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128 Cards in this Set
- Front
- Back
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What is increased intracranial pressure?
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► The pressure of the subarachnoidal fluid that is in the space between the skull & brain
► Caused by any disruption of cerebral circulation |
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What is the complication of IICP?
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► Herniation of the brain stem then death
• Can also be caused by a concussion |
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What can increase intracranial pressure?
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► CVA
► Aneurysm |
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What are the assessments for IICP?
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► Level of wakefulness {lethargic, drowsy, stuporous then coma} {Early Sign}
► Changes in behavior – mental acuity, confusion, purposeless movement, how much sense is the patient making {Early Sign} ► Changes in Vitals {late sign} temp will increase, pulse & resp will decrease, periods of apnea, widening BP, Cheynes Stokes {hyperventilation & hypoventilation}, Kussmaul’s hyperventilation; increase in BP is to oxygenate the brain ► Headache – unrelenting constant with increasing intensity and movement makes it worse ► Projectile vomiting without nausea ► Glascow Coma Scale is a neurological assessment based on eye opening, motor response & verbal response • The least score is a 3 for unresponsiveness • The greatest score is a 15 for consciousness ► Neurological assessment {PERRLA, extremity movement or strength – have the person push or pull, vital signs} |
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What is a Cerebral Vascular Disease?
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► Functional abnormality caused by interruption of oxygen to the brain
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What is the most common cause of Cerebral Vascular Disease?
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► Arteriosclerosis {thickening of the walls without plaque} of the internal carotids
• This can lead to a TIA or a CVA If carotids are clogged it is also elsewhere. |
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What is the etiology of a CVA?
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Age Anti-Coagulant Treatments
HTN Smoking Cardiac Disease Dysrhythmias – causes release of blood clots Diabetes Obesity High Cholesterol Oral contraceptives TIA Family History Drug Abuse Stress |
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What is Transient Ischemic Attack?
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► Neurological dysfunction that can last a few seconds to 24 hours – atherosclerosis
► A sudden temporary loss of motor, sensory and visual awareness ► Precursor to a CVA – Stroke |
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How do you assess a TIA?
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► With a Doppler on the carotids or ausculating the carotids for bruit
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What is the medical management of a TIA?
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► Surgery
• Carotid Endarterectomy – to break and suction plaque or thrombus • Bypass grafting – to increase collateral blood supply ► Non-Surgical – works on platelets • Coumadin, Aspirin – prevents other blood clots • Persantine {dipyridamole} – vasodilator and decreases platelet formation 400-800mg/d {causes headaches, increase reaction to anti-coagulation or dizziness} • Ticlid – given to patients who cannot take aspirin 250mg bid o S.E. are Neutropena, thrombocytopena and increased bleeding time & must be given with food Must discontinue NSAIDs, Aspirin & Antiplatelets Medications @ least two weeks before surgery |
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What is a Cerebral Vascular Accident?
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► Sudden loss of brain function due to disruption in oxygen supply to the brain
► Results in temporary/permanent loss of movement, thought or memory, speech and sensation ► Lasts greater than 24 hours |
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What is the pathophysiology of a CVA?
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► Is a decrease in oxygen in blood flow
► Infracted {necrosis} become edematous {swollen} may lead to displacement of the brain then death |
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How are CVAs classified?
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► Ischemia or hemorrhagic – long term HTN, aneurysm or trauma
• Caused by thrombosis, embolism or decreased blood flow from an arteriosclerosis ► Cerebral Thrombosis – onset is slow; affects one side • Usually happens during or after sleep {everything slows down} ► Cerebral Embolism – sudden with or without LOC • Clot travels to brain from left side of heart or lungs |
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What are the clinical manifestations/assessment of CVAs?
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► CT scan to rule out cerebral hemorrhage
► MRI no good if blood in brain stem ► Assess to motor function, communication ability, perceptual disturbances, bowel & bladder impairment and mental ability ► Motor Loss – flaccid paralysis or decrease Deep Tendon Reflexes returns within 48 hours |
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What are the clinical manifestations/assessment of CVAs? {cont’d}
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► Greatest return is within 4-8 weeks {legs come back 1st, arms last}
► Communication – aphasia may develop {more common with Left CVA} • Perception, discriminates between pain, touch, temperature, size, shape and awareness of space – parietal • Expressive, learning, memory and motor function – frontal • Receptive, hearing memory – temporal • Global is a combination ► Perceptual Disturbances • Visual field loss – the loss of half the visual field {homonymous hemianopsia} change in perception ► Spatial-Perceptual Alterations • Erroneous perception is parietal – brain doesn’t recognize CVA • Proprioception – self & space; ends up with neglect on the affected sides • Agnosia – inability to recognize, sight, touch or sense use • Apraxia – can’t do sequential movements ► Bowel Impairment ► Bladder Impairment – bladder filling but no urge, or loss of sphincter control or both {Catheter} ► Mental ability – emotional lability, depression, chemical imbalance that does not work with meds |
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What should the nurse avoid doing?
