GENERAL NURSING PRACTICE

GOOD THINGS TO SAY

Broad opening Clarify Restate How are things going today? What does this mean to you? What you are saying is .. I see how upset you are about this. You seem sad today. Show nonverbal interest!

Acknowledge Empathy
Silence

COMMUNICATIONS SKILLS:
Express empathy Remain genuine and nonjudgmental Dont appear rushed Express sensitivity to clients culture values

BAD THINGS TO SAY

FALSE REASSURANCE Dont worry , everything will be all right. BELITTLING JUDGING Dont be concerned, everyone feels like that. Its your own mistake; if you had stopped smoking All doctors here are simply great.

DEFENDING

COMMUNICATION BLOCKS
FAILURE TO LISTEN STEREOTYPES AND PREJUDICE CULTURAL MISUNDERSTANDINGS LANGUAGE INAPPROPRIATE FOR NURSE/CLIENT RELATIONSHIP

THE NURSING PROCESS

ASSESSMENT Symptoms of disease = subjective information Signs of Disease = objective information
ANALYSIS Interpreter signs and symptoms Identify clients needs Nursing diagnoses PLANNING Prioritize diagnoses Develop a nursing plan (set goals)

IMPLEMENTATION
Nursing care and procedures Client education

EVALUATION
Compare outcome with expected outcome Test clients understanding and ability of self-care

NURSING DIAGNOSES
The nursing diagnosis is a statement of patients problems and provides the basis for nursing care. Nursing diagnoses are health conditions that nurses are legally licensed to treat! Every nursing diagnosis is associated with several medical diagnoses!

NURSING DIAGNOSIS =patients condition (physiological, psychological, social) EXAMPLES: -Ineffective breathing pattern -fluid volume deficit -Ineffective coping -Knowledge deficit

MEDICAL DIAGNOSIS = disease entity

EXAMPLES: -pneumonia -shock -major depression

A) PHYSIOLOGICAL
NURSING DIAGNOSIS TYPICAL NURSING INTERVENTIONS:

Impaired skin integrity

change clients position

every 2 hours protect bony prominences with foam pad massage to increase circulation

Fluid volume deficit

measure intake/ output, monitor electrolyte levels Encourage client to drink frequently
Monitor vital signs, assess for hypoxia or shock Weigh patient daily to detect fluid retention Monitor vital signs, respiratory rate,ECG, ABCs Monitor consciousness and neurologic status Monitor renal function

Decreased cardiac output

Alteration in tissue perfusion

Ineffective airway clearance

Ineffective breathing pattern

Place client in Fowlers position Postural drainage, percussion every 4 hours Assess chest pain frequently, medication as needed Deep-breath every 4 hours to prevent atelectasis

Impaired gas exchange

Monitor vital signs, ABCs, hemoglobin, hematocrit Check urine/ stool for signs of internal bleeding

Alteration in bowel elimination Constipation

Alteration in bowel elimination: Diarrhea

Increase fluid and fiber intake Avoid use of bed pan Teach client to avoid habitual use of laxatives Fluid and electrolyte replacement Assess for signs of dehydration Catheterization: only if necessary Kegel exercises to strengthen sphincter control

Alteration I urinary elimination

B)PSYCHOLOGICAL
NURSING DIAGNOSIS TYPICAL NURSING INTERVENTIONS:
encourage client to

Fear, Anxiety

express fears and emotions Assign same nurse to care for client if possible Involve client in planning care --- sense of control

Dysfunctional grieving

encourage client to

express sadness and anger encourage client and family to reminisce Ineffective coping
encourage emotional

support: family, support groups let clients increase selfcare levels at their own pace

Sensory- perceptual excess

accept clients

hallucinations or delusions ( do not challenge or ridicule)

Sensory perceptual deficit Alteration in thought process related to memory loss

compensate for loss of hearing,

vision etc. by increasing other sensory stimuli

Orient client to reality: sights,

sounds; call client by name; mention place, time and date frequently Have family provide client with favorite belongings or photos to promote a sense of continuity
remain calm and unhurried ---

Potential for violence

reduce clients feeling of lack of control Remove sharp objects, glass to etc. Allow client to express emotions in non-violent way

C) SOCIAL
NURSING DIAGNOSIS TYPICAL NURSING INTERVENTIONS
spend time with client

Social Isolation

increase trust encourage group activities

Impaired verbal communication

speak slowly and distinctly,

in normal tone reduce clients frustration: allow plenty of time for response ask simple questions that require yes or no as answer do not pretend to understand if you dont !

