NCM-112-LACajcuom Care of Clients with Oxygenation Problems PDF

Care of Clients with Oxygenation Problems- Module Prof. Loyda Amor N. Cajucom, MAN, RN  Learning Outcomes Integrate relevant principles of social, physical, natural and health sciences and humanities in the care of clients with problems in oxygenation Apply appropriate nursing c...

Care of Clients with Oxygenation Problems- Module Prof. Loyda Amor N. Cajucom, MAN, RN  Learning Outcomes Integrate relevant principles of social, physical, natural and health sciences and humanities in the care of clients with problems in oxygenation Apply appropriate nursing concepts and actions holistically and comprehensively. Assess the health status of a group of adult clients with problems in oxygenation whether acute or chronic competently.  Formulate WITH THE CLIENT a plan of care to address the needs/ problems and based on priorities Implement safe and quality interventions WITH THE CLIENT to address the identified needs /problems Evaluate WITH THE CLIENT the health status/competence and/or expected outcomes as agreed at the beginning of the nurse-client working relationship as reflected in the NCP.  Institute appropriate corrective actions to prevent or minimize harm arising from adverse effects or treatment. Use appropriate communication/interpersonal techniques/strategies to ensure a working relationship with the client and/or support system as well as members of the health care team, based on trust, respect and shared decision-making.  Document using appropriate forms and format, clients’ responses/nursing care services rendered and processes/outcomes of the nurse client working relationship. Ensure completeness, integrity, safety, accessibility and security of information. Adhere to protocol and principles of confidentiality in safekeeping and releasing of records and other information.  Discuss pathophysiologic response of clients to alterations/problems in oxygenation, whether acute or chronic. Adhere to ethico-legal considerations when providing safe, quality and professional nursing care Apply ethical reasoning and decision-making process to address situations of ethical distress and moral dilemma Adhere to established norms of conduct based on the Philippine Nursing Law and other legal regulatory and institutional requirements relevant to safe nursing practice  Protect client rights based on “patient’s bill of rights and obligations” Implements strategies/policies related to informed consent as it applies in multiple context. Manage time and available resources (human and physical resources) efficiently and effectively. Maintain a positive practice environment Ensure intra agency, inter-agency, multi- disciplinary and sectoral collaboration in the delivery of health care  Implement strategies/approaches to enhance/support the capability of the client and care providers to participate in decision-making by the inter-professional team Maintain a harmonious and collegial relationship among members of the health care team for effective, efficient and safe client care. Coordinate the tasks/functions of other nursing personnel.  Collaborate with other members of the health team in the implementation of programs and services. Apply principles of partnership and collaboration to improve delivery of health services. Provide insight as a member of the health care team to the quality team in implementing the appropriate quality improvement process on identified improvement opportunities.  Engage in advocacy activities in the hospital that deal with health-related concerns or influences health and social care service policies and access to services; advocates policies that foster the growth and development of the nursing profession Model professional behavior. Exemplify love for country in service of the Filipino. Customize nursing interventions based of Philippine Culture and Values.  Use of appropriate technology to perform safe and efficient nursing activities. Implement system of informatics to support the delivery of health care. Demonstrate caring as the core of nursing, love of God, love of country and love of people. Demonstrate professionalisms, integrity and excellence. Project the positive professional image of a Filipino nurse.  Provide appropriate evidence-based nursing care derived from a variety of theories, care standards, research and client preferences. Gather research findings and incorporate results of such in the care of clients with problems in oxygenation whether acute or chronic FUNDAMENTALS IN THE CARE OF CLIENTS WITH ALTERATIONS IN OXYGENATION ASSESSMENT KNOW WHAT TO ASSESS, HOW AND WHY  History: Establish a Baseline Initial presentation of patient determines the rapidity and direction of the interview Provides data that contribute to diagnosis and treatment plan Limit questions for patients in acute distress – Chief complaint – Precipitating events – Current medications  Organizing Data According to Gordon's 11 Functional Health Patterns Functional Pattern Describes Examples Health Pattern Health Perception/ Client's perceived pattern of health and Compliance with medication regimen, use Health Management well-being and how health is of health-promotion activities such as managed. regular exercise, annual check-ups. Nutritional-Metabolic Pattern of food and fluid consumption Condition of skin, teeth, hair, nails, relative to metabolic need and mucous membranes; height and pattern; indicators of local nutrient weight. supply. Elimination Patterns of excretory function (bowel, Frequency of bowel movements, voiding bladder, and skin). Includes client's pattern, pain on urination, appearance perception of normal" function. of urine and stool. Activity - Exercise Patterns of exercise, activity, leisure, and Exercise, hobbies. May include recreation. cardiovascular and respiratory status, mobility, and activities of daily living. Cognitive-Perceptual Sensory-perceptual and cognitive Vision, hearing, taste, touch, smell, pain patterns. perception and management; cognitive functions such as language, memory, and decision making. Sleep-Rest Patterns of sleep, rest, and relaxation. Client's perception of quality and quantity of sleep and energy, sleep aids, routines client uses. Self-Perception/ Client's self-concept pattern Body comfort, body image, feeling Self Concept and perceptions of self. state, attitudes about self, perception of abilities, objective data such as body posture, eye contact, voice tone. Role-Relationship Client's pattern of role Perception of current major roles engagements and sand responsibilities (e.g., father, relationships. husband, salesman); satisfaction with family, work, or social relationships. Sexuality- Patterns of satisfaction and Number and histories of pregnancy Reproductive dissatisfaction with sexuality and childbirth; difficulties with pattern; reproductive pattern. sexual functioning; satisfaction with sexual relationship. Coping / Stress General coping pattern and Client's usual manner of handling Tolerance effective of the pattern in stress, available support systems, terms of stress tolerance. perceived ability to control or manage situations. Value - Belief Patterns of values, beliefs Religious affiliation, what client (including spiritual), and perceives as important in life, goals that guide client's value-belief conflicts related to choices or decisions. health, special religious practices.  Functional Assessment Physical Activities of Daily Living VS Instrumental Activities of Daily Living PADL IADL Bathing Using the Telephone Dressing Shopping Toileting Preparing food Transfers Housekeeping Continence Laundry Feeding Transportation Managing Money Taking Medicine Katz Index of Independence in Activities of Daily Living Activities Independence Dependence Points (1 or 0) (1 Point) (0 Points) NO supervision, direction or personal WITH supervision, direction, personal assistance assistance or total care BATHING (1 POINT) Bathes self completely or (0 POINTS) Need help with bathing more Points: __________ needs help in bathing only a single part than one part of the body, getting in or out of the body such as the back, genital of the tub or shower. Requires total bathing area or disabled extremity DRESSING (1 POINT) Get clothes from closets and (0 POINTS) Needs help with dressing self Points: __________ drawers and puts on clothes and outer or needs to be completely dressed. garments complete with fasteners. May have help tying shoes. TOILETING (1 POINT) Goes to toilet, gets on and (0 POINTS) Needs help transferring to the Points: __________ off, arranges clothes, cleans genital area toilet, cleaning self or uses bedpan or without help. commode. TRANSFERRING (1 POINT) Moves in and out of bed or (0 POINTS)Needs help in moving from bed Points: __________ chair unassisted. Mechanical transfer to chair or requires a complete transfer. aids are acceptable CONTINENCE (1 POINT) Exercises complete self (0 POINTS) Is partially or totally Points: __________ control over urination and defecation. incontinent of bowel or bladder FEEDING (1 POINT) Gets food from plate into (0 POINTS) Needs partial or total help with Points: __________ mouth without help. Preparation of feeding or requires parenteral feeding. food may be done by another person. Total Points: ________ Score of 6 = High, Patient is independent. Score of 0 = Low, patient is very dependent.  