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► Avoid extreme – hip flexion it increases abdominal, thoracic & brain pressure
► Neck flexion because it decreases blood flow in carotids & adequate drainage ► Use high-top sneakers – should not use a foot board ► Avoid isometric exercises the increase intra cranial pressure/intra-thoracic pressure ► Do not use a hand grasp to prevent contractures may increase ICP use a hand brace |
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What is the medical management of a CVA?
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► Pharmacological agents
• Coumadin – anticoag • Heparin – anticoag • Aspirin – works on platelets • Persantine – works on platelets • Nimotop – subarachnoid hemorrhaging – calcium blocker – decreases vasospasm; works with in 96 hours 60mg • Mannitol – osmotic diuretic get kidney to rid the fluids; works in 20 minutes; will cup with blood must be hung separately – used to relieve pressure immediately • Decadron – reduces edema; steroid, causes diaphoresis; can be given by bolas or po • Thrombolytic agents – works directly on the clot; side effect is bleeding o t-PA – hopes to salvage necrotic areas; check for acute ischemic CBA must be given within 3 hours of attack o Anchrod – stimulates endogenous t-PA |
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What is the nursing care in the acute phase?
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► Bedrest for 24-48 hours {72 hours usually stable}
► Thrombolytic CVA, HOB should be 0-30 degrees ► Do not suction patient it increases ICP ► Oxygen/Mechanical Vent ► Hydration to reduce viscosity; I & O ► ABGs ► BP to adequately perfuse the brain ► Assess cardiac abnormalities & do Neurological assessment |
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What are the nursing diagnosis categories?
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► Altered Tissue Perfusion
► Impaired Verbal Communication ► Altered Nutrition: Less than Body Requirements ► Impaired Physical Mobility |
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What is needed for a successful rehabilitation?
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► Must start rehab within 4-8 weeks
► Motivation ► Individual care plan ► Understand instructions |
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What are the goals for rehabilitation?
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► Improved mobility
► Improved self-concept and self-care ► Improved cognitive function ► Bowel & Bladder continence ► Improved physical function ► Work on the affect side to compensation • Keep clock, bell on the unaffected side |
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What are brain tumors?
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► Gliomas – usually infiltrative and often cannot be totally removed by surgery
• Astrocytomas – most common gliomas • Glioblastoma multiform – highly malignant • Meningiomas – can invade the skull and cause brain tissue compression ► If encapsulated – self-contained the prognosis is good |
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What is the post-op care for a craniotomy patient?
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► Assess for increased ICP
► Take vital signs ► Temperature should be ~100-101º; if it goes above 102º during the first 72 hours, the MD should be notified immediately ► Glasgow coma scale ► Know the patient’s baseline level of consciousness: • Before surgery • Directly after surgery ► Periorbital edema will be at its maximum at 48-72 hours after surgery ► Edema inside the brain will be at its maximum 48 hours after surgery – so – expect a slight decrease in level of consciousness on day 2 post-op |
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What are the sensory/motor alterations for the specific areas of the brain?
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Frontal Personality, behavior, emotions, speech, sphincter control, weakness or paralysis
Parietal Visual deficit, sensory disturbance, impaired sense & perception Temporal Auditory changes, visual field deficit, sensory aphasia, impaired memory, personality changes, psychomotor seizures Occipital Seizures, visual agnosia, visual field deficit Cerebellar Tremors, nystagmus, incoordination, loss of balance, gait disturbances, nuchal headache Brain Stem Cranial nerve palsies, Midbrain-3-4; Pons 5-8, Medulla 9-12 |
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What should the nurse look for when doing a cardiac assessment?
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► Signs & symptoms of the health issue
► Signs & symptoms of improvement or decompensation ► Patterns |
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What is the assessment for heart function & output?
