The practice of nursing by a registered nurse is defined as the process of diagnosing human responses to actual or potential health problems, providing supportive and restorative care, health counseling and teaching, case finding and referral, collaborat
state of Connecticut's definition of nursing according to the Nurse Practice Act
Nursing is primarily assisting the individual (sick or well) in the performance of those activities contributing to health, or its recovery, or a peaceful death that he would perform unaided if he had the necessary strength, will, or knowledge. It is lik
Virginia Henderson: Considered modern day Florence Nightingale
Describe the practice of holistic nursing
Holistic nursing is defined as "all nursing practice that has healing the whole person as its goal" (American Holistic Nurses' Association, 1998, Description of Holistic Nursing). This practice recognizes the totality of the human being - the interconnect
What is a Nursing Diagnosis?
This part of the Nursing Process identifies actual or potential responses to a condition, whereas medical diagnoses identify or determine a specific disease, or pathology. Include: health promotion, nutrition, elimination, activity/rest, perception/cognit
The components of the nursing process = Assess; Diagnosis/Analyze; Plan; Implement; Evaluate
A Delicious PIE (ADPIE)=
Assessment
Gathering information for the purpose of identifying actual or potential problems. (Indirectly and Directly). DATA, DATA, DATA
Part of Assessment - What are the 7 dimensions of the clinical problem?
WDSQQRA
1. Where (location of compliant on PTs body)
2. Duration (how long has the compliant existed?)
3. Setting (where were they when the problem happened?)
4. Quality (what is it like?)
5. Quanitity (how much, ex. pain scale)
6. Relieving or aggravatin
Diagnosis
This measures a patient's actual or potential response(s) to a condition, whereas a medical diagnosis identifies or determines a specific disease or pathology.This is a PT Problem a Nurse is licensed to treat.
PLAN
GOALS, OUTCOMES: Step where I will set goals, develop outcomes, and decide on specific interventions that I can do for the patient to resolve the problem named in the nursing diagnosis.
Implementation
This is where the doing takes place. What you put in your plan gets put into action during the implementation phase. These are all recorded under the intervention section of care plan
Evaluation
Evaluate if our interventions were effective or not; this process never ends & changes will be made as you evaluate. ALWAYS ONGOING.
Functional Health Pattern Assessment (FHPA)
Information to gather:
� Health perception/health management
� Nutritional/metabolic pattern
� Elimination pattern
� Activity exercise pattern
� Sleep/rest pattern
� Cognitive/perceptual pattern
� Self perception/concept pattern
� Role-relationship patter
4 Components of Phyiscal Assessment
1. Inspection (looking)
2. Palpation (touching)
3. Percussion (putting in motion)
4. Auscultation (hearing)
Nursing Diagnosis Examples
Alteration in tissue integrity"
"Potential for Infection"
"Knowledge Deficit"
"Alteration in GI Function"
"Alteration in Cardiac Output"
"Altered respiratory Function"
"Altered skin integrity"
"Alteration in Nutrition"
"Alteration in Fluid Balance, secon
Subjective
What the Patient Says
Objective
What you see, what others can also see
SBAR
? S - situation = what is happening in the present time?
? B - background = what are circumstances leading up to this situation?
? A - assessment = what do I think the problem is?
? R - recommendation = what should we do to correct the problem?
Maslow's Hierarchy of Needs (in order of what comes first)
? Biological & physiological
? Safety
? Belongingness & love
? Esteem
? Cognitive
? Aesthetic
? Self-actualization
? Transcendence
? **ALWAYS REMEMBER: for exams, when asked what to do first, a key will be to always pick the physiological need.
Total Body Water (TBW) = 60% in adults
1 Premature babies = 83%
2 Infants = 77%
4 Elderly = ~50%
? Both the premature baby and elderly have decreased ability to compensate for losses
? Water is vital for homeostasis (ability of body to maintain internal b
? Intracellular Fluid (ICF) = 2/3 of TBW = 40% of persons WT
? Extracellular Fluid (ECF) = 1/3 of TBW = 20% of persons WT
? Interstitial Fluid (ISF) = � of ECF = ~15% of persons WT
? Intravascular Fluid (IVF) = � of ECF = ~5% of persons WT
Total Body Water
Osmosis
movement of water across a semi-permeable membrane from an area of lesser concentration of solutes to an area of greater concentration of solutes
? Purpose of this is to make both sides concentrated equally
? Will eventually cease at a certain point
Diffusion
movement of molecules from an area of higher concentration to an area of lower concentration
? Purpose is to make both sides look equal in terms of solutes
? Will eventually cease at a certain point
Active Transport
pushing of substances across a concentration of electric gradients
? Purpose of this is to push substances across gradients using energy to get the substances where they desire
? Examples: Na/K pump (this helps explain why we are able to have around 100 m
Sequence of blood flow:
Heart ? arteries ? arterioles ? capillaries ? venules ? veins ? back to heart
What is blood