History (continued) Patient without obvious distress – Review of present illness – General cardiorespiratory status Previous cardiovascular (CV) and respiratory diagnostic studies Interventional or surgical procedures Current medications – General health status Family history of coronary artery disease (CAD), asthma, hematologic conditions – Lifestyle survey History (continued)  History (continued) Common symptoms – Dyspnea – Cough – Wheezing – Edema – Palpitations – Fatigue – Chest pain – Hemoptysis – Sputum History (continued) Physical Examination Inspection Face – Apprehension and pained expressions – Pallor or central cyanosis Nose and Paranasal Sinuses 1. Nasal septum 2. Nasal mucosa 3. Nasal turbinates 4. Sinuses Physical Examination: Inspection Inspection – Observation of the tongue and sublingual area Central cyanosis – Blue, gray, or dark purple discoloration – Sign of hypoxemia – Life threatening – Unsaturated hemoglobin exceeds 5 g/dL  Physical Examination (continued) Inspection (continued) Jugular veins – Jugular venous distention (JVD) – Measurement of central venous pressure (CVP) Physical Examination (continued) Tracheal shift  Physical Examination (continued) Inspection (continued) Thorax – Skeletal deformities – Skin condition – Respiratory rate, depth, and rhythm – Pacemaker bulges or implants Physical Examination: Inspection (continued) – Assessment of chest wall configuration Normal ratio of anteroposterior diameter to lateral diameter ranges from 1:2 to 5:7 Abnormal findings – Barrel chest – Pectus excavatum – Pectus carinatum – Spinal deformities (kyphosis, lordosis, scoliosis) Physical Examination: Inspection (continued) – Assessment of chest wall configuration  APL RATIO  Physical Examination (continued) Inspection (continued) Thoracic reference points Apical impulse Figure 28.50 Location of the posterior ribs in relation to the spinous processes. Figure 28.48 Chest landmarks: A, anterior chest landmarks and underlying lungs; B, posterior chest landmarks and underlying lungs; C, lateral chest landmarks and underlying lungs. Figure 28.49 Location of the anterior ribs, angle of Louis, and the sternum. Physical Examination (continued) Physical Examination: Inspection (continued) – Evaluation of respiratory effort Observations on the rate, rhythm, symmetry, and quality of ventilatory movements Normal breathing: effortless, regular, 12 to 20 breaths/min Common abnormal patterns – Tachypnea – Hyperventilation – Air trapping Physical Examination: Inspection (continued)  Physical Examination (continued) Inspection (continued) Abdomen – Distention or ascites – Abdominal adiposity Nailbeds and cyanosis – Clubbing – Discoloration or peripheral cyanosis Physical Examination (continued)  Physical Examination (continued) Inspection (continued) Lower extremities – Arterial disease – Venous disease Posture Weight Mentation Physical Examination: Palpation Palpation – Position of trachea Normally midline Technique Deviation is an abnormal finding Physical Examination: Palpation (continued) – Thoracic expansion Measures degree and symmetry of respiratory movement Technique Chest movement is normally equal on both sides Asymmetry is an abnormal finding Physical Examination: Palpation (continued) Physical Examination: Palpation (continued) – Tactile fremitus Palpable vibrations felt over chest wall when patient speaks Technique Normal findings: vibrations felt over trachea, rarely palpable over periphery Abnormal findings – Decreased fremitus – Increased fremitus Physical Examination: Palpation (continued)  Physical Examination (continued) Palpation Arterial pulses Carotid pulses Brachial, ulnar, and radial pulses Allen’s test Femoral pulses Popliteal pulses Dorsalis pedis and posterior tibial pulses Descending aorta pulse Assessing Peripheral Pulses Assessing Peripheral Pulses Peroneal, Dorsalis Pedis, and Posterior Tibial Pulse Sites  Physical Examination (continued) Palpation  Physical Examination (continued) Palpation (continued) Capillary refill Edema Edema  Palpation Edema – Note location – Scale 1+ = Trace, Slight, Rapid response 2+ =.25 inch, 10-15 seconds 3+ =.25-.5 inch, 1-2 minutes 4+ =.5-1 inch, 2-5 minutes Physical Examination: Percussion Percussion – Evaluation of underlying lung structure Estimates amount of air, liquid, or solid material present Technique Five different tones elicited – Resonance – Hyperresonance – Tympany – Dullness – Flatness Physical Examination: Percussion Physical Examination: Percussion – Assessment of diaphragmatic excursion Difference in level of diaphragm on inspiration and expiration Technique Normal findings: 3 to 5 cm Abnormal findings – Decreased excursion – Increased excursion Physical Examination: Percussion Physical Examination: Auscultation Auscultation – Evaluation of normal breath sounds – Systematic comparison of like areas Normal findings – Bronchial – Bronchovesicular – Vesicular Physical Examination: Auscultation (continued) Physical Examination (continued) – Identification of abnormal breath sounds Absent or diminished breath sounds Displaced bronchial breath sounds to periphery Adventitious sounds: inspiratory or expiratory – Crackles – Rhonchi – Wheezes – Friction rubs  Abnormal Breath Sounds random, sudden re- Crackles dependent lobes inflation of alveoli w/ fluids Rhonchi trachea, bronchi fluid, mucus severely narrowed Wheezes all lung fields bronchus Pleural friction rub lateral lung fields inflamed pleura Physical Examination (continued) – Assessment of voice sounds Bronchophony Whispering pectoriloquy Egophony  Physical Examination (continued) Auscultation Blood pressure measurement Noninvasive blood pressure monitoring Orthostatic hypotension Blood pressure cuff size Korotkoff sounds Auscultatory gap Automated blood pressure devices Pulse pressure Physical Examination (continued) Korotkoff’s Sound Phases  Things to consider to ensure accurateness of indirect BP taking using sphygmomanometer and stethoscope: – BP cuff should be 1/3 of circumference of upper arm—too big, false high reading; too small, false low reading – Bladder must cover 80% of the arm circumference – Arm and sphygmomanometer must be at the level of the heart (arm below—too low BP) – Arm must be supported if not too high – BP cuff 1 inch above antecubital area – Deflate at 2mmHg/sec. (fast—low systolic and diastolic; slow—high diastolic reading) – If BP taken is high take BP on other arm then get average if not equal. For next BP monitoring always get BP on extremity with higher BP – Beware of the auscultatory gap  Physical Examination (continued) Auscultation (continued) Pulsus paradoxus Pulsus alternans Vascular bruits  Sites to Auscultate for Bruits Aorta Right Renal Left Renal Artery Artery Right Iliac Artery Left Iliac Artery Right Femoral Artery Left Femoral  Physical Examination (continued) Auscultation (continued) – Aortic area – Pulmonic area – Erb’s point – Tricuspid area – Mitral area Physical Examination (continued)  Physical Examination (continued) Auscultation (continued) Normal heart sounds – S1 and S2 – Physiologic splitting of S1 and S2 – Pathologic splitting of S1 and S2  Physical Examination (continued) Auscultation (continued) Abnormal heart sounds – Third and fourth heart sounds Physical Examination (continued)  Physical Examination (continued) Auscultation (continued) Murmurs – Timing – Location – Radiation – Quality – Pitch – Intensity Physical Examination (continued)  Physical Examination (continued) Auscultation (continued) Abnormal heart sounds – Murmurs – Mitral valve murmurs – Aortic valve murmurs – Innocent murmurs – Murmurs associated with myocardial infarction  Physical Examination (continued) Auscultation (continued) Abnormal heart sounds – Cardiac rubs – Pericardial friction rub Laboratory and Diagnostics  