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► Pulses {this will fluctuate will the body compensates for a drop in output}
• Check apical {rate & rhythm} • Peripheral pulses {present/absent, bounding/weak, etc.} • Pulse deficit – difference between apical & radial {use 2 nurses} o Dysrhythmias & severe tachycardias may be a cause ► BP – drop from changing positions = Orthostatic Hypotension ► Pulse Pressure – difference between Systolic & Diastolic ► Heart Sounds – S1 & S2, describe any other sounds {systolic or diastolic} ► Pulse Oximetry |
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How does the nurse assess cardiac output?
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► Level of consciousness {brain}
► Intake & Output {kidneys} ► Patent vessels {chest pain} ► Pallor, Diaphoresis, Turgor or Edema {skin} ► Crackles @ base indicative of heart failure {lungs} ► Chest Pain |
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What happens when the client begins to improve?
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► The focus shifts from short to long-term
• Risk factors {modifiable and unmodifiable} • Support system – coping style • Medical history {Diabetes, Rheumatic fever, HTN} • Functional limitations {ADL, socializing, pursing a career} • Medications {prescribed, over-the-counter – very important to ask and herbal remedies • Alternative therapies used |
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What are the diagnostic Tests?
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► CBC, Sed Rate, PT/INR/PTT, BUN, Glucose, Electrolytes
► Cholesterol & lipid profile {total cholesterol, LDL and HDL, Triglycerides} ► Cardiac Enzymes {CK-MB, CK, LDH & Treponin} Elevated in Heart Failure & cardiac muscle pathology – cardiomyopathies ► 12-Lead ECG & EKG ► Echocardiogram – tells of the structure, emptying capability – ejection fraction ► Transesophageal Echocardiogram – must check for gag reflex ► Cardiac MRI |
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Diagnostic Tests Continued
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► Stress test {non-invasive still need consent}
• Pharmacological if patient is unable to exercise {Persantine} ► Radionuclide Scan • Thallium Scan • MUGA • Pet Scan ► Cardiac Catheterization • Looks for blockage • Determines the best care for the heart • Vasovagal reaction – give atropine • Assess for occult blood at arterial puncture site ► Electrophysiology test – gives the site of origin for the dysrhythmia & what type of treatment; looks at conduction • No radiopaque or angioplasty |
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What should the nurse do after a cardiac catherization?
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► Monitor patient during post-procedure for:
• Hematoma • Internal bleeding • Inadequate peripheral perfusion {peripheral pulses, color, movement, temperature & sensation} • Hypotension • Dysrhythmias • Closure of the vessel ► Take vitals q15 minutes until stable ► Assist with activity ► Facilitate rest & family visits ► Report any complaints of chest pain to Dr. immediately ► Administer & monitor anticoagulants ► Ensure a patent arterial line |
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What are the signs & symptoms for Vasovagal?
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► Bradycardia
► Hypotension ► Nausea & Diaphoresis |
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What is the nursing management of a patient experiencing the vasovagal response?
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► Explain the procedure before the line is removed
► Administer analgesics ► Reassure patient ► Administer atropine & notify doctor |
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What should the nurse do for occult bleeding?
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► Apply pressure for more than 10 minutes
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What is the nursing management for patients with line removal?
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► Vital signs & the extremity used for the catheter
► Patient can resume activity within 6 hours |
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What is the general care for patients with cardiac health problems?
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► Decreased cardiac output
► Pain (acute) ► Fluid volume excess ► Knowledge deficit ► Activity intolerance ► Risk for injury ► Psychosocial {anxiety, coping, ineffective therapeutic management, care giver role strain} ► Self care deficit |
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What are the different Classes/Categories of Medications?
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► Beta blockers {…lol}
► Sympathomimetics {dobutamine} ► Angio Converting Enzyme Inhibitors {…pril} ► Diuretics {loop} ► Central acting sympatholytics {clonidine} ► Peripheral acting alpha-adrenergic blockers {prazosin} ► Cardiac glycosides {digoxin} ► Calcium channel blockers {verapamil, diltiazam, nifedipine, nicardipene} ► Nitrates {nitro…} ► Anticholinergics {atropine} ► Anticoagulants {coumadin, heparin…} ► Antiplatelets {ASA, NSAIDs, Persantine – vasodilator, Ticlid} ► Thrombolytics {tPA, …ase} ► Antiarrhythmics ► Antihyperlipidemia {…tin, cholestrymine} |
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What is Mitral Valve Prolapse?
