NCM 213 Oxygenation Midterms PDF

NCM 213 OXYGENATION | MIDTERMS Physiology of respiration Oxygenation lower concentration down the - process of supplying Oxygen concentration gradient Ventilation...

NCM 213 OXYGENATION | MIDTERMS Physiology of respiration Oxygenation lower concentration down the - process of supplying Oxygen concentration gradient Ventilation Perfusion - process of exchanging Oxygen and - supplying oxygenated blood to the cells Carbon dioxide The major function is to supply the body with Difusion oxygen and dispose of carbon dioxide. - the movement of molecules from a region of higher concentration to a region of Respiration - Pulmonary ventilation - External Respiration - Respiratory gas transport - Internal Respiration Pulmonary ventilation - movement of air in and out of the lungs - also known as breathing External respiration - gas exchange between the pulmonary blood and alveoli Respiratory gas transport - oxygen and carbon dioxide in and out of the lungs and tissue Increased carbon dioxide stimuli for breathing. Inhalation increases oxygen and decreases carbon dioxide. Pulmonary ventilation Mechanics of breathing - depends on volume changes in the thoracic cavity - inhalation results in negative pressure - volume changes = pressure Changes - exhalation results in positive pressure Ysabella Son | 3I | 1 NCM 213 OXYGENATION | MIDTERMS laugh - same process but with a different emotion hiccups - sudden inspiration from spasms of the diaphragm yawn - very deep inspiration External respiration - oxygen pickup by hemoglobin and unloading of carbon dioxide in the lungs Gas transportation - oxygen is carried by oxyhemoglobin and plasma in small amounts - carbon dioxide turns to bicarbonate in plasma and in RBC - CO2 + H2O HCO3 + H = bicarbonate Internal respiration - O2 leaves blood and enters tissues - CO2 leaves the tissues and enters blood Control of Respirations Neural regulation - sets the basic rhythm using the inspiratory muscles - phrenic nerves control the diaphragm - intercostal nerves control the intercostal muscles Medulla Oblongata - expiratory/ inspiratory center Pons - smoothens transitions - oft it too much napagwork Apneustic center Nonrespiratory air movements - located in the lower pons, which cough - clears the lower respiratory stimulates the inspiratory neurons passageway of the medulla sneeze - clears the upper respiratory Pneumotaxic center passageway - located in the upper pons, switches crying - inspiration followed by short off the inspiration releases of air Ysabella Son | 3I | 2 NCM 213 OXYGENATION | MIDTERMS - this center likely is involved in the Common symptoms fine-tuning of breathing 1. dyspnea C4: Phrenic 2. chest pain C3 - C5: breathing 3. cough 4. wheezing 5. sputum production 6. hemoptysis Dyspnea - subjective - CRT - onset and severity - tachycardia with hypoxemia - orthopnea - dyspnea with wheeze - dyspnea with stridor (high-pitched grating sound) Non Neural factors Cough Physical factors - talk, cough, exercise, - reflex temperature, and altitude - irritation of the mucous membrane in the Volition factors - conscious control (breath respiratory tract holding) Sputum production Emotional factors - hypothalamus reflexes - history to constant irritant nature Chemical factors - CO2 or blood pH - has color and sometimes smell Assessment of respiratory function Chest pain present problem and assessment of signs - sharp, stabbing, intermittent, dull, aching, and symptoms persistent, comfortable on affected side impact on the patient’s quality of life Wheezing (ADLs) - high-pitched expiration OLD CART assessment (onset, location, - rhonchi low-pitched duration, characteristic, aggravating Hemoptysis factors, relieving factors, and treatment) - always warrant further investigation respiratory and non respiratory symptoms - sudden, intermittent, or continuous, past health, social, and family history determine the source? - risk factors Physical assessment - timing of questions clubbing of fingers - chronic hypoxia - health, personal, social history, and Cyanosis - not reliable for hypoxia family health history Upper respiratory tract Inspect and palpate Ysabella Son | 3I | 3 NCM 213 OXYGENATION | MIDTERMS Nose and sinuses elevation of the scapula S-shaped Mouth and pharynx spine Trachea limits lung expansion within the Lower respiratory tract thorax Posterior thorax osteoporosis - instruct to sit with arms crossed on the chest - do not place in a side-lying position unless when sitting is not viable Anterior thorax - upright or supine for easier displacement of breast Skin - color, turgor, loss of subcutaneous - chest configuration (1:2 AP to L diameter) Four main deformities of the chest associated with respiratory disease: Thoracic inspection 1. Barrel Chest - Normal: thin to slight retraction of ICS overinflation of the lungs - Abnormal: bulging of ICS during expiration increase in the anteroposterior and marked retraction during inspiration diameter of thorax - asymmetric bulging of intercostal spaces emphysema - because of air - inspiration muscles (sternocleidomastoid, trapping scalene, trapezius) 2. Funnel chest (pectus excavatum) - expiration muscles (abdominal, internal a depression in the lower portion of intercostal muscles) the sternum - breathing patterns and respiratory rate compress the heart and great Thoracic palpations vessels respiratory excursion rickets