Monday May 25, 2009

Memorial Day Notes

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relieves the chest pain since this is a vasodilator. This decreases the myocardial oxygen demand. Make sure that the nostril is clean. The purpose is to humidify the air here. This is used to keep the air moist. Adverse effects can include dyspnea, and others. For COPD patients 9095% O2. For the rest of us, 95-100%. IV fluids Always start an IV in the non-dominant hand. For school-age children (Age 6-12), they are working on industry vs inferiority. They really need help here. Phlebitis needs a warm compress. Infiltration requires cold compress. Edema, pain, both need to be removed, and a new IV site needs to be started in both of them. The IV site becomes pale in infiltration, while in phlebitis, the site turns red. Anticoagulants Normal PTT 30-45 seconds. Continuous Heparin can be given but look out for bleeding, epistaxis, melena, and others. Ask for the color of the stool. Aspirin can also have an effect on the stool in bleeding. Coumadin needs to avoid green leafy vegetables because they contain vitamin K and this works against the effect of Coumadin. Diet Soft bland diet. No regular food because soft food is easy to digest. This decreases the workload on the heart so food is easy to digest and absorb. No coffee, tea, or cola drinks because they can stimulate arrhythmias or dysrhythmias. No very cold fluids because they constrict the blood vessels and cause coronary artery spasm. Clear liquids like gelatin and broth is only to be used. Activity Patient is on bed rest for the first 24 hours. After 24 hours, still bedrest following no more chest pain or dyspnea because a portion of your heart muscle has died due to a critical reduction in blood supply. The tissue will take several weeks to close the defect. So the activity should only be gradually increased. Avoid the Valsalva maneuver which is any activity that causes you to close your mouth. Raising your butt on the bedpan or taking a rectal thermometer or passing constipated stool are examples here. Move legs freely to prevent thrombophlebitis. Clients who have had an MI have the greatest fear of death. Pacemaker This is a battery powered pulse generator. This is a device that electrically stimulates the myocardium to retain a normal sinus rhythm. Clients should be on bedrest including no sex to prevent problems. Monitor for s/s of pacemaker failure including, Velcro, dizziness, fatigue, palpitation, hiccups, yawning. Yawning means that you dont have enough

O2 into the brain. Avoid electrical appliances like the microwave. When traveling in the air, dont use to metal detector and no MRI procedures. 7. Coronary Artery Bypass Surgery Look over the notes for these patients. E. Complications 1. Ventricular arrhythmias/dysrhythmias Make sure to be ready for these patients. You can have bradycardia, vomiting, respiratory or cardiac collapse. 2. Congestive Heart Failure This is also known as cardiac decompensation or decompensated heart failure. Here the heart is no longer able to pump an adequate supply of blood to meet the demands of the body. To compensate, the body has: tachycardia, ventricular dilation, and hypertrophy (hyperplasia) of the myocardium. There are a left and right heart failure. In the Left ventricular failure, blood backs up into pulmonary circulation which leads to an increased workload on the heart and pulmonary edema and pleural effusion. Fluid is in the lungs here. Early signs of Left ventricular failure include cool dusky pale skin, persistent moist, nonproductive cough, hyperpnea, palpitations, and frothy sputum. The late signs and symptoms include dyspnea (orthopnea), crackles, and Cheyne-stokes respirations which are alternating periods of apnea with hyperpnea. The treatment for these patients is Morphine Sulfate to dilate peripheral veins which decrease venous return. This also reduces patients anxiety. Also O2 is given in low concentrations which are under 5 L. Aminophylline IV is used as a bronchodilator which makes breathing easier. The rotating tourniquet is also used on page 41. The removal of blood from the vein could be used in the phlebotomy. This reduces circulating blood volume. In right ventricular failure, blood backs up from the right ventricular to systemic circulation resulting in an increased hydrostatic pressure. Here you have peripheral edema which is (pitting edema of the legs). Also ascites is present so you need a Trocar and baseline vitals to prevent shock here. Without this, there could be shock. During a paracentesis procedure, make sure you dont remove more than 700 ccs at a time. Jugular vein distention or distention of the neck veins or use of accessory muscles (sternocleidomastoid muscle) is another s/s. Also hepatomegaly is seen here. Youll have dull aching pain in the right upper quadrant. The client might have anorexia. The general treatment of CHF includes digitalis including digoxin which stimulates the contractility of the heart muscle but the Potassium levels must be monitored to prevent toxicity. Also diuretics are used here including: Lasix, Mannitol, Hydrocellular Thiagade, Diuril, and Urea. These work at the ascending loop of Henle or at the distal tubules. Renal function should be working then here. There are diarrhea, vomiting, arrhythmias, and other adverse effects of this. Also dehydration is seen here. Poor skin turgor is the most indicative of dehydration except in the elderly. So for the elderly, look for dry mucous membranes or loss of weight. Also the diet is an important treatment here. Low sodium diet is important in these patients. Milk is high in sodium. Chicken is the lowest meat in sodium and the highest in protein. Cheese is also high in sodium. Daily weight is also used to used here. Make sure the same amount of clothing, same time of day, and same weighing scale is used each time you weigh the patient.