CLIENTS NEEDS
MASLOWS HIERARCHY OF NEEDS Higher levels can only be achieved when lower needs are fulfilled
Self-actualization Fully achieving ones potential
Self-esteem Confidence, usefulness and sense of purpose

Love and belonging

Safety and security

Need for affectionate relationships overcoming feelings of alienation and aloneness Includes both physical and psychological safety Food, fluids, sleep, homeostasis

Physiological needs

UNIVERSAL PRECAUTIONS
GLOVES Required whenever contact with body fluids is likely: blood secretions Mucous membranes Non-intact skin not required when simply touching intact skin Required if soiling is likely Required if splashes of blood or body fluids are likely

GOWN
MASK

Hand washing

Other Precautions

Always required, whether gloves were worn or not wash before and after contact with clients Wash immediately after gloves are removed Wash before touching noncontaminated surface or item Never recap used needles Discard needles in special sharp container Discard items contaminated with body fluids in biohazard container

PROPER POSITION OF CLIENT

Supine Head of bed flat client lies on back Head of bed flat client lies on abdomen Spinal cord injury

Prone

After lumbar puncture for 3h.

SemiHead of bed Fowlers elevated 30

Head injury increased intracranial pressure

Fowlers

Head of bed elevated 30

High fowlers

Head of bed elevated 90

Head and body are lowered feet are elevated Lying on side

trendelenburg

After cranial surgery bleeding esophageal varices dyspnea (cardiac causes) Orthopnea status asthmaticus pneumothorax Shock

Sims (semiprone)

Unconscious client (unless on respirator)

CANCER SCREENING GUIDE

WOMEN: BREAST SELFEXAM MAMMOGRAP HY > 20 YEARS 35 40 YRS 40 50 YRS > 50 YEARS MONTHLY

PAP SMEAR

ONE BASELINE TEST EVERY 2 YRS. YEARLY ALL SEXUALLY YEARLY ACTIVE WOMEN

MEN:
TESTES SELFEXAM > 16 YEARS MONTHLY

MEN & WOMEN: DIGITAL RECTAL EXAM > 40 YEARS YEARLY

SIGMOIDSCOPY

> 50 YEARS EVERY 3 YRS.

PATIENTS WITH CANCER

TMN:

T = TUMOR SIZE N = LYMPH NODE STATUS M = METASTASES

NURSING INTERVENTION CHEMOTHERAPY wear latex gloves, dont eat or drink when administering drugs (to prevent self exposure) Encourage good oral hygiene Monitor for signs of infection (high risk 7-14 after administration) Monitor intake intake/output Risk of bleeding:avoid aspirin

RADIOTHERAPY

Antiemetic before treatment

Provide good skin care

Wash with water, avoid lotions and

INTERNAL RADIOTHERAPY (CESIUM STICKS)

sunlight Abdomen: expect diarrhea or constipation Upper body: expect dry mouth bed rest during treatment (24-72 hours) foley catheter required minimize time at bedside If radiation source falls out: do not touch! (use forceps to put in lead container)

CLIENT EDUCATION: dont touch source of radiation call immediately if it dislodges

REVERSE ISOLATION TECHNIQUE (during bone marrow suppression): 1. Private room, Laminar air-flow, sterile linen, sterile hygiene equipment 2. Put on shoe covers, put on mask and cap, put on sterile gown, gloves 3. Remove gown after leaving room

VITAL SIGNS
TEMPERATURE Oral 37C = 98.6F
-For routine oral is

PULSE 60 80 per minute

sufficient - rectal is more accurate than oral (0.4C or 0.8F higher than oral) -Count for 30 sec., multiply by 2 - count for 60 sec, if irregular

RESPIRATION 16-20 PER MIN.

