diffusion ❖ Inferior Lobe - movement of gas (O2, CO2) from higher to lower concentration through Semipermeable o Diaphragm Membrane Medulla Oblongata Ventilation - controls Acid-Base Balance by adjusting CO2 that is lost - gas exchange in and out of the Airways Phrenic Nerve o Capillaries - impulses regulate rate and depth of respiration - sends oxygenated blood to Alveoli at 4 LPM - dependent on levels of pH and CO2 in the CSF o Alveoli Acid-Base Balance - receives air at 5 LPM Keywords: ❖ Ventilation Ratio - normal: 4:5 (0.8) Acid-Base Balance - CO2 is 20 times more soluble than O2 Types of Epithelial Cells - O2 is more concentrated than CO2 o Type I Epithelial Cells Power of Hydrogen (pH) - denotes Alveolar Walls (gas exchange occurs) - normal: 7.35 - 7.45 21  NCM 118 – Prelim Zuñiga Medical-Surgical 3 Partial Carbon Dioxide (pCO2) - controlled by the Lungs ✓ Body Position Change to Ease Breathing - normal: 35 - 45 - e.g., Orthopnea Sodium Bicarbonate (HCO3) ✓ Skin is either Diaphoretic, Pallor, Cyanotic - controlled by the Lungs - converted into CO2 and H2O for excretion VENTILATION-PERFUSION DYSFUNCTION - normal: 22 - 26 Shunting Lungs Compensatory Mechanism mnemonic: ROME (Respiratory Opposite Metabolic Equal) Keywords: Metabolic Alkalosis Shunting - compensatory: Bradypnea (by Medulla Oblongata) to - reduced ventilation to a Lung unit retain CO2 leading to increased HCO3 note: Shunting is a pediatric condition leading to Blue Babies due to Tetralogy of Fallot - intervention: Hyperventilation Technique - common in Hepatic Disease (Liver Cirrhosis) note: leading to Ammonia going to Brain, - leads to unoxygenated blood in moving from R to L intervention is to have patient defecate side of the Heart - cause: ARDS, Atelectasis (Lung Collapse), Pneumonia, Hyperventilation Technique Pulmonary Edema note: Nasal Flaring is common sign of ARDS 1) Hold small Paper Bag over Mouth and Nose 2) Take 6 - 12 normal breaths Dead-Space Ventilation 3) Remove small Paper Bag from Mouth and Nose 4) Take few breaths Keywords: 5) Repeat PRN Dead-Sace Ventilation Metabolic Acidosis - reduced perfusion to a Lung unit - compensatory: Tachypnea (by Medulla Oblongata) to - occurs when Alveoli have inadequate blood supply for exhale CO2 leading to decreased HCO3 gas exchange - intervention: Hypoventilation Technique - cause: Pulmonary Embolism, Pulmonary Infarction Hyperventilation Technique Silent Unit 1) Walk/Run for one (1) minute while breathing normally Keywords: though Nose 2) Exhale and pinch Nose while keeping same pace Silent Unit 3) Upon feeling Air Hunger, release Nose and breathe - mix of Shunting and Dead-Space Ventilation gently for 10-15 seconds at about half of what feels - occurs when little-to-no ventilation and perfusion are normal present 4) Return to regular breathing for 30 seconds - cause: Pneumothorax, Severe ARDS 5) Repeat for about ten (10) cycles RESPIRATORY CONDITIONS Respiratory Alkalosis - least harmful of the imbalances Pulmonary Embolism - mostly psychological Keywords: Respiratory Acidosis - compensatory: Tachypnea (by Medulla Oblongata) to Pulmonary Embolism exhale CO2 leading to decreased HCO3 - condition of obstruction by a thrombus (stationary) in the Pulmonary Artery note: Thrombus becoming to Emboli Emergency Respiratory Assessment originated from the Right Ventricle The nurse should ask themselves: “Does the patient have?” - multiple organ failure will occur within 1 hour after onset of symptoms of acute Pulmonary Embolism ✓ Troubled Breathing leading to death - e.g., DOB, SOB - cause (common): Thrombus from DVT (lower extr.) note: (+) Virchow’s Triad and DVT ✓ Use of Accessory Muscles for Breathing predisposes patient with 95% to Pulmonary Embolism - core muscle: Diaphragm - core (inspiration): External Intercostal (elevate ribs) - cause (uncommon): Thrombus from Right Heart, - core (expiration): Internal Intercostal Hepatic Veins, Pelvic, Renal (pull ribs downward) - accessory (inhalation): Sternocleidomastoid Muscle CAUSES / RISK FACTORS (elevate sternum), Pectoralis Minor (pull ribs outward) - accessory (exhalation): Abdominals Predisposing Factors (compress abdomen), Quadratum Lumborum (pull ribs down) ✓ Lung Disorder ✓ Cardiac Disorder ✓ Diminished Level of Consciousness (LOC) - Atrial Fibrillation (Hyper-Tachy-Tachy) will lead to - initial: Restlessness Cardiogenic Shock (Hypo-Brady-Brady) 22  NCM 118 – Prelim Zuñiga Medical-Surgical 3 - Hampton’s Hump may be evident suggesting ✓ Infection Pulmonary Infarction - may lead to Disseminated Intravascular Coagulation (DIC) Electrocardiogram (ECG) - problem in S1Q3T3 ✓ Diabetes Mellitus - S-Wave is too depressed in lead 1 - increased risk for DVT - abnormal Q-Wave in lead 3 - T-Wave is inverted in lead 3 ✓ Thromboembolism - Right Bundle Branch Block (Bradycardia) ✓ Sickle Cell Disease - ST-segment depression (NSTEMI) - clumping (clot-formation) of RBC due to their shape - supraventricular arrhythmia (SVT/VFib leading to Cardiogenic Shock) ✓ Polycythemia - insert RBC leads to thick blood to clot Arterial Blood Gas (ABG) Analysis - Respiratory Alkalosis (initial sx) CLINICAL MANIFESTATIONS - Hypoxemia (initial sx): 90% | PaO2 >80 mmHg Pain in Calf / Leg - due to DVT Independent Nursing Action ASSESSMENT and DIAGNOSIS ✓ Administer O2 Therapy - 2L via Nasal Cannula Initial Diagnostic Tests ✓ ET Intubation Chest X-Ray - Baseline ABG will be needed prior to Intubation - inconclusive within 1-2 hours - elevated Diaphragm is evident ✓ 12-lead ECG - prominent Pulmonary Artery is evident - must be done within 10 minutes - atelectasis may be evident 23  NCM 118 – Prelim Zuñiga Medical-Surgical 3 ✓ Anticoagulant Therapy - [insert] - giving therapy is dependent if either Coronary (needs surgery) or Pulmonary Artery Antibiotic Therapy - different from Thrombolytic Therapy (dilutes clots) meanwhile Anticoagulant Therapy (prevents clot- Antibiotic increase and clot-information) - IV Broad-spectrum Antibiotic to prevent Ventilator- - PTT (during therapy is effective if it is 2-2 ½ times acquired Pneumonia (VAP) more than PTT (baseline result) - antidote (Heparin): Protamine Sulfate o [insert] - antidote (Warfarin): Vitamin K - [insert] - assess sx of abnormal bleeding epistaxis, petechiae - hypovolemic shock sx (initial): hypo-tachy-tachy Pharmacologic Therapy for Pain ✓ Blood Transfusion Opioid - dependent if either Coronary or Pulmonary Artery - antidote (Opioid Overdose): Naloxone (Narcan) note: given via Inhalation (initially and fastest absorption) then Intravenous if contraindicated ✓ Avoid Aspirin and NSAID - exacerbating anticoagulant effect o Morphine Sulfate - NSAID: CoX-2 Inhibition - [insert] ✓ Administer Analgesic Sedatives - Morphine is allowed in low dose - s - normal (dose): 2-4 mg Morphine (in MI) o [insert] ✓ MIO - [insert] - fluid overload will aggravate condition - oliguria predisposes to Cardiogenic Shock Hypotensive Therapy Collaborative Nursing Action Vasopressor - causes vasoconstriction ✓ s - NSS D5W - s Inotropic Agents MEDICAL MANAGEMENT o [insert] Pulmonary Embolectomy - [insert] - removal of the emboli in the pulmonary