or marfan’s syndrome - thoracic expansion (range and limit lung compliance symmetry) 3. Pigeon chest (pectus carinatum) - decreased (chronic fibrotic displacement of the sternum disease) increase in the anteroposterior - asymmetric (splinting, pleurisy, diameter fractured ribs, trauma, and rickets, marfan’s syndrome, or unilateral bronchial obstruction) severe kyphoscoliosis tactile fremitus 4. kyphoscoliosis Ysabella Son | 3I | 4 NCM 213 OXYGENATION | MIDTERMS - Normal: vibrations during speech - may be heard in asthma, (consonants) emphysema, and chronic - absence (emphysema or increased bronchitis consolidation) 3. Rhonchi - increased (lung consolidation) - air moving through secretions in - factors (thickness of chest wall, the larger airways pitch, and location) - deep, low-pitched rumbling or diaphragmatic excursion coarse sound as air moves through - measured after one full inspiration tracheal/bronchial passages in the and expiration presence of mucus - decreased (pleural effusion, - commonly heard during expiration atelectasis, diaphragmatic 4. Stridor paralysis, or pregnancy) - common in epiglottis, croup, and Thoracic percussion foreign body obstruction - a continuous, high-pitched, Resonance normal lung tissue crowing sound heard on inspiration Hyperresonance areas of increased air Abnormal broncophony - intense and clear Dullness heart and liver egophony - distorted E and A Flatness heavy muscles whispered pectoriloquy - hearing whispered words (distinct) Tympany stomach Thoracic auscultation - Normal: voice sounds (faint and distinct) Adventitious breath sounds 1. Crackles (or rale) - air moving through secretions(fluid, pus, mucus) of the small or middle airways. - fine crackles: soft, high-pitched, very brief - coarse crackles: somewhat louder, lower in pitch, brief 2. Wheezes - air moving through a narrowed or constricted airway - high-pitched continuous musical sound - commonly heard during expiration Ysabella Son | 3I | 5 NCM 213 OXYGENATION | MIDTERMS Pulmonary function tests - pathogenic organisms and determine - for chronic respiratory disorders malignant cells - necessary for patients with antibiotics, Arterial blood group studies - ability of the lungs to provide adequate O2 corticosteroids, and immunosuppressive and remove CO2 medications because of decreased - harder/more common immunity - ventilation, and excretion of bicarbonate - must be taken early in the morning, clear - deeper nose and throat, rinse mouth with water, - metabolic states cough deeply, and expectorate to - pain, infection, hematoma, and container hemorrhage Imaging studies - visualizes the extent of the infection or Venous Blood Group Studies - additional data on O2 delivery and tumor growth consumption Chest X-ray - balance of O2 used by tissues and the - detects densities in the lungs (white) amount returning to the right side of the - shows posterior and lateral views heart Contraindicated: Pregnancy - guide in post-op patients at risk for Responsibilities: hemodynamic instability let the patient wear a gown - lower risk than ABG assess for the presence of metal items the nurse should wear a lead shield Pulse oximetry - non-invasive O2 saturation of Hg Education - can be performed in the fingertip, fasting is not allowed forehead, earlobe, and bridge of the nose no pain will be felt - N: 95-100; LDH2 “flipped pattern” signifies decalcified plasma myocardial necrosis. - measurement of blood's clotting tendency - LDH elevation occurs 24 hrs post-MI and and can be used to assess coagulation peaks in 48-72 hrs. disorders and heart disease Troponin (I,C,T) - Troponin I is contractile CHON specific to - valuable in evaluating the effectiveness of cardiac muscles Coumadin (Warfarin) - most specific test for MI detection - normal range is 11 to 16 seconds - Troponin T binds I and C, Troponin C binds Partial Thromboplastin Time (PTT) - measures clotting time after partial calcium thromboplastin reagent addition to - elevated troponin T is as sensitive as plasma CK-MB for the detection of myocardial - the best single screening test for injury coagulation disorders - useful for diagnosis after 4 to 6 hours and - to evaluate the effectiveness of Heparin 4-7 days post MI - normal range 60-70 secs Hydroxybutyrate Dehydrogenase (HBD) - valuable for detecting “silent MI? Ysabella Son | 3I | 37 NCM 213 OXYGENATION | MIDTERMS Activated Partial Thromboplastin Time (APTT) - Serum calcium affects blood coagulability, - evaluates Heparin effectiveness neuromuscular activity, and can cause - normal range 30-45 secs dysrhythmias Laboratory tests C-Reactive Protein (CRP) Blood Urea Nitrogen (BUN) - CHON synthesized by the liver, elevated - decreased cardiac output leads to levels indicate tissue trauma or elevated BUN due to low renal perfusion inflammation - normal range is 10-20 mg/dl - predictor of future coronary events in Serum Lipid Tests seemingly healthy person - assess CAD risk, including Serum Homocysteine Cholesterol, Triglycerides, and Lipoprotein - amino acid produced by body as a by levels product of consuming meat Serum cholesterol: 150-250 mg/dl - linked to atherosclerosis development Triglycerides: fast for 10-12 hours - associated with genetic factors, diet low in prior, 40-150 mg/dl folic acid, vitamin B6 and vitamin B12 Lipoprotein: Brain Natriuretic Peptide (BNP) ○ LDL: less than 130 mg/dl - neurohormones ○ HDL: men 35-65 