Life Expectancy and Healthy Life Expectancy Notes

LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY A. **COVID19 Pandemic** - Dropped the average life expectancy from 72.5 y in 2020 to 71.4 in 2021. - HALE decreased to 62.8 in 2020 and 61.9 in 2021 B. **2019 to 2021** - Life expectancy at birth ↓1.7 years for both sexes....

LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY A. **COVID19 Pandemic** - Dropped the average life expectancy from 72.5 y in 2020 to 71.4 in 2021. - HALE decreased to 62.8 in 2020 and 61.9 in 2021 B. **2019 to 2021** - Life expectancy at birth ↓1.7 years for both sexes. - Decline more evenly split for male (0.8 in 2020 and 0.9 in 2021) more concentrated in 2021 for women (1.3 years) - Same to HALE, men declined to 60.9 y in 2021 and women to 64.1 y. C. **Impact by income Group (2019 to 2021)** - Low income countries - -0.6 y LF and HALE, minimal decline in 2020. - Low-middle income countries - -2.4 y LF, -2.0 y in HALE, with over 70% losses in 2021. - Upper-middle-income and high-income countries - Over half loses during 1^st^ year of Pandemic D. **Pre-Pandemic Trends (2000 -- 2019)** - NCDs - From 59.5% in 2000 to 73.9% in 2019 - CDs - From 32.2% in 2000 to 18.2% in 2019 - Injuries - Remains stable at around 8%. E. **Regional Variations** - African Region - Largest share of CDs deaths (54.9%) during pre-pandemic and remained stable during pandemic. - Western Pacific Region - NCDs account for 88% and CDs 6% of deaths; minimal change during pandemic. - European Region - Significant shift from NCDs (89.6% in 2019) to CDs in 2020 and 2021 with deaths from NCDs dropping to 75.9% and CDs rising to 20.0% in 2021). - Other Regions - WHO saw sizable shifts from NCDs and Injuries back to CDs with increases in CDs ranging from 10% (Eastern Mediterranean Region) to 18% (SEA Region) F. **Income Group Disparity** - Low-income - Nearly 50% of deaths due to CD - Upper-middle income and high-income - NCDs were the largest cause of death in 2019 and 2021 (84.8% and 88.1%) respectively. - Dropped by 9.9% and 8.1% between 2019 and 2021 G. **Top 10 causes of Mortality 2021 (World)** - Ischemic Heart Disease - COVID19 - Stroke - COPD - LRI - Trachea, bronchus, and Lung cancers - Alzheimer's and other dementias - Diabetes Mellitus - Kidney Diseases - TB H. **Maternal and Child Mortality** - Maternal Mort. - Stagnated, far from 2030 target - Under 5 Mort. - Declining but even progress across regions - Neonatal Mort. - Slower decline compared to Post neonatal mort. I. **Maternal Mortality** - 2000 to 2015 - Significant progress during MDG years; dropped during global MMR from 339 to 277 deaths per 100,000 live births. - 2016-2020 - Progress stalled; MMR slight decrease to 223 in 2020. - Regional Insights - African Region - Highest MMR but should decline - SEA - Steepest decline - Americas, Europe, Western Pacific - Increase post 2016 - SDG target - Achieving MMR below 70 by 2030 requires 11.6% annual reduction. J. **Child and Neonatal Mortality** - 2000-2022 - U5MR halved from 9.9 million to 4.9 million deaths - Regional Disparities: - African Region - Highest U5MR, 10x higher than Europe - Neonatal deaths are nearly half of all U5-deaths - SDG Challenges - 59 countries may miss the U5MR target - 64 may miss the neonatal MR target by 2030 - Future Outlook - Achieving targets could prevent 9 million U5MR by 2030 K. **Road Injury** - 2010 -- 2021 - Global road traffic ↓ by 5.9% from 1.25 million to 1.18 million deaths, but reduction fell short of the targets set by UN Decades of Action for Road Safety - Regional Insights: - South-East Asia and Western Pacific - Accounted for over half of global road traffic deaths in 2021 - African Region - Highest crude death rate (CDR) from road injuries at 19.4 per 100,000 population, compared to 6.7 per 100,000 in Europe - Income Disparities - Low-income countries had a CDR of 21.3 per 100,000 - High-income countries had 7.6 per 100,000 L. **Suicide** - 2000 -- 2021 - Global SD ↓ 762,000 to 717,000 - But had slight ↑ in 2021 - Regional Shifts - SEA - Region with highest suicide burden in 2021 - Western Pacific and Europe - Significant reductions in suicide rates - Americas - Increase in suicide CDR from 7.2 to 9.8 per 100,000 - Gender Disparity - Men had more than double the suicide rate of women globally M. **Unintentional Poisoning** - 2000 -- 2021 - Deaths from unintentional poisoning dropped by over 4000 - CDR ↓ by 25% - Regional Insights: - African and Western Pacific Regions: Highest CDRs in 2021 - European Region: Largest decline in CDR, with nearly a two-birds drop - Age and Gender Disparities - Men had 68% higher death rate than