BLOOD PRESSURE Diastolic: 6090mmHg Systolic: 95140mmHg

-count for 5 sec., multiply by 4

-Use appropriate size cuff -(pediatric cuff for

children) -Place 1 inch above antecubital fossa -Apply not too loose -A difference of 15

PREOPERATIVE CARE
IMPLEMENTATION Solid food allowed 8-10 hours before surgery Clear fluids allowed 4 hours before surgery Assess clients understanding of procedure Provide time for client to express concerns

SKIN SHAVING: May actually increase risk of infection If required do immediately prior to surgery Avoid any scratches or skin abrasions Always shave in direction of hair growth (not against)

POSTOPERATIVE CARE
IMPLEMENTATION PACU: Maintain airways-position client on side with neck extended Monitor level of consciousness and reflexes Monitor until vital signs are stable for 30 minutes Monitor body temperature hourly Watch for paralytic ileus (absent bowel sounds)

GENERAL: Turn client every 2 hours Deep breaths to prevent atelectasis ( or incentive spirometry) Cough to remove of chest secretions (place hands over abdominal incision site to act as splint) Monitor drainage for color and amount

WOUND CARE
PRIMARY INTENTION
ASEPTIC SHARP

SECOND INTENTION
ulcers, traumatic

WOUNDS Minimal tissue damage Minimal scar formation (keloid may still form)

injuries, infected wounds intentionally left open until granulation tissue forms or until aseptic

Dry dressing: for wounds closed by primary intention Wet dressing: for open and/or infected wounds (debris and necrotic tissue are absorbed into gauzed) Occlusive dressing (petroleum gauze): around chest tubes, fistulas (to protect from air or moisture born infections)

ASSESSMENT
watch for signs of infection

IMPLEMENTATION
Dressing protects wound from mechanical injury
Pressure dressing if bleeding profusely Wet dressing with antimicrobial solution if prone

to infection Monitor drainage largest amount occurs in first 24 hours

NUTRITION & CALCULATIONS

NUTRITION Health Promotion

Use sparingly Fats, Oils and Sweets 2-3 Servings Cheese, Milk, Yogurt, Meat, Fish, Eggs, Nuts 3-4 Servings Vegetables 2-4 Servings Fruits 6-11 Servings Bread, Cereal, Pasta, Rice

SMOKING:
30% OF ALL CANCERS ARE RELATED

TO SMOKING! MORE THAN 50% OF ALL SMOKERS STARTED BEFORE AGE OF 16!
INCREASED RISK FOR: LUNG CANCER CANCER OF THE ESOPHAGUS, COLON, PANCREAS AND BLADDER

 CHRONIC OBSTRUCTIVE LUNG

DISEASE CORONARY HEART DISEASE PERIPHERAL VASCULAR DISEASE EXERCISES: HELPS TO CONTROL WEIGHT HELPS TO CONTROL BLOOD PRESSURE INCREASE HDL(GOOD CHOLESTEROL) LOWERS RISK CORONARY HEART DISEASE RECOMMEND WALKING, SWIMMING, BIKING, AND LOW-IMPACT AEROBICS.

LOW PROTEIN DIET

Indication Renal failure Liver failure To limit ammonium production Meat, eggs, milk products carbohydrates (pasta, vegetable etc.) supplement with essential amino acids

Purpose
Limit Encourage

HIGH PROTEIN DIET

Indication Undernutrition Burns Nephrotic syndrome To support protein synthesis Meat, fish, dairy, products

Purpose limit encourage

LOW-CHOLESTEROL DIET
INDICATION Purpose Limit Cardiovascular disease Diabetes mellitus To decrease risk of coronary heart disease Fried food! Egg yolk Shell fish, liver, pork Broiled or steamed food! Fruits, vegetables, chicken meat, vegetables oils

encourage

LOW- FAT DIET

Indication Malabsorption syndrome Gallbladder diseases Cystic fibrosis To lower overall fat intake Fatty meat, gravy cream, chocolate nuts Vegetables, fruits, lean meats, fish

purpose
limit encourage

DIABETIC DIET
Indication Purpose Principles Diabetes mellitus To control plasma glucose levels Each meal should contain carbohydrates, fats and protein. Avoid skipping or delaying meals. Frequent, small meals may give better glucose control. Unplanned activity add snack to avoid hypoglycemia.

BLAND DIET
Indication Purpose limit Encourage Gastric and duodenal ulcers To avoid irritation Hot spices, raw foods Milk, butter, eggs, white bread, broiled potatoes

A blend diet used to be prescribed routinely for gastric or duodenal ulcers, but since the discovery that most peptic ulcer disease is caused by the bacterium H. pylori it is treated with antibiotic and a bland diet is rarely indicated. Instead, a well balanced diet with meals at regular intervals is recommended.

