Midterm Notes-CV System PDF

- also known as the tourniquet test, MIDTERM NOTES positive-pressure test, or Rumpel-Leede capillary test. CARDIOVA...

- also known as the tourniquet test, MIDTERM NOTES positive-pressure test, or Rumpel-Leede capillary test. CARDIOVASCULAR SYSTEM - It measures the ability of the capillaries to remain intact under increasing intracapillary pressure. - The following scale are used to report test result: MODULE 3: CARE OF CLIENTS ✔ 0 to 10 petechiae =+1 ✔ 11 to 20 petechiae = 2+ WITH CV DISORDERS & ✔ 21 to 50 petechiae = 3+ HEMATOLOGIC/BLOOD ✔ 51 or more petechiae = 4+ DISORDER c. Activated Partial Thromboplastin Time (APTT) - primarily used in pre-operative screening for bleeding HISTORY (review) tendencies and for monitoring heparin therapy. - Normal fibrin clots form 25-36-secs after reagent DIAGNOSTIC TESTS addition A. BLOOD & URINE STUDIES d. Prothrombin Time (PT, Pro-time) - it measures the time requires for clotting to occur DIAGNOSTIC TESTS after thromboplastin and calcium are added to A. Complete Blood Count (CBC) decalcifies plasma. - it measures the nuber of RBC’s in a microliter - Test of choice for monitoring and anticoagulant normal range: therapy (warfarin or Coumadin) Men – 4.5 to 6.2 million/mm3 - Normal values: Women – 4.2 to 5.4 million/mm3 M- 9.6 to 11.8 sec Children – 4.6 to 4.8 million/mm3 F: 9.5 to 11.3 sec - in patient receiving and anticoagulants, B. Total Hemoglobin Concentration therapeutic range is: 1.5 to 2 times the normal - measures a gram of hgb in a decilitre (100ml) of or control. whole blood. Normal range: e. Plasma Thrombin Time (PTT) 1-3 days – 14.5 to 22.5 g/dL - also known as the thrombin clotting time test 2 months – 9.0 to 14.0 g/dL normal values: 10-15 sec 6-12 y.o – 11.5 to 15.5 g/dL - a plasma time greater than 1 and 1/3 times the 12 to 18 y.o M- 12.0 to 16.0 g/dL control may mean effective heparin therapy, hepatic F – 12.0 to 16.0 g/dL disease, DIC. 18-49 y.o M-13.5 to 17.5 g/dL F – 12.0 to 16.0 g/dL C. BONE MARROW ASPIRATION - aspiration of bone marrow from the iliac crest or C. Hematocrit sternum to obtain specimen to examine - also known as packed RBC volume test microscopically and to perform a biopsy. - it reports the percentage of RBC in a whole blood sample Nursing Considerations: normal range - explain procedure & purpose. Men: 45%-57% - no food of fluid restrictions. Women: 37% to 47% - duration: 5-10mins & result in a day Children: 36% to 40% - mild sedative 1 hour prior to test - local anesthetic is given: assess for allergies D. Platelet count - post procedure: check site for bleeding, inflammation, - it evaluates platelet (thrombocyte) production, which is necessary for blood clotting. s/s of infxn - Normal range is 130,000 to 370,00/mm3 - change dressing q24h. B. BLOOD COAGULATION TESTS D. Blood urea nitrogen (BUN) a. Bleeding Time - it is an indicator of renal function. - measures duration of bleeding after a standard Normal range is 10 to 20 mg/dl incision. - 4 methods and the normal bleeding time E. BLOOD LIPIDS 9 especially cardiac case) Duke method: 1-3 minutes a. Cholesterol Ivy method 1-7 minutes - the client should be on NPO for 10 to 12 hours. Template – 2-8 minutes - normal range is 150 to 250 mg/dl Modified template – 2-10 minutes b. Triglycerides b. Capillary Fragility Tests - the client should observe fasting for 10 to 12 hours - normal range 140 to mg/dl NOTES F. Blood culture -to assist in the diagnosis of infectious diseases of the heart G. ENZYME STUDIES Waves, complexes and intervals a. Aspartate aminotransferase ( AST) - P wave. Depolarization of atria. Duration is 0.04 normal range: to 0.11 secs. Men: 14-20 U/L or 0.23 - 0.33 ukat/L - PR interval. Time of impulse transmission from Women: 10-36 U/L or 0.17 - 0.16 ukat/L the SA node to the AV node. Duration is 0.12 to Newborn: 47-150 U/L or 0.78 - 2.5 ukat/L 0.20 secs. Children: 9 – 80 U/L or 0.15 – 1.3 ukat/L - QRS complex. Depolarization of the ventricles. Duration is 0.05 to 0.10 secs. - range with myocardial infarction - ST segment. Represents the plateau phase of Initial elevation: 4 to 6 hours the action potential. Peak: 24 to 36 hours - T wave. Ventricular repolarization. Should not Return to normal: 4 to 7 days exceed 5mm aplitude. b. Creatine Phosphokinase/Creatine Kinase Common ECG Changes: (CPK-MB) Hypokalemia – U wave, depressed ST segment - it is the most specific cardiac enzyme Hyperkalemia – Prolonged QRS complex, elevated -normal range: ST segment M: 38 to 174 U/L Myocardial infarction – elevated ST segment, F: 26 to 140 U/L inverted T wave, pathologic Q wave. Infants: 2-3 times adult values - Range in Myocardial infarction Onset: 3-6 hrs Peak: 12-18 hrs Return to normal: 3 to 4 days (48-72 hrs) c. Cardiac troponin T (cTnT)/ Troponin I (cTnI) normal levels -Troponin T = maternal diabetes > fetal or maternal infections during the first trimester of pregnancy such as rubella > maternal alcohol ingestion > treatment of anticonvulsant drugs > chromosomal abnormalities - 50% of individuals w/ Down syndrome have CHDs - 40% of individuals w/ Turner’s syndrome have CHDs. CLASSIFICATIONS OF CHDs A. ACYANOTIC (OBSTRUCTIVE DEFECTS) 1. Pulmonary Stenosis 2. Aortic Stenosis 3. Coarctation of the Aorta B. ACYANOTIC (SEPTAL DEFECTS) – Increased Pulmonary Blood Flow 1. Atrial Septal Defect 2. Ventricular Septal Defect 3. Atrioventricular Canal Defect 4. Patent Ductus Arteriosus C. CYANOTIC DEFECTS (decreased pulmonary blood flow) 1. Eisenmenger’s complex 2. Transposition of the Great Vessels/Arteries 3. Tetralogy of Fallot 4. Tricuspid Atresia 5. Pulmonary Atresia PATHOPHYSIOLOGY CHDs produce their effects thru o Abnormal shunting of blood o Alterations in pulmonary blood flow (decreases blood flow towards the lungs) NOTES  Shunting of blood-refers to diverting of blood flow Surgical Intervention: from one system to the other o Pulmonary balloon valvuloplasty (repair; not o Left to right shunting = arterial to venous open heart surgery; there’s insertion of balloon o Right to left shunting = venous to arterial tip/catheter (pulmonary artery) , inig abot sa PV ang tip eh inflate, stretches the valve then Shunting of blood depends on: it opens o Presence of an abnormal opening between o Blalock-Tausig shunt the right and left circulations o Degree of resistance to blood flow thru the opening B. Child and Adolescent w/ PS *increase unoxygenated blood leads to tissue Assess exercise tolerance. hypoxia (cyanosis) Subacute bacterial endocarditis prophylaxis ac & pc treatment for CHD A. OBSTRUCTIVE DEFECTS Antibiotic prophylaxis ac dental procedure to 1. PULMONARY VALVE STENOSIS prevent endocarditis Cardiac catheterization: Valvuloplasty Surgical procedure: Open heart surgery (valvotomy, partial valvectomy *ibanan ang valve for it to open) Most common causative agent is streptococcus viridans 2. AORTIC VALVE STENOSIS *Stenosis - narrowing - Occurs when a defective pulmonary valve does not open properly - Most common cause of right ventricular outflow tract obstruction (RVOTO-Right Ventricular Outflow Obstruction). *Because of stenosis, it increases the pressure in the RV (wa man nakaagi ang blood adto sa Pulmonary Valve) eventually leading to hypertrophy