women - Youngest and oldest populations at highest risk HEALTH SITUATION **I. INFECTIOUS DISEASE** **HIV:** In 2010, lower the cases of HIV **TB:** 9 out of 10 Filipinos are carrier or infected Stagnated on 2020 during ECQ **Malaria:** **Hepatitis:** Most common one is the Hepa B, leads to liver cirrhosis **II. HEALTH SYSTEM STRENGTHENING** 1. Service Delivery 2. Health Workforce 3. Health Financing (hindering UHC) **III. LIFE EXPECTANCY (PHILIPPINES) 2020-2025** Average: 74.4 Female: 77.54 Male: 71.26 **IV. PHILIPPINE HEALTH SITUATIONS** Population (2020) Ph: 109,033,245 MIMAROPA: 3,228,558 Palawan: 939, 594 Puerto Princesa City: 307, 079 **V. TOP 10 Causes of Death (2023) in the Philippines** 1. Ischemic Heart Disease 2. Cerebrovascular Diseases 3. COVID-19 Virus (identified) 4. Neoplasms 5. Diabetes mellitus 6. Hypertensive diseases 7. Pneumonia 8. COVID-19 Virus (unidentified) 9. Chronic upper respiratory diseases 10. Other genitourinary diseases... **VI. Early Childhood Mortality Rates** MIMAROPA **Infant Mortality:** 2022 -- 19 2017 -- 28 **Under 5 Mortality:** 2022 -- 27 2017 -- 33 **Introduction to Disability and Chronic Illness** *Disability:* A physical or mental condition that [limits a person\'s movements, senses, or activities.] *Chronic Illness:* A long-lasting health condition that **[may not have a cure.]** *Chronic Disease:* A type of chronic illness that is **persistent** and **requires ongoing medical attention.** **I. Comparing Disability, Chronic Illness, and Chronic Disease** **Disability:** Can be ***physical, mental, or sensory***. May be present [from birth or acquired later.] **Chronic Illness:** **Long-term** health condition. Examples: asthma, diabetes. **Chronic Disease:** [A type of chronic illness.] Requires ongoing medical care. *Probing Question: Can you think of examples of each category?* Models of Disability **A. Medical Model** - Focuses on the individual\'s limitations. - Seeks to cure or manage the condition. **B. Social Model** - Focuses on societal barriers. - Advocates for changes in society to accommodate disabilities. **C. Biopsychosocial Model** - Combines medical and social models. - Considers biological, psychological, and social factors. *Probing Question: Which model do you think is the most effective, and why?* **II. INFLUENCE OF DISABILITY ON NURSING CARE** a\. Individualized Care: Tailoring care plans to meet specific needs. b\. Communication: Ensuring clear and effective communication. c\. Accessibility: Making healthcare facilities accessible. d\. Advocacy: Supporting patient rights and needs. *Probing Question: How can nurses advocate for patients with disabilities?* **III. Increasing Incidence of Chronic Conditions** a. Aging Population b. Lifestyle Factors *(Poor diet, lack of exercise, smoking)* c. Environmental Factors *(Pollution, exposure to toxins)* d. Improved Diagnosis **IV. Characteristics of Chronic Conditions** a\. Long Duration: Lasts for [months or years.] b\. Slow Progression: Symptoms develop gradually c\. Requires Ongoing Care: Continuous medical attention. d\. Impact on Daily Life: Affects routine activities. *Probing Question: How do chronic conditions affect a person\'s daily life?* **V. Nursing Implications for Chronic Conditions** a\. Continuous Monitoring: Regular check-ups and assessments. b\. Patient Education: Teaching self-care and management. c\. Emotional Support: Providing psychological care. d\. Coordination of Care: Working with other healthcare providers. *Probing Question: Why is patient education important for managing chronic conditions?* **VI. Impact on Families** a\. Emotional Strain: Stress and anxiety. b\. Financial Burden: Cost of treatment and care. c\. Caregiver Role: Family members as primary caregivers. d\. Need for Support: Importance of support groups and resources. *Probing Question: How can families support a member with a chronic condition?* **VII. Support Systems and Resources** - Health Services - Community Services - Financial Assistance - Educational Programs **Conclusion** - Understanding disability, chronic illness, and chronic disease. - Different models of disability. - Influence on nursing care. - Increasing incidence and factors. - Characteristics and nursing implications. - Impact on families and support systems. *Probing Question: What is one new thing you learned today about disability and chronic illness?