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► When the mitral valve bulges back into the left atrium
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What are the signs & symptoms of Mitral Valve Prolapse?
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► Palpitations {PAC, paroxysmal tachycardia}
► Chest pains without ischemia – will not need nitroglycerin ► Anxiety – must manage lifestyle better ► Heart failure – will not occur if being followed by doctor |
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What is the treatment for Mitral Valve Prolapse?
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► Give antibiotics prophylactically before dental work, etc.
► Usually medications • Antiarhythmic medications – propanlol • Antianxiety medications ► Sign & symptoms are not related to the bulging valve ► Valve replacement only if severe |
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What should the nurse assess?
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► Pain
► Palpitations – when does it happen ► Stress ► Fatigue ► Coping/Family Issues |
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What are the interventions for Mitral Valve Prolapse?
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► Echocardiogram
► ECG ► Catheter – check for pressure changes before surgery |
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What is Mitral Stenosis?
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► Thickening of the cusps and the narrowing of the valve opening
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What is the pathophysiology of mitral stenosis?
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► Left atrium dilates leading to pulmonary congestion {SOB} the right ventricle must work harder leading to hypertrophy and heart failure {Left Ventricle no major impact}
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What is the sign & symptom for mitral stenosis?
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► Respiratory symptoms: Progressive Dyspnea on Exertion, high risk for frequent respiratory infections, atrial fibrillation
► Hemoptysis – not life threatening ► Hoarseness – atrium pressing on the larynx ► Dysphagia ► Pinched looking face ► Malar flush – flush over cheekbones |
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What is mitral insufficiency/regurgitation?
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► The inability for the valves to close properly
► Blood leaks back into the left atrium during systole; there is increased pressure in the Left atrium |
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When is mitral insufficiency an emergency?
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► If it occurs as a result of a ruptured chordae tendonae or after an acute myocardial infarction
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What is the sign & symptom for mitral insufficiency?
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► Fatigue, SOB, dysrhythmia
► Cachetic/Emaciated – if chronic ► High risk for pulmonary infections ► Heart failure is caused from fluid build up |
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What is the nursing care for the clients who have mitral stenosis & insufficiency?
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► Assess lungs & heart
► Teach • Sign & symptoms • How to avoid respiratory infections {flu-shots} |
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What is Aortic Stenosis?
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► It is progressive
► Narrowing of the valve opening ► Decrease in cardiac output ► Can lead to heart failure as the left ventricle hypertrophies from being overworked |
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What is the sign & symptom for aortic stenosis?
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► Bounding pulse – caused by the force of contraction of the heart
► Fatigue & Debilitation ► Thrill at the base of the heart ► Harsh murmur ► Syncope – less blood flow to the brain ► Myocardial ischemia – less perfusion to the coronary arteries |
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What is Aortic Insufficiency?
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► Blood regurgitates back into the left ventricles
► Left ventricles fails due to exhaustion |
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What is the sign & symptom for Aortic Insufficiency?
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► Water hammer pulse – quicker fall off in diastole
► Widened pulse pressure due to low diastole ► Fatigue, Dyspnea, Angina, Prone to Ventricular Dysrhythmias |
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What is the nursing care for the clients who have aortic stenosis & insufficiency?
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► Pulse and mental status
► Teaching • Sign & symptoms • How to avoid respiratory infections {flu-shots} |
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What are the commonalities with Mitral Stenosis, Mitral Ins., Aortic Stenosis & Aortic Ins.?
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Big chart! P12
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What is the difference between Rheumatic & Infective Endocarditis?
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► Rheumatic – is a response from the toxins from the organism
► Infective – is a direct invasion of the heart valves by bacteria, fungi, rickettsia or streptococcus viridans |
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What diagnostic tests would be ordered for a client with Endocarditis?
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► Blood cultures
► ECG & echocardiogram to determine the extent of valvular damage |
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What specific observations of the integument & mucous membranes would you include in assessing for a client with infective endocarditis?
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► Nail beds for splinter hemorrhages
► Conjunctiva & Mucous membranes for petechiae |
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Would it be urgent to report these positive findings?
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► No, these are expected findings
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What is the Nursing Diagnosis Categories that would apply to the client with Endocarditis?