mg/dl and - primarily secreted from the ventricles in female 35-85 mg/dl response to increase preload Serum Electrolytes - a blood marker for identifying and treating - Electrolytes affect cardiac contractility, congestive heart failure with normal ranges for Na, K+, and Ca. Urinalysis Na – 135 to 145 - albuminuria seen in hypertension or K+ - 3.5 to 5 meq diabetes patients Ca - 4.5 to 5.5 - myoglobinuria supports MI diagnosis - Serum sodium concentration reflects Hemodynamic monitoring relative fluid balance Central Venous Pressure (CVP) Hyponatremia – fluid excess - refers to the measurement of the pressure Hypernatremia – fluid deficit within the vena cava, right atrium and - Serum potassium venous return Hypokalemia – cardiac irritability; - requires the threading of a catheter into a contributes digitalis toxicity large central vein (subclavian, internal or Hyperkalemia – myocardial external jugular, median basilic, or depression femoral) both can cause ventricular - catheter placement is confirmed through fibrillation/ cardiac standstill chest x-ray Ysabella Son | 3I | 38 NCM 213 OXYGENATION | MIDTERMS - phlebostatic axis: the 0 level must be at Swan Ganz Catheter the right midaxillary line, 4th ICS (right - assesses ventricular function, shock atrium) etiology, and response to medical intervention - a balloon-tipped flow directed 4-lumen catheter is inserted via the antecubital vein into the right side of the heart and floated into the pulmonary artery Normal CVP pressure - 3 to 8 mmHg (5-12 cm H2O) elevated CVP- increase in blood volume decreased CVP- decrease in blood volume Measuring CVP 1. The zero point on the transducer needs to Lumen Functions be at the level of the right atrium. 1st Lumen: Measures CVP, for fluid infusion, 2. The client needs to be supine, with the and provides venous access for blood head of the bed at 45 degrees. samples at the right atrium. 3. The client needs to be relaxed; coughing or 2nd Lumen: Monitors PA systolic, diastolic, straining will cause false increases in the and mean pressure at the pulmonary readings. artery. Complication 3rd Lumen: Contains a balloon (1-1.5 cc). - air embolism and infection 4th Lumen: Includes a thermistor port to Nursing responsibilities measure cardiac output (CO). 1. Inspect site daily for signs of infection Normal range 2. Practice strict asepsis. Cleanse catheter - PAP: 20-30 mmHg insertion site and change sterile dressings - PCWP: 8-13 mmHg; above 25 mmHg daily. indicates impending pulmonary edema Nursing Responsibilities 1. inflation only for PCWP Ysabella Son | 3I | 39 NCM 213 OXYGENATION | MIDTERMS 2. regular site assessment, culture every 48 - color, temperature, and tingling hours, sensation Complications 6. fluid intake increase - infections, dysrhythmias, pulmonary 7. keep extremity extended for 4 to 6 hours as embolism, and pulmonary artery rupture prescribed to prevent arterial occlusion Invasive Diagnostic Tests 8. if the antecubital vessel was used, Cardiac Catheterization immobilize the arm with an armboard - involves inserting a catheter into a blood vessel and threading it to the heart guided by fluoroscopy - provides information on heart structure, valve performance, and coronary circulation Nursing Responsibilities Preprocedure 1. psychosocial support 2. informed consent 3. allergy checks 4. baseline vital signs 5. NPO status (6-8 hours) 6. distal pulse assessment Transesophageal Echocardiography 7. height and weight - provides higher quality images than a 8. encourage to void regular echocardiogram 9. cardiac monitoring - the throat is anesthetized & the 10. patient preparation esophageal scope is inserted - may feel warm or flushing Nursing responsibilities sensation due to contrast medium 1. maintain NPO status for 8 hours before test - fluttering sensation or palpitations 2. check for gag reflex before client resumes may be felt as the catheter enters oral intake of fluids 11. encourage to cough to clear contrast Non-invasive diagnostic tests agent from the artery Electrocardiography (ECG/EKG) Postprocedure - graphical recording of the electrical 1. monitoring vital signs, ECG, and pulses activities of the heart 2. hematoma checks - records heart's electrical activities on a 3. pressure dressing application (small sand rhythm strip bag) - useful for detecting dysrhythmias, 4. bedrest for 6-12 hours myocardial infarction extent, and 5. extremity assessment medication effectiveness Ysabella Son | 3I | 40 NCM 213 OXYGENATION | MIDTERMS - location and extent of myocardial Electrode placement infarction, and evaluation of the effectiveness of cardiac medications ECG paper or strip ECG waveforms Nursing Responsibilities Preprocedure 1. explanation of the test 2. patient will not experience electrocution or shock 3. remove all metal objects 4. wash the skin to reduce skin oil 5. instruct patient to lie still, breathe normally and refrain from talking Sinus Rhythm (SR) Obtaining an ECG - Normal P, QRS, T wave 1. place electrodes in standard positions on - Heart rate: 56 – 99 bpm the chest wall and extremities - P – QRS ratio: 1 is to 1 2. attach to cable wire connected to - Rhythm: regular machine Identify the rhythm (R-R interval) The standard 12-lead ECG is the most commonly 1. Paper and pencil method used tool to diagnose dysrhythmias. - place a straight edge of a paper along the strip then identify the Ysabella Son | 3I | 41 NCM 213 