1 Water mixed with molecules, electrolytes, blood cells, platelets, and proteins
? Difference between blood and plasma
? Plasma is water, molecules, electrolytes, and proteins MINUS the blood cells and platelets
Globulins
responsible for immune functioning
Fibrinogens
responsible for blood clotting
Albumin
maintains oncotic/colloid osmotic pressure
Serous
clear fluid without blood or pus
Sanguinous
bloody or red drainage
Serosanguinous
thin and watery pale red to pink drainage
Purulent
thick, cloudy, yellow, or tan drainage
Cardiac Output
amount of blood pumped by the heart through your intravascular system per minute - 4- 6 L
CO=SV X HR
Stroke Volume (SV)
Determined by figuring out how much blood the heart is pumping out per beat
Normal SV = 60-80 cc or mL
Filtration
Kidneys -- Every minute 20% of CO is going to the kidneys (driving force for filtering and cleansing of blood)
Parkland Formula (Rule of Nines)
Head Arm Torso Leg
Adult: 9% 9% 18% 18%
Children: 18% 9% 18% 14%
= (4mL) x(body weight Kg) x % burned; 1/2 volume in 8; 1/2 volume at following 16 hours
Pulmonary Artery Wedge Pressure (PAWP)
Measures left ventricular preload or volume going to the left ventricle
? Measured by catheter that sits in the pulmonary artery
Normal = 6-12
? FVE = >12
? FVD = <6
Central Venous Pressure (if patient has a central line)
Measure of right ventricular preload (volume)
? Measured via a catheter that sits in the SVC or RA
? Normal is ~5 with a range of 2-8 mmHg
Urine Specific Gravity
Normal = 1.010 - 1.035
? FVD = ? urine specific gravity
? Urine concentrated and SG would be >1.025
? FVE = ? urine specific gravity
? Urine is dilute and SG would be <1.010
Poor man's method of guesstimating osmolality =
2(Na+) + Glucose /18+BUN/2.8= Serum Osmoloality
Serum Osmolality
270-295 (+/- 5)
Urine Specific Gravity
1.001 - 1.035
-Depends on the #, size, and wieght of dissolved substances. Meaning false positives/highs with glucose (Diabetes insipidus), protein, mannitol and/or x-ray dyes are in the urine. False lows with diuretics
Urine Osmolality
Range of Normal 50-290 (1200 mosm/kg -because it's compared to serum level)
Intravenous Fluid Therapy
Two types of solutions:
? Crystalloid = solutions with fluids and electrolytes
? Colloid = large M&M's such as albumin, dextran, or blood
? Daily baseline fluid requirement - rule of thumb:
? 25-30 mL/kg/day (normal adult)
? 20-25 mL/kg/day (obese)
? 25 m
TPN & PPN (Total/Partial Parenteral Nutrition)
? Both are high in glucose, amino acids, vitamins, and fats
? These are ready for cellular use as the gut doesn't have to break it down
? Both are breeding grounds for bacteria because of the high sugar concentration
? TPN needs to go in a central line be
Enteral
Feeding via route that is the mouth, esophagus, stomach, or small intestines
Insensible Loss/24 hours
1000cc/day
Lung/Skin=600-700cc
Sweat= 0-100 cc
Stool = 100-200 cc
Sensible Loss/24 hours
Urine 800-1,500 cc
Total Intake / Output per day
0
Urine Hourly Output
30cc a day or .5-1 mL/kg/hour
Isotonic
Same concentration both inside and outside the cell
? No impact on the cell (no net gain or loss)
? Examples: 0.9% NS or .9%NaCl (308 Osm)
Hypotonic
less concentration outside the cell
? Water rushes into the cell (more concentrated) to rehydrate cell = cell may burst
? Examples: D5W (252 Osm); .5 NS; .45% NS; NaCl (154 Osm)
Hypertonic
more concentration outside the cell
? Water rushes from the cell into the bloodstream (> concentration of particles than plasma)
? Examples: 3% NaCl (1026 Osm)
Anti-Diuretic Hormone (ADH)
controls excretion of water in urine (osmoreceptors sense osmolarity of ECF)
? ADH is also called Vasopressin and is a water retainer that alters collecting tubules water permeability
? Produced by the hypothalamus, but is stored and released by the poste
Aldosterone
0
Atrial Natriuretic Peptide (ANP
0
Intake vs. Output
Intake should always = output
? 2/3 of intake come from liquids & 1/3 from foods
Insensible loss = unnoticed losses (breathing, sweating, water evaporation off of skin)
? For every degree rise over 99�F, persons respiratory rate will ? four breathes per m
BUN
Normal = 10-20
? Measure of protein metabolism
Creatinine (Cr)
Normal = 0.1-1.4
? Measure of muscle metabolism
BUN/Cr ratio
Normal = 10-15:1
? >20:1 = usually means pre-renal azotemia, but may be caused by ? protein catabolism or excessive protein load
? azotemia = abnormally high concentrations of urea and other nitrogenous substances in the blood
? If BUN & Cr are elevated =
Mean Arterial Pressure (MAP)
MAP reflects the average perfusion/ blood pressure.
Normal = 70-110 mmHg; needs to be greater than 60 mmHg
Calculated: Systolic B/P + 2(Dystolic B/P)/3
Syndrome of Inappropriate ADH
1 General Information:
? Release of ADH into an already dilute bloodstream
? Think of it as a system that cannot be shut off - valve is broken and despite decreasing osmolality, more ADH keeps coming
? End result is too much H2O in the blood stream (not a
Diabetes Insipidus
ADH ?
Sodium (Na) ?
Urine Osmolality ? (for what would be expected)
Specific Gravity ? <1.005
1) General Information:
? Deficiency in ADH secretion Diuersis -(have to urinate a lot)
2 Causes/types
? Primary/rare:
? Tumor of the hypothalamus
? Nephrogenic
Describe the common clinical manifestations of cardiac dysfunction.