artery NURSING DIAGNOSIS Pulmonary Endarterectomy - removal of the pulmonary arterial inner lining Actual Physiologic - blood vessels will heal so removal of inner lining is okay Impaired Gas Exchange Inferior Vena Cava Filter - main physiologic nursing diagnosis - catches emboli from DVT - checked through CT Scan (MDCTA) Acute Pain PHARMACOLOGICAL MANAGEMENT Potential Physiologic Anticoagulant Therapy Risk for Ineffective Peripheral Tissue Perfusion Risk for Decreased Cardiac Output Anticoagulant - subq must have no hematoma because that is IM Actual Behavioral - subq 45 degree if fat, 15-30 if skinny - side effect: [insert] Anxiety - main behavioral nursing diagnosis o [insert] - [insert] Ineffective Coping Direct Oral Anticoagulant (DOAC) Potential Behavioral - lesser side effects (bleeding tendencies) but expensive - contraindicated with Thrombolytic Therapy Risk for Decisional Conflict Risk for Powerlessness o [insert] - [insert] Acute Respiratory Failure (ARF) Thrombolytic (Fibrinolytic) Therapy Keywords: Thrombolytic (Fibrinolytic) Therapy Acute Respiratory Failure (ARF) - contraindicated: CVA (increased risk brain bleeding) - s - labor deliver (L&D) CAUSES / RISK FACTORS o [insert] 24  NCM 118 – Prelim Zuñiga Medical-Surgical 3 ASSESSMENT and DIAGNOSIS Ventilation Failure Mechanism Laboratory Tests Central Nervous System (CNS) Dysfunction Metabolic Panel ✓ Drug Overdose CNS Depressant ✓ Head Trauma o Basic Metabolic Panel ✓ Infection o Comprehensive Metabolic Panel ✓ Hemorrhage - includes Liver Function Test ✓ Sleep Apnea Diagnostic Tests Neuromuscular Dysfunction Chest X-Ray ✓ Myasthenia Gravis - Atelectasis of Alveoli is evident ✓ Guillain-Barre Syndrome note: there is 300 million Alveoli meaning a patient can survive with either just the Left or Right Lung ✓ Amyotrophic Lateral Sclerosis ✓ Spinal Cord Trauma Electrocardiogram (ECG) Musculoskeletal Dysfunction Pulmonary Artery Monitoring (PAM) / Swan-Ganz Catheterization ✓ Chest Trauma - assesses Mixed Venous Oxygen Saturation (SvO2) ✓ Kyphoscoliosis ✓ Marasmus (Malnutrition) o Mixed Venous Oxygen Saturation (SvO2) - s Pulmonary Dysfunction Lung Function Test ✓ Asthma ✓ COPD o Incentive Spirometry ✓ Cystic Fibrosis - height and weight must be measured - doctor’s order needed Oxygenation Failure Mechanism o Peak Expiratory Flow (PEF) ✓ ARDS - measures exhalation (how quickly to forcefully ✓ Pneumonia exhale after deep breath) ✓ COPD ✓ PE Bronchoscopy ✓ Restrictive Lung Disease - pharynx to trachea to bronchioles ✓ Heart Failure - there is Risk for Aspiration - assess post-op for Hoarseness (complication) Post-operative Period - perform post-nebulization Postural Drainage Abdominal / Major Thoracic o Bronchoscope ✓ Side Effect - can perform suction ✓ Untreated Post-operative Pain - can retrieve biopsy ✓ V/Q Mismatch Pathology CLINICAL MANIFESTATIONS Altitude Early Phase - decreased diffusion also known as Vague Signs Normal O2 Sat (Compensatory) Restlessness - will later lead to complication Anxiety Fatigue (lack of perfusion to body tissues) Alveolar-Arterial (A-a) Gradient Headache (lack perfusion to Brain) - assesses gas exchange efficiency in Lungs - increased gradient is evident in ARF due to Hypoxemia Hypoxemic Phase also known as Obvious Signs Decompression Injury note: some patients may progress to this phase - too much oxygen from quick recovery in scuba diving within seconds and some within hours will lead to Alveolar Bursting (due Hyperoxygenation) Tachycardia (Lips) NURSING MANAGEMENT Tachypnea (Lips) Circumoral (Lips) Cyanosis