NCM 112_ Examination Notes (Lecture) (1).pdf

NCM 112 (2504)_Examination Notes (Lecture) NCM 112: Examination Notes threats that disregard national (Lecture) borders. 1st Examination Notes...

NCM 112 (2504)_Examination Notes (Lecture) NCM 112: Examination Notes threats that disregard national (Lecture) borders. 1st Examination Notes Is not to be confused with international health, which is Lesson 1: Concept in the Care of at defined as the branch of public Risk and Sick Adult Clients health focusing on developing nations and foreign aid efforts Health System by industrialized countries. Is the maintenance or improvement of health via the National Health prevention, diagnosis, The public system of medical treatment, recovery, or cure of care disease, illness, injury, and other physical and mental Local Health impairments in people. Is a government agency in a country on the front lines of The organized provision of public health. medical care to individuals or a community. Local health departments may be entities of local or state Efforts made to maintain or government and often report to restore physical, mental, or a mayor, city council, country emotional well-being especially board of health or county by trained and licensed commission. professionals. Preoperative Nursing care Global Health A care given before surgery Is the health of populations in when physical and psychological the global context. preparations are made for the operation, according to the The area of study, research and individual needs of the patient. practice that places a priority on improving health and achieving Runs from the time the patient equity in health for all people is admitted to the hospital or worldwide. surgicenter to the time that the surgery begins. Is about worldwide health improvement (including mental health), reduction of disparities, and protection against global 1| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Perioperative Care Intra-operative Care Referred to as perioperative Is patient care during an medicine, is the practice of operation and ancillary to that patient-centered, operation. multidisciplinary, and integrated medical care of patients from Extends from the time the client the moment of contemplation of is admitted to the operating surgery until full recovery. room, to the time of anesthesia administration, performance of Preoperative Phase the surgical procedure and until Runs from the time the patient is the client is transported to the admitted to the hospital or recovery room or Post surgicenter to the time that the Anesthesia Care Unit (PACU). surgery begins. Types of Anesthesia: Begins when the decision to 1. General proceed with surgical Reversible state of intervention is made and ends unconsciousness with loss with the transfer of the patient of sensation of the entire onto the operating room table. body Includes: A medically induced state ○ Obtaining consent of unconsciousness in (secured by the nurse which the patient is after it was signed) completely unaware and does not feel pain during ○ Preparation of clearances surgery or other (cardio-pulmonary, procedures. It affects the nephrology, neurology, entire body, and the etc.) patient typically requires support for breathing, ○ Pre-op meds are given to such as a ventilator. the patient (done by nurses in the ward) 2. Spinal A type of regional ○ Checking the patient anesthesia that involves pre-op injecting a local No nail polish anesthetic into the No jewelries cerebrospinal fluid in the No underwear subarachnoid space, which surrounds the 2| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) spinal cord. It causes loss aware, as the anesthetic of sensation and motor only affects the targeted function below the level area where it's applied. of injection, usually from the abdomen down to the 5. Regional legs. It's commonly used Blocks sensation in large for surgeries involving the region or position of the lower abdomen, pelvis, body and lower extremities. 6. Sedation 3. Epidural Decreased level of Another form of regional consciousness or relaxed anesthesia, epidural state, but not fully anesthesia involves unconscious. injecting a local anesthetic into the Two Types of OR Nurses epidural space outside 1. Scrub Nurse the dura mater of the Assist the doctor in giving spinal cord. Unlike spinal instruments anesthesia, it allows for more precise control of Secure and maintain the the anesthetic level and completeness of SIN can be used for longer (sponges, instruments, & periods. It’s often used needles) during labor and childbirth, as well as for 2. Circulating Nurse surgeries on the lower Assist the limbs and abdomen. anesthesiologist during the anesthesia 4. Local administration Blocks sensation in a specific area of the body Prepare the patient and the OR room (this This type of anesthesia includes the instruments numbs a specific small along with the scrub area of the body. It is nurse) typically used for minor surgical procedures, Skin preparation dental work, or diagnostic tests. The patient remains Disinfect the operation fully conscious and site using disinfectant 3| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) solution (eg. alcohol, should be paid to this in betadine) theaters, as patients are incapable of moving at a time Blood transfusion as when additional risk factors are needed present Introduce maintenance 1. Theatre Preparation drugs (due meds) during To ensure efficient and operating hours safe running of the theater list, it should be Paperworks (eg. consent) managed by a designated person, usually the most senior. Post-operative Care Is the care you receive after a There should be surgical procedure. sufficient staff on duty, and they should all have Postoperative care is the care a clear understanding of you receive after a surgical their role