� Valvular dysfunction may have some of the same presenting symptoms as coronary artery disease (CAD) and processing the data is important. You can't isolate any information!
� Listen for signs and symptoms common to cardiovascular dysfunction:
� fatigue
Troponin (cTn)
� A protein that has three isotypes (T, I, and C)
� Released from dead and injured cells in heart muscle Elevated levels can indicate that there has been injury, such as would occur during a heart attack, even a mild one
� Advantages of troponin, particul
CK-MB (creatine kinase, myocardial muscle enzyme)
level is elevated when there is injury to tissue
-elevation in value indicates myocardial damage, Elevation occurs within hours and peaks at 18 hours following acute ischemic attack; normal value is 0%-5%--
� The level is elevated when there is tissue inj
HDL/LDL ratio
Normal is about 1:3
Electrolytes: ** electrolyte and mineral imbalances can cause cardiac electrical instability and dysrthythmias
Potassium
Hypokalemia causes increased cardiac electrical instability, ventricular dysrthyhmias, and increased risk of digoxin toxicity. ECG shows flattening andinversion fo the T wave, appearance of a U wave, and ST depression
Hyperkalemia causes asystole and vent
Decrease in Sodium- leads to what kind of heart failure?
decrease sodium (use of diuretics and indicating water excess --> right heart failure).
Impact of Hypocalcemia on the heart?
causes ventricular dysrhythmias, prolonged ST and QT intervals and cardiac arrect.
Impact of Hypercalcemia on the Heart
can cause shortened ST segment, widened T wave, atriventricular block, tachycardia, or bradycardia, digitalis hypersensitivity and cardiac arrest
hypomagnesemia on the heart
Low level can cause tachycardia and fibrillation
ECG with hypomagnesemia include tall T waves and depressed ST segments
hypermagnesemia on the heart
can cause muscle weakness, hypotension, and bradycardia. ECG with Hypermagnesemia- prolonged PR interval and widened QRS complex.
Impact of elevated BUN on the heart?
elevated in heart disorders that effect renal circulation like cardiogenic shock and heart failure
Blood Glucose elevated in what type of cardic situation?
can be elevated by and acute cardiac espisode
Identify the components of an ECG and relate it to physiologic events of the heart.
� Uses ultrasound to cardiac muscle function, "EF" ejection fraction (normal ejection fraction: 55-65% with symmetrical contraction of the left ventricle)
� Assess structure, particularly the valves
� No prep, noninvasive
� Transesophogeal echo (TEE) most
Electrocardiography (ECG, EKG): 3 major types:
� Resting - typical one you think of (12 lead)
� Continuous - Holter Monitor - 24 hour measure, patient performs their normal ADL, any cardiac symptoms are noted and correlated with ECG findings. Patient may not shower while Holter Monitor is attached. Ca
The cardiac muscle cells possess unique properties: relate it to physiologic events of the heart....
� Automaticity - spontaneous depolarization - the ability to initiate an impulse spontaneously and repetitively without an external impulse.
� Excitability - the ability of non-pacemaker cardiac cells to respond to an electrical impulse generated from pac
Cardiac Action Potential
� The cardiac cell membrane is selectively permeable to ions. This is known as Action Potential across the cell membrane. At rest the inside of the cardiac cell is negative, the outside is positive.
Depolarization
MUSCLE CONTRACTING. The process by which normally negatively charged cardiac cells (resting) become positively charged on the inside. In other words, at rest there is Ca++ and Na+ outside the cell and K+ inside the cell, potential is -90 mv. Then there is
Cardiac Cycle
� Phase 0 - rapid depolarization (+ on inside)
� Phase 1 - early rapid repolarization
� Phase 2 - plateau phase
� Phase 3 - final repolarization
� Phase 4 - prolonged refractory phase to prevent sustained contraction. The cell now returns to its resting s
Repolarization
muscle is "resetting" itself electrically.
PR interval
Normal 0.12-0.20
Analyze the P waves
Normal .04
� Are they there?
� Is there one for each QRS complex?
� Do they go in the same direction?
� Are they regular?
QRS Complex
Normal (.8-.10 seconds)
Do they look the same?
Do they point in the same direction?
Dp they measure LESS than 0.12 seconds (3 boxes)
Normal Sinus Rythmn`
60-100
The P-P interval (top of one P to the top of the next P)
indicates the atrial rate.
The R-R interval (top of the R to the top of the next R)
indicates ventricular rate
QT interval - represents
entire depolarization and repolarization (normal .34-.43)
Atrial Fibrillation:
There is no PR interval with A.Fib - It's not measurable
� A dysrhythmia originating from the atrial muscle.
� Rhythm: The atrial rhythm of an irregular undulating baseline. The ventricular rhythm is totally irregular.
� Rate: The atrial rate cannot be co
Premature Ventricular Contractions (PVC's):
It originates suddenly in an irritable focus in a ventricle and produces a wide and bizarre ventricular complex on the EKG.
� PVC's can be dangerous or quite benign. All of us have PVC's. Have you ever felt your heart "jump" in your throat?
� A dysrhythmi
Ventricular Tachycardia (V-Tach)
A ton of big QRS complexes, nothing going on in atria, far as we can see (on EKG), they all match though
� Rhythm: Usually not possible to determine the atrial rate. Ventricular rhythm is usually regular or nearly regular. The ventricular rate is 100 to 2
Ventricular Fibrillation (V-Fib)
Complete haywire, QRS complexes but shaped irregularly -- This is a code if not terminated in 5 minutes.