Independent Nursing Action Diaphoresis Use of Accessory Muscle ✓ Administer O2 Therapy Inability to Speak in Full Sentences - 2L via Nasal Cannula Altered Mental Status Pain ✓ Monitor MIO - pain medication must be administered to allow - due to Risk for Fluid Overload that may lead to Kidney interventions to follow through smoothly Failure (check for Oliguria) 25  NCM 118 – Prelim Zuñiga Medical-Surgical 3 ✓ Provide Humidification o Fraction of Ingested O2 (FiO2) - use distilled water - expressed in decimal or percent - must above the line - represents proportion of inhaled O2 - prevents drying of airway passages (due to oxygen being higher concentration) Ventilation affects PaCO2 ✓ Provide Mouth Care goal: PaCO2 of 40-50 (for ARDS to avoid leading to ARF) - use NSS (safest since it is Isotonic to balance solutions in body) or Betadine (not Bactidol since it has alcohol o Tidal Volume (Vt) leading to further drying) - quiet breathing - position in side-lying position to drain - O2 displaced in gas being inhaled ✓ Teach Deep Breathing / Pursed Lip Breathing o Respiratory Rate - promote PNS stimulation - also known as Back-up Rate - safety mechanism of the MechVent ensuring ✓ Reposition patient receives minimum RR (12-20) - Semi-Fowler - means that patients do not initiate - prevents pressure ulcers, pneumonia spontaneous breathing Collaborative Nursing Action Ensure Ventilator Settings ✓ Intubation Ventilator Modes - listen for Lung sounds after insertion (if absent: to provide ventilation without Barotrauma reinsert) to allow respiratory muscles to rest - prepare: (can get in Emergency Cart) o Synchronized Intermittent ❖ Laryngoscope Handle (has battery) Mandatory Ventilation (SIMV) - battery is needed for flashlight to function - also known as Traditional Mode - most uncomfortable mode ❖ Laryngoscope Blade - can be assisted, controlled, or supported - Macintosh III (curved) - provides mandatory breaths with fixed - Miller (straight) Tidal Volume - not used for weaning ❖ Cuffed Endotracheal Tube - contraindicated: Patient-initiated ❖ Large Oral Airway Breathing - opens airway - prevents patient from biting equipment o Pressure Regulated Volume Control (PRVC) - prevents tongue from covering epiglottis o Pressure Control (PC) o Volume Control (VC) ❖ Stylet (Bougie is more elastic) o Pressure Support (PS) - guides in intubation - indicated: Patient-initiated Breathing (no Back-up Rate) ❖ Face Mask - most comfortable mode ❖ 10 cc Syringe - to inflate balloon with air (not more, not less) o Airway Pressure Release Ventilation (APRV) - overinflation may cause Laryngeal Nerve Problem Common Ventilator Settings ✓ Mechanical Ventilation - provides only ventilation (no oxygenation because o Tidal Volume (6-10 mL/kg) Lungs will function for this) o PEEP (5-20) - airway must always be clear for MechVent to function o Rate (10-25 [acidosis]) optimally so perform suction (only when necessary) o PC (5-25) Nursing Consideration Set appropriate Ventilator Alarms Instill 2cc NSS then Hyperoxygenation to release Ventilator Alarms mucous from walls Use Sterile Technique (one-time use of equipment) Inspiration Assist in Positioning (upper torso in elevation not only head as it will impede trachea) o High Inspiratory Volume Baseline ABG will be needed to check success - denotes: Ventilator Adjustments (ABG) ❖ Disconnection ❖ Leak Oxygenation ❖ Anxiety (increased RR demand) affects PaO2 ❖ Increased Back-up Rate goal: PaO2 of >55 (for ARDS to avoid leading to ARF) o Low Inspiratory Volume o Positive End-Expiratory Pressure (PEEP) - denotes: - total capacity of Lungs - prevents Alveolar Collapse ❖ Mucous Plug ❖ Obstruction 26  NCM 118 – Prelim Zuñiga Medical-Surgical 3 ❖ Decreased Back-up Rate - complication: Thrombocytopenia ❖ Shallow Breaths PHARMACOLOGICAL MANAGEMENT Expiration Antidote Therapy o High Expiratory Volume - denotes: Naloxone (Narcan) - Inhalation / IV ❖ Anxiety (increased RR demand) - Opioid overdose ❖ Increased Back-up Rate ❖ During Nebulization Flumazenil (Romazican) - IV o Low Expiratory Volume - Benzodiazepine overdose - denotes: - Barbiturate overdose ❖ Air Leak Bronchodilator Therapy ❖ Bronchopleural Fistula (new opening leading to Leakage) Bronchodilator - contains steroids (ant inflammatory) Alarm - sx: Tachypnea Tachycardia (Palpitations) o High-rate Alarm Short-acting Beta-2 Agonist (SABA) - denotes: o Albuterol (Ventolin) ❖ Agitation - ultrasonic nebulization (USN) ❖ Decreased Tidal Volume ❖ Decreased Back-up Rate Anticholinergic Bronchodilator - given in conjunction with SABA (dual vent) o Low-rate Alarm - denotes: o Ipratropium Bromide (Atrovent) - ultrasonic nebulization (USN) ❖ Apnea (Back-up Rate usually provided) ❖ Over Sedation Antibiotic Therapy Airway Pressure Broad-spectrum Antibiotic - IV o High Airway Pressure - to prevent Ventilator-acquired Pneumonia (VAP) - peak pressure of >35 - denotes: o Piperacillin-Tazobactam (Piptaz) - covers wide range of bacteria (Gram-positive and ❖ Kink in Tube / Circuit Gram-negative) ❖ Water in Circuit - severe infections ❖ Patient Coughing / Gagging (fighting the MechVent) Anti-inflammatory Therapy ❖ Bronchospasm ❖ Thick Mucous (for suctioning) Corticosteroid ❖ COPY, ARDS, CHF, Large Effusion, - complication: Superinfection Pulmonary Edema o Dexamethasone o Low Airway Pressure - also acts as Lung Surfactant - denotes: o Hydrocortisone ❖ Disconnection - [insert] ❖ Loose Circuit ❖ Inadequate Cuff Inflation Hypotensive Therapy ❖ Poorly Fitted Mask ❖ Mucous Plug Vasopressor ❖ COPD - induces vasoconstriction - NSS D5W MEDICAL MANAGEMENT Positive Inotropic Agents Extracorporeal Membrane Oxygenation (ECMO - increases cardiac output by adrenergic receptors - acts like Dialysis - sx: Tachycardia - removes blood through large catheter then oxygenates blood while removing CO2 o Dopamine - bypasses Heart and Lungs meaning oxygenated blood o Dobutamine goes directly to the Aorta o Norepinephrine - MechVent gives Ventilation, ECMO gives Oxygenation - [insert] - closely monitor Platelet Count - before ECMO: IV Heparin (Anticoagulant) Diuretic Therapy - Platelet Transfusions may be needed daily due to continuous consumption of sheer force of ECMO Potassium Wasting Diuretic 27  NCM 118 – Prelim Zuñiga Medical-Surgical 3 - to reduce fluid overload and pulmonary congestion due to cor pulmonale ✓ Smoking o Furosemide (Lasix) Predisposing Factors - [insert] ✓ Male Potassium Sparing Diuretic ✓ Advanced Age - to reduce fluid overload and pulmonary congestion ✓ Post-menopause due to cor pulmonale Other Factors o Spironolactone (Aldactone) - [insert] Structural Changes (Upper Airway) will need surgical treatment NURSING DIAGNOSIS ✓ Tonsillar Hypertrophy Actual Physiologic ✓ Abnormal Posterior Jaw Positions (one or both) ✓ Craniofacial Structure Variation Impaired Gas Exchange ✓ Macroglossia (Big Tongue) - main physiologic nursing diagnosis CLINICAL MANIFESTATIONS Ineffective Breathing Pattern Classic Signs Potential Physiologic mnemonic: Three (3) “S” Risk for Infection r/t Invasive Procedures (e.g., Intubation) Snoring Risk for Aspiration - frequent, loud snoring - followed