CARDIOVASCULAR AND RESPIRATORY SYSTEM_NUSEM 1.docx

**CARDIOVASCULAR AND RESPIRATORY SYSTEM\ ***Medical Surgical and Pharmacology Nursing* **REFERENCE: Joyce Black (MedSurgical), Ignatavicius (MedSurgical -- AnaPhy), Saunders (NCLEX-RN), Brunner and Suddarth (MedSurgical)** [NURSE LICENSURE EXAMINATION] (GOAL) - NOT A VITAL SIGN -- **RESPIRATORY...

**CARDIOVASCULAR AND RESPIRATORY SYSTEM\ ***Medical Surgical and Pharmacology Nursing* **REFERENCE: Joyce Black (MedSurgical), Ignatavicius (MedSurgical -- AnaPhy), Saunders (NCLEX-RN), Brunner and Suddarth (MedSurgical)** [NURSE LICENSURE EXAMINATION] (GOAL) - NOT A VITAL SIGN -- **RESPIRATORY RATE (number of breaths)** because it should be **RESPIRATION (breathing)** **[CARDIOVASCULAR SYSTEM]** **ANATOMY AND PHYSIOLOGY OF THE HEART** **1. HEART** - from Greek word **"cardium"** - location: **mediastinum** (a space between the lungs) deviated to the left. - weight: **300 grams** **(average weight)** - size: **through the weight of the heart** - function: **pumps blood to the body** Emotions is being controlled by the brain (hypothalamus) **2. CONTRACTION** - muscle shortening (ability of the fibers to shorten). - utilizes energy in the form of ATP. [Adenosine Triphosphate] -- product of aerobic (with oxygen) metabolism. THREE important components to form ATP: 1\. oxygen 2\. glucose **3. phosphorus** What electrolyte is needed for components? **potassium** **Key items:** **Hypoxemia**: low oxygen in the blood \> patients are prone to develop anaerobic metabolism \> lactic acid production \> nerve ending irritation \> **PAIN** **Hypoxia**: low oxygen in the tissues of the body Removing IV Cannula, what pressure? *Cotton ball* but in the book, *sterile gauze*. **3. HEART WALL** - 3 layers **- endocardium: innermost layer** (if it swells, [endocarditis]) **- endo means inside** **- myocardium: middle layer (muscular layer) \> source of contraction** (if it swells, myocarditis) **- epicardium: outermost layer** **4. PERICARDIUM** (if it swells, pericarditis) - Thin and fibrous sac that encases the heart. - Pericardial space, what can be seen? ***Pericardial fluid***. - **Pericarditis** \> pericardial effusion (there is accumulation of fluid in the pericardial space) **DANGEROUS & EMERGENCY CONDITION** \> will lead to compression of the heart (cardiac tamponade) \> will affect the pumping function of the heart \> no enough blood supply to circulation \> decrease blood supply to different organs of the body \> cardiogenic shock (due to lack of contraction). **5. PULSE** - Wave of blood created by the contraction of the left ventricle of the heart. - Pulse rate: **60-100 bpm** - Locations: - **Apical pulse** (source of PMI; Point of Maximum Impulse) located to left MCL (midclavicular line) -- located to clavicle which is approximately in line with the nipple. \- **5^th^ intercostal space** \- **Peripheral pulse** - temporal -- near the ear - carotid - neck - brachial -- medial border of the humerus - radial - wrist - ulnar -- pinky side - femoral -- at the groin - popliteal - behind the knee - posterior tibial -- behind and below the medial malleolus - dorsalis pedis -- on the dorsum of the foot in the first intermetatarsal space just lateral to the extensor tendon of the great toe. **6. CORONARY ARTERY** - arises from aorta. - supplies oxygenated blood to myocardium. **I. ISCHEMIA** - reduction or restriction of blood flow and oxygen to a certain body part. - **Plaque** -- fat deposits or build up = obstructing the artery - **Thrombus (blood clots)** - **Congestion of coronary artery \> no blood supply to heart \>** **ACUTE CORONARY SYNDROME \> emergency situation \> can lead to fatality.** - **Myocardial Ischemia \> anaerobic metabolism \> lactic acid \> PAIN \> Angina Pectoris; is not a disease but a SYMPTOM.** - **Angina Pectoris (prioritize the oxygenation of the patient) REVERSIBLE.** - **Myocardial Ischemia \> Anaerobic Metabolism \> Myocardial Injury \> Myocardial Infarction (myocardial tissue death leading to heart attack) IRREVERSIBLE.