OXYGENATION | MIDTERMS Peak of 2 consecutive R-wave and 2. instruct the patient to keep an activity diar make a dot on the paper then 3. avoid operating heavy machinery, electric compare shavers, hair dryers, bathing or showering Regular = sinus Cardiac Stress Testing Irregular = Identify the - noninvasive ways to evaluate the response arrhythmia of the cardiovascular system to stress 2. Times Ten (6 sec method) Types of Stress Tests - obtain a 6 second strip then count 1. Exercise Stress Test: Involves ECG the no. of P waves (Atrial rate) or R monitoring during physical activity. waves (Ventricular rate) within the 2. Pharmacologic Stress Test: Utilizes 6-second strip then multiply by 10. vasodilating agents or dobutamine for - The product is the rate. stress simulation. Measurement of rate: Formulas provided for rate 3. Emotional Stress Test: Evaluates calculation based on big and small squares cardiovascular response to emotional between R-R. stress. Continuous Electrocardiographic Monitoring Exercise Stress Test - standard for patients who are at high risk - patient walks on a treadmill or pedals a for dysrhythmias stationary bicycle Two techniques - ECG is monitored during exercise; lasts - hardwire monitoring 6-12 mins - telemetry Nursing responsibilities Hardwire Monitoring 1. avoid tea, coffee, smoking and alcohol on - comprises 3-5 electrodes, lead cable, and the day of the test a bedside monitor 2. fast for 4 hours prior to test Telemetry 3. wear loose fitting clothes and low heeled - involves a battery-operated transmitter for rubber shoes radio wave transmission to monitors 4. report chest pain, SOB, dizziness Nursing Responsibilities Pharmacologic Stress Test 1. clean the skin with soap and water - physically disabled or deconditioned 2. change electrodes every 24-48 hrs patients 3. assess for skin irritation 2 vasodilating agents Holter Monitoring - dipyridamole (Persantine) - portable device for continuous - adenosine (Adenocard) cardiovascular electrical activity mimic the effects of exercise by monitoring for at least 24 hours maximally dilating the coronary Nursing Responsibilities arteries 1. monitoring activities and time of day - dobutamine (Dobutrex) triggering dysrhythmias Ysabella Son | 3I | 42 NCM 213 OXYGENATION | MIDTERMS a synthetic sympathomimetic, Nursing responsibilities increases heart rate, myocardial 1. must lie still contractility, and blood pressure 2. check for allergy to contrast medium Nursing responsibilities 3. NPO 1. NPO status for 4 hours prior to the test, 4. assess for pregnancy and claustrophobia 2. caffeine restrictions Myocardial Scintigraphy/ myocardial perfusion imaging 3. instruct on common side effects; flushing - most common tests are thallium imaging, or nausea multigated blood pool imaging (muga) Emotional Stress Test - injection of radioactive isotopes via Nursing responsibilities catheter Preprocedure - as the isotope is absorbed by the 1. explain the procedure myocardium, photons are emitted 2. informed consent - external gamma camera will produce an 3. baseline assessment image showing myocardial function, During motion and perfusion 1. monitor the response - studies the left ventricular function and 2. be ready for emergency wall motion of the heart by injecting the 3. provide psychological support patient's red cells with radioactive 4. document technetium-99m to form an image of the Postprocedure blood pool within the heart using an ECG, 1. debriefing gamma camera, and computer 2. reassess vital signs - patient must lie still during the scan MRI Nursing responsibilities - uses strong magnetic fields and radio 1. assess for pregnancy waves to differentiate healthy and 2. stress test may be done simultaneously diseased tissues 3. light meat to prevent nausea and stomach Nursing responsibilities cramping during exercise 1. secure consent Echocardiogram 2. assess for claustrophobia 2D echocardiography 3. remain still during the procedure - uses ultrasound to assess cardiac 4. a loud knocking noise is heard in the MRI structure and mobility in 2 dimensional unit format 5. clients with metal items, artificial - no special preparation required pacemakers, implanted wires, and clips - painless and takes approximately 30-60 are contraindicated mins CT Scan Nursing responsibilities - provides cross-sectional images of the 1. client has to remain still chest, heart, and great vessels Ysabella Son | 3I | 43 NCM 213 OXYGENATION | MIDTERMS 2. supine and slightly turned to the left side with the head of the 15-20 degrees Ysabella Son | 3I | 44 NCM 213 OXYGENATION | MIDTERMS Congenital Heart Defects Management Defects with increased pulmonary blood flow - Nonsurgical: Cardiac Catheterization - involves blood flow from the left side of the - Surgical: Open heart surgery heart (greater pressure) to the right side Atrioventricular canal defect - the defect results from incomplete fusion (less pressure) of the endocardial cushions (absent - increased pulmonary blood flow septum) - decreased systemic blood flow - most common cardiac defect in Down Atrial septal defect (ASD) - abnormal opening between the atria that syndrome causes an increased flow of oxygenated Signs and symptoms blood to the right side of the heart - characteristic murmur - the infant usually has mild to moderate Types of Atrial septal defect 1. ASD 1 (ostium primum): Opening is at the CHF with cyanosis