by apnea of 10 or longer Actual Behavioral - apnea of 5 episodes/hr - resulting to abrupt night awakening with Loud Snort Anxiety - main behavioral nursing diagnosis - Sleepiness - during the day Ineffective Coping Significant Other-reported Episode of Sleep Apnea Potential Behavioral Other Signs Risk for Powerlessness Risk for Noncompliance Excessive Daytime Sleepiness - Epworth Sleepiness Scale of >10 is evident Obstructive Sleep Apnea (OSA) Frequent Nocturnal Awakening Keywords: Paradoxical Breathing - due to increased negative intrathoracic pressure Obstructive Sleep Apnea (OSA) - characterized by chest wall in and abdomen expands - condition of cessation of breathing (apnea) during during inspiration sleep due to repetitive upper airway obstruction - denotes: Insomnia (due to repeated arousals and hypoxemia during sleep) Loud Snoring with Gasping - also known as Resuscitative Gasping ❖ Risk for Poor Neurologic and Cognitive Performance Morning Headaches ❖ Organ System Dysfunction Intellectual Deterioration Irritability - resulting to increased CV risk (if untreated) leading to Impotence increased mortality risk Systemic Hypertension - characterized by: - due to increased SNS stimulation by the Medulla Oblongata leading to Ischemic Stroke while asleep ❖ Recurrent Episodes of Upper Airway Obstruction ❖ Decreased Ventilation Dysrhythmia Pulmonary Hypertension - age (30-70): 26% prevalence of OSA in USA Cor Pulmonale - sex (women): 4-9% of the 26% - due to Pulmonary Hypertension from Hypoxia leading - sex (men): 9-24% of the 26% to RVH CAUSES / RISK FACTORS Polycythemia Enuresis Precipitating Factors ASSESSMENT and DIAGNOSIS ✓ Obesity - due to large neck circumference Diagnostic Tests - increased Peripharyngeal Fat (compresses upper airway) 28  NCM 118 – Prelim Zuñiga Medical-Surgical 3 Polysomnography (PSG) Modafinil (Armodafinil) - definitive test for OSA - promotes alertness - monitors: - does not treat sleep apnea - complication (long-term): Depression ❖ Brain Activity (Electroencephalogram EEG) ❖ Eye Movement (Electrooculogram EOG) Allergy Therapy ❖ Muscle Activity (Electromyogram EMG) ❖ Heart Rate and Rhythm (Electrocardiogram ECG) Clarityn-D ❖ Respiratory Effort (Chest/Abdominal Movement) - s ❖ Airflow (Nasal/Oral Airflow) ❖ Oxygen Level (Pulse Oximetry) ❖ Body Position ❖ Snoring Sound Types of Polysomnography (PSG) o In-Lab Polysomnography - most definitive than home sleep o Home Sleep Apnea Test (HSAT) NURSING MANAGEMENT Collaborative Nursing Action ✓ Weight Loss ✓ Avoid Alcohol ✓ Position - no Supine - yes Prone (prevents tongue collapsing backward) / Side-lying ✓ Mandibular Advancement Devices (Oral Appliance) - suitable for mild-moderate OSA - for patients who cannot tolerate CPAP ✓ Continuous Positive Airway Pressure (CPAP) - suitable for moderate-severe OSA - delivers continuous airstream (during inhalation) to keep airway open during sleep Types of Continuous Positive Airway Pressure (CPAP) o Nasal Mask o Full Face Mask o Nasal Pillow ✓ Bi-Level Positive Airway Pressure (Bi-PAP) - for patients who cannot tolerate CPAP - more effective than CPAP - covers both inhalation and exhalation MEDICAL MANAGEMENT Uvulopalatopharnygoplasty (UPPP) - removes excess Throat tissue - risk for bleeding: check for Frequent Swallowing Genioglossus Advancement (GA) - repositions tongue Maxillomandibular Advancement (MMA) - repositions upper and low jaw Inspire Therapy - acts like Pacemaker but for respiration - stimulates Hypoglossal Nerve PHARMACOLOGICAL MANAGEMENT Excessive Daytime Sleepiness Therapy 29