KNOW WHAT YOUR LABORATORY AND DIAGNOSTIC TESTS MEANS AND ITS IMPLICATION TO CARE  LABORATORY TESTS ABG Complete Blood Cell Count Cardiac Enzymes - CPK-MB , LDH, Troponin I &T Blood coagulation Tests Serum Lipids Serum Electrolytes Blood Glucose BUN and Creatinine Sputum Studies  Steps in ABG Reading 1. Is the pH normal? Analyze the pH 2. Is the PaCO2 normal? Analyze the PaCO2 3. Is the HCO3 normal? Analyze the HCO3 4. Match the PaCO2 or HCO3 to the pH 5. Assess for compensation 6. Analyze PaO2/ SaO2 and determine presence of Hypoxemia. Complete Blood Count  Assessment: diagnostic tests Bone Marrow Biopsy -evaluate how well the bone marrow is making WBCs, RBCs, platelets -common site: post. Iliac crest, also ant, crest, sternum- needle puncture -no fasting necessary; sometimes w/ sedation -monitor VS; pressure dressings  DIAGNOSTIC PROCEDURES Electrocardiogram ( ECG ) PFT BRONCHOSCOPY Diagnostic Imaging * Chest X- ray * Magnetic Resonance Imaging * Echocardiography Pleural Effusion Lung Collapse * Transesophageal Echocardiography *Cardiac Catheterization * Angiography  BRONCHOSCOPY Involves passage of lighted bronchoscope into the broncial tree It may be performed with rigid steel or flexible fiberoptic instrument BRONCHOSCOPY Thoracentecis Bedside Pulmonary Function Tests PFTs includes lung volumes, mechanics of breathing, diffusion, and arterial blood gases Complete PFT takes 4 hours to complete Rarely are all PFTs done in the critically ill patient Review lung volumes and capacities – Two measured at bedside Tidal volume Vital capacity (10 to 15 mL/kg minimal accepted value for weaning with a respiratory rate less than 24 beats/min) Bedside Pulmonary Function Tests (continued) Bedside Pulmonary Function Tests (continued) Mechanics of breathing assessed by measuring – Compliance or the distensibility of the lungs Dynamic – Measured during breathing cycle – Normal is 46 to 66 mL/cm H2O Static – Measured under no-flow conditions so resistance forces are removed – Normal is 57 to 85 mL/cm H2O Bedside Pulmonary Function Tests (continued) Assessment of inspiratory muscle strength – Maximal inspiratory pressure (MIP) – Negative inspiratory pressure (NIP) – Both should be more negative than –20 to – 25 cm H2O – Gives information about spontaneous breathing Bedside Pulmonary Function Tests (continued) Dynamic PFTs – Forced vital capacity (FVC) – Peak expiratory flow rate (PEFR) – Forced expiratory volume in 1 second (FEV1) – Forced expiratory volume divided by the forced vital capacity (FEV1/FVC) – Forced expiratory flow (FEF25%-75%) NURSING DIAGNOSIS FOLLOW P-E OR P-E-S FORMAT  Common Nursing Diagnoses Ineffective Breathing Pattern Ineffective Airway Clearance Impaired Gas Exchange Impaired Spontaneous Ventilation Activity Intolerance Ineffective (Peripheral, Myocardial, Renal, Cerebral) Tissue Perfusion Decreased Cardiac Output NURSING INTERVENTIONS- NURSING INTERVENTIONS CLASSIFICATION KNOW WHICH ONE MATCHES YOUR NDX  Implementation: Health Promotion Vaccinations – Influenza, pneumococcal Healthy lifestyle – Eliminate risk factors, eat right, regular exercise Environmental pollutants – Second-hand smoke, work chemicals, and pollutants  Dyspnea Management Airway management Mobilization of pulmonary secretions Humidification Nebulization Chest physiotherapy  Airway Management: Suctioning Oropharyngeal and nasopharyngeal – Used when the client can cough effectively but is not able to clear secretions Orotracheal and nasotracheal – Used when the client is unable to manage secretions Tracheal – Used with an artificial airway  Artificial Airways Pharyngeal airways – Prevent tongue from obstructing upper airway Oropharyngeal airway Nasopharyngeal airway  Artificial Airways Oral airway – Prevents obstruction of the trachea by displacement of the tongue into the oropharynx Endotracheal airway – Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions Tracheostomy – Long-term assistance, surgical incision made into trachea Artificial Airways (continued)  Endotracheal Tubes Indications Endotracheal tubes (ETT) – Oral ETT – Nasal ETT Endotracheal Tubes Endotracheal Tubes  Endotracheal Tubes (continued) Intubation – Procedure Positioning Preoxygenation and ventilation Limit attempt to 30 seconds – Monitoring Auscultation of breath sounds Disposable end-tidal CO2 detector Chest radiograph Endotracheal Tubes (continued)  Endotracheal Tubes (continued) Complications and prevention/treatment – Tube obstruction – Tube displacement – Sinusitis and nasal injury – Tracheoesophageal fistula – Mucosal lesions – Laryngeal or tracheal stenosis – Cricoid abscess  Tracheostomy Tubes Indications – Preferred for long-term intubation – If patient intubated with ETT for more than 7 to 10 days – Upper airway obstruction or trauma – Neuromuscular diseases  Tracheostomy Tubes (continued) Procedure – Open procedure in operating room – Percutaneous procedure at bedside Complications – Stomal infection – Hemorrhage – Tracheomalacia – Tracheoesophageal fistula – Tracheoinnominate artery fistula – Tube obstruction and displacement Tracheostomy Tubes (continued) Tracheostomy care  Airway Maintenance Humidification Cuff management – Cuff inflation – Cuff pressure – Traditional versus foam (tracheostomy) Suctioning – Keeping the airway patent – Complications – Open versus closed suction systems Airway Maintenance (continued)  Airway Maintenance (continued) – Suction protocols Hyperoxygenation Hyperinflation Catheter external diameter size No greater than 120 mm Hg suction Limit passes to three for 10 to 15 seconds Instillation of normal saline may contribute to hypoxemia and lower airway colonization  Maintenance and Promotion of Lung Expansion Chest Pulmophysiotherapy – Reduces pulmonary stasis, maintains ventilation and oxygenation Incentive spirometry – Encourages voluntary deep breathing Chest tubes – A catheter placed through the thorax to remove air and fluids from the pleural space or to prevent air from reentering or to reestablish intrapleural and intrapulmonic pressures Chest Tube Placement  Chest Tube Chambers Chamber 1: collects the fluid draining from the patient Chamber 2: water seal that prevents air from entering the patient’s pleural space Chamber 3: suction control of the system Chest Tube Drainage System  Maintenance and Promotion of Oxygenation Oxygenation therapy – To prevent or relieve hypoxia Methods of supply – Nasal cannula – Oxygen mask  Oxygen Therapy Principles of oxygen delivery – Oxygen is a drug Both detrimental and beneficial effects – Ordered in liters per minute (L/min) flow – Primary indication is hypoxemia – Goal of therapy: PaO2 greater than 60 mm Hg SaO2 greater than 90%  Oxygen Therapy (continued) Methods of oxygen delivery – Low-flow systems ≤8 L/min flow (nasal cannula) – Reservoir systems Simple face mask Partial rebreathing mask Non-rebreathing mask – High-flow systems Air entrainment mask  Oxygen Therapy (continued) Complications – Oxygen toxicity More than 50% FIO2 for more than 24 hours – Carbon dioxide retention Patients with chronic obstructive pulmonary disease at risk – Absorption atelectasis Washes out the nitrogen Oxygen replaces nitrogen in the alveoli Alveoli shrink and collapse  Oxygen Therapy (continued) Nursing management – Clear oral/nasal secretions – Maintain airway patency – Restrict smoking – Ensure safe functioning of delivery system – Use humidification – Monitor for signs of oxygen toxicity  Respiratory Monitoring Breathing Rate and Pattern Hourly or as Ordered Breath sounds Monitoring O2 Sats Monitoring Peripheral and Central Color  Restoration of Cardiopulmonary Functioning: Cardiac Care Cardiopulmonary resuscitation – Circulation – Airway – Breathing – Defibrillation  Cardiac Care: Acute Hemodynamic Regulation Cardiac Output Monitoring using Central Lines Maintaining Mean Arterial Pressure Fluid Resuscitation and Vascular Support IV Therapy  Circulatory Care Circulatory Care: Arterial Insufficiency - Positioning of affected limb - Perfusion monitoring - Pain management - Surgical Management - Pharmacotherapeutics  Circulatory Care: Venous Insufficiency Thromboembolic stockings Positioning Activity and exercise Peripheral circulation monitoring Pain Management Surgical Management Pharmacotherapeutics Restorative and Continuing Care Cardiopulmonary rehabilitation Hydration Coughing techniques Purse Lipped-Breathing Diaphragmatic breathing  Communication Verbal Nonverbal Paper or “magic slate” writing boards Passy-Muir valve Communication (continued)  Oral Hygiene Hospital-acquired pneumonia – Microaspiration of subglottic secretions – Increased oral bacteria Oral care – Brush teeth – Foam swab to stimulate gum tissue – Deep oropharyngeal suction  Extubation/Decannulation At bedside Instruct patient about the procedure Hyperoxygenate Suction trachea (then oral airway) Deflate cuff Administer oxygen Monitor vital signs  Extubation/Decannulation (continued) Suction airway as needed Monitor for respiratory distress Observe for signs of airway occlusion Encourage voice rest for 4 to 8 hours Monitor ability to swallow and talk Pharmacologic Management Effects of Cardiovascular Drugs (continued) Effects of Cardiovascular Drugs (continued) BLOOD TRANSFUSION  BLOOD TRANSFUSION Recommended infusion time: ❑Whole blood: within 4 hours ❑Packed RBC: 4 hours ❑Apheresed platelet or single donor platelet: between 3-4hours ❑Platelet concentrate: 10-15 minutes ❑Fresh frozen plasma: Within 2 hours ❑Cryoprecipitate: 10-15 minutes  Nursing Outcomes Classification Allergic Response: Systemic Respiratory Status: Airway Patency Respiratory Status: Ventilation Vital Signs Cardiac Pump Effectiveness Circulation Status Tissue Perfusion: (Specify)  EVALUATION MAINTENANCE OF GOOD CARDIAC OUTPUT, PERFUSION, GAS EXCHANGE, ACID-BASE BALANCE AS EVIDENCED BY: normal- PR, RR, O2 Saturation, breath sounds, critical lab values such as ABG, CBC, Myocardial function indices; absence of- arrythmia/dysrhythmias, complications and end stage organ failure. QUIZ 1  INTERPRET: pH= 7.33 pCO2= 50mmHg HCO3= 30meq/L pO2= 75mmHg 1. Your patient is not complaining but appears lethargic, RR is at 10/min, what will be your first action? 2-3. You find that O2 Sat is already at 85% and patient only responds with pain and has sluggish pupillary response, cardiac rate is at 112/minute. What is your PRIORITY nursing diagnosis and why?  INTERPRET: pH= 7.46 pCO2=32mmHg HCO3= 22meq/L pO2= 85 4. Interpret ABG. 5-7. Patient’s RR is at 30/min, with use of accessory muscle but with clear breath sounds. Give three important interventions you will initiate given the assessment.  Indicate the Acid-Base Disorders in Each of the Following Patients pH HCO3- PCO2 Acid-Base Disorder ? 7.34 15 29 Metabolic acidosis 7.49 35 48 Metabolic alkalosis 7.34 31 60 Respiratory acidosis 7.62 20 20 Respiratory alkalosis 7.09 15 50 Mixed Acidosis Your patient manifests with vague substernal chest pain, dyspnea and with positive rales over bilateral lung fields. VS: BP-160/100, RR-24/min, PR-105/min T- 36.8ºC. His 2-D Echo, Chest x-ray and ECG all indicate moderate left ventricular hypertrophy (cardiomegaly). 2D-echo shows Ejection Fraction of 42% 13. What is your priority NDx? 14-17. What class of drugs do you expect this patient be given? (give at least 2 and state why) 18. Among the Nursing Interventions Classification give one NIC you expect to implement given your Priority NDx 19. Give the appropriate NOC for your identified NDx 20. What is your first action in this given patient? PROBLEMS IN OXYGEN TRANSPORT CARDIOVASCULAR PROBLEMS- ASSESSMENT- EVALUATION Oxygen Transport: The Function of the Cardiovascular System and Hematologic System Lecture by: LALNCajucom,MAN,RN Oxygen Transport involves: The Blood vessels as transporting network The Heart as a pump The red blood cells as oxygen carrier Lecture by: LALNCajucom,MAN,RN FACTORS AFFECTING STROKE VOLUME Lecture by: LALNCajucom,MAN,RN  PRELOAD -degree of myocardial fiber stretch at the end of ventricular filling/ diastole AFTERLOAD - amt. of wall tension the ventricle that must develop during systole to eject blood MYOCARDIAL CONTRACTILITY Lecture by: LALNCajucom,MAN,RN FACTORS AFFECTING HEART RATE ❖Sympathetic nervous system stimulation ❖Parasympathetic nervous system stimulation ❖Hormones ❖Certain chemicals: nicotine, caffeine Lecture by: LALNCajucom,MAN,RN STEPS IN CONDUCTING A HOLISTIC CARDIOVASCULAR ASSESSMENT  STEP 1: The Chief Complaint and the History of Present Illness Common Chief Complaints ❑ Chest Pain ❑ Dyspnea Dyspnea on Exertion Orthopnea Paroxysmal Nocturnal Dyspnea ❑ Palpitations ❑ Dizziness and Syncope ❑ Edema STEP 1: The Chief Complaint and the History of Present Illness Common Chief Complaints ❑ Cough and Hemoptysis ❑ Fatigue ❑ Weight Gain ❑ Skin Changes  Step 2. Patient History Risk Factors/ Risk Factor Analysis Concurrent Disorders Past Medical History Medication History Diet and Nutrition Sociocultural History Psychosocial History  Step 3. General Physical Examination: General Survey Skin  Step 3. General Physical Examination: General Survey Nails Step 3. General Physical Examination: General Survey Extremities Step 4. General Physical Examination: Examination of Arterial Pulses Abnormal Pulses: ❑Water Hammer Pulse (Corrigan’s Pulse) ❑Pulsus Alternans ❑Pulsus Bigeminus ❑Pulsus Paradoxus ❑Bounding ❑Weak Step 5. General Physical Examination: Examination of Jugular Veins  Step 5. General Physical Examination: Examination of Jugular Veins  Step 5. General Physical Examination: Examination of Jugular Veins Step 5. General Physical Examination: Examination of Jugular Veins  Step 6. General Physical Examination: Measure the Blood Follow the Pressure guidelines for Method for Indirect Measurement of BP Also measure the Pulse Pressure  Step 7. General Physical Examination: Examination of the IPPA Precordium technique Techniques in Palpating the Precordium  1. Isovolumetric contraction Ventricles pressure rises, CLOSING MITRAL AND TRICUSPID VALVES AND CAUSING VIBRATION HEARD AS S1 Lecture by:  2. Ventricular Ejection Aortic and pulmonic valves open and ventricles eject Blood. Lecture by: Lecture by:  3. Isovolumetric Relaxation Ventricular pressure falls and aortic and pulmonic valves close, causing vibration heard as S2 Lecture by: Lecture by:  4. Rapid Ventricular Filling Rapid ventricular filling causes vibration heard as S3 S3 - Bell Normal in children Heard during ventricular filling Associated conditions: – CHF Move cursor here Lecture by: Lecture by:  5. Slow Ventricular Filling Atria contract and eject blood into resistant ventricles causing vibration heard as S4 S4 - Bell Heard during atrial contraction at apex Associated conditions: – CAD – Hypertension – Aortic stenosis Lecture by: Lecture by:  Other Abnormal Heart Sounds Murmurs Created by turbulent blood flow Associated conditions: Click here to hear – Valvular defects – Defects between aorta and pulmonary artery Lecture by: Other Abnormal Heart Sounds Pericardial Friction Rub - Harsh grating sound - Pericardial surfaces rub together Move cursor here Lecture by:  Functional Assessment/ Quality of Life Physical Function: Measures – General physical health – ADLs – IADLS Psychological Function – Cognitive Status – Affective Status Social Function – Social interactions – Resources – Coping – Subjective well-being  Most Common Clinical Manifestations Chest pain Dyspnea Peripheral edema and weight gain Fatigue Dizziness, syncope, changes in level of consciousness Lecture by: LALNCajucom,MAN,RN  LABORATORY TESTS Complete Blood Cell Count Cardiac Enzymes - CPK-MB , LDH, Troponin I &T Blood coagulation Tests Serum Lipids Serum Electrolytes Blood Glucose BUN and Creatinine Lecture by: LALNCajucom,MAN,RN DIAGNOSTIC PROCEDURES Electrocardiogram ( ECG ) Cardiac Diagnostic Imaging * Chest X- ray * Magnetic Resonance Imaging * Echocardiography Lecture by: LALNCajucom,MAN,RN Lecture by: LALNCajucom,MAN,RN  Echocardiography Non-invasive ultrasound Looks at size, shape, and motion of heart Mitral Regurgitation Lecture by: LALNCajucom,MAN,RN * Transesophageal Echocardiography * Myocardial Scintigraphy * Cardiac Catheterization * Angiography Lecture by: LALNCajucom,MAN,RN  Common Nsg. Diagnoses For Patients with Cardiovascular Disorder Ineffective Tissue Perfusion Impaired Gas Exchange Decreased Cardiac Output Acute Pain Self-Care Deficit Deficient Knowledge Lecture by: LALNCajucom,MAN,RN  Planning and Intervention Decrease/Address Risk Factors for CVD Lifestyle Modification Medication Compliance Continuous Monitoring/Hemodynamic Monitoring Cardiac Rehabilitation Biobehavioral Interventions Lecture by: LALNCajucom,MAN,RN  Nursing Outcomes Classification: Cardiac Pump Effectiveness, Activity Tolerance, Circulation Status, Tissue Perfusion: Cardiac Lecture by: LALNCajucom,MAN,RN  Risk Factors for CVD MODIFIABLE RISK FACTORS NON MAJOR RISK CONTRIBUTING MODIFIABLE FACTORS FACTORS RISK FACTORS HYPERTENSION DIABETES HEREDITY ELEVATED BLD. MELITUS MALE SEX LIPIDS AND OBESITY AGE CHOLESTEROL PHYSICAL CIGARETTE INACTIVITY SMOKING STRESS Lecture by: LALNCajucom,MAN,RN  Lifestyle Modification Diet and Nutrition Exercise Adequate Rest Decrease Alcohol intake Smoking Cessation Lecture