increasing with crying lower end of the septum. - signs and symptoms of decreased cardiac 2. ASD 2 (ostium secundum): Opening is near output may be present the center of the septum. - dyspnea, difficulty feeding 3. ASD 3 (sinus venosus defect): Opening is Surgical treatment near the junction of the superior vena - pulmonary artery banding for infants with Assessment severe symptoms (palliative) - asymptomatic, prone to RTI, dyspnea on - complete repair via cardiopulmonary mild exertion, may develop CHF, feeding bypass difficulties Surgical repair purpose Management - to reduce excessive pulmonary blood flow - Nonsurgical: Cardiac Catheterization and protect the pulmonary vasculature - Surgical: Open heart surgery from hypertrophy and irreversible pulmonary hypertension Ventricular septal defect (VSD) - abnormal opening between the right & left Patent ductus arteriosus (PDA) ventricles - failure of fetal ductus arteriosus to close within the first weeks of life Small VSDs - usually asymptomatic; high spontaneous - high risk: mothers exposed to rubella closure rate during the first year of life during pregnancy Large VSDs Assessment - CHF: tachypnea, tachycardia, excessive - machinery like murmur sweating associated with feeding, - asymptomatic hepatomegaly, Frequent URIs, Poor weight - signs and symptoms of CHF and gain, failure to thrive, Feeding difficulties, decreased cardiac output - decreased exercise tolerance Management - refer for surgical intervention - Medical: Indomethacin (Indocin) Ysabella Son | 3I | 45 NCM 213 OXYGENATION | MIDTERMS - works by stimulating the muscles inside - lower blood pressure in the lower the PDA to constrict extremities – leg pains, cold feet, muscle - PDA Ligation spasms; pulses are weak, delayed or Obstructive defects absent - blood exiting a portion of the heart meets - myocardial hypertrophy an area of anatomical narrowing Management (stenosis) causing obstruction to blood - nonsurgical: balloon angioplasty flow - surgical: resection of the coarcted portion Aortic stenosis with end-to-end anastomosis of the aorta - narrowing or stricture of the aortic valve, Pulmonary stenosis causing resistance to blood flow in the left - narrowing at the entrance to the ventricle results in: pulmonary artery decreased cardiac output - resistance to blood flow causes right left ventricular hypertrophy ventricular hypertrophy and decreased pulmonary vascular congestion pulmonary blood flow Assessment: - pulmonary atresia is the extreme form of - characteristic murmur pulmonary stenosis in that there is total - infants with severe defects demonstrate fusion of the commissures and no blood signs of decreased cardiac output flows to the lungs - children show signs of exercise intolerance, Treatment chest pain, and dizziness when standing - balloon valvuloplasty for long periods of time Surgical treatment Management - Infants: closed valvotomy procedure. - aortic valvotomy (palliative) or - Children: pulmonary valvotomy with valvuloplasty cardiopulmonary bypass (heart lung - minimally invasive procedure that opens a machine) narrowed heart valve to improve blood Defects with decreased pulmonary blood flow flow - pressure on the right side of the heart - valve replacement increases, exceeding pressure on the left Coarctation of the aorta side, which allows desaturated blood to - localized narrowing of aorta shunt right to left, causing decrease Assessment pulmonary blood flow - absent femoral pulses (pathognomonic - typically hypoxemia and cyanosis appear sign) - anatomical defects (ASD or VSD) between - blood pressure is higher in upper the right and left sides of the heart are extremities – headache; epistaxis; pulses present are rapid and bounding Ysabella Son | 3I | 46 NCM 213 OXYGENATION | MIDTERMS Tetralogy of fallot increases the systemic vascular Four defects resistance, thereby pushing more 1. Pulmonary stenosis blood into the pulmonary 2. VSD circulation 3. Overriding of the aorta improves venous return 4. Right ventricular hypertrophy infants may be more comfortable in a knee chest position - polycythemia Diagnostics - history, PE, cardiac catheterization, and angiography Management - conservative: hydration, prevent infection, positioning, oxygen, and morphine - do not allow to cry for long period of time Surgical Assessment - cyanosis - tet spells (hypercyanotic spells/blue spells) - acute episodes of cyanosis and hypoxia occur when the infant's oxygen 1. palliative shunt: Blalock-Taussig requirements exceed the blood supply, - increases pulmonary blood flow such as during periods of crying, feeding, and increases oxygen saturation in or defecating infants who cannot undergo - clubbing of fingers primary repair - growth retardation - provides blood flow to the - exertional dyspnea relieved by squatting pulmonary arteries from the left or Squatting is a compensatory right subclavian artery mechanism to facilitate increased 2. corrective: Brock procedure return of blood flow to the heart for - entails an incision into the right oxygenation ventricular chamber and the Ysabella Son | 3I | 47 NCM 213 OXYGENATION | MIDTERMS cutting of the stenosed pulmonary Mixed defects valve or the removal of obstructing - fully saturated systemic blood flow mixes tissue in the outflow tract of the with the desaturated blood flow, causing a right ventricle desaturation of the systemic blood flow - relieves cyanosis