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► Activity Intolerance
► High risk or actual fluid overload ► Decreased cardiac output |
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What are the signs & symptoms of Endocarditis?
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► Flu-like – mild
► Dysrhythmias ► Severe • Temperatures 102-104 • Chills • Diaphoresis • Petechiae • Clubbing |
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What would be the lab values?
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► Increased WBCs
► Increase ESR – Sed Rate ► Decrease RBC – clubbing ► Decrease Platelets – petechiae |
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A client with Endocarditis is at risk for fluid overload, what specific nursing responsibilities are associated with these facts?
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► Consult with Dr & Pharmacist regarding fluid reduction
► Calculate the total 24 hour fluid intake {PO, IV & IVPB} |
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What are the assessments for identifying an embolus from the left heart valves?
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► Brain – assess mental status for signs & symptoms for a CVA
► Kidney – assess for hematuria, decreasing urinary output ► Spleen – assess left upper quadrant pain ► Coronary arteries – assess for angina |
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What is the assessment for identifying an embolus from the right heart valves?
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► Pulmonary embolus
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Which of the findings should be reported for left & right valves?
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► Any positive findings
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What teaching must be included about antibiotics in general, for the client who has infective endocarditis?
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► The importance of completing the regimen
► Possible side effects of long-term antibiotics – esp. diarrhea & vaginitis ► Treatment 4-6 weeks ► Report side effects – do not stop taking meds ► Eat yogurt to reduce the incidence of super infections ► Teach the side effects of the antibiotics |
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What specific nursing interventions would be associated with the administration of Amphotericin B IVPB for a fungal endocarditis?
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► Assess sodium levels – to keep balance & decrease adverse effects
► Anticipate pre-medication with ASA, steroids, or antihistamines to decrease adverse effects ► Monitor pulse, BP q15-30 minutes with initial therapy ► Monitor closely during the 1st 2hours of each dose for fever, chills, headache, N/V ► Monitor I&O carefully – provide 2-3L of hydration if not contraindicated ► Explain that the adverse effects will subside within 4 hours after infusion |
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A client is taking Cipro IV and Theophylline PO. Based on your knowledge of drug interactions, what would you discuss with the doctor?
► Discuss theophylline levels |
► Discuss theophylline levels
► Rationale: cipro is a fluoro-quinolone antibiotic this class of drug increase the risk of toxicity and concentration of Theophylline. ► Instruct the client to recognize the signs & symptoms of Theophylline toxicity |
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What should be included in teaching to prevent future episodes of infective endocarditis?
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► Explain the risks associated with invasive procedures
► Instruct client to inform all MD & dentists that he/she is high risk for endocarditis ► Discuss prophylaxis with MD |
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What would the nurse teach a client with infective endocarditis who is discharged from the hospital after 5 days & is receiving antibiotic therapy at home?
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► Assess knowledge for activity restriction
► Assess client’s preference for quiet diversional activities ► Assess client’s daily routine for ADL and Antibiotic therapy ► Assess whether or not client has O2 at home & teach safety measures with O2 ► Teach reasons for activity restrictions and the need for rest even though the client might feel better ► Assist the client to make a specific plan for spacing activities to avoid fatigue |
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What is Coronary Artery Disease?
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► Begins with cellular injury to the endothelium, fat & fibrin are deposited at the injured site and hardening happens in the artery, if erosion occurs bleeding and thrombus can happen
► Decrease blood flow to the coronary arteries leading to ischemia ► Symptoms occur during exercise or other activities that increase heart rate |
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What can occur in the continuum of CAD?
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► No symptoms, angina, unstable angina, Acute Coronary Syndrome, AMI
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What are the modifiable risk factors for CAD?
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► Cholesterol
► Diabetes ► HTN – uncontrolled ► Smoking ► Obesity ► Physical Activity ► Lack of Estrogen ► Stress – constant stimulation of the sympathetic ► Contraception |
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What are the unmodifiable risk factors for CAD?
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► Family history
► Age ► Gender ► Race & Hereditary |
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What is angina?
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► Chest pain associated with myocardial ischemia
► Onset occurs with increase cardiac work ► Relieved by rest & nitroglycerin |
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What are some triggers for Angina out of the hospital?
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► Exertion – after a large meal
► Emotion – fear, anger ► Eating ► Cold ► Sexual intercourse – with unfamiliar partner or when tired |
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What are some triggers for Angina in the hospital?