by: LALNCajucom,MAN,RN  Medications Diuretics Digitalis Inotropics ( Dopamine, Dobutamine) Vasodilators : venous (NTG,ISDN), arterial (hydralazine), both (Sodium Nitroprusside) ACE Inhibitors (captopril) Beta Adrenergic Blockers (Propranolol) Sympatholytics (Methyldopa) Calcium Channel Blockers (Verapamil/Nifedipine) Lecture by: LALNCajucom,MAN,RN  Continuous Monitoring / Hemodynamic Monitoring Monitoring of VS,NVS Monitoring of I and O WOF signs of cardiogenic shock or hypovolemic shock WOF signs of perfusion problems in major organ system (cerebral, renal, hepatic, peripheral) Monitor JVP, Pulse Pressure, MAP, Carotid Upstroke, S3 and Rales/Crackles Lecture by: LALNCajucom,MAN,RN Invasive Hemodynamic Monitoring CVP Swan Ganz Catheter Lecture by: LALNCajucom,MAN,RN  Hemodynamic Monitoring Guidelines Monitoring System: catheter, transducer, amplifier Flush System: IV.9NacL + Heparin (Pressurized flushing device) Insertion site: brachial, subclavian, jugular, or femoral veins Safety Standards: informed consent, psychological preparedness of the pt. and family Lecture by: LALNCajucom,MAN,RN  Asepsis Continuous monitoring and competence in emergency preparedness Set-up: well-prepared and checked Balloon Inflation:.8-1.5cc of air; do not over inflate; Inflation should not be more than 15 secs. Prevention of Infection Lecture by: LALNCajucom,MAN,RN  Cardiac Rehabilitation Category of Description and Examples of Nursing Intervention Activities/Actions Supportive Maintaining physiological processes, promoting self-care, assisting in decision making Ex: monitoring pt. status, counseling, providing emotional support Palliative Physiologically oriented, such as symptom relief; may include those aspects to help manage symptoms, risk factors & methods to help w/ ADL’s. Ex: helping client w/ shortness of breath adjust to ADL Lecture by: LALNCajucom,MAN,RN Category of Description and Examples of Nursing Intervention Activities/Actions Restorative Activities that help client return to a previous level of health or to adopt/modify health perceptions reflecting the limitations imposed by cardiac illness Ex: discharge planning on activity modification Educative Implementation of client teaching w/ goal of some degree of behavior change; includes prevention, risk reduction, therapeutic regimen & potential complications Ex: therapeutic diet, wt. reduction Lecture by: LALNCajucom,MAN,RN Category of Description and Examples of Nursing Intervention Activities/Actions Protective Interventions to reduce or eliminate (-) environmental factors or to prevent complications or exacerbation of cardiac illness; includes collaborative roles Ex: limiting no. of visitors, administration of prescribed medications Preventive Aimed at primary, secondary or tertiary prevention; risk factor modification, symptom control, prevention of complications in acute illness & anticipatory guidance Ex: making appropriate referral, assessing client progress Lecture by: LALNCajucom,MAN,RN  Evaluation Quality of Life Functional Capacity Prevention of Complications Compliance to treatment/medication Lecture by: LALNCajucom,MAN,RN  COMMON CARDIOVASCULAR DISORDERS (IN FOCUS: VASCULAR DISORDERS) Lecture by: LALNCajucom,MAN,RN Systemic and Pulmonary Circulation  Peripheral Blood Flow Flow rate = ΔP/R Movement of fluid across the capillary wall; hydrostatic and osmotic force Hemodynamic resistance – Blood viscosity – Vessel diameter Regulation of peripheral vascular resistance  Assessment Characteristics of arterial and venous insufficiency Intermittent claudication Rest pain Changes in skin and appearance Pulses Aging changes  Assessment Venous Arterial Involved areas Lower extremities Upper & Lower extremities S/Sx Tenderness (aching Severe ischemic Pain tiredness); (+) (intermittent Homans sign claudication); Late: pain on rest edema pronounced Usu. None Peripheral Present, difficult to Diminished/absent pulses palpate Lecture by: LALNCajucom,MAN,RN  Venous Arterial skin Thickened;stasis Trophic changes: dermatitis shiny, hairless, tightly drawn, scaly, dry; thick ridged nails color Brawny pigmentation of Pallor/cyanosis ankle & lower leg Rubor w/ (redness & warmth over dependency involved area Cyanosis w/dependency temperature warm Cool Lecture by: LALNCajucom,MAN,RN  Venous Arterial ulcers May develop; May develop; painful non painful Gangrene Not present Present if w/ occlusion Effect of position: Improves Aggravates symptoms Elevation symptom Dependency Aggravates Improves symptom symptom Lecture by: LALNCajucom,MAN,RN Assessing Peripheral Pulses Peroneal, Dorsalis Pedis, and Posterior Tibial Pulse Sites  Continuous-wave Doppler ultrasound detects blood flow, combined with computation of ankle or arm pressures; this diagnostic technique helps characterize the nature of peripheral vascular disease. Color Flow Duplex Image  Care of the Patient with Peripheral Arterial Insufficiency: Assessment Health history Medications Risk factors Signs and symptoms of arterial insufficiency Claudication and rest pain Color changes Weak or absent pulses Skin changes and skin breakdown  Care of the Patient with Peripheral Arterial Insufficiency: Diagnosis Ineffective peripheral tissue perfusion Chronic pain Risk for impaired skin integrity Knowledge deficiency  Care of the Patient with Peripheral Arterial Insufficiency: Planning Major goals include increased arterial blood supply, promotion of vasodilatation, prevention of vascular compression, relief of pain, attainment or maintenance of tissue integrity, and adherence to self-care program.  Improving Peripheral Arterial Circulation Exercises and activities: walking, graded isometric exercises. Consult primary health care provider before prescribing an exercise routine. Positioning strategies Temperature; effects of heat and cold Smoking cessation Stress reduction  Maintaining Tissue Integrity Protection of extremities and avoidance of trauma Regular inspection of extremities with referral for treatment and follow-up for any evidence of infection or inflammation Good nutrition, low-fat diet Weight reduction as necessary Common Sites of Atherosclerotic Obstruction  Risk Factors for Atherosclerosis and PVD Modifiable Nonmodifiable Nicotine Age Diet Gender Hypertension Familial Diabetes predisposition/genetics Obesity Stress Sedentary lifestyle C-reactive protein Hyperhomcysteinemia  Medical Management Prevention Exercise program Medications Pentoxifylline (Trental) and cilostazol (Pletal) Use of antiplatelet agents Surgical management Buerger’s Disease: Thromboangiitis Obliterans Recurring inflammatory process of the small and intermediate vessels of (usually) the lower extremities; probably an autoimmune disorder Most often occurs in men ages 20-35 Risk or aggravating factor: tobacco Progressive occlusion of vessels results in pain, ischemic changes, ulcerations, and gangrene.  Raynaud's Disease Intermittent arterial vaso-occlusion, usually of the fingertips or toes Raynaud's phenomenon is associated with other underlying disease, such as scleroderma. Manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning pain Episodes are usually brought on by a trigger such as cold or stress. Occurs most frequently in young women Protect from cold/other triggers. Avoid injury to hands/fingers.  Other Disorders Aneurysms – Thoracic aortic aneurysm – Abdominal aortic aneurysm Aortic dissection Characteristics of Arterial Aneurysms Repair of an Ascending Aortic Aneurysm AneuRx Endograft Repair of Abdominal Aortic Aneurysm ATHEROSCLEROSIS - ONE TYPE OF HARDENING OF THE ARTERIES TYPES OF LESIONS: - FATTY STREAK - FIBROUS PLAQUE - FIBROPLASIA 2NDARY TO FIBROUS CAP FORMATION OVER THE ATHEROMA - COMPLICATED LESIONS Lecture by: LALNCajucom,MAN,RN  Venous Thrombus Pathophysiology Risk factors Endothelial damage – Venous stasis – Altered coagulation Manifestations – Deep veins – Superficial veins Blood flow and function of valves in veins. Note impaired blood return due to incompetent valve.  Nursing Diagnoses Ineffective Peripheral Tissue Perfusion Body Image Disturbance Impaired Mobility (Arterial) Impaired Skin Integrity (Arterial) Risk for Injury (Venous) Lecture by: LALNCajucom,MAN,RN  Preventive Measures Elastic hose Pneumatic compression devices Subcutaneous heparin or LMWH, warfarin (Coumadin) for extended therapy Positioning: periodic elevation of lower extremities Exercises: active and passive limb exercises, deep-breathing exercises Early ambulation Avoid sitting/standing for prolonged periods; walk 10 minutes every 1-2 hours.  