in the team, procedure. The type of based on their skills and postoperative care you need abilities. depends on the type of surgery you have, as well as your health All equipment should be history. It often includes pain tested before it is management and wound care. needed, and care should be taken with electrical equipment so that cables Principles of Safety, Comfort and do not present a trip privacy During the Perioperative hazard or run across Period areas where there is a Special consideration must be risk of fluids pooling given to patients under general anesthesia The heating should be set at a level that is safe They are unable to take care of and comfortable for their own safety needs or voice patients and staff any concerns 2. Infection Control Pressure Area Protection A meticulous Fundamental aspect of nursing theater-cleaning regime care and particular attention 4| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) is fundamental to ○ Reducing contaminants preventing infection. Disinfection Theaters should be clean ○ Removal of most and dust free, ventilation pathogens systems must be in working order and doors Sterilization must be kept closed. ○ Removal of all pathogens All items needed for the NOTE: operation should be Reusable instruments, theater placed on an adequate drapes, and reusable scrub supply gowns should be processed according to local policy. Regularly used items Sterile Technique should be on hand to Is used for surgery or the minimize movement to preparation of sterile materials and from theater during for multiple patients. It involves: operation ○ Surgical hand rub with long acting antiseptic The theater floor should be cleaned thoroughly ○ Hands dried with sterile everyday and during the towels operation ○ Sterile Field The floors and surfaces should be damp dusting ○ Sterile gown, mask between operations, ensuring any spillage of ○ Sterile gloves blood or body fluids are removed ○ Sterile supplies A cleaning agent of ○ Skin Preparation proven activity should be used. Cloths used must be Principles of Sterile Technique disposable and mop 1. All articles used in an operation heads should be sterilized have been sterilized previously. daily. 2. Persons who are sterile touch Infection Control only sterile articles; persons Cleaning 5| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) who are not sterile touch only 9. Ask a non-sterile person to step unsterile articles. aside rather than trying to crowd past him. 3. Sterile persons avoid leaning over an unsterile area; 10. Step back away from the sterile non-sterile persons avoid field to sneeze or cough. reaching over a sterile field. Unsterile persons do not get 11. Turn head away from the sterile closer than 12 inches from a field to have perspiration sterile field. mopped from brow. 4. If in doubt about the sterility of 12. Stand back at a safe distance anything consider it not sterile. from the operating table when If a non-sterile person brushes draping the patient. close, consider yourself contaminated. 13. Members of the sterile team 5. Gowns are considered sterile remain in the operating table only from the waist to shoulder when draping the patient. level in front and the sleeves to 2 inches above the elbows. 14. Do not wander around the room Keep hands in sight or or go in the corridors above waist level away from the face. 15. Sterile persons keep contact with sterile areas to a minimum. Arms should never be folded. 16. Do not lean on the sterile tables or on the draped patient. Articles dropped below waist level are discarded 17. Do not lean on the nurse’s mayo 6. Follow those rules from tray. passing:Face to face or back to back. 18. Non-sterile persons - when you are observing a case, please 7. Turn back to a non-sterile person stay in the room until the case is or when passing. completed. Do Not wander from room to room as traffic in the 8. Face a sterile area when passing operating room should be kept the area. as a minimum. Patient privacy needs to be respected. 6| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) 19. Keep non-essential conversation Scrub practitioner – responsible to a minimum. for counting all items used in an operation before incision, at first 20. The circulating nurse is in charge layer closure and at skin closure of the room -if you have any questions, please refer them to In counting: her, the supervisor or your ○ 1st counting: before instructor. surgery Sterile Field This consists of: instrument ○ 2nd counting: before trolleys, scrub team, and draped fascia closing patient ○ 3rd counting: before skin There must be a wide margin of closing safety marked by an invisible In naming staff: (chronological wall at the trolly edges, which order) marks the barrier over which ○ Surgeon non-sterile items should not ○ Anesthesiologist cross ○ Resident ○ The rest of the surgical Protective Clothing team Protects theater staff from potential infection from The initial count should be pathogenic microorganisms and recorded before the operation prevents clothing becoming wet begins and any items that are or soiled added during the course of the operation should be recorded by The scrub practitioner wears the circulating nurse sterile, long-sleeved gown Specialist Equipment Footwear and Gloves Electrosurgical (diathermy) Outside shoes should never be ○ Device that uses high worn in theater frequency electrical current to generate heat, The hospital should supply which can cut and non-slip, anti-static theater coagulate body tissue clogs or boots, which should be washed after each use ○ Correct use of equipment will ensure that skin Sharps, Swabs and Instruments integrity remains intact 7| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) ○ The patient should not Obtain a health history be in contact with and perform a physical grounded