LOW-SODIUM DIET
Indication Hypertension Edema due to: -congestive heart failure -liver cirrhosis -nephrotic syndrome -preeclampsia To decrease sodium

Purpose

Limit

Encourage

-canned food -salted snacks -smoked meat -ham, bacon -soy sauce Salt substitute, potassium chloride

HIGH POTASSIUM DIET

Indication -thiazide diuretics -diabetic ketoacidosis -burns -chronic vomiting -to avoid potassium depletion -bananas, prunes -avocados -soy beans

Purpose

Encourage

0THER DIETS
High fiber diet Constipation Diverticulitis May reduce risk of colon cancer Crohns disease Diverticulitis (active inflammation

Low fiber diet

Low purine diet

Uric and stones Gout

High acid ash (cranberry juice, prunes, meat)

Calcium stones

VITAMINS
SOURCES DEFICIENCY CAUSES

Liver, egg yolk, carrots Milk, sunshine

Poor night vision Growth retardation (children) Bone, deformities - children: rickets - adults: osteomalacia Deficiency is very rare

Vegetables oils

Liver, egg yolk, green leafy vegetables Citrus fruits

B1 Liver, meat

Bleeding disorders ( deficiency of coagulation factors) Scurvy (tooth loss, impaired would healing) Peripheral neuropathy (Wernicke-Korsakoff (alcoholics)

B2

Liver, meat

Inflammation of tongue and lips (glossitis and cheilosis)

Anemia neuropathy anemia

B12 Liver, meat Folic Green acid leafy vegetable

FLUIDS AND ELECTROLYTES

ACID / BASE DISORDERS

a) How to draw arterial blood gases:

Draw into heparinized syringe

Must be sterile

Discard if in contact with room air

Keep on ice, transport to lab immediately Apply pressure to puncture site for 5-10

minutes

B) How to assess Arterial Blood Gases:

- First Step: Check pH

pH < 7.35 (acidosis) pH = 7.4 (normal) pH > 7.45 (alkalosis) - Second Step: determine primary cause of disturbance In case of acidosis: - if CO2 > 40mmHg: cause is respiratory - if HCO3 < 24mmHg: cause is metabolic

In case of alkalosis: - if CO2 < 40mmHg: cause is respiratory - if HCO3 > 24 mmHg: cause is metabolic

CAUSE OF ACID / BASE DISORDERS

Clinical causes Simple hypoxia Blood pH Primary -acute disturbance respiratory distress Respiratory < 7.35 CO2 Hypoventilation: acidosis

Metabolic acidosis

< 7.35

HCO3

Respiratory > 7.45 alkalosis

CO2

- Diabetes ketoacidosis -Shock lactate - diarrhea Hyperventilation: -High altitude -anxiety

-vomiting -diuretics

Metabolic alkalosis

> 7.45

HCO3

RESPIRATORY ACIDOSIS
ASSESSMENT
Somnolence, confusion

Coma
pH < 7.35 HCO3 >26 mg/dl

IMPLEMENTATION
Monitor arterial blood gases

Maintain open airways

MEDICATIONS: Bronchodilators Antidote (if caused by drug overdose)

METABOLIC ACIDOSIS
ASSESSMENT Compensatory hyperventilation Kussmaul respiration:deep sighing pH <7.35 HCO3<22mg/dl

IMPLEMENTATION Monitor arterial blood gases Monitor K+ levels

MEDICATIONS: Sodium bicarbonate Diabetic ketoacidosis: insulin

RESPIRATORY ALKALOSIS
ASSESSMENT Light headaches, anxiety Numbness around mouth Hyperventilation pH> 7.45 HCO3 <22mg/dl

IMPLEMENTATION Monitor arterial blood gases Breathe into paper bag Oxygen if client is hypoxic

SODIUM LEVELS
Na+ levels usually reflect the bodys water content, rather than the bodys Na+ content, for example, high Na+ levels are usually due to loss of water. CAUSES:
Hypernatremia Client dehydrated
-Indicates water loss -Diarrhea, sweating renal

losses

Hypernatremia client -Indicates net Na+ gain overhydrate -Cushings syndrome -Hyperaldosteronism hyponatremia -indicates water retention -renal failure Excessive ADH production hyponatremia -sodium replaced by other solutes -hyperlipidemia -hyperglycemia (diabetes mellitus -hyperproteinemia(multiple myeloma)

