Herzing UniversityNF 216WEEK 1./Complete solution rated A

WEEK 1 PNEUMOTHORAX • Description • Assessment • Interventions o COMPLICATIONS:PNEUMOTHORAX ▪ COMPLICATION: CARDIAC TAMPONADE CHEST TRAUMA • COMPLICATIONS: PULMONARY CONTUSION • damage to the lung tiss ...

WEEK 1 PNEUMOTHORAX • Description • Assessment • Interventions o COMPLICATIONS:PNEUMOTHORAX ▪ COMPLICATION: CARDIAC TAMPONADE CHEST TRAUMA • COMPLICATIONS: PULMONARY CONTUSION • damage to the lung tissues resulting in hemorrhage and localized edema • may be mild, moderate, or severe • Pt may have decreased breath sounds, tachypnea, tachycardia, chest pain, hypoxemia, and blood-tinged secretions to more severe tachypnea, tachycardia, crackles, frank bleeding, severe hypoxemia (cyanosis), and respiratory acidosis • Control pain-can relieve itself give fluids and pain meds • Supplemental oxygen  mechanical ventilation may be required CHEST TRAUMA Anatomy and physiology ❖ The chest (thoracic cage) extends from the lower end of the neck to the diaphragm. ❖ The diaphragm is a muscle that separates the thoracic cavity from the abdominal cavity. ❖ The mediastinum contains the heart, great vessels, esophagus, and trachea. A thoracic aortic aneurysm can develop in this area of the chest. Blunt Trauma-no visible entry point may be hard to know the extent of the damage • More common than penetrating trauma • No visible entry point • Difficult to know extent of damage • Usually due to motor vehicle crashes, falls, bicycle crashes (from handlebars) • Flail chest is frequent complication Penetrating Trauma • Entry point visible • Consequence depends on where the penetration is • Never remove any penetrating object • Care more focused around finding source of bleeding and controlling it. • Pneumothorax is frequent complicatiom TIME IS CRITICAL:ASSESSMENT IS KEY • Level of responsiveness • Vital Signs-blood pressure is stable • Estimated blood loss • Recent drug or alcohol use (can be associated with trauma) • Inspect airway, thorax, neck veins, breathing difficulty-symetrical rise and fall • Assess for airway obstruction, flail chest, tamponade, hemothorax, tension pneumothorax • Assess rate and depth of breathing (any stridor, nonsymmetrical chest movement, nasal flaring) • Assess for cyanosis, distended neck veins, petechiae, lacerations and burns, increased cap refill • Ensure trachea is not deviated DIAGNOSTICS ▪ Chest X-RAY ▪ CT ▪ CBC ▪ Coagulation Studies ▪ Type and Crossmatch ▪ ABG ▪ EKG ▪ NURSING/MEDICAL MANAGEMENT ▪ Initiate aggressive resuscitation ▪ ABC ▪ Monitor for complications and correct ▪ May be preparing patient for emergency surgery MECHANICAL VENTILATION • Prepare client psychologically for use of ventilator • Monitor client’s response to the ventilator o Assess vital signs at least every 4 hours o Listen to lung sounds (crackles, wheezes, equal, decreased or absent breath sounds) o Assess need for suctioning o Respiratory monitoring o Evaluate ABGs, continuous pulse oximetry monitoring o Check for hypoxia (restlessness, cyanosis, anxiety, tachycardia, increased respiratory rate) o Check neurologic status o Check chest for bilateral expansion • Provide good oral hygiene at least twice each shift • Assess need for tracheal/oral/nasal suctioning every 2 hours and perform as necessary • Move endotracheal tube to opposite side of mouth every 24 hours to prevent ulcers • Monitor I and O • Create alternative methods of communication with client (letter board, pencil and paper); provide access to call light • Perform and document ventilator and equipment checks-care for client first, ventilator second o Check ventilator settings as ordered by health care provider-tidal volume (TV), respiratory rate, pO2 (fraction of inspired oxygen), mode of ventilation, sigh button/cycle (usually 1-3/h) (may cause lung damage from excessive pressure) o Check that alarms are set (low pressure and low exhaled volume) o Check temp and level of water in humidified system o Check PEEP (positive end expiratory pressure) maintained at end of expiration to open collapsed alveoli and improve oxygenation o Drain condensation from tubing away