** **CEREBRAL ISCHEMIA** - Brain damage - Dead tissues in the brain - Patients will develop stroke. **II. RISK FACTORS of Acute Coronary Syndrome:** - **Aging** - **Type A Personality \>** *hyperactive, impulsive, perfectionist* - **Hypertension and Diabetes Mellitus \>** prone to clot formation - **Exertion --** physical stress - **Emotion --** sudden burst of emotions - **Extreme cold --** vasoconstriction (narrowing of blood vessels) \> decreased blood flow. - **Excessive intake \>** *fat, salt, sugar, caffeine* - **Embolism (dislodged) / thrombosis \>** blood clot, thrombus is still attached to the wall of blood vessels. - **Risk increases with family history.** - **Obesity \>** *atherosclerosis (hardening of fat)* - **Men \> women (premenopausal)** - **African -- American** - **Smoking, sedentary lifestyle, alcoholism** **III. SIGNS AND SYMPTOMS of ACS:** - **Pain** - Substernal and radiating to jaw, neck, shoulder, arm and back. - **Abnormal heartbeat** -- "pounding" **(palpitation)** and chest tightness. - **Increased heart rate** **(tachycardia)**, feeling of **"indigestion".** - **Notice patient's gesture.** - Clutching of chest: **Levine's sign** is considered as the universal sign of chest pain. **Angina Pectoris** - The pain will last less than 15 min. - Relieved by rest and nitrate. **Myocardial Infarction** - The pain will last more than 15 min. - Not relieved by rest and nitrate. - Medication: **morphine** **IV. DIAGNOSTIC TESTS:** **[ECG / EKG ]** *electrocardiogram* - Graphical representation of cardiac electrical activity (CEA) - *Doppler ultrasound or 2D echo: visualize the anatomical structure of the heart.* - **QRS complex** - **Upward lines 3 waves in the ECG -- PRT waves** - **Downward lines 2 waves in the ECG -- QS waves** - **Isoelectric lines -- FLAT LINES in the ECG which signify that there is no electrical activity.** - **ECG Zones in the ACS** - **Ischemia: TIschemia \> T wave Inversion** - **Injury: InjuriST \> ST segment elevation** - **Infarction: InfarQtion \> pathologic / large Q wave** **[Serum Cardiac Biomarkers]** -- indicators of myocardial tissue death. [ELEVATION TIME: ] - **MyOglobin -- after One hour.** - **Troponin -- after Two to four hours.** - **CK-MB -- after cuatro-sais \> four to 6 hours** - **AST = SGOT -- after 8 hours.** - **LDH (lactate dehydrogenase) -- after 1 day (24 hours)** [When is it logical to check the SCB?] **In a case of MI** [Which of them is the gold standard?] **Troponin** - **Heart Status monitoring** - VS, telemetry (continuous ECG monitoring), serum cardiac biomarkers - **Enhance myocardial tissue oxygenation.** - Administer O2 therapy (priority) and position the patient to [high fowler's] \> will promote maximum lung expansion. - **Acute MI complications** - Detect: **cardiac Arrhythmia** (1^st^ complication) \> PVC (Premature Ventricular Complex) [Anong uri ang arrhythmia ang nagdedevelop kay patient?] **PVC \> if not treated, it will lead to condition known VTACH (Ventricular Tachycardia) \> V -fibrillation.** **[VTACH AND V-fibrillation = DANGEROUS !!! ]** **- Every minute chance of survival lessens \> if not treated will lead to CARDIAC ARREST.** - **Recommendations** \- First 24 hours: **CBR (complete bed rest) without BRP (bathroom privileges)** OFFER BEDPAN \- exercise: **passive rom exercises, stretching, brisk walking (30 mins; 5 mins warm up, 5 mins cool down)** \- diet: **low sodium, low saturated fat, [high fiber] (can help us promote bowel movements to prevent constipation & straining)** **Why is it necessary to avoid straining? Because straining can cause** *Valsalva maneuver* which can cause vagal stimulation that will lead to **bradycardia**. **-** instruct the patient to stop smoking - **Treat with medications** **1. Nitrate -- can be given to MI as a vasodilator to promote blood flow** **-** Nitroglycerin or NTG (Nitrostat) **-** Isosorbide Dinitrate (Isordil) **-** Isosorbide Mononitrate (Imdur) **-** **note:** **drug of choice to relieve pain in Angina Pectoris** \- **action:** **vasodilator** (relaxes blood vessels) \> promote blood flow \- **route:** **transdermal** (patch/paste; ideally in the morning after taking a bath) **It should be slow absorption.** Arm or Chest \> Non hairy and dry skin I. What if the area is hairy? What to do? **"clip" or "trim" the hair.