SIMPLE DEHYDRATION
Water are lost in same proportion ASSESSMENT Poor skin turgor Sunken eyes Dry mucous membranes Dark urine, increased specific gravity Increased hematocrit

METABOLIC ALKALOSIS
ASSESSMENT Shallow respirations Weakness, hyporeflexia if K+ is low pH > 7.45 HCO3 > 26 mg/dl IMPLEMENTATION Monitor arterial blood gases Restore fluid volume

IMPLEMENTATION
Fluid replacement Weigh client daily Monitor intake and output Monitor urine specific gravity

OVERHYDRATION
ASSESSMENT
Increased blood pressure Increased central venous pressure Distended neck veins Pitting edema Pulmonary edema - crackles

IMPLEMENTATION
Semi Fowlers position Fluid restriction Weigh client daily Low sodium diet Diuretics as ordered

POTASSIUM LEVELS
K+ is the major cation of the intracellular fluid

Small changes in extra cellular K+

concentration are very significant!

CAUSES: Hypokalemia

-hyperaldosteronism ( Conn syndrome) Excessive production of mineral corticoids by adrenal glands

-potassium loss -Renal loss: diuretics - gastrointestinal loss: diarrhea Laxative abuse (commonly) Transcellular shift -Alkalosis -Acute glucose load -Insulin excess

Hyperkalemia -Hypoaldosteronism (Addisons disease) -Lack of mineralcorticoid production by adrenal glands -Artifact: RBC hemolysis during blood rawing -transcellular shift -Acidosis

HYPERKALEMIA
ASSESSMENT Irritability Diarrhea Cardiac arrhythmias Cardiac arrest

IMPLEMENTATION
Monitor ECG Insulin plus IV glucose to redistribute K+ Fluids to increase urinary output

HYPOKALEMIA
ASSESSMENT Muscle weakness and cramps Constipation IMPLEMENTATION Monitor ECG, especially if client is on digitalis Carefully replace potassium Never give IV bolus of potassium!

CALCIUM LEVELS
Car plays a crucial role in excitable tissues (heart,

muscles, nerves) Small changes in extracellular Ca2- concentration are very significant

CAUSES: Hypocalcemia

-chronic renal failure (high phosphate, low calcium levels) -Hypopharathyroidism -Lack of dietary Ca2and vit D

Hypercalcemia

-Cancer metastases to

bones - hyperparathyroidism -Vitamin D poisoning

Free (=effective) Ca2+depends on pH Acidosis high free Ca2+ Alkalosis low free Ca2+

HYPERCALCEMIA
ASSESSMENT Anorexia, nuasea Abdominal IMPLEMENTATION Carefully increase client mobility Avoid trauma: risk of pathological fractures Avoid large doses of vitamin D

HYPOCALCEMIA
ASSESSMENT

Tingling Numbness Hyperactive raflexes, tetany Chvostek sign, trousseau sign IMPLEMENTATION Promote regular milk intake Keep 10% Ca gluconate on hand

IV SOLUTIONS
Osmolarity: total concentration of active

solutes in a fluid Isotonic solution: solution with same osmolarity as human plasma Hypertonic solution: makes blood cells shrink Hypotonic solution: makes blood vessels expand

5% DW

10% DW
0.9% NS Lactate Ringer

TONICITY COMPOSITION Isotonic 235 mOsm/L dextrose Hypertonic 561 mOsm/L dextrose Isotonic 154mM/L Cl Isotonic 148mM/L Na 4mM/LK 4.5mM/L Ca2156 mM/L Cl

CARDIOVASCULAR DISEASES

SIGNS AND SYMPTOMS

Orthopnea Difficulty breathing in supine position Pulsus alternans Beat to beat change in pulse amplitude -indicates increased pressure in the pulmonary circulation -chronic lung disease Left heart failure - Left heart failure

Pulsus paradoxus Exaggerated decline of pulse pressure during inspiration

-cardiac tamponade Constrictive pericarditis Massive pulmonary embolism

Kussmauls sign - Constrictive Distention of jugular pericarditis veins with inspiration

HYPERTENSION
ASSESSMENT Asymptomatic ( The Silent Killer) Headache, blurred vision if greatly elevated BP BP > 140/90 mmHg Assess possible damage to kidneys