Nursing Interventions: Venous Problems Teach to avoid: smoking, injury & infections, constrictive clothing, standing or sitting for long periods, crossing legs at knee, oral contraceptives Teach client to: wear antiembolic stocking, elevate legs, do ankle push-ups when standing, walk daily to tolerance, deep breathing exercises, ROM exercises Lecture by: LALNCajucom,MAN,RN  For thrombophlebitis: a. maintain bed rest 7-10 days b. prevent valsalva maneuver c. elevate legs d. apply antiembolic stockings e. apply warm, moist packs to involved site f. do not rub legs g. give thrombolytics/anticoagulants as ordered Lecture by: LALNCajucom,MAN,RN  For clients with venous ulceration: a. maintain bed rest w/ leg elevated when ulcer is acute b. monitor for signs of cellulitis and report immediately c. give antibiotics as ordered d. know and inform client that skin grafting may be necessary e. Adequate protein, vitamins C and A, iron, and zinc are especially important for wound healing. Lecture by: LALNCajucom,MAN,RN  Care of the Patient with Leg Ulcers: Assessment History of the condition Treatment depends upon the type of ulcer. Assess for presence of infection. Assess nutrition. Arterial Ulcer, Gangrene Due to Arterial Insufficiency, and Ulcer Due to Venous Stasis  Medical Management Anti-infective therapy is dependent upon infecting agent. – Oral antibiotics are usually prescribed. Compression therapy Débridement of wound Dressings Other  Care of the Patient with Leg Ulcers: Diagnosis Impaired skin integrity Impaired physical mobility Imbalanced nutrition Collaborative Problems/Potential Complications Infection Gangrene  Care of the Patient with Leg Ulcers: Planning Major goals include restoration of skin integrity, improved physical mobility, adequate nutrition, and absence of complications.  Mobility With leg ulcers, activity is usually initially restricted to promote healing. Gradual progression of activity Activity to promote blood flow; encourage patient to move about in bed and exercise upper extremities. Diversional activities Pain medication prior to activities  Other Interventions Skin integrity – Skin care/hygiene and wound care – Positioning of legs to promote circulation – Avoidance of trauma Nutrition – Measures to ensure adequate nutrition – Adequate protein, vitamins C and A, iron, and zinc are especially important for wound healing. – Include cultural considerations and patient teaching in the dietary plan. Cellulitis and Lymphatic Disorders Cellulitis: infection and swelling of skin tissues Lymphangitis: inflammation/infection of the lymphatic channels Lymphadenitis: inflammation/infection of the lymph nodes Lymphedema: tissue swelling related to obstruction of lymphatic flow – Primary: congenital – Secondary: acquired obstruction  CASE STUDIES: SEAT WORK Scenario: AJ is a 45-year-old man who is the breadwinner if the family. He has a long history of smoking of 10 sticks per day since he was 15 years old. His doctor is concerned since evaluation of his condition shows that he is suffering from arterial insufficiency, Buerger’s disease and his left arm already has (+) pain 8/10 during dependency, intermittent claudication, and a non-healing cut over the 4th digit, there is numbness over distal phalanges up to just below the elbow. He is recommended for doppler scan of the affected arm and was already pre-empted by the doctor that there is possibility of amputation. AJ states he would rather die than live without his arm and be a burden to his family. 1. IF YOU ARE THE NURSE, HOW WOULD YOU RESPOND TO AJ? GIVE THE ETHICAL PRINCIPLES YOU BASE YOUR RESPONSE (5 points) 2. What is your priority PHYSIOLOGIC Nursing Diagnosis? 3. What is your priority PSYCHOSOCIAL Nursing Diagnosis? 4. Give your priority intervention for #2 5. What is your priority intervention for #3 6. Chart the above assessment and plan of care and encounter with patient, using SOAPI format. Assessment and Management of Patients with Hypertension  Blood Pressure = Cardiac Output x Peripheral Resistance Cardiac Output = Heart Rate x Stroke Volume  Hypertension AKA High blood pressure Defined by the Seventh Report of the Joint National Commission on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) is defined as BP ≥140/90 millimeters of mercury (mmHg)., based on the average of two or more accurate blood pressure measurements taken during two or more contacts with a health care provider (https://cdn.ymaws.com/www.aparx.org/resource/resmgr/CEs/CE_Hypertension_The _Silent_K.pdf.)  Incidence of Hypertension- “The Silent Killer” Primary hypertension Secondary hypertension 28-31% of the adult population of the U.S. have hypertension. 90-95% of this population with hypertension have primary hypertension. Incidence is greater in southeastern U.S. and among African-Americans. Factors Involved in the Control of Blood Pressure JNC 8 Classification of Hypertension CLASSIFICATION OF HYPERTENSION Comparison of ACC/AHA vs ESH  Factors that Influence the Development of Hypertension Increased sympathetic nervous system activity Increased reabsorption of sodium, chloride and water by the kidneys Increased activity of the renin-angiotensin system Decreased vasodilatation Insulin resistance  Manifestations of Hypertension Usually NO symptoms other than elevated blood pressure Symptoms seen related to organ damage are seen late and are serious: – Retinal and other eye changes – Renal damage – Myocardial infarction – Cardiac hypertrophy – Stroke  Major Risk Factors Hypertension Smoking Obesity Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or GFR 180/120 and must be lowered immediately to prevent damage to target organs. Hypertensive urgency – Blood pressure is very high but no evidence of immediate or progressive target organ damage.  Hypertensive Emergency Reduce BP 25% in first hour Reduce to 160/100 over 6 hours Then gradual reduction to normal over a period of days Exceptions are ischemic stroke and aortic dissection Medications – IV vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate, enalaprilat, nitroglycerin Need very frequent monitoring of BP and cardiovascular status  Hypertensive Urgency Patient requires close monitoring of blood pressure and cardiovascular status. Assess for potential evidence of target organ damage. Medications – Fast-acting oral agents: beta-adrenergic blocker- labetalol; angiotensin-converting enzyme inhibitors: captopril or alpha2- agonists-clonidine Evaluation: Base on treatment goals IN FOCUS: CARDIAC DISORDERS – MODULE 4  LEARNING OUTCOMES: AT THE END OF THE MODULE, THE NURSING STUDENTS WILL BE ABLE TO: DISCUSS THE NURSING CARE OF CLIENTS WITH SPECIFIC CARDIAC DISORDERS APPLY KNOWLEDGE ON THE NURSING CARE OF CLIENTS WITH SPECIFIC CARDIAC DISORDERS GIVEN SPECIFIC HYPOTHETICAL SITUATIONS  CAD and Angina Pectoris CORONARY ARTERY DISEASE- HEART DISEASE CAUSED BY IMPAIRED CORONARY BLOOD FLOW -ANGINA PECTORIS, MYOCARDIAL INFARCTION, CARDIAC DYSRHYTHMIAS AND HEART FAILURE Lecture by: LALNCajucom,MAN,RN  ANGINA PECTORIS- A SYMPTOMATIC PAROXYSMAL PAIN OR PRESSURE SENSATION ASSOCIATED WITH TRANSIENT MYOCARDIAL ISCHEMIA LASTING NO MORE THAN 5-15 MINUTES -PAIN DESCRIBED AS CONSTRICTING/SUFFOCATING/SQUEEZING -USUALLY STEADY, INCREASE IN INTENSITY ONLY ON ONSET AND END OF ATTACK -LOCATED ON PRECORDIAL AREA OR SUBSTERNAL AREA BUT MAY RADIATE Lecture by: LALNCajucom,MAN,RN Anginal pain varies from mild to severe May be described as tightness, choking, or a heavy sensation It is frequently retrosternal and may radiate to neck, jaw, shoulders, back, or arms (usually left). Anxiety frequently accompanies the pain. Other symptoms may occur: dyspnea/shortness of breath, dizziness, nausea, and vomiting. The pain of typical angina subsides with rest or NTG. Lecture by: LALNCajucom,MAN,RN Types of Angina CLASSIC – EFFORT OR EXERTIONAL ANGINA VARIANT ANGINA- REST ANGINA OR PRINZMETAL ANGINA; VASOSPASTIC; NOCTURNAL ASSOC. W/ RAPID EYE MOVEMENT SLEEP, CYCLIC REGULAR PATTERN OF OCCURRENCE Lecture by: LALNCajucom,MAN,RN  UNSTABLE- WORSENING ANGINA (WORSE FREQUENCY, SEVERITY, DURATION); PREINFARCTION ANGINA SILENT MYOCARDIAL ISCHEMIA- NO COMPLAINTS OF ANGINAL PAIN Lecture by: LALNCajucom,MAN,RN Assessing Chest Pain Lecture by: LALNCajucom,MAN,RN  Nsg. Diagnoses Ineffective Myocardial Tissue Perfusion Acute Pain Anxiety Noncompliance Lecture by: LALNCajucom,MAN,RN  Nursing Interventions Assess pain (pqrst) and VS. Administer anti-anginal medication if needed give O2 (hospital setting). Educate on Self-care: Teach client how to prevent pain recurrence and how to manage pain occurrence; ENSURE compliance to medications Reduce anxiety by providing