� "VF or Vfib" is the result of electrical chaos in the ventricles. Impulses from irritable foci fire in a totally disorganized manner so that ventric
Asystole
CODE/Flatline/Goner
� Ventricular asystole, sometimes called ventricular standstill, is the complete absence of any ventricular rhythm.
� There are no electrical impulses in the ventricles and therefore no ventricular depolarization, no QRS complex, no co
Infective Endocarditis
infection of the endocardium, which includes the valves. It occurs mainly in people with a history of:
� Intravenous drug abuse (IVDA)
� Valve Replacement
� Mitral valve prolapse (MVP) or other structural cardiac defects
� May follow dental procedures (du
Pericarditis
inflammation of the pericardium (the sac around the heart).
� Can be chronic or acute, not uncommon in cancer patients with "malignant effusion"
� May be infective or just inflammatory.
Signs and symptoms of pericarditis:
� Friction Rub - usually best her
Restrictive Cardiomyopathy
The heart becomes rigid and can't properly fill with blood between heartbeats.Restrictive filling and reduced diastolic filling of one or both ventricles; normal or near-normal systolic function Idiopathic, amyloidosis, endomyocardial fibrosis.
Rx like CH
Hypertrophic Cardiomyopathy
massive ventricular hypertrophy, w/small ventricular cavities, often genetic, chest pain, dysrhythmia.
means there is an abnormal thickening of the heart muscle affecting the heart's ability to pump blood, making the heart work harder.
Rx like MI ischemia
Congestive / Dilated Cardiomyopathy
Ventricles dilate and enlarge, most common, systolic function impaired.
An ongoing disease process that damages the muscle wall of the lower chambers of the heart-- The walls of the heart chambers stretch (dilate) to hold a greater volume of blood than no
Atherosclerosis
is the accumulation of lipid-containg plaque in the arteries (main cause of Coronary Artery Diease -CAD)
Coronary atherosclerosis produces symptoms of and complications according to the location and degree of narrowing of the arterial lumen, thrombus form
ischemia
inadequate blood supply that deprives the cardiac musle cells of oxygen needed for their survival
Angina Pectoris
refers to chest pain that is brought about from myocardial ischemia.
infarction
Death of cells
myocardial infarction
An MI occurs when the myocardial tissue is abruptly and severely deprived of oxygen. It is life-threatening.
� MI is characterized by necrotic muscle tissue. The blood supply can be interrupted slowly (e.g. CAD) or suddenly (e.g. thrombus stuck in narrowe
Discuss the pathophysiologic basis for the clinical manifestations of angina pectoris
Angina is chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and O2 Supply.
Agina is caused by an imbalance between oxygen supply and demand.
Causes include obstruction of coronary blood flow resulting from atherosclerosis
There are three major types of Angina:
Three types:
1) Exertional angina - stress or exercise
2) Prinzmetal's - heart spasms, otherwise healthy patients, young, although some have had prior cocaine use
3) Unstable/crescendo - at rest, treat immediately as an emergency, Here You give nitrates,
Signs and Symptoms of Angina include
� Chest pain, radiating to neck, jaw, arm, back of shoulders
� Shortness of breath (+/- pain, especially in women)
� Easily fatigued
� Nausea and vomiting
� Diaphoresis
� Apprehension/anxiety
� Pallor of lips/nail beds
Discuss the pathophysiologic changes that accompany an acute myocardial infarction.
Blood supply halted suddenly or slowly, necrosis begins w/in 20 minutes. After 6 hours entire muscle thickness may be dead. Zones of necrosis, injury, ischemia (think bulls eye.) As MI progresses, get local vasodilation, pt becomes acidotic, w/K+, Ca++, a
Identify clinical manifestations of patients with an acute myocardial infarction
chest pain that occurs suddenly and continues despite rest and medication is the presenting symptom in most patients with MI. Some PTs have prodromal (early, nonspecific) symptoms. In many cases the signs and symptoms of MI are the same as those of unstab
Examine the pathophysiologic changes that occur in heart failure.
� Heart failure = the inability of the heart to pump sufficient blood to meet the demands of the body.
� The problem can be that the demands are increased, for example with volume overload or increased metabolic rates
� more commonly, the problem is due t
Discuss medical treatment and nursing interventions for the patient with congestive heart failure and cardiogenic shock.
1) Optimize Stroke Volume, by reducing preload and afterload and improving cardiac muscle contractility...
-Reduce preload: diet reduced in sodium and water, meds: diuretics, vasodilators,
-Reduce afterload: meds to reverse excessive vasoconstriction comm
Treatment of cardiogenic shock aims to decrease pain
and reduce myocardial oxygen requirements by decreasing the preload and afterload.
� If dysrhythmias are underlying cause they must be treated.
� If cause is hypovolemia, infuse plasma expander.
� IV morphine given to decrease pain, reduce pulmonary conge
Preload
Equivalent to volume (how much blood is coming into the atria).
What is Starlings Law?
the greater the force of contraction and the better the cardiac output
-related to preload, also known as the end diastolic volume - (how the heart doesn't overfill)
Mechanisms to compensate for decreased CO:
� Increased Heart Rate: however, if it is too fast there will not be enough diastolic filling time and CO may fail. Also, increased rate will tire the heart muscle, increases myocardial oxygen need.