3. Pulmonary Embolism This is a blood clot that travels to the lungs. This is why we dont give IVs through the legs. TED hose is used here. Make sure to measure from the knee to the heel when measuring this. Also make sure to measure the width at the cuff. Also avoid venous punctures at the knees when possible. If the IV line is suspected of a blood clot, get a syringe and irrigate the blood clot, then inform the doctor. Low dose of Heparin is important to be used here. Patients are getting 1 tablet of aspirin a day to help thin the blood. This helps to prevent clots. S/S include: peripheral edema, CVP, distention of the neck veins, and others. The clients here need anticoagulants. Thrombolytic agents inside therapy are important here. These include streptokinase, uronkinase, and TPA are examples. Monitor for internal bleeding. 4. Pleural Effusion There are dyspnea, tracheal shift or deviation away from the effusion. This is towards the unaffected side. To relieve the dyspnea, you remove fluids, but this can cause loss of electrolytes here. This procedure is called a thoracentesis. 5. Cardiac Arrest This is a sudden stop of the cardiac function. When this happens, you make sure to use your ABCs. Check airway, breathing, and circulation. Circulation is checked through the carotid pulse. If there is none, then you do CPR on a firm surface such as the floor. Obstruction of Arteries 1. Raynauds Disease Upper extremities (females 18-30 years) Brunner 704-705. a. Signs & Symptoms i. Intermittent attacks of pallor or cyanosis of the fingers. ii. Color changes, on exposure to cold, to a dead white appearance. iii. Paresthesia. Make sure to check the bath water. b. Management i. Position, dependent or flat. ii. Avoidance of tobacco. Caffeine must also be controlled. iii. Wear wool gloves in winter months. These are warmer than cotton or nylon. 2. Buergers Disease Lower extremities (males 20-35 years) Brunner 699. a. Signs & symptoms i. Paresthesia of the foot pain. ii. Intermittent claudication which is burning sensation of the legs. iii. Gangrene may set in which could lead to amputation. b. Management i. Avoidance of tobacco. ii. Avoid prolonged sitting or standing. So elevate the legs. iii. Avoid tight or restrictive clothing. iv. Amputation may be necessary

III. Congenital Heart Defects Defects in the heart or vessels after birth. A. Risk Factors 1. Fetal exposure to drugs from mother. There is drug withdrawal. 2. Maternal viral infection (rubella). This is most critical in the 1st trimester (2-10 weeks). 3. Maternal metabolic disorders (diabetes mellitus). 4. Maternal complications of pregnancy. a. Increased age. b. Antepartal bleeding - Comparison of placenta previa and abruptio placenta (Handout page 87). 5. Genetic factors. 6. Chromosomal abnormalities (Downs syndrome). B. Types of congenital heart defects 1. Acyanotic Group The absense of cyanosis. Blood is diverted from the left side of the heart (oxygenated blood) to the right side (unoxygenated blood). There is an increased amount of blood flow to the lungs. C Coarctation of the aorta A Aortic Stenosis P Patent Ductus Arteriosus V Ventricular Septal Defect A Atrial Septal Defect 2. Cyanotic Group Cyanosis occurs due to the presence of deduced oxygen in the circulating blood as a result of right to left shunt or missing or oxygenated and unoxygenated blood. T Tricuspid atresia T Transposition of the great vessels T Truncus arteriosus T Tetralogy of Fallot a. 4 Defects for Tetralogy of Fallot: H Hypertrophy of the right ventricle O Overriding (dextroposition) of the aorta P Pulmonary stenosis I Interventricular septal defect b. Signs & symptoms - Dyspnea, which needs O2. More signs and symptoms to look up. c. Diagnostic Tests d. Surgical Repair Preparation of the parents for the childs surgery.

Kawasaki Disease -Acute febrile disease in children. Pathophysiology - Cardiovascular system is primarily involved. - Blood vessels are inflated Damage to coronary arteries of the heart. Etiology: Unknown - Peak age is 3 years old. 1:5 male ratio. S/S - Fever 1-3 weeks - Lethargy, irritability - Oral mucosa is red, strawberry tongue - Lips dry, cracked and red, - Cervical lymphadenopathy Treatment: controversial Goal of treatment: prevent coronary thrombosis leading to coronary aneurysm and death. - IVIG - High Dose ASA Nursing Interventions: Comfort measures. Systemic Lupus Erythematosus This usually affects the heart and the women 8 times more than the men. S/S - Skin rash (butterfly) on the face and nose. - Also vomiting - Alopecia - Convulsions Diagnostic Tests - Decreased RBC Anemia Symptoms - Fatigue - Anorexia Central Nervous System The CNS consists of the brain and spinal cord. Cerebrum Houses the nerve center that controls sensory and motor activities and intelligence. -Divided into the right and left hemispheres. Because motor impulses descending from the brain cross the medulla, the right hemisphere controls the left side of the body and the left hemisphere controls the right side of the body. More notes needed here on this page.