* LOWER RESPIRATORY TRACT DISORDERS **Restrictive Pulmonary Disease** Problem that limits the ability to expand the lungs (can't inhale air) **Pleuritis (Pleurisy)** - Inflammation of the Pleura - Two (2) thin layers of tissue that separate lungs from chest - Visceral and Parietal is inflamed a. **Causes** - Viral Infection - Pneumonia - Tuberculosis - Tumor - Trauma b. **S/SX** - Sharp pain in chest on inspiration - Coughing/sneezing (Pleuritic Chest Pain) - If the cause is infectious: - Dry cough - Fever - Chills - Elevated WBCs c. **Complications** - Increases serous fluid production - Pleuritic Pain is not controlled this **may cause DOB deeply and coughing** - **Untreated infection, leads to** empyema \[pus in chest\] d. **Dx Test** - Auscultate for Pleural Friction Rub (lung sound) - Chest x-ray - UTZ - CT Scan - Forced Vital Capacity (FVC) -- measured by spirometry - Hx, ECG, Serum troponin (if suspicious) - Blood Test - Sputum Analysis/Examination - Thoracentesis -- remove fluid from the thoracic cavity, a potential spac3 exist in L and R side of chest cavity between inner chest wall and lung (can be diagnostic or therapeutic purposes) - Thoracoscopy -- visual examination of lung surfaces and pleural space through a *thoracoscope.* e. **Tx** - NSAIDs or opioids for pain, deep breathing and coughing - Nerve block, anesthetic injection near IC nerves - O2 Administration - Antibiotics - Chest Physiotherapy f. **NDx** - Acute Pain r/t inflammatory process aeb chest pain - Ineffective breathing pattern r/t bacteria caused by pleurisy aeb SOB and coughing - Impaired gas exchange r/t decreases the function of Lung tissue g. **NMx** - Nursing Assessment - Hx taking - Assessment for dyspnea and SOB - Monitor RR& O2 Sat. - Reduce Pain - Assess using pain scale - Assist in deep breathing exercises and relaxation techniques - Administer pain medications, check response, and assess after 30 minutes - Place in comfortable position - Maintain Effective breathing pattern - Assess Vs q 2-4h - Keep head elevated and assist in position change - Administer O2 support, if ordered or based on O2 Sat. level - Instruct on correct proper breathing techniques (Elevated head, straight spine, inhale through the nose and exhale through the mouth, palm on the abdomen) - Improve gas exchange - Provide O2 and HT breathing and coughing exercises, monitor VS - No smoking and diaphragmatic breathing and pursed lip breathing - Administer medication - Frequently change position with the head always elevated h. **Prevention** - Treat RT infection - Early management of the underlying cause of pleurisy - **Pleural Effusion** - Excess fluid collects in pleural space - Fluid is reabsorbed by the lymphatic system a. **Types** **Transudative** Occurs due to increased hydrostatic pressure or low plasma oncotic pressure **↓ Protein and LDH** E.g. CHF, Cirrhosis, Nephrotic syndrome, PE, hypoalbuminemia b. **S/SX** - ↑SOB (no space for lung expansion) - Cough - Tachypnea c. **Diagnostic test** - Chest X-ray - Black -- Breaks and fracture - Gray -- muscle, fluid, fats - White -- bones - Chest CT Scan - Thoracentesis - Chest Tube thoracostomy - hollow plastic to drain fluid d. **Complications** - Lung damage - Infection (Empyema) - Pneumothorax (Air in the chest cavity) - Pleural thickening and scarring of lung's lining e. **Assessment** - Chest Examination **Empyema** - Abscess or pus in the pleural cavity - Commonly, Gram-positive a. **Causes** - Pneumonia - Tuberculosis - Lung Abscess - Trauma b. **S/Sx, Ndx, Tx, Ntx** - Same to patient with Pleuritis and Pleural Effusion **Pulmonary Fibrosis** - Scarring of the lungs a. **Etiology** - Hereditary - Exposure to viral illnesses - Wood and metal dust exposure b. **Causes** - Autoimmune disorders such as Lupus erythematosus or Rheumatoid Arthritis - Chronic GERD - Idiopathic PF c. **S/SX** - Progressive SOB - Inspiratory crackles - Chronic cough - Fatigue (common) - Clubbing of fingers -- abnormal shape of nail and nail bed due to low oxygen d. **DxT** - Chest X-ray -- lung infiltrates - CT Scan - Spirometry - ABG may show reduced PaO2 - Bronchoscopy - Lung biopsy -- rule out other causes and show inflammation - ANA titer -- if an autoimmune process is involved e. **Tx** - Pirfenidone and Nintedanib - O2 therapy - Pulmonary rehabilitation - Lung transplant **Atelectasis** - Collapse of part or all of a lung - Caused by a blockage of air passages or by pressure on the lung a. **S/SX** - DOB - Cough - Chest Pain b. **Therapeutic Measures** - Position on the unaffected side for re-expand - Breathing exercise - Clap or percussion on the chest to loosen mucus - Tilted the body (postural drainage) so that the head is lower than the chest to drain mucus **Obstructive Pulmonary Diseases** **Chronic Obstructive Pulmonary Disease** - Difficulty exhaling (narrowed airways or blocked by inflammation) - Loss of elastic fibers causes an increase in compliance - Air trapping due to excess mucus production - More effort is required for the weakened alveoli to push air out - Airflow limitation in emphysema and bronchitis is progressive and minimally reversible - Asthma may also be present **R**estrictive disorder = difficulty of air ente**R**ing the lungs **O**bstructive disorders = difficulty of getting air **O**ut **Chronic Bronchitis** - Similar to acute bronchitis - Sx. occurring for at least 3 months of the year for 2 consecutive years - There may be multiple exacerbations, each lasting 2 weeks or more. **Blue bloater** - Color dusty to Cyanotic - Recurrent cough and ↑ sputum production - Hypoxia - Hypercapnia (↑ pCO~2~) - Respiratory acidosis - ↑ Hbg - ↑RR - Exertional dyspnea - ↑ Incidence in heavy cig smokers - Digital clubbing - Cardiac enlargement - Use of accessory muscles to breathe - Right-sided heart failure **Emphysema** - Pathological dx - Affects the air spaces distal to terminal bronchiole a. **Etiology** - Firsthand smoking and Secondhand (passive) smoking - Indoor and outdoor air pollution - Exposure to industrial chemicals b. **Familial disposition** - Deficiency of alpha-antitrypsin (a1 AT) - Children with smoking parents (high risk) c. **Prevention** - No cure for COPD - Avoidance of smoking and inhaled irritants According to Global Initative for Chronic Obstrucitve Lung Disease guidelines (2009), **smoking cessation** is the most effective and cost-effective intervention to reduce COPD risk d. **S/Sx** - Cough - Sputum production - Dyspnea on exertion - Pt. with chronic bronchitis, cough, SOB and activity intolerance - Productive cough - Usually worse in winter month - Crackles and wheezing - Use of accessory muscles - Diminished breath sounds - ABGs (Arterial blood gases) may be checked during exacerbation - ↑ paCO2 and ↓ PaO2 - Polycythemia -- ruddy skin color - Cyanosis **Pink Puffer** - ↑ CO2 retention - Minimal cyanosis - Purse lip breathing - Dyspnea - Hyperresonance on chest percussion - Orthopneic - Barrel chest - Exertional Dyspnea - Prolonged Expiratory time - Speaks in short jerky sentences - Anxious - Use of accessory muscles to breathe - Thin appearance e. **Late stages of COPD** - Lose weights and can be malnourished - Have difficulty eating due to severe dyspnea and increased work of breathing expands more calorie f. **Types of Ephysema** 1. Centrilobular 2. Panlobular 3. Panacinar **Chronic Bronchitis vs Emphysema** **Adventitious Breath Sounds** **a. Crackles (Rales)** - Popping - Discontinuous - *Bronchiectasis* - *Bronchitis* - *Pneumonia* - *Fibrosis* - *CHF* **b. Wheezing** - Wheeze, musical during exhalation - Continuous - *Asthma* - *COPD* - *Airway obstruction* **c. Rhonchi** - Snoring - Secretions in the large airways - Continuous **Complications of COPD** a. *Emphysema* - Develop large air spaces within the lung tissue ***(bullae)*** or adjacent to the pleurae ***(blebs)*** - Listers that can rupture and cause the lungs to collapse b. RSHF may develop c. Death usually results from respiratory infection or respiratory failure **Dx** - Spirometry - Chest x-ray - Blood gas analysis correlated with Hx and PE om diagnosed COPD *NOTE: If lung function improves after giving of bronchodilator, then asthma is suspected rather than COPD* - A1 deficiency is checked if there is suspected with a family history of COPD - CBC, electrolytes and sputum culture may be assessed - Classified according to spirometry **COPD STAGES** g. **Therapeutic Measures** - Relieve symptoms - Prevent disease progression - Improve exercise tolerance - Improve health status - Prevent and treat complications - Prevent and treat exacerbations - Reduce mortality - Prevent or minimize side effects from treatment - **Smoking Cessation** - Can slow disease progression and prolong life - Minimized exposure to other respiratory contaminants - Hair spray, baby powder, and aerosol should be avoided. h. **O2 therapy** - 1-2 L/Min - Higher flow rates suppress hypoxic drive - Oxygen tank at home for 88% O2 sat i. **Medications** - Adrenergic and anticholinergic metered-dose inhalers (MDIs) or nebulized mist treatments (NMTs) - Corticosteroid inhalers to control inflammation - Antibiotics Note: - **Antitussive** agents should be **avoided** since they need to cough up secretions. - Oral theophylline bronchodilators -- avoided for its side effects - Oral corticosteroids -- used late in the disease ↑ reduction in airway inflammation, buy ideally reserved for acute exacerbations j. **Supportive Care** - Pneumococcal vaxx and annual influenza vaxx - Avoidance of crowds and exposure to people - Good hydration - Cool mist humidifier - Chest