of RV or right sided heart failure *There’s blood pulling in the right side of the heart, - Most common left ventricular outflow tract there will be jugular vein distension; increase in obstruction (LVOTO). CVP reading *to increase blood flow, LV should pump harder *lead to LV hypertrophy, myocardial ischemia, left Clinical Manifestations: sided heart failure, tissue hypoxia a. Critical/severe narrowing in newborns - Occurs at any age, more common in boys than in ⮚ Hypoxia, right ventricular failure girls b. Mild to moderate in child and adolescent ⮚ Asymptomatic Clinical Manifestations: ⮚ Decreased tolerance to exercise; fatigue: a. Newborns w/ critical/severe AVS dyspnea: chest pain ⮚ S/S of severe CHF Metabolic acidosis ⮚ Tachypnea Diagnostic Evaluation: ⮚ Faint peripheral pulses, poor perfusion, poor Auscultation: murmur at left upper sternal border capillary refill cool skin (pulmonic area), ejection click ⮚ Poor feeding Palpation: thrill ECG: right ventricular hypertrophy b. Child and Adolescent Chest x-ray: right ventricular enlargement ⮚ Chest pain, dyspnea on exertion, unusual firing, 2D-Echo: visualize size, obstruction, degree of dizziness, near syncope, fainting hypertrophy ⮚ Palpitation, murmur/thrill ⮚ Sudden death Management: A. Newborns w/critical/severe PS Diagnostic Evaluation: Stabilize & improve O2 sat with Prostaglandin Auscultation: systolic ejection murmur at aortic (PGEI) infusion (common brand name: area, ejection click alprostadil) ECG: left ventricular hypertrophy Intubation & ventilation Chest x-ray: Increased cardiac silhouette (cardiac Inotropic support: Dopamine/Dobutamine enlargement), increased pulmonary vascular (increase strength in contraction improving marking oxygenation) 2D-Echo w/ Doppler: reveals anatomy and unt pressure gradient NOTES  2D-Echo: aortic arch narrowing w/ lesions such as Management: (VSD/PDA) Neonate: o PGE infusion Management o Inotropic support a. Neonate o Intubation and ventilation Medical: o Cardiac catheterization: aortic balloon o PGE1 infusion (somehow make the DA remain valvuloplasty. open before interventions/surgical procedures) o Surgical valvotomy. o Intubation & ventilation Child/Adolescent Surgery o Restrict exercise. o Subclavian flap repair (the left subclavian o Aortic balloon valvuloplasty thru cardiac artery pulled down and sutured to the edge of catheterization. aorta widening the coartation) o Surgery-Valvotomy/aortic valve replacement o End to end anastomosis (putlon and stricture, then sumpay the end to end) Sub-acute bacterial endocarditis prophylaxis Lifelong follow-up is required b. Child/Adolescent Surgery 3. COARCTATION OF THE AORTA o End to end anastomosis Manage hypertension (beta-blockers; meds ends w/ “lol”) Recurrence o Balloon angioplasty o Redo surgical intervention SBE prophylaxis Life-long follow up B. SEPTAL DEFECTS 1. ATRIAL SEPTAL DEFECT - Characterized by a narrow aortic lumen (stricture) Types: Preductal - proximal to ascending aorta (before ductus arteriosus) Postductal - distal to left subclavian artery: more common (98%) Incidence: 2x as often in males as in females may be a feature in Turner's syndrome Clinical Manifestations: Incidence: 8% - 13%, Ave: of 9% of all CCDS/CHDs; a. Newborn more in females than males ⮚ Asymptomatic until PDA (Patent Ductus Arteriosus) closes Types: *PDA closes 24-72 hrs after birth Ostium secundum - most common; abnormal *Complete closure of DA will occur in 2-3 weeks opening in middle atrial septum ⮚ PDA closure leads to severe CHF, poor Ostium primum - abnormal opening at bottom of perfusion. tachypnea, acidosis, absent femoral atrial septum pulses (hallmark sign) Ostium venosus - abnormal opening at top of atrial septum b. Adolescent ⮚ Asymptomatic, hypertension in upper extremities Clinical Manifestations: w/ absent weak peripheral pulses, nosebleeds, Ostium secundum & ostium venusos headache, cramps ASDs-usually asymptomatic Ostium primum ASD - s/s vary depend on c. Adulthood - upper body is more developed than the associated defects lower body o CHF o frequent Upper respiratory infections Diagnostic Evaluation: o poor weight gain Auscultation: systolic murmur o decrease tolerance to exercise ECG: normal or left & right ventricular hypertrophy Diagnostic Evaluation: NOTES  Auscultation: murmurs, split S2 Poor exercise tolerance, syncope Chest x-ray: normal to inc, right atrial & ventricular dilation, increased pulmonary markings Diagnostic Evaluation: ECG: right ventricular volume overload Auscultation: Murmurs, increased pulmonary 2D-Echo: site of ASD, L to R shunting vascular resistance, loud S2, S3 gallop Chest x-ray: normal or cardiomegaly & increased pulmonary vascular markings ECG: normal or biventricular hypertrophy 2D-Echo: visualize size, #, & site of defect, PA pressure, & lesions Management: Cardiac catheterization: size of shunt, assess PVR Ostium Secundum ASD (pulmonary vascular resistance) o Monitor and reassess small spontaneous closure (up to age of 2 years) Management: o Due to spontaneous closure in some children, Small VSD: treatment is delayed fill child is of school age o no medical mgt. but followed up closely in hope o Primary repair-suture closure of ASD defect closes spontaneously o Pericardial patch repair of ASD o Prophylactic antibiotics o Cardiac catheterization Ostium Primum ASD o Monitor growth and development Large VSD o Manage CHF o CHF mgt.: digoxin & diuretics (furosemide, o Refer for repair spironolactone) o Avoid oxygen Sinus Venosus ASD o Increase caloric intake o Refer for surgical closure in early childhood o Refer for surgical intervention- usually repaired a) Transcatheter closure thru cardiac before first year of life catheterization a. One stage approach-open heart surgery: b) Surgical closure thru open heart surgery patch closure preferred b. Two stage approach: 2. VENTRICULAR SEPTAL DEFECT ✔ First: closed heart (PA banding to restrict PA blood flow ✔ Second: Patch to close VSD and remove PA band. Complications: CHF, frequent URIs, failure to thrive, poor weight, bacterial endocarditis Eisenmenger's Syndrome o Treatment: Heart or heart to lung transplant - Opening between left and right ventricles form 3. ATRIOVENTRICULAR CANAL / SEPTAL DEFECT imperfect closure during fetal development / ENDOCARDIAL CUSHION DEFECT Incidence: - Most common type of CCD/CHD: 20%-25% Clinical Manifestations: Small VSDs-usually asymptomatic o 1/3 close spontaneously during the first year of life Large VSDS o Tachypnea, tachycardia, excessive sweating associated w/ feeding, hepatomegaly, frequent - Forms upper part of the ventricular septum and URIS, poor weight gain, failure to thrive, lower part of the atrial septum feeding difficulty/poorly - Consist of large hole in center of heart plus a o Diaphoretic (sign of CHF) single, large valve (combination of tricuspid and o Cyanosis mitral valve that crosses the defect. - 40% -50% with this defect has Down Syndrome *EISENMENGER'S COMPLEX/SYNDROME Severe CHF and cyanosis from right to left Types/Variations: shunting Partial AV canal defects - 2 AV valve rings are Healthy childhood but progressive cyanotic in complete and separate adulthood. NOTES  Complete AV canal defects - a common AV