metal objects examination to establish as the provision of an vital signs and a alternative pathway for database for future the electrical current comparisons. could result in a burn Assess the patient's usual level of Waste Disposal functioning and typical Body fluids collected in suction daily activities to assist in bottles should be treated with a the patient's care and gelling agent and allowed to recovery or rehabilitation solidify before being double plans. wrapped to prevent leakage Assess mouth for dental All clinical waste (placed in caries, dentures,and yellow bags) should be labeled partial plates. Decayed by the date, theater number, teeth or dental prostheses and case number (to allow may become dislodged traceability) during intubation for anesthetic delivery and Waste disposal: occlude the airway. ○ Yellow – infectious ○ Red – sharps Nutritional Status and ○ Black – general Needs - determined by measuring the patient’s Nursing Responsibilities During height and weight, triceps Perioperative period. skinfold, upper arm 1. Physical Preparation circumference, serum Before any treatment is protein initiated, a health history is obtained and a physical Obesity greatly increases examination is performed the risk and severity of during which vital signs complications associated are noted and a database with surgery. is established for future Fluid and Electrolyte comparisons. Imbalance - dehydration, hypovolemia, and 2. Physiologic Assessments electrolyte imbalances Age of patient should be carefully 8| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) assessed and Endocrine Function - documented. diabetes, corticosteroid intake, amount of insulin Drug and Alcohol Use - administered. the acutely intoxicated person is susceptible to Immunologic Function - injury. existence of allergies, previous allergic Respiratory Status - reactions, sensitivities to patients with pre-existing certain medications, past pulmonary problems are adverse reactions to evaluated by means of certain drugs, pulmonary function immunosuppression. studies and blood gas analysis to note the Previous Medication extent of respiratory Therapy - it is essential insufficiency. that the patient’s medication history be Cardiovascular Status - assessed by the nurse cardiovascular disease and anesthesiologist. increases the risk of complications. The following are the medications that cause particular concern during Hepatic and Renal the upcoming surgery: Function - surgery is contraindicated in 1. Adrenal Corticosteroid patients with acute Not to be discontinued nephritis, acute renal abruptly before the insufficiency with oliguria surgery. Once (aka hypouresis, is the discontinued suddenly, low output of urine), or cardiovascular collapse anuria (no urine output) may result for patients or other acute renal who are taking steroids problems. Any disorder of for a long time. A bolus of the liver on the other steroids is then hand can have an effect administered IV on how an anesthetic is immediately before and metabolized. after surgery. Presence of trauma 2. Diuretics 9| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Thiazide diuretics may transmission is cause excessive interrupted and apnea respiratory depression due to respiratory during the anesthesia paralysis develops. administration. Pre Op Checklist: Day of Surgery 3. Phenothiazines Client teaching completed These medications may Consent form signed increase the hypotensive NPO action of anesthetics In gown Allergy and ID bands on 4. Antidepressants No jewelry-bands taped Monoamine oxidase Voiding prior to transfer inhibitors (MOAIs) Pre-op meds increase the hypotensive Side rails up after pre-op effects of anesthetics. Contact lens out 5. Tranquilizers dentures/bridges out medications such as Nail polish removed barbiturates, diazepam Vitals within 4 hours of surgery and chlordiazepoxide or 30 minutes after pre-op may cause increased Pre-op lab work on chart anxiety, tension, and Abnormal lab values even seizures if Skin prep withdrawn suddenly. History of aspirin, antidepressant, steroid, NSAIDs 6. T. Insulin When a diabetic person is Respecting Spiritual and Cultural undergoing surgery, Beliefs interaction between Help patients obtain spiritual anesthetics and insulin help if he or she requests it; must be considered. respect and support the beliefs of each patient. 7. Antibiotics “mycin” drugs such as Ask if the patient’s spiritual neomycin, kanamycin, adviser knows about the and less frequently impending surgery. streptomycin may present problems when combined When assessing pain, remember with curariform muscle that some cultural groups are relaxant. As a result nerve unaccustomed to expressing 10| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) feelings openly. Individuals from simple/partial some cultural groups may not mastectomy make direct eye contact with others; this lack of eye contact is not avoidance or a lack of interest but a sign of respect Radical ○ Extensive surgery, Listen carefully to the patient, beyond the area especially when obtaining the obviously involved history. Correct use of communication and ○ Directed at finding interviewing skills can help the a root cause nurse acquire invaluable information and insight. Remain ○ Condition of unhurried, understanding, and surgical procedure: caring. radical prostatectomy, Types of Surgery: radical 1. Degree of urgency hysterectomy Necessity to preserve the client’s life, body part, or 4. Urgent body function Requires prompt intervention, may be life 2. Degree of Risk threatening if treatment Involved in surgical is delayed more than procedure is affected by 24-48 hours the client’s age, general health, nutritional status, Condition of surgical use of medications, and procedure: mental status ○ Intestinal obstruction 3. Extent of Surgery