IMPLEMENTATION
DIET:
Reduce weight! Reduce salt intake to <2g/day Reduce cholesterol and saturated fats MEDICATIONS: Diuretics, B blockers, ACE inhibitors

CLIENT EDUCATION
Promote diet and lifestyle changes Teach importance of compliance with medications

EVALUATION Evaluate other risk factors of coronary heart disease

CORONARY HEART DISEASE

Risk Factors: FIXED -male sex -Family history -Older age

MODIFIABLE
-cigarette smoking High LDL -low HDL Diabetes mellitus hypertension
HDL= GOOD CHOLESTEROL

LDL=BAD CHOLESTEROL

CHOLESTEROL

TRIGLYCERIDES

TC = HDL + LDL + triglycerides TC > 240mg/dl: increased risk for CHD LDH > 160mg/dl: increased risk for CHD LDL/HDL < 4 desirable -Increased levels with age -TC > 200mg/dl: increased risk for CHD -estrogen and oral contraceptives increase triglycerides
CHD = CORONARY HEART DIS.

TC =TOTAL CHOLESTEROL

CHEST PAIN
Classic angina Substernal pain Transient (<10 min) Provoked by exercise Relieved by rest or nitrates Change in pattern(more frequent, severe or prolonged) Angina at rest or at night

Unstable angina

Variant angina

Due to coronary artery vasospasm Not provoked by exercise

Substernal pain arm, shoulder, jaw Lasts > 30 min. Not relieved by rest or nitrates Enzymes: Creatinekinase Lactate dehydrogenase

Myocardial infarction

OTHER CAUSES OF CHEST PAIN

KEY FEATURES PULMONARY -Sudden onset dyspnea/tachypnea EMBOLISM -Pleuritic chest pain -Vomiting blood indicates pulmonary infarction Pneumothorax -sudden onset sharp pain -aggravated by breathing -dull to percussion

Pleurisy

Peptic ulcer

Psychosomatic

-well localized pain -aggravated by breathing -dull to percussion -Burning gnawing pain -Lower substernal area, epigastrium -Often relieved by food or antacids -Sharp, often localized to a point -Usually of short duration

ANGINA PECTORIS
ASSESSMENT Chest pain, lasting 3-5 minutes Radiates to neck or left arm Alleviated by nitroglycerin ANALYSIS Adequate pain relief IMPLEMENTATION Monitor vital signs ECG Monitor for signs of shock Administer oxygen, nitroglycerin as ordered

CLIENT EDUCATION Promote diet and lifestyle changes NITROGLYCERIN SUBLINGUAL Protect from light moisture and heat Seek immediate help if 3 doses 5 mins. apart do not lessen pain
UNSTABLE ANGINA LAST LONGER THAN 15 MINS - INCREASES INTENSITY - OCCUR AT REST

1. 2. 3. 4.

TEACH CLIENT IMPORTANCE OF REDUCING FACTORS: Stop smoking Control blood pressure Lower lipids aggressively Control blood glucose in diabetes patients

MYOCARDIAL INFARCTION
ASSESSMENT
Crushing substernal pain Lasts > 30 mins. Not relieved by rest or nitroglycerin ECG changes : ST changes, Q waves Cardiac enzymes: - CPK-MB peaks 18-21

hours after MI - LDH peaks 48-72 hours after MI

ANALYSIS Adequate cardiac output Adequate pain relief Coping with anxiety IMPLEMENTATION Bed rest for 24-48 hours (semi-Fowlers position) Avoid straining since this increases blood pressure(stool softeners if needed) Monitor ECG, ABGs and blood pressure

Monitor complications: congestive heart failure, arrhythmias MEDICATIONS: Morphine: give IV avoid IM injections in cardiac patients Oxygen Anticoagulation
CLIENT EDUCATION Slowly increase physical activity Promote dietary and lifestyle changes

ARRHYTHMIAS
SICK SINUS MODE -sudden tachycardias / bradycardias - Normal P waves on ECG -PR interval prolonged ( > 0.2 s) - Every P followed by a QRS -occational QRS dropouts

AV BLOCK 1ST DEGREE

AV BLOCK - 3rd DEGREE

AV BLOCK 3rd DEGREE

QRS independent of P waves (ventricles beat independently from atria)

VENTRICULAR FLUTTER IS IMMEDIATELY LIFE-THREATENING!

ATRIAL FLUTTER IS MUCH LESS SERIOUS.