� Improved Stroke Volume: sympathetic stimulation improv
Understand normal and abnormal Troponin and CK/CK-MB levels and their
significance.
...
Compare the various methods of hemodynamic monitoring (eg. Central Venous Pressure [CVP], Pulmonary Artery Pressures [PAP], and arterial pressure monitoring) with regard to indications for use, potential complications, and nursing responsibilities. Can id
SWAN Ganz Cather - CVP, right atrium pressure, right ventricle pressure & PAWP
Describe the nursing management of patients with hypertension.
Dietary changes that include the reduction of salt intake. Other lifestyle changes such as increasing the amount of exercise and administering ordered antihypertensives.
There are many drugs to treat hypertension, including combination agents. Here are ju
Nursing Diagnosis
This describes and documents a patient's actual or potential health problem. It must answer the following 3 questions. What is the problem? What is it related to? How is it manifested?
Intervention
a way in which you address the problems described in the nursing diagnosis.
Goal
must be specific, and measurable.
Filtration
a solute is pushed through a membrane, the solute acts fairly passively and the process of
filtration depends centrally on the size of the solute and the size of the pores through which the
solute is being pushed. Examples: glomerulus and capillaries.
Describe the role of the kidneys in regulation of the body's fluid composition and volume.
filter the blood, removing water and electrolytes and waste material, and returning some of the material to the body while excreting the rest in urine. Helps maintain electrolyte and fluid balance.
Describe the role of the heart in regulation of the body's fluid composition and volume.
pumps fluid (in the form of blood) throughout the body, so that blood can deliver oxygen and nutrients to the cells.
Describe the role of the endocrine glands in regulation of the body's fluid composition and volume.
Secrete various hormones (currently discussing aldosterone, ADH (anti-diuretic hormone), and ANP (atrial natriuretic peptide), which work on kidney and heart to increase/decrease the reabsorption of water, salt, potassium.
Aldosterone: works on kidney, re
Mitral stenosis
severe narrowing of the mitral valve, impedes blood flow through the stenotic valve, increasing pressure in the left atrium and pulmonary circulation. These problems may lead to low cardiac output, pulmonary hypertension, edema, and right-sided heart fail
An aortic stenosis complication. This is enlargement and thickening (hypertrophy) of the walls of your heart's main pumping chamber (left ventricle).
can develop in response to some factor � such as high blood pressure or a heart condition � that causes t
Left ventricular hypertrophy
Cardiac Index
Cardiac index (CI) is a haemodynamic parameter that relates the cardiac output (CO) from left ventricle in one minute to body surface area (BSA),[1] thus relating heart performance to the size of the individual. The normal range of cardiac index in rest i
Knowing PTs history, what further questions are you going to ask?
OLDCARTS (how long, how often, when, relieving or aggravating symptoms etc etc).
SIADH 4 Nursing Interventions & Treatment Plan:
Relationship between Atherosclerosis, Angina and MI? Employ seizure precautions - perform mental status assessment
? Strict I/O and monitor electrolytes
? Fluid restrict, give diuretics
? Consider demeclocyline (a tetracycline) because it increases free w
SIADH 5 Lab Values & Tests:
? Serum Na+ = < 130 mEq/L
? Serum osmolality = < 280 mOsm/kg
? Urine osmolality = > 500 mOsm/kg
? Urine Na+ = > 20 mEq/L
Relationship between Atherosclerosis, Angina and MI
Atherosclerosis:
Process of building up fatty deposits that harden with age in the insides of arteries over time. Build up may partially or completely occlude the artery leading to ischemia
Angina
Chest pain caused by ischemia
MI
When there is muscle deat
Heart Failure
Inability of heart to pump sufficient blood to meet demands of the body
Demand may have increased (FVE, increased metabolic rates)
Impaired pumping of the heart
When the heart fails, compensatory mechanisms go into effect
these are meant to maintain CO, B
What happens in Heart Failure?
Increased HR
if hr is too fast there wont be enough filling time
CO will decrease, Heart will tire
Increased Stroke volume
Sympathetic stimulation improves venous return to the hear
increased preload ends up being too much for the heart and CO decreases
V
Four categories of Heart Failure
1) Left vs Right
2) Chronic vs Acute
3) Systolic vs Diastolic
4) High output vs Low
Left Sided Heart Failure Cause / Pathology
Cause: HTN, CAD, Valve Dz, Idiopathic
Pathology:
Pulmonary congestion from impaired LV fn
LV cant pump blood out into aorta and systemic circulation
Pulmonary BV and pressure increase forcing blood into pulmonary tissue
Pulmonary edema and impaired gas ex
Left Sided Heart Failure Signs and Symptoms
Dyspnea/SOB
Cough
Crackles
Decreased 02 Sat
s3
anxiety
fatigue/exercise intolerance
tachy and/or weak and thready pulse
Right Sided Heart Failure Cause / Pathology
Cause: Left Sided Heart Failure, Right Ventricular MI, Pulmonary HTN, Idiopathic
Pathology:
Right Ventricle fails leading to congestion in the tissue
cant accommodate blood that normally returns to the heart increased venous pressure (JVD, CVP >8)
Right Sided S/S
Lower extremity edema
hepatosplenomegaly
Ascites
Wt gain
Weakness and fatigue
JVD
Heart Failure Treatment
Aimed at improving CO
Optimize/reduce preload�control diet for water salt
Diuretics
Afterload control
ACE-I
Control HR with Digoxin (.5-2)
good for ppl who cant take a BB or CCB
Decrease in K will cause toxicity (watch for visual changes)
Education!