valve 2D-Echo: shows PDA w/ blood shunting orifice w/ defects in both atrial & ventricular septal tissue Management: Ebstein Anomaly - displacement of tricuspid Symptomatic premature neonate valve tissue into right ventricle o Indomethacin IV infusion over 30 minutes every 12-24 hours x 3 doses o Ibuprofen o Monitor growth & development o Reassess spontaneous closure o Increase caloric Intake for normal weight gain o Diuretics (furosemide, spironolactone) Clinical Manifestations: Partial defect Cardiac catheterization o Similar to ASD - largely asymptomatic o for small PDAs: coil occlusion o for large PDAs: Intravascular coil, Teflon plug, Complete Defect - Increased pulmonary blood occlusive umbrella flow, similar to ASD and VSD combined o Abnormal growth, easy fatigability, Surgery: hypertension, recurrent infections, cyanosis o PDA ligation via lateral thoracotomy (closed murmurs heart surgery) o Thoracoscopic surgical technique, ligation of Management: ductus (closure w/o thoracotomy) Surgical repair before child enters school o Palliative or corrective surgery for infants w/ complete AV defect w/ CHF -Valve C. CYANOTIC DEFECTS reconstruction SBE prophylaxis 1. TETRALOGY OF FALLOT 4. PATENT DUCTUS ARTERIOSUS - Most common of complex CHD - 6%-10% of all CCDs/CHDs - Ductus Arteriosus: vital link by which blood from right side of heart Composed of four abnormalities bypasses lungs & enters systemic circulation Large VSD (Ventricular Septal Defect) After birth no longer needed Pulmonic valve stenosis (RVOTO) Usually closes during the first 24-72 hrs.; Right ventricular hypertrophy complete closure w/ fibrous tissue w/in 2 3 Dextroposition of Aorta (Aortic override) - aorta weeks lies directly over the VSD - Most children display some degree of cyanosis = Incidence: common in premature infants who weighs "BLUE BABIES" less than 1,500 grams Manifestations: Clinical Manifestations: 1. Cyanosis: hypercyanotic attacks (tet spells) Small to moderate PDA – usually asymptomatic a. Infants Large PDA during the first months of life occur in AM on o CHF, tachypnea crying, feeding, defecating o Poor weight gain, failure to thrive, slow growth, Hyperpnia, Irritability, diaphoresis, loss of rapid breathing consciousness o Catch pneumonia easily Placing infant in knee-chest position o Tires quickly, decreased exercise tolerance b. Toddlers and older children Diagnostic Evaluation: child may spontaneously assume a squatting Murmurs at pulmonic area position Chest x-ray: normal/cardiomegaly, increased pulmonary vascular markings c. Older children ECG: varies/LA dilation & LV hypertrophy may faint during exercise NOTES  Clubbing of fingers & toes More common in infants whose mothers have ⮚ Tetspell; life threatening hypoxic event (very diabetes and in boys cyanotic) - Prompt cardiologist for surgical - Survival depends on communication between R & intervention L sides of heart in form of PDA or ASD/VSD 2. Polycythemia (increase RBC due to chronic Clinical Manifestations hypoxia) S/S evident soon after birth: Cyanosis, tachypnea, metabolic acidosis, poor feeding Diagnostic Evaluation: No murmur may be related to associated defect, Diagnostic Evaluation: single S2 Murmurs (pulmonic area), loud S2, thrills Chest x-ray: newborn: normal/ cardiomegaly ECG: RV hypertrophy ECG: biventricular hypertrophy 2D-Echo: shows abnormality and degree pf 2D-Echo: show abnormality, transposed vessels, RVOTO coronary artery pattern, degree of mixing across septum Management: Medical: Medical Management: o Monitor oxygen saturation PĢEI infusion o Monitor growth and development För severe hypoxia: balloon atrial septostomy o Monitor hypoxic spells (Rashkind) o Knee-chest position o Catheter inserted via vena cava, passes o Morphine foramen ovale, inflated to enlarge ovale o Beta-blockers (propranolol) opening o Phenylephrine Treat pulmonary over circulation w/ diuretic as needed Surgical management: o Palliative: Surgical Management: - Blalock-Taussig shunt (BT shunt): tube 1. Arterial Switch Procedure – (Jatene operation) graft between left subclavian artery and procedure of choice PA. Performed during first week of life, ideally (first 2-3 o Definitive: patch closure of VSD, relief of weeks of life) RVOTO w or w/o transanular patch across the Aorta & PA switch back to anatomically correct PV position - Done at a later stage 2. Rastelli operation-done for TGA, VSD, & PS Long-term follow-up: Repaired during first year SBE prophylaxis VSD patch repaired to include LV to Aorta outflow Monitor exercise tolerance continuity w/ pulmonary blood flow via RV to PA Monitor for arrhythmias homograft Complications: 3. Atrial switch procedure - Mustard or Senning Hypoxia, tet spells, polycythemia, CHF procedure Performed in older children 2. TRANSPOSITION OF THE GREAT Rerouting of atrial blood flow VESSELS/ARTERIES Disadvantages o RV is left as systemic ventricle development of RV dysfunction o Increased incidence of atrial arrhythmias & baffle obstruction Complications: Severe hypoxia Multi-organ ischemia 3. TRICUSPID ATRESIA - Aorta originates in the right ventricle and pulmonary artery originates in the left ventricle Incidence: accounts for 5%-10% of CHDs Associated lesions: VSD, ASD, PDA, PS, COA NOTES  Management: similar to tricuspid atresia - No tricuspid valve - Right ventricle: smaller & underdeveloped - Child's survival depends on associated lesions - Obligatory PFO/ASD, PDA, VSD Clinical Manifestations: Cyanosis Diagnostic Evaluation: Murmurs vary, depend on associated lesion 5. HYPOPLASTIC LEFT HEART SYNDROME Chest x-ray: normal to increased cardiac silhouette ECG: R to L atrial & LV hypertrophy 2D-Echo: shows abnormality & R to L atrial shunting Management: If left untreated, patient will die Stabilize w/ PGE1 infusion Intubate & ventilate as needed - Underdevelopment of the left side of the heart Surgery: required - Abnormalities include: First surgery: newborn Critical mitral valve stenosis/atresia o Too little pulmonary blood flow: BT shunt Hypoplastic left ventricle o Too much blood flow: PA banding Critical aortic stenosis/atresia o Balanced blood flow: do nothing Hypoplastic ascending aorta w/ severe coarctation of aorta Second surgery (6-9 months of life) o Bidirectional Glen shunt-end to end Clinical Manifestations: anastomosis of SVC to R Pa Newborn-completely well once the PDA closes: Third surgery (2-5 years) o s/s of CHF, tachypnea o Fontan completion: VC to PA connection o decreased urine output, poor feeding (extracardiac/ intracardiac baffle) o lethargic, change in LOC o pallor/gray color SBE prophylaxis o weak peripheral pulses Lifelong follow up needed o signs of multi-organ system failure Complications: cyanosis Diagnostic Evaluation: systolic murmur, single S2 4. PULMONARY ATRESIA Chest x-ray: varies from normal to increased cardiac silhouette, increased pulmonary markings ECG: RV hypertrophy, decrease electrical forces in V5& V6 2D-Echo: shows abnormalities, altered blood flow pattern Management: Fatal w/o treatment Resuscitation & stabilization w/ PGE1 infusion Balloon atrial septostomy Inotropic support as needed No pulmonary valve opening Assess hepatic, renal, neurologic function Refer Blood cannot flow from the right ventricle into for surgical mat pulmonary artery and the lungs RV may be small/ underdeveloped Surgical Management: Tricuspid valve may be abnormal Palliative, staged repair ASD allows blood to exit right heart o Stage 1 - Norwood Coexisting PDA only source of lung blood flow (neonate)-reconstruction of hypoplastic NOTES  aorta: pulmonary artery & homográft: repair of ✔ limit feeding time: 15-20mins coarctation & creation of BT shunt o child: o Stage Il- Bidirectional Glenn shunt (6-9 ✔ Small, frequent meals months) ✔ high-calorie, nutritional supplements ✔ Transect the SVC off the RA and directly 5. Preventing infxn suture to side to R PA gate BT shunt o routine childhood immunizations o Stage Ill-Fontan (8 mos.