immediately - pulmonary congestion occurs and cardiac Tricuspid atresia output decreases - failure of the tricuspid valve to develop Hypoplastic left heart syndrome - no communication exists from the right - underdevelopment of the left side of the atrium to the right ventricle heart occurs, resulting in a hypoplastic left Assessment ventricle and aortic atresia - cyanosis, tachycardia, and dyspnea are - progressive deterioration with cyanosis seen in the newborn and decreased cardiac output are seen, - older children exhibit signs of chronic leading to cardiovascular collapse hypoxemia and clubbing - the defect is fatal in the first few months of Treatment life without intervention - neonate whose pulmonary blood flow Surgical treatment depends on the patency of the ductus - necessary; transplantation in the newborn arteriosus, a continuous infusion of period may be considered prostaglandin E1 is initiated until surgery Preoperative period smooth muscle relaxant 1. mechanical ventilation vasodilator 2. ontinuous infusion of prostaglandin E1 keeps DA patent Complete transposition of the great vessels - trial septostomy - the aorta is connected to the right - fontan procedure (connects superior vena ventricle, and the pulmonary artery is cava to the pulmonary artery) connected to the left ventricle Ysabella Son | 3I | 48 NCM 213 OXYGENATION | MIDTERMS Assessment - pulmonary veins drain into the right - cyanosis atrium through the liver (hepatic) - cardiomegaly veins and the inferior vena cava Nonsurgical - Prostaglandin E1: increase blood mixing temporarily - Balloon atrial septostomy Surgical - arterial switch procedure (aorta is switched with pulmonary artery) Total anomalous pulmonary venous connection - there is a failure of the pulmonary veins to join the left atrium Surgical treatment - the defect results in mixed blood being - corrective repair is performed in early returned to the right atrium and shunted infancy from the right to the left through an ASD - the pulmonary vein is anastomosed to the - the right side of the heart hypertrophies, left atrium, the ASD is closed, and the whereas the left side of the heart may anomalous pulmonary venous connection remain small is ligated - signs and symptoms of CHF develop, Truncus arteriosus Cyanosis, and murmur - failure of normal septation and division of Types the embryonic bulbar trunk into the 1. Supracardiac TAPVR (total anomalous pulmonary artery and the aorta, resulting pulmonary venous return) in a single vessel - pulmonary veins drain into the right - blood from both ventricles mixes in the atrium through the superior vena common great artery, causing cava desaturation and hypoxemia 2. Infracardiac TAPVR Ysabella Son | 3I | 49 NCM 213 OXYGENATION | MIDTERMS Assessment - characteristic murmur is present - the infant exhibits moderate to severe CHF and variable cyanosis, poor growth, and activity intolerance Surgical treatment - close the hole between the two ventricles, often with a patch - implant a tube (conduit) and valve to connect the right ventricle with the upper portion of the pulmonary artery — creating a new, complete pulmonary artery - construct the single large vessel and aorta to create a new, complete aorta Ysabella Son | 3I | 50 NCM 213 OXYGENATION | MIDTERMS Vascular disorders Dolens - painful - sudden venous hypertension Venous Thromboembolism - deep vein thrombosis and pulmonary - deep veins embolism make up the condition edema, warm, and deep veins - frequently not diagnosed because often appear more prominent clinically silent tenderness - common in patients post-op - superficial veins tenderness, redness, and warmth Diagnostic Exams - careful assessment of lower extremities feeling of heaviness, functional impairment, ankle engorgement, edema, areas of tenderness - Homan Sign is not reliable for DVT (less than ⅓ only have positive results) Prevention - identification of risk factors and preventive measures - compression stockings and devices, early Risk factors ambulation, leg exercises - endothelial damage - LMWH (low molecular weight heparin) as - venous stasis ordered - altered coagulation anticoagulant Pathophysiology - lifestyle changes - virchow’s triad > phlebitis > formation of weight loss, smoking cessation and thrombus (phlebothrombosis) regular exercise - endothelial damage (damaged vessels) Medical Management - venous stasis (slow blood flow) - goal: prevent thrombus from growing and Virchow’s triad fragmenting 1. hypercoagulability - anticoagulant therapy and ultrasonic- 2. venus stasis assisted thrombolytic therapy 3. endothelial damage ultrasound that is specific for veins - phlebitis is the opposite of venous to check the presence of a thromboembolism thrombus Clinical manifestations may result in UA assisted - nonspecific except phlegmasia cerulea thrombolysis dolens (severe blockage in multiple veins) Phlegmasia - swollen/ inflamed Cerulea - blue Ysabella Son | 3I | 51 NCM 213 OXYGENATION | MIDTERMS Pharmacologic Therapy - unfractionated heparin, low-molecular weight heparin, oral anticoagulants, factor Xa and direct thrombin inhibitors (CHON involved in clotting process), and thrombolytic therapy - endovascular management anticoagulants and thrombolytics are contraindicated thrombectomy, ultrasound-assisted thrombolysis, Risk Factors and balloon angioplasty - common in people whose occupations Nursing Management require