Pt wi
Cardiogenic Shock
Most severe form of heart failure
also called end stage LVF. Failure of the heart to pump adequately, reduced cardiac output and compromising tissue perfusion. Necrosis of more than 40% of the left ventricle, usually the result of occlusion of coronary ve
RX Cardiogenic Shock
Decreased Pain and reduce O2 requirements by decreased preload and afterload
Treat the cause
Morphine (pain)
Hemodynamic monitoring
Diuretics and Nitrates to decrease pressure
Vasopressors for organ perfusion
Intra-aortic balloon may be used during MI to
Describe common nursing diagnoses of patient with fluid problems --Fluid volume excess
Potential for: alteration in skin integrity (b/c edematous tissue is fragile tissue), impaired gas exchange...
Describe common nursing diagnoses of patient with fluid problems --Fluid volume Deficit
Potential for: injury, potential for constipation, altered mucous membranes, hyperthermia, decreased cardiac output, impaired skin integrity
Compare and contrast fluid imbalances -Diabetes Insipidus (DI)
Is when you have no ADH, so you just pee a ton! 5-20L urine/day. Dry, dry, dry. You get hypernatremic.
Compare and contrast fluid imbalances Syndrome of Inappropriate ADH (SIADH)
ADH ?
Sodium (Na) ?
Urine Osmolality ? (for what would be expected)
Specific Gravity ? >1.030
Issue: you don't stop secreting ADH, so you don't pee hardly at all (oliguria), because you are retaining all your water. You look euvolemic, b/c all the extra w
Delineate the Nursing Interventions in patients with fluid volume imbalances --FVE
the goals are to decrease input and/or increase output.
Decrease amount of fluid the person takes in, either orally or by line.
Increase output: administer ordered diuretics.
Monitor I&Os
Monitor Weight
Check for edema (extent? Pitting?), care for it (ede
Delineate the Nursing Interventions in patients with fluid volume imbalances --FVD
the goals are to increase input and/or decrease output
Monitor I&Os: Monitor urine color and specific gravity
Monitor Weight
Check for edema, care for it (edematous tissue is fragile) - may be up in weight but edematous and still have FVD
Monitor for elec
1) Prioritize nursing care for the client during the emergent phase of burn injury.
ISSUES:
1)Fluid therapy: assess needs, begin IV fluid replacement, insert urinary cath, monitor urine output
2) Wound care - start hydrotherapy or cleansing, debride as necessary, assess extent and depth, initiate topical antibiotic tx, administer tetanus
Parkland Formula to establish the correct rate and timing of fluid replacement
WEIGHT(KG) X %BURNED X 4ML
TBSA burned (%) X weight (kg) X 4ml. Give half that amount in first 8 hours, rest over next 16 hours.
Say I weigh 70kilos. 70kilos X4ml = 280mL. Then, assuming 25% of my body is burned, 280mLX25 = 7000mL. So I'd need 3.5L fluid
What is the significance of atrial natriuretic peptide (ANP)?
Atrial natriuretic peptide is a hormone secreted by cells in the atria in response to high BP. When secreted, ANP causes salt and water to leave the vasculature, reducing CO and blood volume and system BP. COUNTERS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM.
Describe common nursing diagnoses of patients with electrolyte problems --Hyperkalemia
Alteration in Cardiac output
Alteration in urinary elimination
Altered nutrition
Diarrhea/Alteration in GI function
Activity intolerance related to muscle weakness
High risk for injury
Describe common nursing diagnoses of patients with electrolyte problems --Hypokalemia
Decreased cardiac output
High risk for injury
Alteration in nutrition
Alteration in bowel elimination
Ineffective breathing pattern
Describe common nursing diagnoses of patients with electrolyte problems--Hypernatremia
Common nursing diagnoses of patients with which type of electrolyte problem?
-Impaired Swallowing/Dysphagia
-Education
-Potential for Injury
-FVD related to actual or relative Na+
Describe common nursing diagnoses of patients with electrolyte problems--Hyponatremia
(Depends on cause)
potential for injury (failing, seizure)
knowledge deficit (if med related or FVE/FVD
What are the nursing interventions related to edema?
Restrict fluid and sodium, diuretics, elevate edematous limbs to promote drainage, reduce vasoconstriction and tight clothes, stockings/wrappings.
What are the nursing interventions related to the central nervous system manifestations of electrolyte abnormalities?
Maintain seizure precautions. Monitor any changes in LOC.
Clarify the use of diuretics in the treatment of hyperkalemia.
Diuretics: make you pee, and when you pee, you excrete potassium. 80-90% of potassium is excreted through the urine.
Clarify the use of ion-exchange resins in the treatment of hyperkalemia.
Ion-exchange resins, e.g. kayexalate, is a product that exchanges sodium for potassium in the GI tract, binds potassium, and then it's excreted in the stool. Way to pull K+ out of system. (Dog that will bite you is if you become constipated --> leads to t
Clarify the use of insulin (with glucose) in the treatment of hyperkalemia.
Insulin piggybacks on K+ to pull K+ into cells (ECF?ICF transfer), give insulin with glucose so as not to induce hypoglycemia
Clarify the use of calcium in the treatment of hyperkalemia.