from the client o Verify that tracheostomy or endotracheal cuff is inflated to ensure tidal volume • Observe for GI distress (diarrhea, constipation, tarry stools) • Document observations/procedure in medical record • Administer oxygen as prescribed • Types of mechanical ventilators o Pressure cycled ventilator ▪ Pushes air into the lungs until a specific airway pressure is reached ▪ Used for short periods, mostly in the post anesthesia care unit o Time cycled ventilator ▪ Pushes air into the lungs until a preset time has elapsed ▪ Used for pediatric or neonatal clients o Volume cycled ventilatory ▪ Pushed air into the lungs until a preset volume is delivered ▪ A constant tidal volume is delivered regardless of the changing compliance of the lungs and chest wall or the airway resistance in the client or ventilator o Microprocessor ventilator ▪ A computer or microprocessor is built into the ventilator to allow continuous monitoring of the ventilatory functions, alarms and client parameters ▪ The type of ventilator is more responsive to clients who have severe lung disease or require prolonged weaning • Modes of ventilation- a BVM should me made available at the bedside for all clients receiving mechanical ventilation o Noninvasive positive pressure ventilation or BiPAP ▪ Ventilatory support given without using and invasive artificial airway; masks and nasal masks are used instead ▪ An inspiratory positive airway pressure (IPAP) and expiratory positive airway (EPAP) are set on a large ventilator or a small flow generator ventilator with a desired pressure support and positive end pressure (PEEP) level. This allows more air to move into and out of the lungs without the normal muscular activity needed to do so. ▪ Can be used in certain situations of COPD distress, heart failure, asthma, pulmonary edema and hypercapnic respiratory failure o Controlled ▪ The client receives a set tidal volume at a set rate ▪ Used for clients who cannot initiate respiratory effort ▪ Least used mode, if the client attempts to initiate a breath the ventilator locks out the client’s inspiratory effort o Assist control ▪ Tidal volume and ventilatory rate are preset on the ventilator ▪ The ventilator takes over the work of breathing for the client ▪ The ventilator is programmed to respond to the client’s inspiratory effort if the client does initiate a breath ▪ Delivers the preset tidal volume when the client initiates a breath while allowing the client to control the rate of breathing o SIMV ▪ Similar to assist control ventilation in that the tidal volume and ventilatory rate are preset on the ventilator ▪ Allows the client to breathe spontaneously at his rate and tidal volume between the ventilator breaths ▪ Can be used as a primary ventilatory mode or as a weaning mode ▪ When SIMV is used as a weaning mode, the number of SIMV breaths is decreased gradually and the client resumes spontaneous breathing o Interventions ▪ Assess vital signs, lung sounds, respiratory status and breathing patterns (client will never breathe at a rate lower than the rate set on the ventilator) ▪ Monitor skin color, particularly in the lips and nailbeds ▪ Monitor the chest for bilateral expansion ▪ Obtain pulse oximetry readings ▪ Monitor ABG ▪ Assess the need for suctioning and observe the type, color and amount of secretions ▪ Assess ventilator settings ▪ Assess the level of water in the humidifier and the temp of the humidification system, because extremes in temp can damage the mucosa in the airway ▪ Ensure that the alarms are set ▪ If a cause for alarm cannot be determined, ventilate the client manually with a BVM until the problem is corrected ▪ Empty the ventilator tubing when moisture collects ▪ Turn the client at least every 2 hours or get the client out of bed, as prescribed to prevent complications of immobility ▪ Have resuscitation equipment available at the bedside • Ventilator controls and settings and descriptions o Tidal volume ▪ The volume of air that the client receives with each breath o Rate ▪ The number of ventilator breaths delivered per minute o Sighs ▪ The volumes of air that are 1.5-2 times the