prolonged standing 1. assessing and monitoring anticoagulant - hereditary weakness of the vein wall therapy contribute, however rare, before puberty 2. monitoring and managing potential - pregnancy (uterus grows which complications compresses blood flow) - bleeding, thrombocytopenia, and Pathophysiology drug interactions - reflux of venous blood > venous stasis > 3. providing comfort accumulation of venous blood > vein 4. providing compression therapy (ensures distention that the valve returns to its proper shape) Clinical Manifestations - stockings - dull aches, muscle cramps, increased - external compression devices and muscle fatigue in lower legs, ankle edema, wraps and a feeling of heaviness of legs, - intermittent pneumatic nocturnal cramps compression devices - If deep veins are involved, there are signs 5. positioning the body and encouraging and symptoms of chronic venous exercise insufficiency (edema, pain, pigmentation, 6. promoting home, community-based, and and ulcerations) transition care Diagnostic Exams Varicose veins - duplex ultrasound scan (non-invasive) - abnormally dilated, tortuous, superficial - venography and CT venography veins caused by incompetent venous (minimally invasive) valves Prevention - common in the lower extremities but can - avoid activities or clothing that cause occur elsewhere venous stasis Medical Management Ysabella Son | 3I | 52 NCM 213 OXYGENATION | MIDTERMS - exercises and changing position Arterial Disorders - graduated compression stockings Peripheral Arterial Occlusive Disease - weight reduction - blockage or narrowing of an artery in the Surgical treatment legs - ligation and stripping (remove the - symptoms are dependent on the affected varicose vein) artery and how severe the blockage - thermal ablation (applies heat to close the - occurs most often in men and common varicose vein using a catheter) cause of disability - sclerotherapy (injection using a 34 gauge - legs are most frequently affected needle) Clinical Manifestations Ligation and stripping - intermittent claudication claudication is when pain occurs during movement - rest pain critical ischemia Diagnostic Exams - history and assessment - continuous-wave doppler (UA) - ankle brachial index/ ABI (measures the blood pressure in the ankle and arm) - treadmill testing for claudication Vein ablation - duplex ultrasonography Medical Management - exercise (walking) program - unsupervised walking exercise programs - exercise + weight reduction + smoking cessation - pentoxifylline (increases blood flow to affected area) - cilostazol, antiplatelets - “-statins” (people high in cholesterol has increased risk so this is given to lower Nursing Management cholesterol level) 1. promoting comfort and understanding Endovascular management 2. promoting home, community-based, and - balloon angioplasty, stent, stent graft, and transitional care atherectomy Surgical Management - for severe/disabling claudication Ysabella Son | 3I | 53 NCM 213 OXYGENATION | MIDTERMS - endarterectomy (surgical incision) Signs of impending rupture - bypass grafts (blade/ shredding device to - severe back or abdominal pain vaporize plaque) Signs of rupturing aneurysm Nursing Management - rupturing Nursing care of the postoperative patient - constant intense back pain, falling BP, 1. maintaining circulation decreasing hematocrit 2. monitoring potential complications Rupture to peritoneal cavity 3. home care - fatal when hematomas are in the lower Aortic Aneurysm thorax - weakened area in the upper part of the Medical Management aorta - controlling blood pressure and risk factors - commonly caused by atherosclerosis ticking time bomb like stroke if not - high morbidity and mortality rates controlled - commonly occurs in the abdominal aorta - sodium nitroprusside (vasodilator; and thoracic aorta treatment for acute hypertension) Risk Factors - surgery to repair aneurysm and restore - men, race (caucasian), age (65 years and vascular continuity with a vascular graft or above), genetics, tobacco use, and stents hypertension - cerebrospinal fluid drainage to improve Diagnostic Exam spinal perfusion - imaging Studies Nursing Management Thoracic Aortic Aneurysm 1. there may be inflammation when graft is Clinical Manifestations used since it is a foreign body - pulmonary problems 2. post implantation syndrome - depends on how rapidly aneurysm dilates fever, leukocytosis, and and thrombocytopenia - how pulsating mass affects surrounding Raynaud’s and Buerger’s structures Raynaud Phenomenon - pain during supine position - autoimmune - dyspnea, cough, stridor, hoarseness or - intermittent arteriolar vasoconstriction that aphonia, dysphagia results in coldness, pain, and pallor of the Abdominal Aortic Aneurysm fingertips or toes Clinical Manifestations - triggered by emotions or sensitivity to cold - only 40% are symptomatic - acrocyanosis (variant) - “feel their heart beating in their abdomen - variable prognosis when lying down” some slowly improve, some - systolic bruit become progressively worse, others no change Ysabella Son | 3I | 54 NCM 213 OXYGENATION | MIDTERMS Risk Factors - moderate-to-severe claudication that - Women and Age ( - sickle cells can adhere to the small blood reduction of globin chain production within vessels hemoglobin > imbalance of configuration Clinical Manifestations of hemoglobin > increased rigidity and - anemia, jaundice, enlargement