physiotherapy - Dietitian consultation - Breathing exercises - Lung transplant - Exercise tolerance in pulmonary rehabilitation k. **Surgery** - Surgical removal of diseased lung tissue called lung volume reduction surgery, a high-risk procedure - Does not lead to longer survival - ***Endobronchial Valve* --** a new treatment, similar to lung reduction surgery (w/o surgery), to ↑ FEV1 and exercise tolerance l. **NPx for COPD** 1. Impaired Gas Exchange 2. Ineffective Airway Clearance 3. Activity Intolerance m. **End-of-life Planning** - Asses if pt. has living waiver of durable power of attorney for health care - Pt. make decisions if wanted to be intubated and mechanically ventilated or have CPR - CPR is rarely successful with end-stage COPD - Pt. must be aware of palliative care options **Asthma** - Nearly half-million hospitalization annually - Prevalent in African Americans - Deaths common in lower socioeconomic groups - Sx are intermittent and generally reversible - Some people develop chronic inflammation and permanent changes called **REMODELING** a. **Etiology** - Hereditary - Allergic to airborne allergens such as pollens or molds - Tobacco smoke, air pollution, early use of antibiotics and sensitization to house-dust mites and cockroaches b. **Asthma Triggers** - Dust mites - Cockroaches - Certain medications - Cat and dog dander - Pollens - Emotional upset - Exercise - GERD (stomach acid can reflux into the esophagus and be aspirated causing exacerbation), usually night c. **Prevention** - Early exposure to daycare - Rural environment - Appropriate control of childhood asthma - Avoidance of smoking d. **S/SX** - Intermittent, referred as "attacks" - Chest tightness - Dyspnea - Coughing and difficulty moving air in and out of the lungs - Coughing and difficulty moving air in and out of the lungs - ↑ RR - Hypoxemia (Tachycardia, ↑ restlessness) - Wheezing, sometimes audible even w/o stethoscope - Use of accessory muscles - Absence of audible wheezing can be an ominous sign -- status asthmaticus *Classified accrd. To frequency of sx.* a. **Emergency** - If symptoms persist after 30-minute treatment, seek medical attention - **Status Asthmaticus** is life threatening - *Bronchospasm is not controlled and symptoms are prolonged* b. **Diagnostic test** - Spirometry - Peak flow rate - Forced expiratory volume (FEV1) - To differentiate from COPD, administer adrenergic - Asthma symptoms are reversible with meds, COPD cannot - Allergy skin test - Increased Serum IgE - Eosinophils levels - ABG during acute attacks c. **Tx** - Learn to monitor and manage asthma at home - Asthma action plan d. **Avoidance of triggers** - Avoid triggers - Use bronchodilators if cannot be avoided - Inhalers use before exercise - High-salt diet worsen exercise-induced airway inflammation - Keep mouth and nose covered to avoid cold air triggers - Avoid cigarette smokes - Avoid aspirin and NSAIDs - Avoid beta-blocking medications (propranolol, metoprolol) - Short-acting beta agonist (SABAs) such Albuterol for intermittent symptoms - MDI often called "rescue" inhalers **ASTHMA ACRONYM** **A**drenergic (Beta 2 Agonists) (Albuterol) **S**teroids **T**heophylline **H**ydration (IV) **M**ask O~2~ **A**nticholinergic e. **Health Teaching** - Use short-acting bronchodilator first before corticosteroid e. **Long-acting beta-agonist bronchodilators (LABAs)** - Salmeterol (Serevent) or Formoterol (Foradil) - Keeps airway dilated for up to 12hrs or more - No longer recommended f. **If inhaled meds do not control symptoms or if nocturnal** - Oral Antileukotrienes may be added - Theophylline bronchodilators are used as last resort - Immunotherapy (allergy shots) may be used g. **Acute Asthma Attack** - Treated with inhaled (MDI or NMT) or subcutaneous SABA, or rarely, IV Aminophylline - IV or PO corticosteroids (methylprednisolone and prednisone) are potent anti-inflammatory agents that are **useful in acute episode, but avoided for long-term therapy**, if possible, of their cushingoid side effects - Corticosteroids must be tapered before discontinuing - O2 is not necessary since hyperventilation may occur during acute attack - If attack is prolonged and pt. becomes cyanotic or PaO2 levels fall, O2 therapy will be used **Cystic Fibrosis** - Hereditary - Retained digestive enzymes - Destroy exocrine pancreas - Sweat is high in sodium and chloride, since electrolytes are not reabsorbed as they pass through the swear ducts - Respi symptoms, often the first visible manifestation - Thick tenacious sputum - Finger Clubbing - Hemoptysis - Foul-smelling stool due to lack of enzyme in small intestine - Bowel obstruction - Cirrhosis - Cholecystitis - Cholelithiasis (Gallstone) c. **Complications** - Bronchiectasis - Pneumothorax - Cor pulmonary and respiratory failure - Bowel obstructions as results of thick mucus binding with poorly digested fecal matter - **Respi SX + Excessive amount of NaCl in swear = CF** - Chest x-ray and spirometry may be done d. **Tx** - No cure for CF - Tx is aimed at controlling infection and relieving sx e. **Removal of thick sputum** - Hydration - Use of vibratory positive expiratory pressure (PEP) device - Chest physiotherapy or high-frequency chest wall oscillation up to four times a day - Regular exercise - A hot shower f. **Medications** - Nebulized mist treatments using normal or hypertonic saline or mucolytic meds may be used before chest physiotherapy - Dornase alpha (Pulmozyme), an enzyme that breaks up and loosens mucous g. **Prevention of infection** - Annual flu vaccination - Antibiotics - Home IV antibiotic therapy ASSESSMENT OF CARDIOVASCULAR **TYPES OF DYSPNEA** - Exertional - Paroxysmal nocturnal dyspnea - Orthopnea - Cheyne-stokes -- gradual increase in depth **CHEST PAIN** A. Location *(Heart is located in mediastinum, midclavicular, 4^th^ to 5^th^ ICS)* B. Character/Quality - Pressure - Tightness - Crushing - Burning - Aching - Heaviness - Dullness - Heartburn/Indigestion C. Timing: Onset, duration, frequency a. Onset: Sudden or gradual b. Duration: How long does it last? c. Frequency: Continuous or Periodic D. Setting/Precipitating factors - Awake, at rest, sleep interrupted? With activity? With eating, exertion, exercise, elimination, and emotional upset E. Intensity/Severity - Range from 0 (no pain) to 10 (most painful) F. Aggravating factors a. Activity b. Breathing c. Temperature G. Relieving factors d. Medication (nitroglycerin, antacid) e. Rest f. No relieving factors H. Associated factors - Fatigue - SOB - Palpitations - N&V - Sweating - Anxiety - Lightheadedness - Dizziness **EDEMA** - Abnormal accumulation of serous fluid in connective tissues a. Causes: - CHF - Na+ Retention - Liver disease - Hypoproteinemia - Venous or Lymphatic Obstruction b. Pitting Edema - 0 to 4+ - Every +1 in grade = 2cm **PALPITATION** - Rapid, forceful, irregular heartbeats felt by the pt. **HEMOPTYSIS** - Coughing up of blood - Small quantities of dark-clotted blood indicate **mitral stenosis** - Mixture of blood and pus indicates **pulmonary suppuration** - Pink, frothy sputum indicates **pulmonary edema** - Blood-streaked sputum indicates **acute pulmonary congestion** - Frank hemoptysis is due to **lung pathology**. **FATIGUE** a. Syncope and fainting may be caused by anoxemia b. Ferrous Sulfate (Increase RBCs) **OTHER PERTINENT DATA** a. Cyanosis *(Bluish discoloration of the skin and the mucus membranes)* b. Abdominal pain or discomfort c. Clubbing of fingers *(angle of the nail is 180 deg due to chronic hypoxia)* d. Jaundice *(Yellowish discoloration of skin and sclera)* - Anicteric sclera -- healthy sclera - Icteric sclera -- some part of eyes is yellow Physical Assessment of the Heart **Inspection and Palpation** - Aortic Area -- 2^nd^ ICS to R of Sternum - Pulmonic -- 2^nd^ ICS to the L of Sternum - Right Ventricular Area -- Circle around the 5^th^ cartilage to the L of the midsternal line a. Erb's Point (3^rd^ ICS) L b. Tricuspid (4^th^ ICS) LL Sternal Border - Apical or Left Ventricular Area -- 5^th^ ICS at MCL **Percussion** - Assess the size of the Cardiac Area of Dullness c. Clavicle - Resonance on spaces - Flat over muscle and bone **Auscultation** - Check rate and rhythm of the apical pulse - Heart Sounds d. S1 - Sound of AV valves closing; - Loudest at apex e. S2 - Closure of Semilunar valves; - Loudest at the base - Abnormal Heart Sounds f. Murmurs - Vibrations within the heart and GV caused by turbulence of flow g. Rubs - Sounds of interfacing of parietal and visceral surfaces of the pericardium - Heart patterns - Heart Rate - \100 Tachycardia **NOTE:** *Location for CPR, locate for xiphoid process, two-finger lower half of the breast bone, in the middle of the chest, 1/3 depth.