set tidal volume, deliver 6-10 times per hour; may be used to prevent atelectasis o Fraction of inspired oxygen (FiO2) ▪ The oxygen concentration delivered to the client; determined by the client’s condition and ABG level o Peak airway inspiratory pressure ▪ The pressure needed by the ventilator to deliver a set tidal volume at any given compliance ▪ Monitoring peak airway inspiratory pressure reflects changes in compliance of the lungs and resistance in the ventilator or the client o Continuous positive airway pressure ▪ The application of positive airway pressure throughout the entire respiratory cycle for spontaneous breathing clients ▪ Keeps the alveoli open during inspiration and prevents alveolar collapse, used primarily as a weaning modality ▪ No ventilator breaths are delivered, but the ventilator delivers oxygen and proved monitoring and an alarm system; the respiratory pattern is determined by the client’s efforts o Positive end expiratory pressure ▪ Positive pressure is exerted during the expiratory phase of ventilation, which improves oxygenation by enhancing gas exchange and preventing atelectasis ▪ The need for PEEP indicates a sever gas exchange disturbance ▪ Higher levels of PEEP (more than 15 cm H2O) increase the chance of complications, such as barotrauma tension pneumothorax o Pressure support ▪ The application of positive pressure on inspiration that eases the workload of breathing. ▪ May be used in combination with PEEP as a weaning method ▪ As the weaning process continues, the amount of pressure applied to inspiration is gradually decreased • Causes of ventilator alarms o High pressure alarms ▪ Increased secretions are in the artificial airway or the client’s own airway ▪ Wheezing or bronchospasm is causing decreased airway size ▪ The endotracheal tube is displaced ▪ The ventilator tube is obstructed because of water or a kink in the tubing ▪ Client coughs, gags or bites on the ET ▪ Client is anxious or fights the ventilator o Low pressure alarm ▪ Disconnection or leak in the ventilator or in the client’s airway cuff occurs ▪ The client stops spontaneous breathing • Alarm safety and alarm fatigue o It is the responsibility of the nurse to be alert to the sound of an alarm, because this signals a client problem o The nurse needs to respond promptly to an alarm and immediately assess the client o According the joint commission the most common contributing factor related to alarm related sentinel events is alarm fatigue, which results when the numerous alarms and the resulting noise tends to desensitize the nursing staff and cause them to ignore alarms or even disable them. o Some recommendations include establishing alarm safety as a facility policy, identifying default alarm settings, identifying the most important alarms to manage, establishing policies and procedures for the alarms and to educate staff o Never set the alarms controls to OFF • Complications o Hypotension caused by the application of positive pressure, which increase intrathoracic pressure and inhibits blood return to the heart. o Respiratory complications such as pneumothorax or subcutaneous emphysema as a result of positive pressure o GI alterations such as stress ulcers o Malnutrition if nutrition is not maintained o Infections o Muscular deconditioning o Ventilator dependence or inability to wean o Bradycardia as a result of intrathoracic pressure or activated vagal response • Weaning o Process of going from ventilator dependence to spontaneous breathing o Methods include ▪ SIMV • The client breathes between the preset breaths per minute rate of the ventilator • The SIMV rate is decreased gradually until the client is breathing on her own without the use of the ventilator ▪ T-piece • The client is taken off the ventilator and the ventilator is replace with a T-piece or CPAP which delivers humidified oxygen • Client is taken off the ventilator for short periods initially and allowed to breath spontaneously • Weaning progresses as the client is able to tolerate progressively longer periods off the ventilator ▪ Pressure support • Predetermined pressure set on the ventilator to assist