Simple ○ Bladder ○ Only the most obstruction overtly affected areas involved in ○ Kidney or ureteral the surgery stones ○ Condition of ○ Bone fracture surgical procedure: ○ Eye injury 11| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) traumatized or ○ Acute cholecystitis malfunctioning tissues 5. Emergent 9. Ablative Requires Removes a deceased emergent/immediate body part intervention because of life-threatening 10. Palliative consequences Relieves or reduces pain or symptoms of a Condition of surgical disease; it does not cure procedure: ○ Gunshot or stab 11. Transplant wound Replaces malfunctioning structures ○ Severe bleeding ○ Abdominal aortic aneurysm 12. Cosmetic Performed primarily to ○ Compound alter or enhance personal fracture appearance ○ Appendectomy 13. Major Surgery Involves a high degree of 6. Diagnostic risk Allows to confirm or establish diagnostic Longer and extensive diagnosis than a minor procedure To determine the origin 14. Minor Surgery and cause of a disorder Normally involves little or the cell for cancer risk, often done with local anesthesia 7. Corrective Excision or removal of Factors that Affect Surgery deceased body part, then 1. Age corrects it Very young and elder patients are greater 8. Reconstructive surgical risks than Restore function or children and adult appearance to 12| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) General health surgery is ○ Barriers to learning least risky when the client’s general health is ○ Patient and family good concern 2. Nutritional Status ○ Learning styles and Required for normal preferences tissue repair The content focuses on 3. Medications information that will increase Regular use of certain patient’s familiarity with medications can increase procedural events, which surgical risk includes: ○ Surgical experience 4. Mental Status (procedural) Disorder that affect cognitive function ○ What the patient may Perioperative Nursing Care: Common experience (sensory) Nursing Diagnosis ○ What actions may help Knowledge deficit decrease anxiety (behavioral) Anxiety Intraoperative Phase Risk for ineffective airway clearance Circulating Nurse Functions: Manages the operating room Fear related to disturbed sleep and protects the safety and pattern health needs of the patient by monitoring activities of Anticipatory grieving related to… members of the surgical team and checking the conditions in Perioperative Nursing Care: the operating room Preoperative teaching The education should begin with: Responsibilities: ○ Assessment ○ Assures cleanliness in the OR ○ Baseline knowledge of the patient and family ○ Guarantees the proper room temperature ○ Readiness to learn humidity and lighting in OR 13| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) ○ Make certain that the ○ Keep track of the time the equipments are safely patient is under functioning anesthesia and the time the wound is open ○ Ensure that supplies and materials are available ○ Checks equipment and for use during surgical materials such as procedures needles, sponges, and instruments as the ○ Monitors aseptic surgical incision is closed technique while coordinating the movement of related personnel ○ Monitors the patient Postoperative Phase throughout the operation to ensure their safety Post-op Phase Scale (0-2) Assessment items: Scrub Nurse Functions ○ Activity, able to move, Assists the surgeon during the voluntarily or on whole procedure by anticipating command the required instruments and 4 extremities — 2 setting up the sterile table 2 extremities — 1 No — 0 Responsibilities: ○ Scrubbing for surgery Breathing ○ Able to breathe deeply ○ Setting up sterile table and cough freely — 2 ○ Preparing sutures and ○ Dyspnea, shallow or special equipment limited breathing — 1 ○ Assists the surgeon and ○ Apnea — 0 assistant during the surgical procedure by Consciousness anticipating the required ○ Fully aware — 2 instruments, sponges, ○ Arousable when called — drains, and other 1 equipment ○ Unresponsive — 0 14| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) ○ Blood loss Circulation ○ Hyperventilation ○ ± 20% of pre-anesthesia ○ Exposed skin level — 2 Replace By: ○ ± 20% to 49% of ○ IV fluids pre-anesthesia level — 1 ○ Blood products, colloids, ○ ± 50% of pre-anesthesia or crystalloids level — 0 Monitor For: Spo2 ○ Fluid and electrolyte ○ Maintains SpO2 >92% in imbalances ambient air — 2 ○ Pulmonary edema ○ Maintains SpO2 >90% with oxygen — 1 ○ Water intoxication ○ Maintains SpO2 1.5 mg/ml (heart damage or MI) 28| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) 2. Creatine Kinase (CK-MB) Death Enzyme that is released in the bloodstream when the Heart attack (due to blood clot heart, brain, and skeletal after surgery) muscle is damaged Hence, prior to surgery, blood An increase of this enzyme thinners must be given – indicates problem anticoagulants (ex. heparin) Normal: 0-0.5 mg/ml Infection Continuation of CABG Long-term need for breathing Creates a new path for blood to machines flow Arrhythmias Takes a healthy blood vessel from the chest or leg area Kidney problems ○ Chest – internal mammary gland Memory loss ○ Leg – saphenous vein Stroke ○ Arm – radial artery Cardiac Complications: 1. Perioperative MI A.K.A. “heart bypass surgery” Baseline troponin must be checked (pre- and post-) Doesn’t cure heart disease, it just Obtain ECG creates a bypass for the blood flow but it can reduce the following 2. Low Cardiac Output symptoms: Due to left ventricle ○ Chest pain dysfunction – chronic heart ○ SOB failure Recommended for: Doctor will initiate: ○ Blockage ○ Fluid replacement ○ Severe narrowing (atherosclerosis) ○ Inotropes support ○ Severe chest pain (drugs that tell your heart to Risks: beat/contract; ex. Bleeding Digoxin, epinephrine) 29| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) ○ Bradyarrhythmias