of bones of premature destruction the face and skull Types of thalassemia - tachycardia, cardiac murmurs, 1. Alpha or Beta thalassemia cardiomegaly, dysrhythmia, heart failure - milder and can be asymptomatic if only one alpha gene is mutated Ysabella Son | 3I | 59 NCM 213 OXYGENATION | MIDTERMS - erythrocytes are extremely - severe hemolytic episode after ingestion of microcytic but anemia is mild fava, beans, menthol, tonic water, and (more than 2 alpha mutations) some chinese herbs 2. Beta thalassemia Clinical Manifestations - mild forms have microcytosis and - asymptomatic; normal Hgb levels & mild anemia reticulocyte count most of the time - severe = thalassemia - days after exposure: pallor, jaundice, major/Cooley’s anemia hemoglobinuria, increased reticulocyte, - can be fatal for the first few years of symptoms of hemolysis life - “Heinz bodies” - hematopoietic stem cell (HSC) - hemolysis is often mild but in more severe transplantation can cure but when types, recovery may not occur not possible, transfusion of PRBCs Heinz bodies and iron chelation - small, round inclusions in red blood cells - life-long transfusions that indicate oxidative damage to the cell 3. Thalassemia Major - tiny dots in red blood cells that can be - most severe kind of beta seen under a microscope thalassemia (2 beta gene - damage to hemoglobin, a protein in red mutations or more) blood cells, usually through oxidative stress - severe anemia, marked hemolysis, Diagnostic Exams ineffective erythropoiesis - G-6-PD deficiency screening test - regular chelation reduced Medical Management complications of iron overload - arrest the source - long-term survivors of beta - transfusion only in severe hemolytic state thalassemia may experience Nursing Management neurologic complications 1. education about the disease, list of - death is often due to heart failure medications and substances to avoid Glucose-6-Phosphate Dehydrogenase Deficiency 2. seek advice prior to any treatment - G-6-PD gene 3. hemolysis treatment for hemolytic produces an enzyme within the episodes erythrocyte essential for membrane 4. medic-alert bracelets stability of RBCs Polycythemia - hemolysis when the erythrocytes are - refers to an increased volume of RBCs stressed by certain situations - considered as cancer - X-linked defect - hgb and hct are significantly elevated - oxidant drugs trigger hemolysis Ysabella Son | 3I | 60 NCM 213 OXYGENATION | MIDTERMS Types of Polycythemia - symptoms from increased blood viscosity 1. Primary Polycethemia or Polycythemia (angina, claudication, dyspnea, Vera thrombophlebitis, elevated BP - caused by a mutation or biological - elevated uric acid (gout, renal stone) factor in the body that leads to the - pruritus, erythromelalgia (redness, warmth bone marrow overproducing red and burning pain affecting the extremities) blood cells (from birth) Medical Management 2. Secondary Polycythemia - goal: reduce risk of thrombosis without - caused by factors that reduce the increasing risk of bleeding, and reduce risk amount of oxygen reaching the of evolution body's tissues, such as smoking, - low-dose aspirin (to prevent bleeding), high altitude, or congenital heart hydroxyurea, phlebotomy disease (developed) - aggressive management of Primary Polycythemia or Polycythemia vera atherosclerosis (antihypertension and - proliferative disorder of the myeloid stem antihyperlipidemic) cells - allopurinol (for uric acid) - hypercelllular bone marrow resulting to - anagrelide, interferon alfa-2b (treat blood elevated erythrocytes, leukocytes, and conditions and blood cancer) thrombocytes Nursing Management - bone marrow may become fibrotic > - symptom management inability to produce many cells = “burnt out - monitoring progression and complications phase” > metaplasia (not spongy or hard Secondary Polycythemia already) or AML (acute myeloid leukemia) - excessive production of erythropoietin - death results from thrombosis, - response to reduced amount of oxygen, hemorrhage, and rarely evolution to AML “hypoxic stimulus”, from - takes RBCs from spleen or liver which hemoglobinopathies, or from neoplasms > overworks the organs all increase erythropoietin production Diagnosis Medical Management - elevated Hgb JAK2 gene (+) (Janus Kinase - if mild, not necessary 2) - treati the primary condition first - decreased serum erythropoietin - therapeutic phlebotomy Clinical Manifestations Hemophilia - ruddy complexion, splenomegaly - refers to a group of - symptoms from increased blood volume bleedingdisordersresulting froma (headache, dizziness, tinnitus, fatigue, deficiencyof specificcoagulation proteins paresthesias, blurred vision) Most common types 1. hemophilia A or classic hemophilia - factor VIII deficiency Ysabella Son | 3I | 61 NCM 213 OXYGENATION | MIDTERMS 2. hemophilia B or Christmas disease - factor IX deficiency Assessment - abnormal bleeding in responsetotrauma or surgery - epistaxis (nosebleeds) - joint bleeding causing pain, tenderness, swelling, and limitedrange of motion - tendency to bruise easily Medical management - replacement of the missing clotting factor Nursing management 1. prepare to administer replacement factorsasprescribed 2. assess neurological status andmonitorhematuria. 3. control joint bleeding by immobilization, elevation, and the application of ice 4. apply pressure (15 minutes) for superficial bleeding Ysabella Son | 3I | 62