Calcium temporarily antagonizes K+'s deleterious effects on myocardium, until K+ can be forced into cells by insulin and glucose.
Describe the cardiac arrhythmias in hyperkalemia
Wide, flat P wave, prolonged PR interval, widened QRS,
tall, peaked T-wave
also vfib, cardiac arrest
Describe the cardiac arrhythmias in hypokalemia
Slightly prolonged PR interval,
Slightly peaked P wave,
ST depression,
PROMINENT U-WAVE
Explain the differences between peripheral versus central lines
A normal IV is a peripheral line that has a short catheter inserted into a peripheral vein. A central line (which can be inserted peripherally) goes into the SVC, IVC or right atrium. The PICC line is a type of central line that is inserted into a periphe
List at least four considerations when inserting a peripheral line.
Wash your hands!!! Hand hygiene is super important. Needs to be a sterile procedure! Clean area with betadine. Also consider the condition of the vein, other medical conditions, and whether the patient is R or L handed.
Describe treatment of air emboli
Left lateral position, administration of 100 % O2
Describe diet modification for hyperkalemia.
Low K diet (<60mEq/d), avoid foods high in K: salt substitutes, bananas, whole-grain breads, eggs, coffee, citrus fruits, fruit juices, watermelons, tomatoes, milk, avocados, raisins, cantaloupe, processed foods and meat (beef, pork etc.).
Describe diet modification for hypokalemia.
High K diet includes: bananas, whole-grain breads, eggs, coffee, citrus fruits, fruit juices, watermelons, tomatoes, milk, avocados, raisins, cantaloupe, processed foods and meat (beef, pork etc.).
Describe diet modification for hypernatremia
Low Na+ Diet
Describe diet modification for hyponatremia
The type of diet that is recommend for this electrolyte imbalance ______ includes broths, tomato juice, canned foods, processed foods, etc.
Explain cardiac physiology in relation to cardiac anatomy and the normal conduction system of the heart.
Normal conduction system: SA node (60-100 bpm), AV node (40-60 bpm) ? Bundle of His and Purkinje fibers (20-40 bpm)
Discuss the clinical significance and related nursing implications of radiological and laboratory tests used to diagnose cardiac disorders.
Troponin - is the current gold standard test. Rises w/in 4-6 hours of cardiac event onset, and stays in blood for days. It is released from dead and injured cardiac cells.
Normal <0.5 ng/ml
Heart injury 0.5-0.8 ng/ml
Likely MI > 0.8 ng/ml
Creatinine Kinas
Identify the components of an ECG and relate it to physiologic events of the heart.
PQRSTU
P is the atrial depolarization, coming from SA node.
PR is time it takes to get from SA to AV node.
QRS is how long it takes to get from AV fiber to Bundle of His and represents the depolarization of the
ventricles.
ST is repolarization of the vent
Atrial Flutter
slow QRS irregular ~60 bpm
1st degree AV block
PR interval >.20 seconds (normal .12-.20)
2nd degree AV block
normal P waves, PR interval progressively longer until a QRS complex is missed. In fact, the atrial rhythm is regular, just the ventricle slows down and lazes out
3rd degree AV block
Ventricular rhythm regular and so is atrial but there is no communication between the two so the p waves (atria) march out at a rate of 60-100 bpm and the QRS complexes (ventricle) are at a rate of 30-45 bpm.
Describe the nursing management of patients with infectious diseases of the heart--Endocarditis
Isolate causative organism w/blood cultures, penicillin IV 6weeks typically, ADL's as tolerated, discharge teaching, if valves severely damaged may need surgery. Often seen w/IVDA (IV drug abuse), valve problems, or post dental procedures
Describe the nursing management of patients with infectious diseases of the heart--Pericarditis:
An acute or chronic inflammation of the pericardium. S/s include friction rub, timed with heartbeat, must be differentiated from pleural rub. Analgesics, anti-inflammatory drugs, antibiotics, pericardialcentesis
Describe the nursing management of patients with infectious diseases of the heart--Rheumatic Carditis:
caused by hemolytic streptococcus. Manifests as rheumatic myocarditis, rheumatic pericarditis and/or rheumatic endocarditis. Seen usually in older folks who had untreated strep infections as kids. Treat w/long-term penicillin, valve surgery if needed, pre
Describe the relationship between atherosclerosis, angina, and myocardial infarction (MI).
Atherosclerosis ? coronary artery disease ? angina ? MI.
Describe modalities used to improve myocardial perfusion and the nurses' roles when caring for these patients.
1) Decrease O2 demand of myocardium
* nitrates ? afterload and preload decrease
* beta blockers
* calcium channel blockers
*analgesics
* antidysrhythmics
2) Improve circulation (so as to enhance O2 supply)
* administer O2, usually 2-4 L by canula
*positio
State the path of a drop of blood beginning in the SVC.
Superior vena cava ?right atrium? Tricuspid Valve? right ventricle? pulmonary valve? pulmonary artery? lungs? pulmonary veins?left atrium? bicuspid/mitral valve? left ventricle? aortic valve? aorta? arteries? arterioles ?capillaries? venules? veins? vena
State the clinical signs and symptoms for left versus right heart failure.