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► Anxiety
► Acute blood loss ► Severe anemia ► Pain |
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What are the different types of Angina?
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► Careful assessment is necessary
► Stable – may be described as pressure; predictable onset, same severity, same thing relieves it; no hospitalization ► Unstable – more frequent, unpredictable, more severe, last longer; pre-infarction; may require hospitalization ► Equivalent – pain in shoulder, jaw, ear, teeth, feeling with indigestion or need to burp ► Clients must be able to learn to recognize “their” angina ► Printzmetal’s – no relationship with activity, may occur at rest, or at night; caused by spasms |
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What are the diagnostic tests for Angina?
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► ECG
• Changes to ST with ischemia • Changes to Q wave • Changes to QRS with Acute Myocardial Infarction ► Patient history – description of chest pain ► Pharmacological/Exercise Stress Test ► Echocardiogram ► Nuclear Scan – Thallium or Cardiolite ► Invasive – catheterization, coronary artery angiography • Measures ejection fraction {low reading is evidence of heart failure} ► Labs – CBC, Electrolytes, Lipid Profile, Cardiac Enzymes – CK-MB, CK & Trepanin |
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What is the treatment?
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► Conservative – lifestyle change, blood pressure control & medications
► Meds – Beta blockers, calcium channel blockers, Antilipids, ACE inhibitors, Antiplatelets {persantine, ASA} ► Need oxygen |
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What is the treatment in the hospital?
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► Rest
► Oxygen 2-4L via nasal cannula |
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What is the treatment at home?
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► Life style adjustment
► Medications ► Possibly cardiac rehab ► Observe closely for sign & symptoms of heart failure |
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What is the need for oxygen caused by?
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► Increase cardiac rate
► Increase contractibility ► Increase in pre-load – blood volume, increase in after-load – BP |
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Med for Angina
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p17
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What is acute Myocardial Infarction?
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► Necrosis of myocardial tissue due to prolonged severe decrease in blood flow
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What are the signs & symptoms for AMI?
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► Differences in gender & racial experience of pain
► Severe, crushing substernal chest pain ► Diaphoresis, feeling of dread – fear ► Nausea ► Pain unrelieved by rest or nitroglycerin |
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What is the pathophysiology of AMI?
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► 90% from a thrombus & 10% from spasms
► infracted area is surrounded by area of injury, where the pain comes from, which can be saved from going on to become infracted by using • Thrombolytic therapy • Beta Blockers • Calcium Blockers |
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How is an infarction diagnosed?
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► On the basis of an ECG
• Anterior & Anterolateral = ventricles=pumping problems – cardiac shock • Inferior & Posterior = coronary=AV block, Edema |
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What is the healing process for AMI?
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► Inflammation process occurs within 2-3 days {increase WBC, ESR, Temp-low grade}
► Most dangerous time for healing is 1st 4-5 days – clients will be in CCU • Cardiogenic shock • Dysrhythmias |
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What are the diagnostic tests for AMI?
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► Clinical picture – emergency room
► ECG – elevation in ST & Q waves ► 3 day pattern is necessary to make a definitive diagnosis & determine the area affected • Anterior surface – left anterior descending – high risk for shock and heart failure • Inferior surface – right coronary – high risk for bradycardia & AV Block ► Cardiac enzymes – • CK-MB & Trepanin elevated in 2-4 hours • CK is elevated 3-6 hours; can elevate if given a IM injection • LDH is elevated in 48-72 hours |
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What is the Immediate Treatment?
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► Pain relief {NTG, Morphine}
► Oxygen ► Anti-platelet therapy (ASA) ► Thrombolytic if applicable |
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What is thrombolytic therapy in CAD?
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► Best is if begun within the first few hours
► Dissolves the clot; must be soon ► Need a history of MI ► Pain began < 12 hours before admission ► Classic early ECG sign ► No symptoms of Cardiogenic shock ► No history of CVA ► No surgery or trauma in 6 months – healing needs clot ► No uncontrolled HTN – risk for a stroke ► It is given IV in ER or Intracoronary in Cardiac Lab – most common ► It is given also with Heparin & Nitroglycerin & is continued for 3-4 days; Oral coumadin & ASA |
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What is the expected outcome for AMI?
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► Pain is gone in 30-60 minutes
► ST segment falls ► Mortality is decreased by 50% |
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What is the nursing care post-thrombolytic?