* Assessment of Extremities **Inspection** - Color h. Inadequate circulation may produce pallor, rubor, or cyanosis i. Cyanosis is visualized in good lighting j. Vascular nail beds offer the best visualization - Circulation k. Hair growth - Absence of hair growth means inadequate circulation l. Clubbing - Prolonged hypoxia m. Capillary Refill - Less than 3 sec, prolonged filling time is indicative of inadequate circulation **Palpation** - Edema n. Assess over bony prominence such as medial malleolus, anterior tibia, and sacrum - Press for 5 seconds and measure for pitting - Pulse o. Carotid, dorsalis pedis, popliteal, posterior tibia - Temperature of lower extremities - Presence of varicosities - Auscultation - N arteries do not produce sounds - Bruits p. Blowing sounds heard in conditions like AV fistula DIAGNOSTICS **NON-INVASIVE ECG** - Graphing recording of electrical activity heart - Resting ECG -- Single recorded picture of the electrical activity of the heart - Preparation a. Secure Electrodes to appropriate location on the chest and extremities - ECG Placements - White on Right - Clouds over grass (White over Green) - Smoke over fire (Black over fire) - Middle Heart Chocolate (Brown by heart) b. Instruct client to remain still c. Reassure client d. Remove all metallic objects **NON-INVASIVE HOLTER MONITORING** - Continuous ambulatory ECG over time (usual 24 hours). **NON-INVASIVE STRESS TEST** - Continuous multi-lead ECG monitoring during controlled and supervised exercise usually on a treadmill e. **Preparation** - Obtain written consent - Instruct client to eat a light meal 1-2 hours before the exam (no caffeine, alcohol, or smoking) - Instruct to wear comfortable clothing and rubber-soled walking shoes. - Secure electrodes to appropriate locations on the chest f. **During** - Obtain baseline BP and ECG - Instruct client to exercise as instructed and report any pain, weakness, SOB, or other symptoms - Monitor BP and ECG g. **Post** - Compare - Resume normal activities after rest **NON-INVASIVE ECHOCARDIOGRAM** - Diagnosis of CV disorders - Visualization of internal cardiac structures for size, shape, position, and movement - All 4 valves and ventricles - Client Preparation h. Instruct to remain still i. Secure Electrodes for simultaneous ECG tracing j. Explain no electrical shocks k. Lubricate skin l. Post - Clean lube from the chest **NON-INVASIVE PHONOCARDIOGRAPHY** - Recording of heart sounds with simultaneous ECG - Client Prep m. Instruct to remain still n. Secure electrodes for simul. Tracing o. Explain there will be no pain **INVASIVE CARDIAC CATHETERIZATION** - Invasive but often definitive test for diagnosis of cardiac disease - Catheter is inserted into the right or left of the heart to obtain information p. Inserted in an antecubital vein and advanced into the vena cava, R atrium, VC q. For L, inserted into the brachial or femoral and into the Left Ventricle - Purpose r. Measure IC pressure and O2 levels in various parts of the heart s. Injection of dye allows for visualization of the heart chambers. - Nursing Care t. Informed Consent u. Ask about allergies, particularly to iodine if dye is used v. NPO for 12 hrs w. Temporarily suspend metformin for dye - Do not restart until oral intake has resumed and renal function is normal x. Record height and weight, baselines VS, and monitor Peri. Pule y. Inform the client that a feeling of warmth and fluttering once the cath is inserted. z. Post - Assess circulation to the extremity - Check peri. Pulses, color, sensation of affected extremity q15m for 4 hours - Observe the insertion site for swelling and bleeding - Assess VS **INVASIVE CORONARY ANGIOGRAPHY /ARTERIOGRAPHY** - Dye into the coronary arteries to assess the structure of the arteries using an X-ray - Preparation: a. Written Consent b. Hx of allergies to dye and shellfish c. Initiate IV **INVASIVE AORTOGRAPHY** - Radiopaque contrast medium into the aorta to visualize aorta, valve leaflets, and major vessels on a movie film - Pretest d. Informed Consent e. Dye will be injected and to report dyspnea, numbness, or tingling - Posttest f. Assess puncture site freq for bleeding or inflammation g. Assess peripheral pulses distal to the injection site every hour for 8 hours posttest. **INVASIVE CORONARY ARTERIOGRAPHY** - Visualization of coronary arteries by radiopaque contrast dye. - Purpose h. Eval. of heart disease, and angina, loc of areas of infarction, and extent of lesions. **INVASIVE CARDIAC NUCLEAR SCAN** - Radionucleotide imaging - Identify ischemic or infarcted tissue - Tracer is injected into the vein to the bloodstream - Travels to heart - Releases energy - Energy detected by camera - Create pictures **INVASIVE BONE MARROW ASPIRATION** - Presence and size of WBC, RBC, and megakaryocytes - Sites i. Sternum j. Iliac Crest k. Tibia - Notes l. During withdrawal, pain is burning and sharp m. After the needle is removed, pressure dressing is applied to the puncture site n. If the pt has thrombocytopenia, pressure is applied 3 to 5 minutes. **INVASIVE MRI** - Uses a strong magnetic field to examine anaphy properties of the heart - Pacemaker, metal plates, prosthetic joints, or other metallic implants must be screened out. - Explain to expect intermittent