PEACEMAKERS
POSTOPERATIVE Continuous monitoring of ECG Monitor for signs of hemothorax (hypotension, restlessness) Monitor for signs of pneumonia( dyspnea, absent breath sounds) Monitor for lead migration --- tamponade (distended neck veins) Avoid underarm lifts when transferring patient

CLIENT EDUCATION Avoid heavy lifting Avoid difficult arm maneuvers, stretching or bending Report hiccups, palpitation or dizziness immediately Caution with electromagnetic devices: transformers, cautery, electric razors, antitheft devices. Carry ID card

ASSESSMENT: HEART FAILURE

LEFT HEART FAILURE RIGHT HEART FAILURE

SIGNS & SYMPTOMS: SIGNS & SYMPTOMS:

Dyspnea Orthopnea Non-productive cough at night Pulsus alternans

Pitting edema (Ankles) Weight gain Norturia Jugular vein distention Hematomegaly

CAUSES: -Ischemic heart disease -Arterial hypertension -Valvular disease

CONSEQUENCES: Pulmonary congestion -Dyspnea, orthopnea Renal hypoperfusion - Salt retention

CAUSES: -left sided heart failure -lung disease -pulmonary hypertension

CONSEQUENCES: Increase venous pressure -Edema -Liver congestion, ascites

CONGESTIVE HEART FAILURE

ASSESSMENT Signs of left or right heart failure ANALYSIS Adequate cardiac output Adequate tissue oxygenation

IMPLEMENTATION High Fowlers position Reduce physical activity Monitor central vein pressure Monitor body weight Auscultate lungs for crackles (fluid accumulation) Watch for deep vein thrombosis (high risk due to vascular congestion)

MEDICATIONS: Oxygen as needed Digitalis (increases heart strength) Diuretics (decreases fluid accumulation CLIENT EDUCATION DIET: Restrict salt and fluid Avoid food high in sodium Avoid potassium loss(unless potassium sparing diuretics are used)

ASSESSMENT : SHOCK
Flow of blood to peripheral tissue inadequate to sustain life

SHOCK TYPE Heart failure (cardiogenic shock)

SIGNS AND CAUSES Cool, pale skin Distended neck veins - myocardial infarction -Cardiomyopathy -Arrhythmias

BLOOD LOSS (hypovolemic shock)

SEPSIS (septic shock)

ANAPHYLAXIS (allergic shock)

Cool, pale skin Collapsed neck veins -Hemorrhage -Addisons crisis Warm, dry skin Edema despite hypovolemia - Gram negative bacteria endotoxins Pruritus urticaria Respiratory distress -Immune reaction -(type IV mediated by IgE antibodies

HYPOVOLEMIC SHOCK
CAUSES: Hemorrhage (internal or external bleeding) Fluid loss from wounds especially in burns patients) neurogenic: Vasodilation --- reduced cardiac filling

ASSESSMENT Confusion, restlessness Drop in blood pressure Rapid, weak pulse Pale, cold, sweaty skin Low purine output ANALYSIS Adequate issue perfusion? Risk of renal and pulmonary damage

IMPLEMENTATION Supine position, legs elevated Maintain open airways, IV access Rapid volume restoration (blood; colloids) Monitor vital signs Monitor ABG Monitor urinary output: Notify physician if < 30 mL/h

MEDICATIONS: Vasoactive drugs to maintain perfusion pressure (dopamine, epinephrine) Oxygen as needed

PERICARDITIS
Infection Often preceded by cold Viruses - Uremia (kidney failure) - Myxedemia (hypothyroid)

metabolic

ASSESSMENT Mild or sharp pain over sternum Pericardial friction rub on auscultation Increased venous pressure --constrictive pericarditis
ANALYSIS Adequate pain relief? Adequate cardiac output

IMPLEMENTATION Leaning forward may alleviate pain Monitor vital signs Check for signs of cardiac tamponade MEDICATIONS: Salicylates, corticosteriods antibiotics

CARDIAC TAMPONADE
ACCUMULATION OF FLUID IN PERICARDIAL SPACE

ASSESSMENT

Dyspnea Cyanosis Falling blood pressure shock Increased CVP distended neck veins Pulsus paradoxus

IMPLEMENTATION

Assist with emergency thoracotomy

MYOCARDITIS
ASSESSMENT

Fatigue Dyspnea ECG changes ANALYSIS Risk of congestive heart failure ---- decreased cardiac output