the client in respiratory effort • As weaning continues the amount of pressure is decreased gradually • Pressure may be maintained while the preset breaths per minute of the ventilator are decreased gradually. • What • The process of artificially ventilating the lungs • Why • Patient can not perfuse • Surgery • Provide adequate oxygenation when patient can not • Rest respiratory muscles because they are exhausted • When • Decrease in PAO2-normal is 75 to 100 anything 60 or below is intubate • Increase in CO2 • Decreasing LOC • Having multiple seizures to prevent respiratory arrest • Swelling, anaphylaxis • Protect airway when patient is unconscious or increasingly lethargic • ET • Passing an endotracheal tube through nose or mouth into trachea • Oral is preferred • Confirm placement by checking end-tidal carbon dioxide levels-turns purple to yellow & chest x- ray. condensation in the tube and lung sounds • Settings • Rate: Breaths per minute • in which we want the patient • to breathe. • Tidal Volume: ability of the lung • And chest wall to distend/expand • Ability of the lung to expand-most people is 500 mL-weight can make that higher • PEEP: Positive End-Expiratory Pressure • Pressure it takes for the lungs to stay open in the alveoli • The higher PEEP the more support they need • 20 is high • 5 is normal for intubation • FIO2: stands for Fraction of Inspired • Oxygen • For COPD do not go to high • Modes of Ventilation • Assist Control (CMV) • most common mode • continuous manual ventilation • every time they attempt to take a breath the ventilator triggers and gives them a breath • we set the tidal volume and the vent supports them to get to that • patient can breathe over the ventilator, if it is set to10 they will get 10 regardless. They can take extra breaths • full support mode • when they act-up they need to be sedated because of hyperventilation • Synchronized Intermittent Mandatory Ventilation (SIMV) • same as assist control but if they want to take their own breath, they can without an assist from the ventilator • considered lower support • good for weaning • will tell you how many breaths they took • Pressure Control (CMV) • not only a mode but a function that can be added to other modes • changing the pressure it takes to hit a certain volume-not PEEP • setting the tidal volume and will kick in when they do not meet it • if they meet it without help then that’s great • NONINVASIVE POSITIVE PRESSURE VENTILATION • Mask used to deliver positive-pressure ventilation • CPAP-chronic respiratory failure, sleep related disorder. 1 level of care • BIPAP-2 levels of care. Required less effort from the patient • EPAP-more comfortable than the CPAP • No head or facial trauma, no vomiting or nausea, copious secretions are a no. • Replaces and endotracheal tube • Allows long term use of mechanical ventilation and ET tube • Maintain sterility when suctioning • NURSING MANAGEMENT • Enhancing Gas Exchange-check with capno, SPO2, chest x-ray. • Promoting effective airway clearance-suctioning, encourage them to cough • Promoting the optimal level of mobility • Preventing complications-ventilator acquired pneumonia because the tube is a foreign body. Oral care is huge do it. • Promoting optimal communication • Promoting coping abilities • Monitoring and responding appropriately to alarms/potential complications • Recognizing when patient may be ready for support weaning-patient should be following commands before they are extubated ACUTE RESPIRATORY FAILURE • Description o Occurs when insufficient oxygen is transported to the blood or inadequate carbon dioxide is removed from the lungs and the client’s compensatory mechanisms fail o Causes include a mechanical abnormality of the lungs or chest wall, a defect in the respiratory control center in the brain, or an impairment in the function of the respiratory muscles o In oxygenation failure or hypoxemic respiratory failure, oxygen may reach the alveoli but cannot be absorbed or used properly, resulting in a PaO2 lower than 60mm Hg, arterial oxygen saturation (SaO2) lower than 90 or partial pressure of arterial carbon dioxide (PaCO2) greater than 50mm Hg occurring with acidemia. o Respiratory failure can be hypoxemic, hypercapnic or both. Inadequate gas exchange is the mechanism behind failure. Arterial oxygen, carbon dioxide or both are not kept at normal levels, resulting in failure. o Many clients experience both hypoxemic and hypercapnic respiratory failure and retain carbon dioxide in the alveoli displaces oxygen, contributing to the hypoxemia o Manifestation of respiratory failure are related to the extent and rapidity of change in PaO2 and Pa CO2 • Assessment o Dyspnea o Restlessness o Confusion o Tachycardia o Hypertension o Dysthymias o Decreased LOC o Alterations in respiration and breath sounds o Headache, but this is less common • Interventions o Identify and treat the cause of respiratory failure o Administer O2 to maintain the PaO2 level higher than 60 to 70 mm Hg o Place the client in a Fowler’s position o Encourage deep breathing o Administer bronchodilators as prescribed o Prepare the client for mechanical ventilation if supplemental o2 cannot maintain acceptable PaO2 and PaCo2 levels. • GAS EXCHANGE: ARDS/ARF • Sepsis is the number one cause of ARF • Drug overdoses • Trauma • Sudden & life-threatening-low o2 in the blood or can not get rid of CO2 • Decrease in arterial oxygen (Pa02) to less than 60mmHg (hypoxemia) • Increase in arterial carbon dioxide (PaC02) to greater than 50mmHg (hypercapnia) • pH less than 7.35 • Ventilation or perfusion mechanisms are impaired • Ventilation-mechanics of moving air in and out of the lung • Quality-O2 that is supplied with each breath-can be affected by collapses alveoli or trauma from a bad hemorrhage because of low RBC-can not deliver O2 • CLINICAL MANIFESTATIONS • Early signs: Fatigue, restlessness, headache, dyspnea, agitation, elevated BP • Hypoxemia progression: confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, respiratory arrest • Use of accessory muscles and decreased breath sounds • When in doubt grab an ABG • MEDICAL MANAGEMENT • Correct the underlying cause • Endotracheal intubation-can try BiPAP but will probably need tubing • Mechanical ventilation • Preventing further complications ACUTE RESPIRATORY DISTRESS SYNDROME • Description o A form of acute respiratory failure that occurs as a complication cause by a diffuse lung injury or critical illness and leads to extravascular lung fluid o The major site of injury is the alveolar capillary membrane o The interstitial edema causes compression and obliteration of the terminal airways and leads to reduced lung volume and compliance o The ABG levels identify respiratory acidosis and hypoxemia that do not respond to an increased percentage of oxygen o The chest x-ray shows bilateral interstitial and alveolar infiltrates; interstitial edema may not b e noted until there is a 30 % increase in fluid content. o Causes include sepsis, fluid overload, shock, trauma, neurological injuries, burns, DIC (disseminated intravascular coagulation), drug ingestion, aspiration and inhalation of toxic substances • Assessment o Tachypnea o Dyspnea o Decreased lung sounds o Deteriorating ABG levels o Hypoxemia despite high concentration of O2 o Decreased pulmonary compliance o Pulmonary infiltrates • Interventions o Identify and treat the cause of the acute respiratory distress syndrome o Administer O2 as prescribed o Place the client in a Fowler’s position o Restrict fluid intake as prescribed o Provide respiratory treatments as diagnosed o Administer diuretics, anticoagulants or corticosteroids as prescribed o Prepare the client for intubation and mechanical ventilation using PEEP ACUTE RESPIRATORY DISTRESS SYNDROME • A form of acute respiratory failure that occurs as a complication of other conditions that lead to extra vascular lung fluid. • Fluid leaking into alveolar sac • Airways narrowed because of interstitial fluid • Sudden onset • Usually second to a primary diagnosis • High mortality rate • Difference between the two ARF is the inability of the individual to breath on their own. ARDS is due to a widespread inflammation in the lung • In ARDS the capillary membrane that promote gas exchange