Left sided heart failure - basically a lot of breathing problems: backs up in lungs, so wet lungs and you get S.O.B., hypoxia, cyanosis, chest pain, blood-tinged sputum, ?pulmonary capillary wedge pressure, paroxysmal nocturnal dyspnea, S3 gallop, fatigue
Define preload and afterload
________=volume coming into ventricles (end diastolic pressure). Increased in hypervolemia, w/regurgitation of cardiac valves. (BUCKET) PAWP reflects left ventricular preload. CVP reflects right ventricular preload. (Barring arrhythmias and valve problems
What is Starling's Law?
Starling's Law states that the more a myocardial fiber is stretched during filling, the more it shortens during systole and the greater the force of contraction. Stretch makes a strong heart! So as preload?, so do contractile force, SV, and CO, and also t
What is a DASH diet?
an antihypertensive eating plan that is promoted by the National Heart, Lung, and Blood Institute for patients suffering from hypertension. It is based on a diet rich in fruits and vegetables, and low fat or non fat dairy.
S1
Lub" sound
Systole, ventricles are contracting
Aortic and pulmonic valves are open
Mitral and tricuspid valves are closed
Heard best at 4th intercostal space left sternal border (tricuspid) and 5th intercostal space left mid clavicular line (mitral)
S2
Dub" sound
Diastole
Ventricluar relaxation/atrial contraction
Aortic and Pulmonic valves are closed
Mitral and tricuspid valves are open
Heard best at 2nd intercostal space right sternal border (atrial) and 2nd intercostal space left sternal border (pulm
S3
Congestive heart failure gallop. Blood is sloshing into an overfilled ventricle (CHF=S3, three letters in this), normal if under 30
S4
Pre-systolic murmur = hypertension or new MI due to stiff ventricle
Murmurs
These two things can cause _______.
Stenosis: Caused by a narrowing of an open valve
Regurgitation: Caused by blood flowing backwards through a closed valve
Troponin
released from dead and injured cells in the heart, remains in the blood stream longer than CK-MB
Normal values: ? 0.5 ng/mL
Levels between 0.5-0.8 ng/mL may reflect heart injury
Above 0.8 ng/mL strongly suggests an MI
Creatinine Kinase:
This enzyme related to heart, brain and skeletal tissue
CK-MB is associated with heart tissue
Normal: 0-6%
It will elevate within 4-6 hours after a MI, peak at 24 hours and return to normal at 48 hours
Lipid Profile
Identifies risk factors
Total Lipids: 400-1000 mg/dL
Total Cholesterol: 115-200
HDL (Good cholesterol)
Normal: 30-60
LDL (Bad cholesterol)
Normal: 80-190
Triglycerides: 4-150
Angiography
Catheter is advanced under fluoroscopy to the coronary arteries.
Dye is injected, which allows for the patency of the arteries to be viewed
If blocked, balloons or stents may be placed
Pre-Test Nursing Care
NPO status
Assess pulses
Confirm no allergies to
MUGA Scan
Video images of the ventricles to check whether they are pumping blood properly
Thallium Scan
Heart will have decreased thallium uptake in areas of damage
Echocardiogram
Ultrasound to assess structure of the heart
Electrocardiogram (EKG, ECG)
Tracing of electrical activity of the heart
PR Interval
Normal: .12-.20 seconds
Measure from beginning of P wave to beginning of QRS complex
Represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node
QRS
Measure from beginning of Q wave to end of S-wave
Normal 0.04-0.10 second
Measure from beginning of QRS complex to end of the T wave
Represents the entire ventricle depolarization and repolarization
Normal: 0.34-0.43 seconds
cardiac tampanade
A Potential complication of Pericarditus is?
Rheumatic Carditis:
Seen in older people who had untreated streptococcus infections as children.
S/S
Early: Like strep throat, fever, chills, sore throat, white patchy exudate on back of a "hot" looking throat, enlarged tender lymph nodes, acute otitis in children, belly pai
How to treat acute MI
MONA - morphine, Oxygen (3L), Nitrates (vasodilators), Aspirin (Some may add on CCB or BBs)
EKG Changes with MI
T wave?
inverted (angina or MI)
ST?
elevation MI
depression Angina
Q?
widens with mi
Improving Myocardial Perfusion
How do you treat an MI?
Decrease 02 demand AND Improve circulation
MEDS to Decrease 02 demand
MONA
BB
CCB
Antidysrhythmics
Improve Circulation
Antiplatelet (Heparin, ASA)
Thrombolytics (clot busters)
PCTA (angioplasty)
Compress plaque against vessel (with cath)
Anticoags given to suppress clots
Complications:
Acute closure
Bleeding at insertion site
Reaction to dye---what kind of allergy do you want to ask about?
Decreased BP and shock
Hypokalemia
Dysrhythmias
Coronary
CABG
Indication: >70% occlusion
Vessel taken from mammary artery or savenous vein
Post Op
Watch fluid balance-pressure is really important
Tell family that pt will be pale, puffy and cold
Complications
Decreased CO
Pulmonary dysfunction
Neuro dysfunction
Acute
Cardiogenic SHOCK
Left sided HF - with Distended JVD and clear lung sounds-- tricky -- see other
Most severe form of failure also called end stage LVF-necrosis of 40% of the left ventricle
Accounts for most hospital deaths following MI
Potential Causes:
Cadiac tamponade, P
High Fowler's position
90 degrees sitting up
Semi Fowler's Position
30 degree angle
Fowler's Position
45-60 degree angle in bed