adequate information regarding illness; teach stress management techniques Lecture by: LALNCajucom,MAN,RN  Myocardial Infarction is a life threatening condition characterized by the formation of localized necrotic areas within the myocardium. It is life threatening because it is usually associated with the development of dangerous dysrhythmias as well as heart failure. Heart attack Lecture by: LALNCajucom,MAN,RN  MI can be classified also according to Forrester's MI Classification which is as follows: Subset Clinical Picture I No pulmonary congestion; No peripheral hypoperfusion II With pulmonary congestion but without peripheral hypoperfusion III With peripheral hypoperfusion but without pulmonary congestion IV With both pulmonary congestion and peripheral hypoperfusion Lecture by: LALNCajucom,MAN,RN  several factors that determine the extent of left ventricular dysfunction: infarct size; the smaller the infarct size the better the prognosis, and when infarction has become greater than 40% of the myocardium tendency for cardiogenic shock is higher location of infarct, since anterior wall infarction is more associated with greater left ventricular dysfunction Lecture by: LALNCajucom,MAN,RN  presence of collateral circulation, which provides alternative route for blood allows for better prognosis function of the uninvolved myocardial tissues; Presence of old infarcts further compromises the hearts function presence or utilization of cardiovascular compensatory mechanisms which may allow for initial normalization of cardiac output but later decompensation may occur or it may eventually increase O2 demand, which is detrimental to the myocardium Lecture by: LALNCajucom,MAN,RN  ECG: Areas of ischemia may show with peaked or inverted T wave and/or ST segment depression, areas of injury result with ST segment elevation while areas of infarction are depicted by abnormal Q or prominent Q, with widening of the QRS complex. Through the ECG, the areas of ischemia, injury and infarction can be determined through the leads where the changes occur and the areas such leads correspond. Lecture by: LALNCajucom,MAN,RN Effects of Ischemia, Injury, and Infarction on ECG Lecture by: LALNCajucom,MAN,RN  Laboratory Studies: elevated CPK-MB which increase 4-6 hours after onset, peaks w/in 12-24 hours and normalizes within 3-4 days; LDH1 isoenzyme elevates within 8-12 hours from onset, peaks within 3-4 days and returns to normal within the next ten days; leukocytosis for 10,000 to 20,000 cells/mm3 appears within 24-48 hours and disappears in 1 week. Lecture by: LALNCajucom,MAN,RN  Elevated troponin T or troponin I which are more specific for cardiac necrosis and remain elevated from 5-7 days post infarction. Stress/Treadmill Test: ECG during exercise to assess cardiac capability during rest then exercise; it may reveal ischemia, injury or infarction and the degree or level of exercise/activity that causes such changes in the heart. Lecture by: LALNCajucom,MAN,RN  Echocardiography: used to assess CVS function. A transducer is placed over relevant anatomical areas of the heart. For MI patient, it is done to detect atrial or ventricular masses/thrombi, chamber dilatation, hypertrophy and assess ventricular wall motion. Moreover, cardiac output, stroke volume and ejection fraction can be derived to determine the hearts over-all functioning. Lecture by: LALNCajucom,MAN,RN  Cardiac Cathetherization and Coronary Angiography: used to assess coronary anatomic structures, and locate area of obstruction and determine extent of obstruction Lecture by: LALNCajucom,MAN,RN  CARDIAC TAMPONADE accumulation of excess fluid within the pericardial space, resulting in impaired cardiac filling, reduction in stroke volume, and epicardial coronary artery compression with resultant myocardial ischemia. ASSESSMENT  Nursing Interventions Monitor hemodynamic status, VS q1 Monitor I and O Positioning Sitting, leaning forward O2 support Watch out for Complications Bed rest Post Op Care Psychosocial-spiritual support  Evaluation Absence of chest pain Normal perfusion- BP, Pulse Pressure, O2 Sat and cardiac markers Normal Gas Exchange- ABG and O2 Sat normal, pinkish skin color, (-) fatigue/easy fatigability  CARDIOMYOPATHIES The American Heart Association describes cardiomyopathies as “a heterogeneous group of diseases of the myocardium associated with mechanical and/or electric dysfunction that usually (but not invariably) exhibit inappropriate ventricular hypertrophy or dilatation due to a variety of etiologies that are frequently genetic. Cardiomyopathies are either confined to the heart or part of generalised systemic disorders and often lead to cardiovascular death or progressive heart failure- related disability” (Maron et al, 2006). CLASSIFICATION TYPES OF CARDIOMYOPATHIES Dilated cardiomyopathy (DCM); Hypertrophic cardiomyopathy (HCM); Restrictive cardiomyopathy (RCM); Arrhythmogenic cardiomyopathy (ACM); Unclassified cardiomyopathies. ASSESSMENT Assessment  Nursing Diagnosis Decreased Cardiac Output Impaired Gas Exchange Fluid Volume Excess Self-Care Deficit Activity Intolerance Intervention Interventions  Evaluation Normal or optimal cardiac output Controlled/ managed signs and symptoms Feeling of well being When the pumping efficiency of the heart is so low, that the blood circulation is inadequate to meet tissue needs, the heart is said to be in congestive heart failure. Lecture by: LALNCajucom,MAN,RN  CONGESTIVE HEART FAILURE ETIOLOGY:CARDIAC VS. NON-CARDIAC CAUSES OF HEART PRELOAD CONTRAC- AFTERLOAD FAILURE TILITY I. Cardiovascular Causes MI √ Systemic HTN √ Aortic/Mitral Stenosis √ Aortic/Mitral Regurgitation √ Cardiomyopathies √ Coarctation of the aorta √ Atrial/ventricular septal √ defect Severe pericardial effusion √ Cardiac Tamponade √ Lecture by: LALNCajucom,MAN,RN  CAUSES OF HEART PRELOAD CONTRAC- AFTERLOAD FAILURE TILITY II.Non- Cardiovascular Causes Renal Failure √ Excessive Administration of √ IV Fluids Thyrotoxicosis Excessive myocardial workload Anemia Excessive myocardial workload Lecture by: LALNCajucom,MAN,RN  Classification of Etiologies 1. Volume Overload valvular incompetence, overtransfusion, structural deformities, hypervolemia 2. Pressure Overload aortic stenosis, hypertrophic cardiomyopathies, hypertension 3. Myocardial Dysfunction myocarditis, CAD, ischemia, infarction, dysrhtymia, toxic disorders Lecture by: LALNCajucom,MAN,RN 4. Filling Disorders mitral/ tricuspid stenosis, cardiac tamponade, restrictive pericarditis 5. Increased Metabolic Demand anemias, fever, thyrotoxicosis Lecture by: LALNCajucom,MAN,RN  Prevalence Epidemiology – Affects nearly 5 million Americans currently, 400,000 new cases diagnosed each year Cost – Annual direct cost in >$10 billion dollars Incidence increased with age – Effects 1-2% of patient from 50-59-years-old and 10% of patient over the age of 75 Frequency – It is the most common inpatient diagnosis in the US for patients over 65 years of age – Visits to their family practitioner on average 2-3 times per year Gender – Men> women in those between 40 and 75 years of age – The sexes are equal over 75 years of age Lecture by: LALNCajucom,MAN,RN Pathophysiology of Heart Failure Neurohumoral Adaptations – “double-edged swords” – Renin-Angiotensin-Aldosterone System – Sympathetic Nervous System – Antidiuretic Hormone – Atrial and Brain Natriuretic Peptides – Endothelin Lecture by: LALNCajucom,MAN,RN Lecture by: LALNCajucom,MAN,RN Neurohumoral-RAAS Lecture by: LALNCajucom,MAN,RN  Help initially Vasoconstriction – Redistributes blood to vital organs Restoration of Cardiac Output – Increased myocardial contractility and heart rate – Expansion of the extracellular fluid volume Lecture by: LALNCajucom,MAN,RN Hurt long-term Lecture by: LALNCajucom,MAN,RN  Precipitating Causes Common Rare – CAD (70%) – Anemia – Systemic Hypertension – Connective Tissue Disease – Idiopathic – Viral Myocarditis Less Common – Hemochromatosis – Diabetes Mellitus – HIV – Valvular Disease – Hyper/Hypothyroidism – Hypertrophic Cardiomyopathy – Infiltrative Disease including amyloidosis and sarcoidosis – Mediastinal radiation – Peripartum cardiomyopathy – Restrictive pericardial disease – Tachyarrhythmias – Toxins – Trypanosomiasis (Chagas’ disease) Lecture by: LALNCajucom,MAN,RN  Systolic vs. Diastolic Diastolic dysfunction – EF normal or increased – Hypertension Systolic dysfunction – EF < 40% – Usually from coronary disease Lecture by: LALNCajucom,MAN,RN  Subtypes of Systolic Heart Failure High output Right Heart Failure – Severe anemia – Peripheral edema – AV malformations Left Heart