-5 years) o yearly influenza vaccine ✔ IVC to PA connection o prevent exposure to crowded places & people with Cardiac Transplantation o communicable dse SBE prophylaxis o handwashing Lifelong follow up required o report fevers and signs of respi. Inten 6. Reducing fear and anxiety o educate pt & family Complications: Metabolic acidosis COMMON CARDIOVASCULAR Cardiovascular collapse Multisystem failure DISORDERS IN CHILDREN Death 1. KAWASAKI DISEASE - aka mucocutaneous lymph node syndrome NURSING CARE FOR A CHILD W/ CHD - a multisystem vasculitis identified by a febrile illness with Nursing Assessment several distinguishing features that compromise vital height & wt. body system. V/S & Oxygen sat. skin, mucous membranes, nails for cyanosis and *Japanese pediatrician Tomisaku Kawasaki clubbing signs of respiratory distress, check breath sounds, heart Etiology: sounds Unknown Strict I & O Exposure to infectious agents; retrovirus Level of activity Propironibacteriae & Group A streptococcus Feeding pattern Hypersensitivity reactions Monitor growth and development Incidence: Nursing Dx Leading cause of acquired heart disease in children in Impaired Gas Exchange R/T altered pulmonary blood the U.S. flow/ pulmonary congestion Peak age of occurrence is in the toddler Decreased CO r/t decreased myocardial fxn 80% of patients are under age 5 & seldom occurs in Altered nutrition: less than body requirements r/t children over 8 years of age. excessive energy demands required by inc. cardiac Most frequently seen in Japan and in children of workload Japanese heritage Risk for infection r/t chronic illness More common in boys than in girls. Fear and anxiety r/t life-threatening illness Seasonal epidemics that usually occur in late winter and early spring. Nursing interventions: 1. Relieving resp. distress Clinical Manifestation: o Position: reclining: semi-upright Stage 1 (Acute Febrile Phase) o Suction secretions as needed o Severely ill and irritable (days 1-11) o O₂ inhalation as prescribed o High spiking fever for 5 or more days o Meds: diuretics & bronchodilators o Bilateral conjuctival infection (red eyes) o May have NGT feedings because of inc. risk for o Oropharyngeal erythema, "strawberry tongue", aspiration with respi, distress red and dry lips *check correct placement, auscultate the bell of the o Indurative edema of hands and feet, erythema of stet in between/below xiphoid process; gurgling sound palm and soles, general edema.or periunqual *chest x-ray desquamation. o Erythematous rash 2. Improving cardiac output o Cervical lymphadenopathy o Rest o Carditis o Provide play w/ minimal exertion o Iridocyclitis and aseptic meningitis o Meds: diuretics, digoxin, afterload-reducing meds (captopril, enalapril) Stage 2 (Subacute Phase) o Appears 12-20 days 3. Improving oxygenation and activity tolerance o Acute symptoms of stage 1 subside. Child remains o pulse oximetry anorectic and irritable. o oxygen o Dry, cracked lips with fissure o Desquamation of toes and fingers 4. Providing adequate nutrition o Arthralgia (pain in the joint) and arthritis o infant: (temporary) ✔ SFF (small frequent feeling), fortified o Coronary thrombosis; aneurysms formula/breastmilk NOTES  o If IVIG is administered, monitor the BP and HR at Stage 3 (Convalescent Phase) the start of infusion, after 15mins, after 30mins then o Appears well (day 21-60) hourly until infusion is complete. o Transverse grooves of fingers and toenails (Beau's lines) Preserving Oral Mucous Membranes (offer/consume o Coronary thrombosis; aneurysm (may occur) cold liquids/foods; soft and bland foods) Improving Skin Integrity (not aggressive soaps, loose Diagnostic Evaluations: and soft clothing) Fever and four of the six other criteria listed Maintaining Fluid Balance (Temp q4H) Electrocardiogram, echocardiogram, cardiac Reducing Fear catheterization & angiocardiography. Laboratory tests: o ⬆ CBC-leukocytosis (acute stage) o ⬆ ESR - elevated(acute) o ⬆ Erythrocytes and hemoglobin - slight decrease A C-reactive protein -positive o ⬆ Platelet count 2. RHEUMATIC FEVER o ⬆ IgM, IgA, IgG. & JgE - an acute autoimmune disease that occurs as a o ⬆ Urine-protein and leukocytes present sequelae of Group A beta hemolytic streptococcal o ⬆ Elevated transaminase infection. - Characterized by inflammatory lesions of connective Management: tissue and endothelial tissue, primarily affecting the Single dose of immunoglobulin (IVlg) joints and heart *reduce the incidence of artery abnormality and reduces the inflammation of blood vessels Etiology: Aspirin therapy After a streptococcal infection of the throat or of URTI *decreases pain, addresses fever and reduces risk for blood clot Incidence: Thrombolytic therapy Peak incidence occurs in children 6 to 15 years of age Supportive measures Incidence after a mild streptococcal pharyngeal infection o Fluid & electrolytes balance is 0.3% and after a severe streptococcal infection is 1% o Provide comfort to 3% Complications: Clinical Manifestation Cardiac complications Major Manifestation: Aspirin toxicity (indicator: tinnitus) o Carditis (systolic murmur, prolonged PR and QT intervenals) Nursing Assessment: o Polyarthritis History taking that support the diagnosis such as fever & o Chorea (seizure; murag gasayaw) skin manifestation. o Erythema marginatum (non-prupritic macular trunk Perform physical examination, concentrating on the w/ pale center) cardiovascular disease. o Subcutaneous nodules (firm, painless) Nursing Diagnosis: Minor Manifestation Pain related to conjunctival inflammation and imitation o History of previous rheumatic fever or evidence of Decreased Cardiac Output related to vasculitis and pre-existing rheumatic heart disease. aneurysm o Arthralgia Altered Oral Mucous Membrane related to disease o Fever process o Laboratory abnormalities (⬆ ESR, ⬆ C-reactive Risk for impaired Skin Integrity related to edema, protein, ⬆ WBC) dehydration, desquamation and bed rest. o ECG changes Fluid Volume Deficit related to hyperthermia, anorexia, and oral ulcer Diagnostic Evaluations: Jones criteria - presence of 2 major manifestations or Nursing Interventions: one major and 2 minor manifestations, with a recent Reducing Discomfort streptococcal infection. o Provide period of uninterrupted rest ECG done to evaluate PR interval o Provide pain medication routinely (q6H) during Laboratory test the acute phase rather than PRN Group A streptococcal culture or antistreptolysin-O o Perform comfort measures to the eyes (ASO) titer to detect streptococcal antibodies from o Perform comfort measures related to joint pain and recent infection tender lymph nodes* (PROM – passive range of CXR for cardiomegaly, heart failure motion q4H; assist pt in doing so) o Provide quiet, peaceful environment with diversional Management: activity such as listening to music. Antibiotic therapy o Benzathine penicillin IM (single dose) Maintaining Cardiac Output o Oral erythromycin for children allergic to o Institute cardiac monitoring and assessment for penicillin complication (HR, BP q2H) Oral salicylates (aspirin) or NSAIDs (naproxen o Closely monitor intake and output and administer sodium) oral IV fluids as ordered. Corticosteroids NOTES  Neurologic agent to control chorea (Phenobarbital; WBC shows atypical lymphocytes Diazepam) Epstein-Barr virus (EBV) antigen test (Mononuclear spot Bed rest during acute phase until ESR decreases, test) C-reactive protein becomes negative & pulse rate Heterophil antibody (a titer of 1:160 considered returns to normal diagnostic) Mitral valve replacement Viral cultures from saliva, blood or lymphatic tissue (may Secondary prevention of recurrent ARF* take 6 to 8 weeks for results) Elevated LFT with hepatic complications. Complications: Heart Failure Management: Pericarditis, pericardial effusion Prompt recognition of the illness & preventing exposure Aortic or Mitral regurgitation (balik-balik ang blood) of the virus to others. Permanent cardiac damage Providing supportive care for the associated symptoms Maintaining adequate hydration and nutrition Nursing Assessment: Providing adequate rest period Assess for signs of cardiac involvement Preventing complications Monitor pulse for 1 full minute to determine HR Providing education and support to child and family Assess for temperature elevation Observe for involuntary movements* Complications: Assess child ability to feed self, dress, and activities if Splenic rupture chorea or arthritis present do other Thrombocytopenia purpura Assess pain level using scale appropriate for child's age Hemolytic anemia Assess parent's ability to cope with illness and care for Pericarditis the child Hepatitis Encephalitis Nursing Interventions: Improving Cardiac Output (maintain bedrest especially Nursing Diagnosis: in acute phase; approximately 2 weeks) Hyperthermia Relieving Pain Altered comfort related to the sore throat, headache, & Protecting the child w/ Chorea acute illness Ineffective airway clearance related to soft tissue swelling Fluid volume deficit related to fever or decreased intake COMMON CARDIOVASCULAR Altered Nutrition: less than body requirements related to DISORDERS IN YOUNG ADULT decrease intake from sore throat Fatigue, activity intolerance related to disease process 1. EPSTEIN – BARR VIRAL INFECTION (INFECTIOUS Nursing Management: MONONUCLEOSIS) Assess for presence of symptoms that may lead to - aka Glandular fever, “kissing disease”, Mono complications - Acute, self-limiting infectious disease characterized by Obtain blood test by finger puncture for diagnostic an increase in the mononuclear (monocytes and purposes Provide bedrest during acute illness. Gradually lymphocytes) elements in the blood. increase activity as tolerated. - Incubation period is 4-6 weeks after exposure Administer antipyretic for fever Address comfort needs Transmission: Monitor hydration status contact with saliva, close intimate contact and blood Provide gargles with warm saline for pharyngitis contact Provide cool, soft, bland, non-acidic foods when the child's throat is sore Incidence: Collaborate with school to arrange make-up schoolwork Most commonly transmitted in adolescents assignment Teach child with splenomegaly to avoid heavy lifting, Risk Factors: trauma to abdomen and vigorous athletics Adolescents & Young adults with close, intimate contact Monitor for signs of hepatitis Immunocompromise clients 2. PERICARDITIS Manifestations: - Inflammation of the pericardium* Fever - It may be acute or chronic; it may be accompanied by an Splenomegaly outpouring of fluid or a collection of pus in the pericardial Abdominal pain sac. Anorexia - Aggravated by inhalation, yawning, & coughing Skin rash Severe sore throat Types of Pericarditis: Exudative pharyngitis Acute pericarditis Lymphadenopathy o Fibrinous Headache o Exudate (serous) Fatigue* o Antibiotic therapy: salicylates or indomethacin Jaundice (with hepatitis) may be used to inflammation. Malaise Chronic pericarditis Diagnostic Evaluations: o referred to as chronic or adhesive History & physical o Three times more prevalent in men than women NOTES  o May result from fibrosing of pericardial sac from o Give prescribed drug regimen for pain & trauma or neoplastic disease. symptomatic relief o Associated with the following disorder: ✔ NSAID for acute pericarditis ✔ Rheumatic heart disease ✔ Corticosteroids for more severe symptoms ✔ Congenital heart disease o Explain to the patient and family the difference ✔ Renal failure between pain of MI and pain of pericarditis. o Encourage the patient to remain on bed rest when Etiology: chest pain, fever, and friction rub occur. Unknown o Assist patient to position of comfort. Other causes: o Infection: Viral, Bacterial, Fungal and Parasitic Maintaining Cardiac Output o Connective tissue disorder (SLE) o Assess heart rate, rhythm, BP, respiration at least o Myocardial infarction; early 24 to 72 hours; or late hourly in the acute phase week to 2 years after MI o Prepare for emergency pericardiocentesis or o Malignant disease surgery o Chest trauma, heart surgery, including pacemaker o Assess for signs of CHF implantation. o Monitor closely for development of dysrhythmias o Drug induced (procainamide & phenytoin) 3. MYOCARDITIS Clinical Manifestation - is an inflammatory process involving the myocardium Sharp and often sudden pain in anterior chest with necrosis of the myocytes and associated Pericardial friction rub inflammatory infiltrate. Dyspnea Fever, sweating, chills Etiology: Dysrhythmias Viral Infection (cox sackie virus A&B strain, influenza virus, rubeola, rubella, adeno virus and echo virus) Diagnostic Evaluations: Hypersensitivity Reactions Echocardiogram Bacterial Infections (TB, diphtheria,Typhoid, Pneumonia, Chest x-ray Tetanus) ECG Radiation Therapy (Breast cancer / lung cancer) WBC and differential elevations Chemical Poisoning such as chronic alcoholism Antinuclear antibody serologic test elevated in SLE Parasitic Infections Pericardiocentesis BUN Clinical Manifestations: Fatigue and dyspnea Medical Management: Palpitation Bacterial pericarditis – penicillin or other antimicrobial Occasional precordial discomfort Rheumatic fever – Pen G Cardiac enlargement Tuberculosis - antituberculosis chemotherapy Abnormal heart sounds: murmur, S3 or S4 or friction Fungal pericarditis – amphotericin B and fluconazole rubs Systemic Lupus Erythematosus – steroids Signs of CHF Renal pericarditis – dialysis, indomethacin, Fever with tachycardia biochemical control of end-stage renal disease. Gallop rhythm* (characterized by tripling or quadrupling Neoplastic pericarditis – intrapericardial instillation of of heart sound upon auscultation) chemotherapy. Pulsus alternas (regular