Increased Intracranial Pressure (ICP) The brain is composed of brain tissue, blood, and CSF. Within this space there is no room to expand or increase in volume because of the rigid skull. The normal ICP level is 10-15 mm hg. ICP occurs when the brain cannot accommodate further volume changes. As ICP increases, cerebral blood flow decreases leading to tissue hypoxia, decrease serum pH and an increase in carbon dioxide level. 1. 2. 3. 4. 5. 6. 7. 8. CVA Head injury Brain tumor Meningitis Hydrocephalus Meningomyelocele Cerebral Aneurysm Hemorrhage Lead Poisoning (Plumbism)/Encephalopathy

Signs & Symptoms 1. Headache Always present. It becomes worse upon awakening. 2. Projectile vomiting The emesis is ejected with force. This occurs due to pressure on the medulla. 3. Papilledema Swelling of the optic nerve. The client will have visual disturbances or diplopia (double vision) so patch one eye at a time. Other signs/symptoms 1. Blood Pressure Widening pulse pressure. The difference between the systolic and diastolic increases. In shock, the pulse pressure does the opposite. 2. Pulse Bradycardia (40-60). Shock is tachycardia(100-160). 3. Respirations Irregular, labored, grunting, stertortous. Shock is rapid and shallow. 4. Skin Dry, warm, and flushed. In shock, its cold, clammy, and moist 5. Pupils Dilated. Shock is constricted. 6. Temperature Elevated. In shock, its decreased. 7. LOC Progressive, deterioration. For shock its usually stuporous. 8. Motor Power Loss of motor, or loss of power. There are 5 levels of consciousness 1. Alert/Conscious 2. Lethargic 3. Stuporous 4. Semicomatose/Semi Coma 5. Comatose/Unconsciousness Know the cranial nerves here and their function in the book.

The glascow coma scale A scale for evaluating the degree of a coma by determining the motor, verbal, and eye opening to standardized stimuli. 13-15 10 or under 7 or under Fully responsive Requires emergency attention Indicates coma

The scale evaluates eye opening, motor response, and verbal response here. Seizures/Convulsions/Epilepsy/neurotoxicity a. Grand mal (Generalized Seizure) Aura Tonic Clonic Convulsions Unconsciousness b. Petit Mal c. Focal side (Jacksonian) d. Psychomotor (Partial complex seizure) Aphasia
a. Expressive Aphasia Here the patient knows the objects name, but

the client cannot say it. So to help this patient, repeat the objects name multiple times. Up to ten times. Also these patients will usually point to the objects that they want instead of saying the name of the patient. Have a communication board to help these patients. Show drawings of common objects such as a bed pan or anything the patient will need at the bedside. Have the client say the name of the object for the client. b. Receptive Aphasia The inability understand the spoken word. If you talk to the patient to come with you, the client didnt understand that and may not walk with you or not move. To communicate, first get the attention of the client. Then face the person and speak slowly and clearly. Dont cover your face or mouth because the client can read your expression. Use gestures. Give one instruction at a time. Allow the client to receive that communication. Give time to receive that message. c. Global Aphasia This is a combination of receptive and expressive forms. The prognosis is usually poor with these patients. Emotional lability (Behavioral changes) This can be very drastic. For the family who is concerned with the patient, tell them that this is part of the illness and focus on their feelings to help them cope with the disease at hand. There is a rapid shifting of emotion.

The nursing intervention is to divert the attention. Use anything to distract the attention of the client. Hemaianopsia For these clients, talk on their good side, which is the opposite side of the side affected here. This is different from homonymous diplopia where the brain side affected is where the good side is. Leakage of CSF (Nose & Ears) Test the fluids for glucose in clients who come in with a cold after a head injury. If its positive, they have leaking CSF. The bulging of the anterior fontanels is another sign here. As opposed to a depressed fontanel which is a sign of dehydration. Normal CSF pressure is 80-180 mm of H2O. Diagnostic Tests
1. Lumbar puncture this is between the 3rd and 4th vertebrae. Have the patient sit

laterally knees to chest to widen the spaces. After the procedure, have the patient lie supine to apply pressure on puncture site and prevent CSF leakage. Minimal risk for paralysis because of middle site. If the CSF is clear, there is an embolus. If its bloody, then theres a chance of cerebral hemorrhage. Remove CSF decreases ICP. Inject a dye myelogram.
2. Cerebral Angiography (Angiogram) This is visual procedure of the arteries and

veins to detect aneurysm, occlusion, hematoma, or others. A dye is injected, and you will feel a warm, flushed feeling for 30-40 seconds. The patient should be NPO prior to this because all dyes have a GI effect and the patient could vomit if it happens. The site should be shaved here. The client should know theyll be on a movable x-ray position so the dye will circulate throughout the brain.