let fluid into the alveoli causing atelectasis • Lungs become stiff in ARDS because of atelectasis • Onset of ARDS is fast • CLINICAL MANIFESTATIONS • Rapid onset of severe dyspnea • Tachypnea • Tell tale sign of ARDS is Hypoxemia that does not respond to oxygen  severe hypoxemia. Refractory hypoxemia • Bilateral infiltrates on CXR that quickly worsen • May hear diminished first but will get Crackles present once fluid builds up • Difficult to ventilate due to decreased pulmonary compliance • Chest x-ray is the definitive test and will be taken every day to see if what we are doing is taking effect • Look at ABGs • May look like they are in congestive heart failure so be aware • With ARDS you will need a ton of steroids • Run a BNP to see if they are aware from their baseline to see if it is an exacerbation-the higher the enzyme the better the heart stretch the worse the exacerbation of CHF. • TREATMENT • Endotracheal intubation-always with ARDS • Mechanical ventilation-always with ARDS • Circulatory support-systemic hypotension may occur due to fluid being in the lungs and in the interstitial space • Adequate fluid volume • Nutritional support • Prone position • Increased PEEP can be driving the patient to hypotension, because it decreased cardiac output. • The nurse is caring for a client with ARDS. What does the nurse anticipate the results of the initial ABG to be? • 1. Metabolic Acidosis • 2. Metabolic Alkalosis • 3. Respiratory Acidosis • 4. Respiratory Alkalosis******************************** HYPERTENSIVE CRISIS • Description o An acute and life-threatening condition required immediate reduction in BP o Emergency treatment is required, because the target organ damage (brain, heart kidneys, retina of the eye) can occur quickly o Death can be caused by stroke, kidney failure or cardiac disease • Assessment o And extremely high BP, systolic over 180 and or diastolic over 120 o Headache o Drowsiness and confusion o Blurred vision o Changes in neurological status o Tachycardia and tachypnea o Dyspnea o Cyanosis o Seizures • Interventions o Maintain a patent airway o Administer antihypertensive medications intravenously as prescribed o Monitor vital signs, assessing the BP every 5 mins o Monitor neurological status o Maintain bed rest, with head of the bed elevated at 45 degrees o Assess for hypotension during the administration of antihypertensives; place the client in supine position of hypotension occurs. o Have emergency medications and resuscitation equipment readily available o Monitor IV therapy, assessing for fluid overload o Insert a foley catheter as prescribed o Monitor intake and urinary output; if oliguria or anuria occurs, notify the PCP HYPERTENSIVE CRISIS-greater than 120 or MAP is greater than 150-blood pressure increases so fast that the body can respond, a sudden increase. Do not drop rapidly can cause issues. • Will have an A line • Two classes that require immediate intervention • Hypertensive emergency-risk for organ damage like the kidneys so I and O • Hypertensive urgency- no risk for organ damage • Blood pressures extremely elevated • hypertensive Emergency • Must be lowered quickly; evidence or target organ damage • Acute, life-threatening • Goal- reduction of mean blood pressure by 20% to 25% within first hour of treatment • Further reduction to goal BP of 160/100 • Exception- ischemic stroke (no benefit from immediate pressure reduction) • Pharmacological treatment Hypertensive emergency • Intravenous vasodilators • Nitroprusside (nitropress)************* number one drug given IV through the arterial line • Nicardipine (cardene) • Clevidipine (cleviprex) • Enalapril (Vasotec) • Labetlol (trandate) • Assess fluid volume status Nitroprusside-vasodilator, is metabolized to cyanide but kept low. Look for cyanide, breath smells like almonds • Drug of choice for hypertensive emergency • Ability to lower B/P almost instantly through IV administration • Continuously monitor clients receiving drug • Med is metabolized to cyanide • Don’t rapidly change the pressure to fast or it pulls away blood from the organs Hypertensive urgency • B/P very elevated