alteration of strong and weak Postmyocardial infarction syndrome – bed rest, heartbeats) aspirin and prednisone. Postpericardiotomy syndrome – treat symptomatically Diagnostic Evaluation: Emergency pericardiocentesis (for heart contraction) Transient ECG changes Partial pericardiectomy or total for recurrent Elevated WBC count and sedimentation rate constrictive pericarditis. Chest x-ray (heart enlargement and congestion) Elevated antibody titers Complications: Stool and throat cultures Cardiac tamponade (occurs when there’s too much fluid Endomyocardial biopsy (blood or pus) in the heart CHF Medical Management: Hemopericardium Diuretic and digoxin therapy for CHF and atrial fibrillation Nursing Assessment o Diuretic therapy (control pulmonary congestion) Evaluate complaint of chest pain* (especially in yawning, o Digoxin therapy* (lanoxin; increases myocardial during respi, coughing) contraction) Auscultate heart sounds* (in different positions; friction Antidysrhythmic therapy rub) o Quinidine (depresses heart excitability and Evaluate history of precipitating factors conduction) o Procainamide (decrease the irritability of heart Nursing Diagnosis: muscles) Chest pain related to pericardial inflammation Steroid therapy Decreased Cardiac Output related to impaired Antimicrobial therapy ventricular expansion Strict bed rest Nursing Interventions: Complications: Reducing Discomfort CHF NOTES  Cardiomyopathy Nursing Interventions: Nursing Interventions: Observe for signs of infiltration & inflammation, possible Assess for fatigue, palpitations, fever, dyspnea & chest complications of long term I.V. drug administration, at pain. the venipuncture site. Auscultate heart sounds Watch for signs of embolization. Evaluate history for precipitating factors. Monitor the patient's renal status (BUN levels, creatinine clearance, and urine output) Observe for signs of heart failure such as dyspnea, tachypnea, tachycardia, crackles, neck distention, edema and weight gain. Nursing Diagnosis: Provide reassurance by teaching the patient and his Hyperthermia related to inflammatory/ infectious process family about this disease and the need for prolonged Decreased Cardiac Output related to decreased cardiac treatment.* contractility and dysrhythmias Make sure a susceptible patient understands the need Activity Intolerance related to impaired cardiac for prophylactic antibiotics before, during, and after performance and febrile illness. dental work, childbirth and genitourinary, G.I. or gynecologic procedures. Nursing Interventions: Reducing Fever Maintaining Cardiac Output (strict I&O) COMMON CARDIOVASCULAR *weight gain suggests severe fluid retention *auscultate apical pulse (4th ICS specifically in the left DISORDER AFFECTING ADULT center of the chest; below nipple) Reducing Fatigue 1. CORONARY HEART DISEASE (CHD) - also known as CAHD (Coronary Artery Heart 4. ENDOCARDITIS Disease), CAD (Coronary Artery Disease), IHD - An infection of the endocardium, heart valves, or a (Ischemic Heart Disease) cardiac prosthesis resulting from bacterial or fungal - diseases of the heart that result from decrease in blood invasion. supply to the heart muscles. - Relapse happens after 2 weeks - Increase risk of >30% of IBW - Athero : fatty deposits; Arterio: Spasm Causes: Enterococci (major causative agent) Atherosclerosis is the major cause of obstruction in CHD I.V. drug - accumulation/deposition of cholesterol, lipids, fats, Mitral valve prolapse fibrous plaques and clots in the intima of the arterial Prosthetic heart valve wall. Rheumatic heart disease Streptococci & Staphylococci Etiology / Risk Factors: A. Non-modifiable Risk Factors Diagnostic Evaluation Sex (Gender) (more common in males) Blood test: Increasing Age – 40 years old above (40-65 years old o Normal or elevated WBC count above) o Abnormal histiocytes Heredity (Family Hx) o Elevated ESR Race o Positive serum rheumatoid factor Normocytic normochromic anemia (normal size RBC is B. Modifiable Risk Factors decreased in production; insufficient number) Major Modifiable Risk Echocardiography may identify valvular damage o Elevated Cholesterol level ECG may show AF and other arrhythmias o Hypertension Three or more blood cultures in 24-to 48 hour period o Smoking o Physical Inactivity Medical Management: Bed rest Minor Modifiable Risk Factors Maintaining sufficient fluid intake o Obesity (high LDL) Surgery to replace defective valve o Diabetes Mellitus/Glucose Tolerance Antibiotics: based on infecting organism o Stress and Behavioral Pattern Aspirin o Menopause o Homocysteine level Nursing Assessment: o Inflammatory Response Anorexia Arthralgia Current Recommendations for Cholesterol and Night sweat Lipoproteins Valvular insufficiency 1. Total blood cholesterol – less than 200mg/dl Chills 2. LDL – less than 160mg/dl (if with less than 2 other risk Fatigue factors, 130mg/dl (if with 2 or more other risk factors) Intermittent, recurring fever 3. HDL – less than 40mg/dl Weakness Weight loss Clinical Manifestations Malaise Atherosclerosis – no subjective clinical manifestations Loud, regurgitant murmur unless there is critical deficit in blood supply to the Signs of cerebral, pulmonary, renal or splenic infarction myocardium (can only be seen through angiogram) NOTES  Regular exercise Myocardial Ischemia – temporary lack of oxygen Control blood pressure supply to myocardium resulting from or due to decrease Control Diabetes Mellitus. Cholesterol level and Weight coronary blood flow (CHD) either by obstruction or Moderate alcohol intake vasospasm Low sodium diet o Common symptom is Angina Pectoris or chest pain Medications as prescribed *Anaerobic metabolism produces lactic acid and o Lipid lowering agents causes pain o Anti-hypertensive therapy o Anti-platelet therapy Phases of Atherosclerosis Development o ACE inhibitors (“pril”) 1. Phase I – present in most people 30 years of age and o Beta blockers (“lol”) younger. o Nitrates Type I (Initial Lesion) – microscopic adaptation of smooth muscle and occurs more often in the branches B. Restore Blood Supply near the arteries Techniques to open vessel and restore blood supply Type II (Fatty Streaks) – fatty streaks are flat in the o Percutaneous Transluminal Coronary intimal layer of coronary artery Angioplasty (PTCA) Type III (Preatheroma) – raised fatty streaks in the *insertion of balloon catheter from femoral artery to intimal layer of CA the blocked artery; inflated several times and will flatten the atheroma 2. Phase II – represents the development of vulnerable plaques Directional Coronary Atherectomy (DCA) Type IV (Atheroma) – further changes in the intimal *removal/excision of the atheroma structure caused by large amount of accumulation of extracellular lipids and fibrous tissues Intracoronary Stents Type V (Fibroatheroma) – formation of new fibrous o Nursing consideration: Instruct the client to limit connective tissues as a thin protective cap over the movement of sheathed leg and keep the head of atheroma the bed below 30 degrees to prevent bleeding and hematoma at the site 3. Phase III – marked by acute disruption of type IV and V o Close monitoring of anticoagulant status and lesions that causes thrombus formation