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► Observe for bleeding GI, GU, Cerebral & Site
• Keep injections to a minimum, no rectal temps; risk for bleeding depends on agent used ► ECG – reperfusion dysrhythmias can occur – ventricular pc & tachycardia ► Observe for Angina – re-occlusion occurs in 20-30% of clients; tells the extent of a new one |
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What are the complications of Myocardial Infarction?
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► Dysrhythmias {PVC}
► CHF ► Cardiogenic Shock ► Less Common: Thombo-emboli, pericarditis – usually occurs after surgery |
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What is the common nursing diagnosis for AMI?
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► Pain related to ischemia
► High risk for decrease cardiac output ► Anxiety related to fear of death ► Knowledge deficit |
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What is the CCU care?
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► Assess for angina
► Bed rest & complete care except feeding; diet decrease in fat & sodium ► Valsalva maneuver & turning in bed increases heart rate ► ROM exercises especially for legs & foot {isometric exercises} |
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What is cardiac rehab?
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► Phase I – occurs in the hospital; want to maintain levels
• OOB in chair • Walk in the room • Walk in the hall • Teach – disease management and medications ► Phase II – Client is self management {formal rehab} • 4-6 weeks walking is recommended {gradually increase activity & gradually resume normal activity} • Explore alternative ways of achieving intimacy • Teach – risk factor reduction; sexual activity obtain physician guidance – guidelines if you can walk 2-3 flights of stairs without fatigue or angina is okay ► Phase III – Maintenance • Client is expected to continue rehab |
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What is the outcomes/prognosis for AMI?
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► All client is at risk for a 2nd MI
► Less fatal if client is on ASA ► Men do well ► Women start back to their multiple roles to soon & become depressed ► Women have less positive outcomes than men since the usually have MIs later in life |
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What is the nurse’s role for balloon angioplasty procedures?
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► Same as percutaneous procedure except explaining what will be done during the procedure
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What is the pre-surgery procedure?
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► Infuse antiplatelet {ReoPro}
► Groin line or cannula will be left in for several hours |
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What should the nurse do when the line is being removed?
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► Patient may be anxious explain procedure
► Anticoagulant will be discontinued ► Apply pressure for 20-30 minutes ► Pressure dressing ► May cause bradycardia, hypotension ► Must monitor every 15 minutes for 1 hour |
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What should the nurse be assessing for Post-Op?
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► Client will receive antiplatelet medication IV {Reo-Pro, heparin, ASA}
► Bleeding ► Hypotension ► Closure of the coronary artery {will see signs of myocardial ischemia} ► Dysrhythmias ► Assess inadequate perfusion ► Assess for chest pain |
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What will be the discharge & home care teaching?
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► NTG
► Antiplatelets {ASA, Ticlid, Plavix, Persantine} ► Antihypertensives/Antianginals {beta’s, calcium blockers, ace inhibitors – will have metallic taste} ► Cardiotonics/Diuretics {Digoxin, Lasix} used in heart failure ► Report signs & symptoms to MD ► Care for percutaneous site ► Disease process and life style modification ► Glucose control, if diabetic ► Life style changes to reduce risk factors ► Sexual counseling |
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What is the pre-op nursing care for a thoracotomy?
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► Usual pre-op work-up and consent
► Emphasize pulmonary hygiene – deep coughing and incentive spirometer ► Give information on length of stay and activity |
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What is the post-op ICU nursing care for a thoracotomy?
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► Explain the progression {extubation, foley out, OOB to chair & activity, chest tubes out, pacemaker wires, arterial line & Swan Gantz}
► Assess chest tube drainage {>200 ml in 4-6 hours okay} ► Assess urinary output {<30 ml per hour is a problem} ► NTG – angina; {store out of light and in a glass dark bottle} epinephrine, dobutamine & dopamine are used to increase cardiac contractibility |
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What are the major complications of Cardiac Surgery?
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► Bleeding – may lead to cardiac tampanade – pressure from the pericardium; check chest tubes, Hgb, Hct closely
► Atelectasis – deep breathe & incentive spirometer to prevent ► Decreased cardiac output – look for wheezing, crackles ► Dysrhythmias – atrial, PVCs, Ventricular tachycardia ► Pain |
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What will be the exercises the client will do post-op?