IMPLEMENTATION Strict bed rest Monitor vital signs Listen for lung rales and crackles Auscultate for heart mumurs
MEDICATIONS: Diuretics for congestive heart failure

RHEUMATIC HEART DISEASE

ACUTE RHEUMATIC FEVER -occurs 1- 4 wks after tonsillitis streptococcal infection Affects children 5 15 years RHEUMATIC HEART DISEASE -occurs many years after rheumatic fever -involves mitral valve>aortic valve Manifests itself in adults

Polvarthritis Carditis -pericarditis -endocarditis Erythema Subcutaneous nodules

early: often asymptomatic Late: congestive heart failure

ASSESSMENT
History of rheumatic fever Malaise fever

PLANNING
Increase comfort and rest

IMPLEMENTATION
Monitor vital signs Antibiotics, digitalis, diuretics as prescribed

ANTIBIOTIC PROPHYLAXIS: Penicillin every 4 weeks IM (for 5-10 years after acute episode) Continue indefinitely if risk of infection is high

ENDOCARDITIS
ASSESSMENT
History of sore throats, dental procedures,

rheumatic fever Malaise, weakness Night sweats, chills Sub acute endocarditis: low fever Acute inefective endocarditis: high fever Heart murmurs

IMPLEMENTATION Antibiotics Monitor for heart failure and arterial embolization CLIENT EDUCATION PROPHYLACTIC ANTIBIOTICS NEEDED FOR: Dental procedures if bleeding likely GI surgery Urinary track surgery Prostate surgery

BLOOD VESSELS
Artriosclerosis -calcification and narrowing of blood vessels - claudication: insufficient blood supply to leg muscles - > pain in calf when walking quickly relieved by rest Arterial Atrial fibrillation-> risk of embolism thromboembolia Sudden onset Painful Absent pulse

Raynauds phenomenon

Vasospasm of finger arteries Cyanosis followed by hyperemia (white bluered) Precipitated by cold or emotional upset CAUSES: -Cold antibodies -Connective tissue diseases -Neurologic disorders Thrombophlebitis Usually painful (inflammation of veins)

Plebothrombosis

Often asymptomatic High risk of lung embolism

ARTERIOSCLEROSIS
ASSESSMENT Heart: coronary heart disease Brain: dementia, TIA, stroke (from dislodged thrombi) Kidneys: renal artery stenosis-renal failure Legs: cold, pale, intermittent claudication

CLIENT EDUCATION Stop smoking If diabetic: tight control of blood glucose!!!

RAYNAUDS DISEASE
ASSESSMENT Cold, numb hands Ulceration and gangrene of finger tips IMPLEMENTATION Avoid exposure to cold (gloves, boots) Avoid any injury to hands Avoid smoking MEDICATIONS: Analgesics vasodilators

ANEURYSMS
- Weakened arterial wall local distention risk rupture.

KEY FEATURES

ATHEOSCLEROTIC

-Mainly abdominal

aorta -a/w Hypertension SYPHILITIC -mainly ascending aorta Positive lab test for syphilis (VDRL)

DISSECTING

-aorta (ascending or descending) -a/w hypertension

BERRY

-intracranial arteries - congenital

ASSESSMENT
Often asymptomatic Abdominal aneurysm: Pulsating mass Dissecting aneurysm: Sudden tearing pain

IMPLEMENTATION
Monitor vital signs Monitor for signs of shock Type and cross-match blood

PHLEBOTHROMBOSIS
Risk factors-endothelial injury, slow blood flow, abnormal clotting Trousseaus sign- venous thrombosis, often a/w neoplasms ASSESSMENT Deep vein thrombosis is often asymptomatic Leg pain and swelling

Superficial thrombophlebitis: warm, red and painful

Deep vein thrombosis: Homans sign (pain upon dorsiflexion of foot) IMPLEMENTATION ACUTE DVT: Bed rest to prevent dislodging thrombus Elevate limb to reduce swelling Measure calf and thigh circumference daily

Anticoagulants and analgesics as ordered COMPLICATIONS Watch for signs of pulmonary embolism (sudden chest pain, dyspnea) Watch for bleeding tendency due to anticoagulation CLIENT EDUCATION Use compression stockings to prevent DVT (but not during acute DVT)