and the ongoing assessment for bleeding. development of type VI lesion. Type VI – (Complicated lesion) Laser Ablation o lasers are used with balloon angioplasty to vaporize 4. Phase IV – if the thrombus reduces or significantly atherosclerotic plaque. After initial balloon blocks flow through the artery. angioplasty, a brief burst of laser radiation is administered and additional remaining plaque is 5. Phase V – when the thrombus over the disrupted plaque removed. begins to calcify or fibrose forming a chronic stenotic lesion. Transmyocardial Revascularization (TMR) o high powered laser is guided to the left ventricle PATHOPHYSILOGY (ATHEROGENESIS) between heart beat when ventricle is filling with blood. Laser then creates 15-40 1mm channels through the myocardium promoting growth of small new blood vessel (Angiogenesis). Surgical Management: Cardiac Surgery o Reparative o Reconstructive – CBAG (Coronary Artery Bypass Graph) o Substitutional – ECC (Extra Corporeal Circulation) or simply heart lung machine Function of ECC Diagnostic Procedures/Studies for Ischemia Divert circulation from the heart to lungs, providing the ECG surgeon with a bloodless operative filed. B-mode ultrasonography Performs all gas exchange functions Doppler flow studies Filters, rewarms or cools the blood Intravascular ultrasound Circulates oxygenated, filtered blood back into the Electronic-beam computed tomography arterial system Thallium 201 Imaging Echocardiographic Stress Test* Coronary Artery Bypass Graft (CABG) PET and NMRI* involves the bypass of a blockage in one or more of the Cardiac Catheterization* coronary arteries using the saphenous veins, internal mammary artery or radial artery as conduits or Medical Management: replacement vessel. Primary Goal: Reduce and control risk factors and restore involves the use of CPB (Cardiopulmonary Bypass) blood supply to the myocardium. Complication of CABG A. Reduce Risk factors Post-op bleeding Cessation of cigarette smoking Wound infection and dehiscence NOTES  Intraoperative stroke *Nicotine stimulates release of catecholamines MI (epinephrine/ NE) which causes vasoconstriction Blood clots Sexual Activity Multiple organ system failure Stimulants (Ex. Cocaine, amphetamines) Death Cicardian Rhythm patterns *pattern in sleep-wake cycle; usually occurs early morning because of a decrease work load from lying Nursing Management down overnight. Reduce Risk Factors Increase HR= Decrease Left Ventricular Diastole leading o Provide health education about reducing risk factors to decrease blood filling leading to decrease CO. for CHD. o Participate in risk factors screening for both children Assessment of Angina Pectoris: and adults 1. Characteristic of Pain o Teach stress reduction technique. Relieved by rest and NTG tablet (Nitroglycerin; o Instruct post menopausal women to discuss the vasodilator) unlike chest pain associated with Ml. need for estrogen HRT with their physician. Last only for 2-5 mins if precipitating factor is relieved o Monitor BP, HbA₁c for diabetic clients. Described as "SQUEEZING, CHOKING. BURNING, o Explain the diagnostic tests when the pt will seek PRESSING, CRUSHING, ACHING OR BURSTING treatments PRESSURE". May clench fist over sternum - LEVINE's sign Restore Blood Supply Located RETROSTERNALLY/SUBSTERNALLY (lower o Administer medication as ordered before half of sternum) intervention May radiate to: Left shoulder and upper arm and then ✔ Anti-platelet medication (Aspirin) may travel down the inner aspect of the left arm to the ✔ Anti-coagulant (Heparin) elbow, wrist and fourth and fifth finger ✔ Calcium channel blockers o may also radiate to the Right shoulder neck, jaw, or ✔ Nitrates (NTG) epigastric region Blood typing and cross matching in the event of Emergency CABG Surgery 2. Vital signs (increase BP and HR) Post procedure, monitor vital signs esp. quality and rhythm of pulse in ECG Types/Patterns of Angina Report Indication of coronary ischemia (ST segment) Stable Angina (predictable – less than 15 mins) Unstable Angina (Pre-infarction angina, Cresendo 2. ANGINA PECTORIS (CARDIAC PAIN OF EFFORT) angina, Intermittent Coronary syndrome) - temporary state of myocardial hypoxia characterized by *unpredictable, usually occur at night; more than 15 transient paroxysmal attack of substernal or precordial mins but less than 30 mins pain. Variant Angina (Prinzmetal's Angina) - results when myocardial oxygen demand exceeds *may occur in early hours of the day; pt is resting; ST myocardial oxygen supply. elevation. Nocturnal Angina Causes: *occurs during at night, possibly connected to REM Atherosclerosis (Random Eye Movement) Hypertension Angina Decubitus Diabetes Mellitus *associated w/ paroxysmal chest pains (pain is eased Thromboangitis Obliterans when sitting down, appears when standing) Polycythemia Vera (increase number in RBC – blood will Intractable Angina become viscous resulting to blockage) *severe and unresponsive to interventions Aortic Regurgitation Post-infraction angina *occurs after MI INSERT PATHOPHYSILOGY OF ANGINA PECTORIS Diagnostic Test: Electrocardiography Exercise electrocardiography (Stress Test Treadmill Exercise) Radioisotope Imaging Electron Beam Computed Tomography (calcium detection/measurement in coronary arteries) Coronary angiography Medical Management of Angina Goal: I. Reduce acute attack/Restore coronary blood flow II. Prevention of further attacks to reduce the risk of MI Precipitating Factors of Angina: Medical Management of Angina Physical Exertion I. Relieving Acute attack/Restore Coronary blood flow Extreme of Temperature Pharmacologic treatment Strong Emotions o Opiate analgesic – used to relieve acute pain Consumption of Heavy Meal (blood flow increase in (leads to respiratory depression: beware) stomach) o Vasodilators Cigarette Smoking ✔ Ex. Nitroglycerin – Drug of choice since 1867 ✔ Isosorbide Nitrate NOTES  o Beta Adrenergic Blocking Agents (BABA) Encourage and help plan regular program of daily o Calcium-channel blockers exercise to promote improved coronary circulation Instruct clients who smoke to quit smoking and avoid passive smoking ( Other Medications Urge overweight clients to lose excess weight o Platelet Aggregation Inhibitors – prevent thrombus Help client who leads an active, hectic life to adjust formation activities to a level below that which precipitates anginal o Anticoagulants (Aspirin, Heparin, Warfarin) attacks. Nursing Intervention of Patient under NTG Therapy 3. MYOCARDIAL INFARCTION Assume sitting or supine position when taking the drug. - process by which myocardial muscle is destroyed due to Take maximum of 3 doses at 5 minutes interval. interruption of or insufficient blood supply for a Gradual change in position to prevent orthostatic prolonged period resulting in a sustained oxygen hypotension. deprivation. If taken Sublingual, NTG causes burning or stinging - characterized by the formation of localized necrotic sensation under the tongue. areas within the myocardium. SL route produce onset of action within 1 – 2 minutes, duration of action is 30 minutes. Risk Factors for MI: Offer sips of water before giving SL nitrates because Age: 35-74 years old dryness of mouth inhibits