Pre OP Preparations: Anticoagulants ○ Tachyarrhythmias ○ For blood thinning to avoid blood clotting and heart ○ Give beta-blockers blockage (propranolol) ASAP ○ Discontinue 3 days pre-op ○ Pericarditis (not abruptly) (inflammation of pericardium) Antiplatelets ○ Discontinue at least 5 days 3. Cardiac Tamponade pre-op Abnormal amounts of fluid accumulated at the Instruct the patient to take a bath pericardial sac One hour prior – antibiotics are This compresses the heart → given decrease cardiac output → shock Beta-blockers within 24 hours of surgery 2 Variations of CABG 1. Off Pump or Beating Heart NPO at midnight Surgery Will not use pump Signed consent and surgery complete teaching Operating while the heart is Post Op beating Maintain airway patency Monitor VS Stabilization of a specific Must control the following to avoid area only, using special further complications: equipment, then CABG is ○ BP performed ○ cholesterol level Prepare protamine sulfate Quite challenging since the (antidote) for heparin rest of the heart is still moving Post-op Assessment Hypothermia 2. Minimally Invasive Surgery Incision, then the tube is Ineffective respiration inserted 30| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Fluid electrolyte imbalance does not slow to a dangerously slow rate Pain Indications: Incision drainage (>100cc – notify ○ Bradyarrhythmias (main physician) indication) Anorexia ○ Decreased BP Fatigue ○ Dizziness Chest tube (if applicable) must be ○ Chest pain maintained ○ Low pulse oxygenation To Improve Heart (Lifestyle) Smoking cessation ○ Atrial fibrillation Eat healthy food Limit sugar, salt, and saturated fats ○ Sustained supra-ventricular Exercise for 30-60 minutes (helps tachycardia regulate BP and prevent high cholesterol) ○ Sustained ventricular Manage weight tachycardia Manage stress (reduce emotional stress) ○ Patients under CRT (cardiac Get a good sleep (7-9 hours) resynchronization therapy) With heart failure Possible Nursing Diagnosis desynchronization of Ineffective tissue perfusion left and right Acute chest pain ventricles Activity intolerance ○ Myocardial infarction 2. Pacemaker Insertion The implantation of a small Two Types of Pacemaker electronic device that is usually 1. Temporary Pacemaker placed in the chest (just below the Leads implanted on collarbone) to help regulate slow epicardium electrical problems with the heart Epicardial or transvenous Pacemaker ○ May be recommended to Power source – implanted ensure that the heartbeat outside of the body 31| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Follow-up care or medical 2. Permanent Pacemaker appointments Totally implanted Assess risk for infection Keep incision dry for days (for Leads threaded temporary pacemaker) transvenously to right atrium Sponge bath only or right ventricle Avoid lifting heavy objects Avoid MRI Power source – implanted Avoid anti-theft device in malls subcutaneously, right after the skin Implantable Cardioverter Defibrillator Detects and stops arrhythmias Nodes: 1. SA Node (Sinus Node) Continuously check the heartbeat Give electrical signals to and can deliver shock to restore atrium for contraction regular rhythm 2. AV Node Help in contractions Patient Education Educate about pacemaker Monitor pulse (60-100 bpm) Carry pacemaker information cards at all times Medic alert ID should be worn 3. Valve Replacement Transtelephonic pacemaker This is done to correct the monitoring problems caused by one or more diseased heart valves. Nursing responsibilities Instruct patient to avoid keeping a Indications: phone or MP3 player in the pocket ○ Mitral valve surgery over your pacemaker ○ Valvular disease Instruct patient to avoid standing Types of Valvular Diseases: for too long near certain 1. Mitral Stenosis appliances, such as microwaves, Problem with the opening long exposure to metal detectors, Blood will just flow high-voltage transformers continuously and can cause backflow Discharge Plan Causes mitral insufficiency 32| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Commonly occurs when a Can lust only up to 10-15 patient has rheumatic fever years (some will degenerate) 2. Aortic Stenosis Nursing Responsibilities Assessment Preparation: Murmur sounds (low pitch sounds) ○ Assist on the preparation of needed materials Indicates defect or valve problems ○ Reinforce and supplement Diagnostic Test information Electrocardiogram (ECG) ○ Emotional support Risks: Cardiac output decrease Post care: Activity intolerance ○ Assess for S/S of heart Fatigue failure or presence of emboli Infection Ineffective anticoagulant therapy ○ Auscultate changes in heart sounds Nursing responsibilities: Monitor patient’s HR and BP ○ Assess VS Ensuring that they are taking their meds ○ Monitor effects of IV fluids Types of Valve Used in Replacement: ○ Transfer patient when stable a. Mechanical Valve Made from durable ○ Education on metals/polymers that can anticoagulation therapy exist within the body without infection ○ Minimizing risk for cardio carditis Can exist in the body for more than 30 years ○ Schedule follow-up for ECG b. Biological/Bioprosthesis Valve 4. Repair of Congenital Abnormalities Made from the tissue of pig, diseases/abnormalities since birth: cow, horse, or human ○ PDA (patent ductus arteriosus) ○ ASD (atrial septal defect) 33| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) ○ VSD (ventricular septal Failure to thrive defect) Feeding difficulty ○ COA (coarctation of aorta) Give small frequent meals every 3 ○ TOF (tetralogy of fallot) hours Patent Ductus Arteriosus Patient must be in upright position Ligament between the pulmonary artery and the aortic valve remains Treatment: open, which causes the oxygenated IV indomethacin or indocin and deoxygenated blood to mix (NSAIDs) To reduce fever, pain, and swelling Decrease prostaglandin level – Coil insertion hormone that prevent blood clot Surgery formation Atrial Septal Defect Manifestations: Abnormal opening in the septum ○ For small opening between right and left atrium (asymptomatic) Mixing of oxygenated and Using stethoscope: deoxygenated blood ○ Continuous murmur sounds There is left to right shunting of ○ Turbulent blood flow increase blood volume ○ Wide pulse pressure (hard to Increase pulmonary pressure → detect diastole) ventricular hypertrophy (enlargement due to too much Slow weight gain contractions) ○ The body is not getting enough oxygen for the Manifestations: tissues Generally asymptomatic Murmur sounds might not be heard Fatigue Dyspnea Fatigue with exertion Tachypnea and vomiting Frequent respiratory infection Atrial arrhythmias NGT is recommended Chronic heart failure to young adults if not treated Frequent respiratory infections 34| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Treatment: the narrowing and decreased blood If not dosed in school age, it must flow below it. be repaired (6-12 years old) Device closure Clinical Manifestations Septal occluder by using catheter The symptoms of Coarctation of the Surgery Aorta can vary depending on the Patch or stitches severity of the narrowing and the age at diagnosis. Common clinical Medical Management manifestations include: Antibiotics → to prevent infections ○ Hypertension: Elevated Digoxin with diuretics (cardiac blood pressure in the upper glycoside drugs) → to treat CHF extremities, which may be and heart rhythm problems (atrial significantly higher than in fibrillations) the lower extremities. ACE inhibitors ○ Difference in Pulses: Ventricular Septal Defect Stronger and bounding Abnormal opening in the septum pulses in the arms compared between right and left ventricle to weaker or absent pulses in Most common form of chronic heart the legs. disease ○ Claudication: Pain or fatigue Manifestations: in the legs during exercise 4-8 weeks (loud harsh murmurs) due to poor blood flow. All defect problems will manifest within 8 weeks in a newborn child ○ Headaches: Caused by high Sometimes, it will eventually close blood pressure. on its own (spontaneous closure) ○ Shortness of Breath: Treatment: Especially during exercise or Digoxin with diuretics physical activity. ACE inhibitors ○ Heart Murmur: A systolic Coarctation of Aorta murmur, often heard on the is a congenital condition back between the shoulder characterized by the narrowing of blades, due to turbulent the aorta, the large blood vessel blood flow across the that carries oxygen-rich blood from narrowed area. the heart to the rest of the body. This narrowing obstructs blood flow, leading to increased pressure above 35| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) ○ Cold Feet or Legs: Due to Catheter-Based Interventions reduced blood flow to the Balloon Angioplasty: A balloon lower extremities. catheter is inserted into the narrowed area and inflated to ○ Signs of Heart Failure: In widen the aorta. infants, severe CoA may present with symptoms of Stent Placement: A stent (a small heart failure, including poor mesh tube) may be placed in the feeding, irritability, rapid narrowed area to keep it open. breathing, and failure to thrive. Medical Treatment Medical management is often used Treatment to control symptoms or as a bridge The treatment for Coarctation of to surgical or catheter-based the Aorta depends on the severity treatment. of the condition and the patient's ○ Antihypertensive age. The goal is to relieve the Medications: To control high narrowing and restore normal blood blood pressure, which is flow. common in CoA patients, even after the narrowing is Surgical Treatment repaired. Commonly used ○ Resection with End-to-End medications include Anastomosis: The narrowed beta-blockers, ACE inhibitors, segment of the aorta is or calcium channel blockers. surgically removed, and the two healthy ends are ○ Prostaglandin E1 (PGE1): In reconnected. neonates with severe CoA, ○ Patch Aortoplasty: A patch is PGE1 may be used to keep used to widen the narrowed the ductus arteriosus open, area of the aorta. ensuring blood flow to the lower body until corrective ○ Subclavian Flap Aortoplasty: surgery can be performed. A section of the subclavian artery is used to enlarge the ○ Diuretics and Digoxin: May narrowed area. be used in infants or children with heart failure symptoms ○ Interposition Graft: A to manage fluid overload synthetic graft is used to and improve heart function. replace the narrowed section of the aorta. Nursing Interventions 36| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Nursing care for patients with clean and dry, and monitor for signs Coarctation of the Aorta focuses on of infection. monitoring, patient education, and postoperative care. Patient and Family Education: Medication Adherence: Educate Assessment and Monitoring: the patient and family about the Monitor Blood Pressure: Regularly importance of taking prescribed check blood pressure in all four medications, especially extremities to detect differences antihypertensives. and assess the effectiveness of treatment. Lifestyle Modifications: Encourage a heart-healthy diet, regular Monitor Pulses: Assess peripheral physical activity (as tolerated), and pulses, especially in the lower smoking cessation. extremities, to identify any signs of decreased perfusion. Follow-Up Care: Stress the importance of regular follow-up Observe for Signs of Heart visits with a cardiologist to monitor Failure: Monitor for symptoms such blood pressure and ensure the as tachycardia, tachypnea, poor aorta remains open. feeding (in infants), and edema. Signs of Recurrence: Teach the Pain Management: Provide patient and family to recognize appropriate pain relief, especially symptoms that may indicate after surgical interventions. recurrence of