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► OOB day 1
► Walk in cubicle day 1-2 ► Transfer to step down day 2-3 ► Exercises will be to strengthen, gait & balance and chest PT if necessary |
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What are some teaching for the client?
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► May feel a clicking sensation when moving & bump on sternum {okay}
► May have a memory deficit, handwriting changes, caused by a mini emboli |
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What are the differences of CABG vs. Valvular Surgery?
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CABG Valvular
Uses saphenous vein – can lead to edema after discharge Uses internal mammary artery – greater pain for a longer duration Uses a mechanical valve Healing is slow High risk for edema Tell patient to elevate legs then walk Tell patient to do daily weights Infection Lifelong anticoagulant therapy is need for tissue grafts Xenografts/heterografts – short term anticoagulant therapy {good for young, childbearing age women} Must check PTT or INR |
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What is surgery with intractable heart failure?
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► Cardiac transplant
► Similar to thoracotomy ► Longer length of stay ► Observe & teach for rejection ► Increase risk for infection {immunosuppressed – give steroids & cephasporins} ► Exercise ► Observe for failure |
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What are the signs & symptoms of failure?
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► Fever & malaise
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What are the tests that are done?
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► Biopsy
► Blood test |
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What is heart failure?
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► Major complication for people with cardiovascular health problem
► Anemia ► HTN ► CAD – most common ► Valvular Disease ► Endocarditis ► Anything that affects the myocardium – surgery ► Dysrhythmias |
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What are the hallmark signs of heart failure?
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► Fluid overload
► Inadequate tissue perfusion |
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What are the most common preventable causes of readmission to the hospital?
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► Lack of compliance diet/medication
► Lack of compliance with medical follow up ► Unable to recognize early symptoms ► Worsening degree of heart failure |
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What are the basic concepts to heart failure?
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► Heart is pumping ineffectively – r/t damaged valves/myocardium
► Fluid overload & inadequate tissue perfusion ► Left heart failure – usually happens 1st then Right heart failure |
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What are the signs for pulmonary edema?
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► Acute fluid overload & heart failure
• SOB • Pale • Cough, Frothy sputum • Pain ► Cardiogenic or non-cardiogenic • Severe PND • Dysrhythmias • Orthostatic Hypotension • Moist rales • Diaphoretic • JVD • Peripheral Edema • Hepatic engorgement/Ascites |
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What is the management of severe heart failure/CAD/Dysrhythmias?
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► Hospitalization
► Oxygen ► Nitro IV – for venous dilation which decreases cardiac workload ► Digoxin ► Give meds in the least amount of fluids to reduce fluid overload ► Calcium channel blocker ► ACE inhibitors – will cause a metallic taste in clients ► Co-Reg ► Fluid restriction |
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What are the nursing responsibilities for heart failure?
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► Assess urinary output & bowel elimination
► Manage fluids ► Monitor dig levels ► Pulse oximeter ► Diet low salt & low fat ► Skin care ► Dangle feet at the bedside to decrease pre-load |
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What will be the discharge teaching?
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► Diet & Fluids
► Walking is best exercise ► Daily weights & keep a record – earliest sign of Heart failure • 2 pounds a day & 5 pounds in a week – not good ► Loss of appetite ► Increase SOB with activity ► Unexplained confusion ► Unusual fatigue |
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What will the nurse assess for?
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► Evidence of PND, Orthopnea
► Cough – especially dry, hacking, persistent, when lying down {early sign} ► Pulmonary crackles ► 3rd heart sound ► Pattern of weight gain |
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What is cardiogenic shock?
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► Combination of pulmonary congestion & decrease tissue perfusion
► Very common after anterior AMI |
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What are the compensatory mechanisms for shock?
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► Increased heart rate
► Increased contractibility ► Vasoconstriction ► Hemodynamic monitoring is essential |
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What the nursing care for Cardiogenic Shock is geared towards?
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► Assessing patient for early signs
► Supporting family & patient ► Evaluating outcomes of treatment |
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When is a person is in shock?
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► Urine output of < 30 ml per hour
► Mental status changes |
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What are the medications & treatments commonly used?
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► Very difficult to treat
► Digoxin ► Diuretics ► Low dose of dopamine – renal perfusion ► Dobutamine, Epinephrine – vasoconstriction – causes tachycardia ► Nitroglycerin, Nitroprusside – vasodilation ► Hemodynamic monitoring ► ABGs ► Oxygen ► IntraAortic Balloon Pump |