clanking or thumping sounds from magnetic coils - Instruct to remain still. Chest Trauma **PNEUMOTHORAX** - Air in the chest - Air has entered the pleural space outside of the lungs a. S/SX - Dyspnea - Tachycardia - Pleural Pain - Asymmetrical Chest Expansion - Decreased breath sounds - Negative pressure pulls air into the lungs via the nose and mouth - If either of the VP or PP is perforated, air will enter pleural space, negative pressure will be lost, and the affected side will collapse. **TYPES OF PNEUMOTHORAX**  **A. TENSION PNEUMOTHORAX** - Closed, air, and therefore tension builds up in the pleural space and is unable to escape. - Increased tension, pressure is placed on the heart and great vessels pushing them away from the affected side -- **mediastinal shift.** a. Types - Spontaneous - Occurs without associated injury - Are at risk for recurrence - Underlying lung disease may cause blister-like defect like bullae and blebs that can rupture air into pleural space - Traumatic - Penetrating chest injury allows air to enter the pleural space - Occur from a knife or gunshot wound or protruding rib. **B. OPEN PNEUMOTHORAX** - Air enters and escapes from a passage in the pleural space. **C. CLOSED PNEUMOTHORAX** - Air accumulates in a closed space **HEMOTHORAX** - Blood in pleural space - Can occur w/o pneumothorax (hemopneumothorax is w/) and is often the result of traumatic injury a. S/Sx - Sudden Dyspnea - Chest pain - Tachypnea - Tachycardia - Restlessness - Anxiety - Breath Sounds - Diminished or absent - Sucking sound b. If develops - Hypoxemic - Hypotensive - Trachea may deviate to the unaffected side - Muffled heart sounds - Bradycardia and shock occur if emergency intervention is not provided c. Diagnostic Test - Hx - PA - ABG UTZ - Chest X-ray - CT Scan d. Therapeutic Measure - Small Pneumothorax i. Bed rest and high-flow O2 ii. Needle insertion into the pleural space - Recurrent Pneumothorax i. **Sterile Talc** ii. Antibiotics (Tetracycline) 1. Inserted through thoracentesis 2. **Pleurodesis or Sclerosis** a. Prevents recurrent pneumothorax e. Nursing Care - Level of Consciousness - Skin and Mucus membranes color - O2 sat - RR and depth - Dyspnea - Chest pain - Restlessness **RIB FRACTURE** - Falls are common cause of broken ribs in the elderly - 4^th^ to 9^th^ ribs are commonly affected a. S/SX - Depp Breathing - Coughing Effectively - Atelectasis or pneumonia - Displaced ribs can also dmg. organs and lung tissue causing pneumothorax a. Therapeutic Measures - Rib belts (past) - Pain control - Keep comfortable and allow coughing and deep breathing - Give analgesics **FLAIL CHEST** - Multiple ribs are fractured - **Paradoxical Respiration** - Collapses with inspiration and bulges with expiration a. S/SX - Paradoxical movement of a portion of the chest wall - Inhalation draws in - Exhalation bulges - Dyspneic and tachycardic b. Therapeutic Measures - Oxygen and analgesics - Intubation - Treatment for pneumothorax may be needed for lung dmg. - Surgical stabilization b. NDx - Impaired Gas Exchange - Ineffective Breathing Pattern - Acute Pain **ACUTE RESPIRATORY FAILURE** - Hypoxemia may result from inadequate ventilation or poor oxygenation. - Hypercapnia and respiratory Acidosis may occur when CO2 can't be eliminated. a. Etiology - Chronic Airway Obstruction - CNS disorders that affect muscles of breathing, such as stroke, spinal cord injury, or myasthenia gravis - Inhalation of toxic substances - Opioid overdose - Aspiration b. Prevention - Avoid respiratory infections - Notify the Physician if sputum becomes purulent - Sedatives and narcotics - Can precipitate failure - Respiratory Depressants - Careful monitoring and early intervention c. S/SX - Restless - Confused - Agitated - Sleepy - ABG show decreased PaO2 and pH and increasing PaCo2 which can lead to **Respiratory Acidosis** d. Dx Test - Sputum cultures or chest X-ray - Additional test to determine non-pulmonary causes - Pulse Oximetry - **Capnography** - Monitoring of partial pressure of CO2 and respiratory gasses e. Therapeutic Measures - Easy to mistaken S/Sx of agitation or confusion with sedatives which will speed up onset of respiratory failure. - O2 therapy via cannula or mask - High-flow O2 - May be necessary to oxygenate patient, if the pt has a chronically high PaCo2, the high flow can interfere with the hypoxic drive - Never give a chronic Co2 retainer more than 2L of oxygen - If the flow rate is greater than 1 to 2 L/min, mechanical ventilation via endotracheal tube or noninvasive positive-pressure ventilation (NIPPV) may be required - Antibiotics f. NDx - Ineffective Airway Clearance - Impaired Gas Exchange