Failure – hyperthyroidism – Pulmonary congestion Low cardiac output Biventricular Failure – Systemic and pulmonary congestion Lecture by: LALNCajucom,MAN,RN  Physical Exam Major Criteria Minor Criteria – Paroxysmal nocturnal – Ankle edema dyspnea – Nocturnal Cough – Neck Vein Distention – Dyspnea on ordinary – Rales exertion – Cardiomegaly – Hepatomegaly – Pulmonary Edema – Pleural Effusion – S3 Gallop – Tachycardia >120bpm – Hepatojugular Reflex Lecture by: LALNCajucom,MAN,RN  Confirming the presence of CHF – History and Physical Exam MI Dependent Edema Positive hepatojugular reflex Displacement of the cardiac apical pulsation Gallop rhythm Lecture by: LALNCajucom,MAN,RN  Negative Prognostic Factors Clinical – Increased Age, Diabetes, Smoking Laboratory – Hyponatremia, Elevated neurohormones Hemodynamic – Reduced EF, Increased Pulm Cap Wedge Pressure Electrophysiological – A-fib, A-flutter, Ventricular ectopy, V-tach Lecture by: LALNCajucom,MAN,RN  NYHA Classification Class I – Symptoms with greater than ordinary activity Class II – Symptoms with ordinary physical activity Class III – Symptoms with minimal physical activity Class IV – Symptoms at rest Lecture by: LALNCajucom,MAN,RN  Six-Minute Walk Test Distance Hospitalization Mortality rate Walked (m) Rate in 1 year in 1 year (%) (%) 300 40.9 10.2 301-374 33.6 7.9 375-449 27.4 4.2 >450 19.9 3.0 Lecture by: LALNCajucom,MAN,RN Right vs. Left sided Heart failure Right Sided Heart Failure: Inability of the right ventricle to move blood into the left side Inc. in RVEDP Backflow of bld. to the right atrium Inc. in RAP Backflow of bld. to the systemic circulation Lecture by: LALNCajucom,MAN,RN  Inc. systemic pressure (venous pressure) leading to Systemic congestion Peripheral edema congestion of abdominal organs (+) JVD If venous distension progresses: Blood backs up in hepatic veins Congestion of GI tract Liver dysfunction, Congestion of portal Weight gain RUQ pain circulation Anorexia, abdominal discomfort and nutritional Engorgement of spleen problems and ascites DOB, SOB Lecture by: LALNCajucom,MAN,RN Left Sided Heart Failure Inability of the left ventricle to move blood into the systemic circulation Inc. in LVEDP Backflow of bld. to the left atrium Inc. in LAP Backflow of bld. to the pulmonary circulation Lecture by: LALNCajucom,MAN,RN  Congestion in the Pulmonary Circulation Increased pulmonary capillary wedge pressure Pulmonary Edema Eventually, RVP may increase Crackles which will then Impaired gas lead to the Cough exchange function pathophysiological changes and Dyspnea, Orthopnea, PND, manifestations of SOB Cyanosis right sided heart failure Low O2 Saturation Lecture by: LALNCajucom,MAN,RN Assessment: Important manifestations to watch-out for signs of compensatory mechanisms such as tachycardia, elevated BP, edema, cardiac dilatation and hypertrophy based on PE, ECG, chest x-ray and echocardiography SOB, dyspnea, orthopnea, fatigue due to pulmonary congestion and inc. cardiac workload (+) S3 Fluid retention, edema, elevated CVP, (+) JVD Lecture by: LALNCajucom,MAN,RN  Nsg. Dx: Decreased Cardiac Output Impaired Gas Exchange Fluid Volume Excess Self-Care Deficit Activity Intolerance Lecture by: LALNCajucom,MAN,RN  Principles of Treatment Systolic HF Diastolic HF  Preload  Preload  Afterload  Afterload  Ionotropy  Filling time  Neurohumoral ? Neurohumoral activity activity Lecture by: LALNCajucom,MAN,RN  Treatment of Systolic Heart ACE Inhibitors Failure – Decrease the rate of mortality in all patient with systolic heart failure – Causes balanced vasodilation and prevents myocardial hypertrophy and fibrosis Lecture by: LALNCajucom,MAN,RN  Beta-Blockers Use in stable, chronic disease Titrate slowly Decrease Cardiac Sympathetic Activity Contraindications-bradycardia, heart block or hemodynamic instability Lecture by: LALNCajucom,MAN,RN  Aldosterone Antagonists Spironolactone (Aldactone; RALES 1999) –Class III/IV, ACE, Lasix, EF < 35% –Hyperkalemia, gynecomastia Eplerenone (Inspra; EPHESUS 2003) –More pts on beta-blockers Lecture by: LALNCajucom,MAN,RN  Hydralazine (Apresoline) and isosorbide dinitrate (Sorbitrate) Hydralazine Reduces systemic vascular resistance by preferentially dilating arterioles Isosorbide Dinitrate Preferential Venodilator-reduces ventricular filling pressure and treat pulmonary congestion Reduces mortality Poor tolerability Lecture by: LALNCajucom,MAN,RN  Digoxin May relieve symptoms, does not reduce mortality More admission for suspected digoxin toxicity Lecture by: LALNCajucom,MAN,RN  Diuretics Mainstay of symptomatic treatment –Improve fluid retention –Increase exercise tolerance –No effects on morbidity or mortality Lecture by: LALNCajucom,MAN,RN  Antiplatelet Therapy and Anticoagulation Increased risk of Thromboembolic events, 1.6-3.2% per year Antiplatelet therapy (aspirin) in not useful in patient in sinus rhythm Coumadin for patient with atrial fibrillation or a previous thromboembolic event Lecture by: LALNCajucom,MAN,RN  Nonpharmacological Management Sodium Restriction to 2g/day Risk Factor Management Exercise – Decreases mortality (NNT=4) – Decreases hospitalizations (NNT=5) Multidisciplinary, Disease-Management Approach Lecture by: LALNCajucom,MAN,RN Principles of Treatment-Diastolic Dysfunction  Preload  Afterload  Chronotropy  Neurohormonal Activity Lecture by: LALNCajucom,MAN,RN  Diastolic Dysfunction Acute Management is the SAME Chronic Management is CONTROVERSIAL – Diuretics-dec fluid volume – CCB-promote left ventricular relaxation – ACE-I-promote regression of left ventricular hypertrophy – Beta-blockers/antiarrhytmic agents-control heart rate or maintain atrial contraction Lecture by: LALNCajucom,MAN,RN Nursing Interventions: CHF Assess extent of failure (LSHF vs. RSHF) Administer medications as ordered (cardiac glycoside, diuretics) Monitor VS and hemodynamic status If with pulmonary edema: fowlers to high fowlers position, O2 by (+) pressure if available, apply rotating tournique Strict I and O monitoring as well as weight monitoring Restrict dietary sodium Give appropriate teaching Lecture by: LALNCajucom,MAN,RN  Activity Intolerance Bed rest for acute exacerbations Encourage regular physical activity; 30-45 minutes daily Exercise training Pacing of activities Wait 2 hours after eating before doing physical activity. Avoid activities in extremely hot, cold, or humid weather. Modify activities to conserve energy. Lecture by: LALNCajucom,MAN,RN  Patient Teaching Medications Diet: low-sodium diet and fluid restriction Monitoring for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight Exercise and activity program Stress management Prevention of infection Know how and when to contact health care provider Lecture by: LALNCajucom,MAN,RN Gerontologic Considerations Module 5 Lecture by: LALNCajucom,MAN,RN  LEARNING OUTCOMES: AT THE END OF THE MODULE, THE NURSING STUDENTS WILL BE ABLE TO: DISCUSS THE DIFFERENCE IN THE NURSING CARE OF ELDERLY CLIENTS WITH SPECIFIC CARDIOVASCULAR DISORDERS TO OTHER ADULTS GIVEN HYPOTHETICAL SITUATIONS, APPLY KNOWLEDGE ON THE NURSING CARE OF ELDERLY CLIENTS WITH SPECIFIC CARDIOVASCULAR DISORDERS  Changes in CVS Function in the Elderly Organ/ Morphologic Physiologic Clinical Changes Effects Effects Part Vessels Atherosclerosis, Stiffness and Systolic calcification dec. hypertension compliance Heart Atherosclerosis Stiff ventricles, Decreased Amyloid Dec. compliance, exercise deposition Dec. CO, tolerance, Collagen limited cardiac Dec. receptor reserve, Accumulation activity arrhythmias, LVH diastolic dysfunction Lecture by: LALNCajucom,MAN,RN Some Implications to Care of Elderly They are more hemodynamically unstable. Compensatory mechanisms are less effective, decompensation occurs. Lecture by: LALNCajucom,MAN,RN  Some symptoms normal to an elderly may become exaggerated/extreme-must be aware when it can be considered normal. Cardiac workload is too much— need to ensure decreasing such workload Lecture by: LALNCajucom,MAN,RN Proposed care model and skill needed for geriatric patients with heart failure.  References Bates, Guide to Physical Examination Brunner and Suddarths, Medical-Surgical Nursing DeLaune and Ladner, Fundamentals of Nursing- Standards of Practice Estes, Health Assessment Ignatavicius, Medical-Surgical Nursing Jarvis, Physical Examination and Health Assessment Potter and Perry, Fundamentals of Nursing Swearingen, Manual of Critical Care Urden, Stacey and Lough, Foundations of Critical Care Nursing “Love has nothing to do with what you are expecting to get, it’s what - Anonymous you are expected to give…which is everything”