coarctation, such as new-onset hypertension, Postoperative Care: claudication, or changes in pulse Monitor for Complications: Watch strength. for signs of complications such as bleeding, infection, or re-coarctation (narrowing Tetralogy of Fallot recurrence). Four key Anatomical Abnormalities: ○ Pulmonary stenosis Encourage Gradual Activity: ○ Ventricular septal defect Gradually increase activity levels as (VSD) tolerated, and monitor for signs of ○ Overriding aorta claudication or other symptoms of Blood goes from decreased blood flow. artery to right ventricle Wound Care: Provide care for the ○ Hypertrophy of right surgical site, ensuring it remains ventricle (thickened muscle) 37| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Surgery → within 2-4 months old Main common problem → direction of blood flow 5. Left Ventricular Assist Device (LVAD) LVAD is implanted in the chest Manifestations: Determine the degree of pulmonary Helps pump blood from the ;left stenosis (check cyanosis) ventricle of the heart and on to the rest of the body Difficulty feeding (cause slow weight gain) A control unit and battery pack are worn outside the body and they are Patient is easily tired connected to the LVAD through a port in the skin Symptoms of chronic hypoxia Indication Clubbing of fingers Weakened heart or heart failure Polycythemia Decreased pulmonary blood flow → too much O2 in the blood → increase thrombus formation → increase risk of stroke Hypoxemia Decrease oxygen in the brain → can cause fainting, brain damage, or death Nursing Care for Hypercyanotic Episodes Knee-chest position 6. Heart Transplant ○ Trapping the fluid in lower An operation in which a diseased, extremities failing heart is replaced with a healthier donor heart Provide oxygen Indications Give morphine if needed People who has advanced (end stage) heart failure, but are Fluid replacement otherwise healthy, may be considered for a heart transplant 38| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) ○ Musculoskeletal assessment Cardiomyopathy ○ VS CHF ○ Edema assessment Vascular heart disease ○ ROM Cardiac tumors ○ Auscultation Refractory malignant arrhythmias Post: Contraindications ○ Health teaching Systemic infections ○ Cardiopulmonary training Limited life expectancy endurance exercises Severe irreversible pulmonary hypertension ○ Musculoskeletal strength and endurance Severe cerebral or peripheral vascular diseases ○ Breathing training Pulmonary parenchymal disease ○ Increase ADL’s overall functional level Neoplastic diseases (cancers) Complications Cirrhosis (liver) Graft failure → death Rejections; S/S: Unresolve substance abuse ○ Low grade fever HIV ○ Increase in resting BP Blood types in selecting a heart: ○ Hypotension with activity Best → AB Worst → O ○ Myalgia (muscle pain) Things to do ○ Fatigue Prior: ○ Transplant evaluation ○ SOB ○ Exercise tolerance test ○ Decrease exercise endurance 39| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) ○ Ventricular dysrhythmia ○ To recanalize the occluded vessels and restore vascular ○ Soft heart murmurs supply Bacterial infections ○ Prevent development of stroke Hypertension Carotid Artery Disease Renal impairment fatty/waxy deposits builds up on carotid arteries (atherosclerosis) → bleeding/anemia restrict blood flow to the brain (intra) local or general anesthesia Donor recipient size mismatch Procedure: Incision in anterior part or border sternum of the neck (anterior border sternocleidomastoid muscle) Opens carotid artery and removes plaque Risks Cerebral perfusion Alternative procedure (not the best option) Carotid angioplasty and stenting ○ dilate carotid path and put stent to stabilize vessel ○ Catheter with small balloon is attached and inflated inside then mesh tube stent is pleased Most common complication: Part 3: Vascular System Stroke or (TIA) transient ischemic attack 1. Endarterectomy Other complication: 40| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Embolization during surgery Complex surgery to remove chronic (thrombus formation) → causes blood clots at the pulmonary artery occlusion → decrease cerebral of the lungs tissue perfusion This is done when medication is not Common cranial nerve damage: successful (blood ○ VII → local cord paralysis thinners/anticoagulants) ○ X → difficulty of managing Pulmonary embolism – rare but life saliva threatening ○ XI → tongue deviation Blockage ○ Can cause scar tissue in the ○ XII → gag reflex/deglutition lungs that can alter BP and affect lung function → makes Nursing Care breathing difficult Maintain patent airway ○ If left untreated – lung death Keep the head aligned straight → heart failure → death Do not flex – lie on side ○ Can affect everyone (no gender/age preferences) Elevate head of the bed Prevention ROM exercises Minimize stress on operation site Regulate BP Anticoagulant or antiplatelet At risk therapy With history of DVT ○ Warfarin (coumadin) ○ Heparin Signs and Symptoms Dyspnea Maintain BP stable (20mmHg) → to Reduced exercise tolerance avoid bleeding or ischemia Fatigue and chest pain Inform physician if there is edema Must be detected earlier to avoid especially if it affects airway complications Pulmonary Endarterectomy A.K.A. pulmonary thrombus Diagnosis is often delayed and endarterectomy unrecognized (there is no hallmark sign) 41| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Diagnostic Tests Aortoiliac Endarterectomy Pulmonary angiography Peripheral artery disease (can cause paralysis/numbness) Angioscopy Poor oxygenation of the tissue MRI Femoral Endarterectomy Lung function test This is done to remove fatty buildups (plaque) from the femoral Assessment artery. When plaque builds up in the High jugular pressure must be artery, it can make it hard for blood checked to flow in the leg. Check liver for hepatomegaly Nursing Responsibilities: Consent Heart failure Collect blood test Murmur over pericardium 12 leads ECG Treatment Surgery only 2D ECHO Pulmonary vasodilators (ex. Sildenafil, bosentan, iloprost) NPO as always Anticoagulants (given until surgery) Vital Signs (especially SPO2) Vitamin K inhibitors (reversal Check intravenous access and effects) arterial line (IV cannula - gauge 18 - any procedure) Assess hemodynamic and cardiac status Pre-op Peripheral and neurovascular Check signs of hypoxia (must be assessment (hourly for 8 hours, if avoided preoperatively) or stable 2 hours for 8 hours) hypercapnia (elevated CO2 levels in the blood) Monitor neurologic status (glasgow coma scale: check level of Post-op consciousness) At ICU under sedation Input and output monitoring 42| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) 2. Aneurysmectomy ○ Form when blood clots To repair aortic aneurysm (stretches accumulate in the wall of an of the wall) artery That is likely to rupture if left Where Does Aneurysm Commonly untreated Found? Abdominal Aorta Forms of Aneurysm: 1. Fusiform Aka Abdominal Aortic Aneurysm ○ Around the wall Forms when artery is weakened and stretched ○ Dilation in entire circumference Can lead to rupture (tension increase in wall) ○ Because of blood pressure, it causes stretches on the Typically asymptomatic. arterial wall that might cause rupture. Causes: 2. Saccular Hypertension ○ out -poaching, only affecting Atherosclerosis a distinct portion of the Hyperlipidemia arterial wall. Smoking Genetic predisposition 3. True and False Aneurysm Age ○ True: Gender Genetic acquired Med condition disease Chronic inflammation Arterial wall Signs and Symptoms: weakened Gnawing pain (burning ache pain) May last 4 hours a day ○ Fake/False: Complication Occurred because of Rupture (life threatening) the trauma of vessel Thoracic Aortic Aneurysm injury to the three Less common than AAA layers. Frequently misdiagnosed 4. Dissecting Aneurysm Difficult to manage surgically 43| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) aneurysm form in upper part of tachycardia aorta, in your chest rupture, bleeding, clots Assessment Back pain because of increase on Patient Teaching: aneurysm Avoid lifting heavy objects Wound care Shortness of breath Pain management (pain reliever) Check signs of rupture Hoarseness Diuretics Difficulty of swallowing Intravascular Stenting to address acute arterial closure Mass visible in suprasternal notch and restenosis (pulsating mass) Stainless steel or cobalt chromium Thoracic rupture excruciating pain from chest to back Antiembolic Stockings To improve blood circulation in the Diagnostic Test leg veins. X-ray CT scan w/ contrast To promote supplementing action, Aortic angiography to prevent DVT in immobile client Ultrasonography Nursing management: Maintain blood pressure Below 130 or 140 Antihypertensive ○ Beta blockers (propranolol) ○ Calcium channel blockers (amlodipine) Check vital signs 3. Bone Marrow Aspiration ○ Every 30mins for first hour Purpose: a test to identify a particular disease. It monitors Pain scale progression or treatment of disease. Hypovolemic shock monitoring Anemia: low red blood cell count. They will confirm it through BMA - 44| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) Bone Marrow Problems: Assessment of cellular morphology, Myelofibrosis, Myelodysplastic maturation of rbc syndrome. May be cause why bone marrow cannot produce enough rbc Reticulocytes- immature rbc produced in bone marrow. In 1-2 Blood Cell Conditions: Leukopenia, days, it will mature Polycythemia, cancers of bone marrow like leukemia or lymphoma, RBC lasts 90-120 days. Old rbc will be going to the spleen hemochromatosis (genetic disorder in which iron is increased in the Establish diagnosis of leukopenia, blood system). etc Posterior iliac crest- pelvic girdle Nursing Responsibilities main source of bone marrow - Assess risk of bleeding Anterior iliac crest- secondary Ability of patient to stay lateral Local anesthesia, Needle decubitus or prone position perpendicular angle, rotate motion, (posterior) aspirate into 1 mL into empty tubes for slide smears or into Put direct pressure for 5-10 minutes heparin solution until bleeding stops and cover with sterile gauze pad Adequacy of specimen- presence of bony spicules Monitor signs of bleeding and notify the doctor Biopsy needle- advance needle 1- 2 cm into the marrow Label the specimen correctly. Patient’s name, age, sex, hosp Prevent patient in taking aspirin number because it has risk for bleeding - Rosenthal needle (Bone marrow Administer pain reliever as needed needle) 16 to 28 gauge needle, 12-20 cc syringe 4. Bone Marrow Transplant This procedure involves Useful tool in staging hematologic transplanting blood stem cells, disease which travel to the bone marrow where they produce new blood cells 45| Yara, A.  NCM 112 (2504)_Examination Notes (Lecture) and promote growth of new bone No risk for rejection. Highly marrow. successful. Indication Blood cancers 3. Allogeneic ○ Leukemia Stem cells are taken from ○ Lymphoma closely matched sibling BOne Marrow Disease genetically different but in ○ Aplastic Anemia the same species. Immune System or Genetic disease high risk of recipient immune ○ Sickle Cell Anemia system rejection, thus needs immune system therapy. Prior to Transplantation Chemotherapy and TotalBody Human Leukocyte Antigen Irradiation ○ involves identifies ○ to suppress bone marrow/ specific blood test immune system. ○ donor and recipient ○ patients are matching test. immunocompromised - high risk of infection. ○ the higher the match the higher the chance ○ Side Effect of Chemotherapy: of acceptance, the Alopecia lower the risk for rejection. Types of Bone Marrow Transplant 1. Autologous Five Phase of Transplant The patient receives their 1. Stem Cell Procurement own stem cells. Stem Cells