drug absorption. Sex : Men Instruct client to avoid drinking alcohol to avoid Diet: Increase cholesterol hypotension, weakness, and faintness. Lifestyle: Advise client to always carry three tablets in his pockets. o Stress Store NTG in cool, dry place, use dark/amber colored o Strenous physical activity air-tight container; may be destroyed by heat, light or o Smoking moisture. o Alcohol ingestion Change stock of NTG every 6 months o Obesity Observe for S/EI headache, flushed face, dizziness, faintness. Tachycardia – these are common during the Causes/Etiology: first few doses of the meds Atherosclerosis ⚠ DO NOT DISCONTINUE THE DRUG! ⚠ Spasm (Arteriosclerosis) Transderm–Nitro is applied once a day usually in AM Emboli (on the chest wall Thrombus *Do not touch the part w/ Nitroglycerin for it causes headache; use gloves Clinical Manifestations Evaluate effectiveness: Relief of Chest Pain Chest Pain o Location: Over the lower sternal region II. Prevention of further attacks o Radiation: Neck, jaw, shoulder, back or left Education & counseling regarding modification of Risk o Intensity: Heavy, vise-like increasing steadily in Factors intensity, "crushing pain" o Duration: Hours to days Surgical Management: o Relief: Not relieved by rest and NTG CABG (Coronary Artery Bypass Graft) Abdominal pain/indigestion o recommended if severe narrowing of one or more Profuse perspiration: moist clammy skin with pallor branches of the coronoary arteries exist. Drop in BP o Main purpose is myocardial revascularization. Dyspnea, weakness and fainting PTCA (Percutaneous Transluminal Angioplasty) Nausea and vomiting Intravascular Stenting Anxiety and restlessness Laser therapy Depth of the Various Types of Infraction Nursing Management: Transmural Infarction – entire thickness of the I. Relieve / Reduce Acute pain & restore coronary blood myocardium is involved flow Subendocardial Infarction – damaged has not Assess and document the clinical manifestation of penetrated thickness of myocardial wall angina* Inferior Wall Infarction – Right coronary artery lesion Cardiac monitoring (12-lead ECG) Anterior Wall Infarction – Left anterior descending Note new characteristic or increase pain branch of coronary artery is affected Administer medications as ordered Lateral Wall Infarction – circumflex branch of coronary o Guide in the Treatment of client with Chest Pain: artery is affected. (MONA) Posterior Wall Infarction – Left coronary artery lesion ✔ M – Morphine sulfate ✔ O – Oxygen therapy Diagnostic Evaluation: ✔ N – Nitrates (NTG) Electrocardiography ✔ A – Aspirin o abnormal Q wave Promote rest and security and allay fear and anxiety to o ST segment elevation help reduce pain o T wave inversion II. Prevent further attacks through Self-care Myoglobin Educate the client to avoid activities or habits that would o detected within 2 hours after an acute MI precipitate angina* Explain the importance of daily management of HPN Leukocytes o 10.000-20.000mm WBC NOTES  o appears on the second day after an MI and 1. Cardiogenic shock disappears in 1 week C/M: o Position Emission Tomography (PET) o decreased BP o Magnetic Resonance Imaging (MRI) o restlessness o cold clammy skin Troponin T o Diaphoresis o increase within 3-6 hours after pain has started o grayish skin color remains elevated for 14-21 days o Rapid pulse o Decreased urine output Troponin I o rise in 7-14 hours after an acute MI Treatment: o elevation persists for 5-7 days o Administer vasopressors – Norepinephrine, dopamine, dobutamine CK-MB o Administer vasodilators – Nitroglycerine o Onset: 3-6 hrs, peak: 12-18 hrs, return to normal: 3-4 days 2. PVC (Premature Ventricular Contraction) notify physician if > 6/min. and the client is symptomatic LDH (hypotension & chest pain) o Onset: 14-24 hrs, peak: 48-72 hrs, return to normal: Treatment: Lidocaine next 7-14 days 3. Ventricular Tachycardia (VTAC) AST HR> 120 beats per minute o Onset: several hrs, peak: 12-18 hrs, return to normal: 3-4 days IV. Anxiety related to fear of death, complex environment, and uncertainty of etiology and prognosis Objective of Treatment Assess level of anxiety and coping mechanism of patient to promote adequate circulatory function with and family healing of the myocardium, Administer anti anxiety meds. to limit the size of the infarction Explain all procedures to patient and invite question to prevent death V. Activity intolerance related to imbalance between Nursing Diagnosis and Nursing Management: myocardial oxygen supply & demand I. Alteration in comfort, Pain related to tissue ischemia Promote bed rest and increased mobilization associated with coronary artery occlusion. Place patient at rest of decreased O2 demand Assess chest pain* Assist with implementation of self-care activities on a Perform actions that decreases myocardial oxygen gradual basis demand Instruct to avoid any sudden effort o Administer medications as ordered (pts may receive sedatives and hypnotics; Diazepam [Valium] VI. Altered pattern of elimination; constipation related to Chlordiazepoxide [Ativan]) restricted activity o Administer oxygen Administer stool softener o CBR without TP Offer diet bulk and fibers o Semi-fowlers / High fowlers position Limit gas forming foods o Reduce blood volume by decreasing salt intake & water intake CARDIAC REHABILITATION o Reduce anxiety* - process by which a person is restored to and maintains optimal, physiologic, psychosocial, vocational and II. Cardiac output deficit related to failure of the recreational status myocardium to pump associated with death & necrosis of the myocardium. Goal: Assess BP, pulses, breath sounds To help patient live as full, vital, productive, life as Restrict stimulant possible while remaining within the limit of the heart's Provide small frequent meal and easily digested food ability to respond to increase in activity and rest. Provide supplemental oxygen Maintain IV line medications as access to deliver PHASE I emergency - begins with admission Provide bedside commode Provide CBR with the use of bedside commode Start passive exercise III. Altered tissue perfusion related to decrease cardiac Sit for brief period and dangle feet output, vasoconstriction and thromboembolic formation Allow to ambulate for 15-20 minutes Assess skin temperature and color Allow bathroom privileges with self-care acts Monitor and record vital signs every 1-2 hours to Allow brief walks in the hallway with supervision determine presence of impending cardiogenic shock & other complications PHASE II Administer thrombolytic agent as ordered* If (-) complications, patient is discharged by the 2nd (Streptokinase, Urokinase) week *watch for signs of bleeding, hypersensitivity, stroke o Performs large muscle exercises at least 20-30 Administer stool softeners minutes, 3-4 times a week Watch for complications o May return to work at the end of 8 or weeks if asymptomatic o Sexual intercourse may resume 4-8 weeks after MI Complications: if the physician agrees NOTES  o Requirement before resuming sexual intercourse: ✔ Should be able to climb 2 flight of stairs before Clinical Manifestations: resuming sexual activity - Usually asymptomatic ✔ Caution not to eat / drink alcoholic beverages