** II\. Avoid shaving, why? **It can cause abrasion or wound which make it quick to absorption.** III\. How long should a patch stay in the body of the patient? **12 to 16 hours.** IV\. Rest period: **8 hours** V. Rotate the side of application **to avoid or prevent skin irritation.** VI\. Use gloves **to avoid absorption in your skin.** **- actions: decreases myocardial demand, decreases cardiac workload, decreases vascular resistance, decreases pain sensation.** **- route: IV (rapid effect which might affect the normal functioning of the body)** **- Adverse Effect: CNS depression \> respiratory depression** I. Before giving the medication, should you check your respiratory rate? **YES.** II\. 26 bpm (abnormal RR) but can give the medication, why? **Because it would relax the patient that would lower the RR.** III\. How about 10 bpm, can you give medication? **No.** Report immediately to the doctor and prepare the antidote (reverse the drug effect or toxicity). \- **antidote:** \>\> to toxicity: Naloxone (Narcan) \- **antidote:** \>\> to withdrawal: Methadone **3. Blood thinner** **- decreases blood viscosity to increase tissue perfusion** **- risk: bleeding** **[TYPES OF BLOOD THINNER:]** **A. tPA (tissue plasminogen activator)** - **Thrombolytic -- dissolving the clot.** - **Ex: "-ase"** - **Urokinase** - **Streptokinase** - **Alteplase** - **Antidote: Aminocaproic Acid** **B. Anti-platelet** - **ex: ASA (Aspirin) (Antidote: Activated Charcoal)** - **Clopidogrel (Plavix, Platexan)** - **Dipyridamole (Persantin)** **C. Anti-coagulant** - **Ex: Heparin (Antidote: Protamine sulfate)** - **Warfarin (Coumadin) side effects: Blood in the urine (Antidote: Vitamin K)** - **GREEN LEAFY VEGETABLES: HIGH IN VITAMIN K** - **Multivitamins** - **If respiratory depression occurs, the best intervention would be to: administer narcotic antagonist.** **4. Anti-hyperlipidemic** **- HMG Coenzyme A Reductase Inhibitor \> "statins"** **\* Atorvastatin (Lipitor)** **\* Simvastatin (Zocor)** **\* Rosuvastatin (Crestor)** - **Administer at bedtime (hour of sleep)** - **A/E: Hepatotoxicity** - Check liver enzymes. **\* [ALT (SGPT)] -- specifically on liver** **\* AST (SGOT) -- liver and heart** **\* Bilirubin** - **Rhabdomyolysis -- muscle breakdown** - Report muscle inflammation or pain. - **Others: Teratogenic, Cataract** **[RESPIRATORY SYSTEM]** **2 Divisions:** - Upper Respiratory Tract (URT) \- Nose \- Pharynx - naso pharynx - oro pharynx - laryngo pharynx - Larynx = **"voice box"** - Trachea = **"windpipe of the body"** - Lower Respiratory Tract (LRT) \- Lung/s = **main respiratory organ** - **R -- 3 lobes** - **L -- 2 lobes** = Chest Surgeries - **Lobectomy (1 lobe) or Bilobectomy (2 lobes)** - **\* post-op: Place the patient to the Unaffected side** (non-operative side) - **Pneumonectomy (whole lung)** - **\*post-op: Affected** **[VENTILATION]** -- movement of gases (breathing) **2 phases:** - **Inhalation/inspiration** -- increases O2 [Normal Value of Atmospheric Oxygen] = 20% to 21%[\ What is the Normal Partial Pressure (PaO2) in the body?] 80-100 mm Hg [What is normal O2 saturation?] 95% to 100% - **Exhalation/expiration** -- decreases CO2 - **Atm CO2 (atmospheric CO2)** - **\ - **PaCO2 (Partial Pressure of CO2)** - **35 -- 45 mm Hg** **Note: CO2** is needed for acid-base balance [What is the nature of carbon dioxide in terms of PH?] **ACIDIC** **Increased PaCO2 = Respiratory Acidosis** **Decreased PaCO2 = Respiratory Alkalosis** - **HYPERVENTILATION** -- breathing rapidly and having a rapid loss of CO2 \ low PaCO2. [What if the patient is having hyperventilation?] **Prob:** **Respiratory Alkalosis** **Management:** Ask the patient to breathe into a **brown paper bag** **or any paper bag**. - **HYPOVENTILATION --** slow breathing or slow gas exchange \> it will cause retention of CO2 \> high PaCO2. [What if the patient is having hypoventilation?] **Prob:** **Respiratory Acidosis** **Management:** administer O2 or ask the patient to perform a certain breathing exercise (pursed-lip breathing). - Medulla Oblongata = **main respiratory center** **Role**: initiation and regulation of breathing **Medulla Oblongata needs a driving force (stimulus to breathe)** - NON-PATHOLOGIC STIMULUS (normal) = **high level of carbon dioxide (CO2)** - PATHOLOGIC STIMULUS (w/ COPD) = **low level of oxygen** **COPD (Chronic Obstructive Pulmonary Disease)** - **IRREVERSIBLE** - **Increased pressure in the lungs \> increased Pulmonary Resistance** - **Aka: CAL (Chronic Airflow Limitation)** - **Prob: Restricted flow of AIR** - **2 main forms: Chronic Bronchitis & Pulmonary Emphysema (old version: w/ Bronchial Asthma = reversible & Bronchiectasis)** - **Chronic Bronchitis =** long term cough with mucus - **Pulmonary Emphysema =** damage to the lungs over time **Note: Subcutaneous Emphysema =** caused by complication of chest tube insertion. **Factors:** - **Cigarette Smoking \#1** - **Over-exposure to dust and cotton** - **Pollution of air** - **Deficiency of alpha 1 anti-trypsin - responsible for** **alveolar recoil = needed to deflate the alveoli (genetic abnormality: family history can be considered as a factor for developing COPD).** [What if there is no alpha 1 anti-trypsin?] ***MAHIHIRAPAN MAILABAS ANG CARBON DIOXIDE*** **CHRONIC BRONCHITIS** **Term:** Blue bloater **Problem:** Inflammation of the bronchi \> increased mucus production \> airway swelling or airway narrowing **Hallmark:** Productive cough (lasting for at least 3 months) **PULMONARY EMPHYSEMA** **Term:** Pink puffer **Problem:** Loss of alveolar elastic recoil \> air-trapping of CO2 \> fixation of ribcage/alveoli in the inspiratory position **Hallmark:** Barrel Chest (increased antero-posterior diameter of ribcage) **S/Sx of COPD:** - **Dyspnea** - **Impaired Gas Exchange = increased CO2 \[hypercarbia/hypercapnia\] \> respiratory acidosis** - **= decreased O2 \[hypoxemia/hypoxia\]** - **weakness, fatigue \> anorexia \> weight loss** - **Pallor to cyanosis** - **Clubbing of fingers** **MANAGEMENT of COPD:** - **Assessment of Respiratory Status** - **Tuberculin test** - **Sputum test** - **Lung sounds** - **Bronchodilator** - **Albuterol (Proventil)** - **Salbutamol (Ventolin)** - **Ipratropium Bromide (Atrovent)** - **Ipra + Salbu (Combivent)** - **Theophylline (Aminophylline)** - **Epinephrine (Adrenalin)** - **Corticosteroids -- reduces inflammation (anti-inflammatory drug)** - **Prednisone** - **Hydrocortisone** - **Beclomethasone** - **Fluticasone** - **Delivery of O2 = Yes to Low Flow of oxygen because it maintains hypoxic drive in COPD** - **No to high flow of oxygen because it would remove the stimulus for them to breathe (decreased breathing)** - **High flow oxygen suppresses hypoxic drive in COPD causing depression of medulla oblongata.** [How low oxygen is low?] **Brunner book: 1-2 lpm but in board exam: 2-3 lpm** [How to deliver 2-3 lpm of oxygen?] **\#1 Venturi Mask -- most precise/accurate way of delivering oxygen because it is calibrated.** **\#2 Nasal Cannula -- most comfortable** - **Expectorant and mucolytic** - **Guaifenesin -- expectorant (liquefy the lower respiratory tract secretions)** - **Acetylcysteine -- mucolytic (break down mucus to aid high-risk respiratory patients in coughing up thick, tenacious secretions)** - **Fluid intake, calories, protein should be increased.** - **Gas Exchange promotion** - **Pursed lip breathing** - **Purpose: to promote excretion of CO2 by inhaling through your nose and exhaling through your mouth (2x longer) to eliminate carbon dioxide.** - **Heart Complication** - **Patient might develop Cor Pulmonale \> a right ventricular hypertrophy (enlargement of right ventricle because of compensation due to increased pulmonary resistance) \> may lead to right-sided Heart Failure.** - **Heart Failure -- signs of systemic congestion** - **peripheral edema** - **cerebral edema (inc. ICP)** - **hepatomegaly** - **splenomegaly** - **Jugular vein distention** - **weight gain** - **hypertension** **MANAGEMENT for HF:** - **daily monitoring of weight** - **diet: low sodium, low fat, and high fiber diet** - **diuretics to promote urination (every morning) Aldactone, Lasix** - **digitalis (Digoxin) to strengthen the heart \[Digibind/DigiFab\] DIGOXIN IMMUNE FAB**