with no evidence or organ damage • Associated with headaches, epistaxis, or anxiety • Oral agents may be given; Goal is to normalize BP within 24 to 48 hours • Clonidine (Catapres)-PO-vasodilator changes in about an hour-can be given to children for ADHD MAP = SBP + 2 (DBP) 3 • MAP = 83 +2 (50) 3 • MAP = 83 +100 3 • MAP = 183 3 • MAP = 61 mm HG • Example for a client with an 83/50 BP. A MAP of 60 is the lowest minimal acceptable level for adequate perfusion. PULMONARY EMBOLISM • Description o Occurs when a thrombus forms (most commonly in a deep vein) detaches, travels to the right side of the heart and then lodges in a branch of the pulmonary artery. o Client prone to PE are those at risk for DVT, including prolonged immobilization, surgery, obesity, pregnancy, heart failure, advanced age, or a history of thromboembolism o Fat emboli can occur as a complication following fracture of a long bone and can cause PE o Treatment is aimed at prevention through risk factor recognition and elimination • Assessment o Apprehension and restlessness o Blood tinged sputum o Chest pain o Cough o Crackles and wheezes o Cyanosis o Distended neck veins o Dyspnea accompanied by anginal and pleuritic pain, exacerbated by inspiration o Feeling of impending doom o Hypotension o Petechiae over the chest and axilla o Shallow respirations o Tachypnea and tachycardia • Interventions o Notify the Rapid response team and primary health care provider o Reassure the client and elevate the head of the bed o Prepare to administer oxygen o Obtain vital signs and check lung sounds o Prepare to obtain an ARB o Prepare for the administration of heparin therapy and other therapies o Document PULMONARY EMBOLISM • Obstruction of pulmonary artery by a thrombus • Associated with trauma, surgery, older age, and prolonged immobility • Sudden death is the first clinical sign in 25% of people Pathophysiology • Emboli- may be air, fat or amniotic fluid • Alveolar dead space • Impaired or absent gas exchange Manifestations • Dyspnea • Chest pain • Anxiety • Tachycardia • Apprehension • Diaphoresis • Tachypnea (most frequent sign) The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse’s priority action? • a. Elevate the head of the bed and apply oxygen.************************************** • b. Listen to the client’s lung sounds. • c. Pull the call bell out of the wall socket. • d. Assess the client’s pulse oximetry. Assessment and Diagnostics • CXR-usually is normal • ECG-sinus tach • Pulse oximetry-low • ABGs-hypoxemia hypocapnia • V/Q scan • MDCTA • D-dimer-checks for the evidence of clots, is a blood test • Pulmonary angiogram • Assessment Management • Lyse the existing emboli & prevent new ones • alteplase, TPA- “clotbusters” used with massive PE (obstructing blood flow) • Nasal oxygen; severe hypoxemia req. intubation & ventilation • Establish IV lines • Vasopressors if needed • Pulse ox & ABGs • CBC, coagulation studies • Indwelling urinary catheter • Morphine or IV sedatives (midazolam) It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse’s priority action? • a. Monitor the client’s oxygenation.******************************************************************** ** • b. Teach the client about potential side effects. • c. Monitor the IV insertion site. • d. Monitor for bleeding Anticoagulation • Enoxaparin- SQ –no specific lab value but check the platelet count • Fondaparinux-they do not need frequent blood work • Rivaroxaban • Apixaban • Edoxaban • Warfarin- 2-3 is normal INR levels; Antidote- phytonadione (Vitamin K) • (often used after sx; 3-6 mos. Duration) The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client’s international normalized ratio (INR) is 2.0. What is the nurse’s best action? a. Increase the heparin dose. b. Increase the warfarin dose. c. Continue the current therapy. d. Discontinue the heparin.********************************** Heparin is given IV and you do not need it anymore they have bridged over to the warfarin which takes 3 to 5 days to kick in Thormbolytics Used in clients with massive PE, hypotension, & low bleeding risk Recombinent tissue plasminogen activator kabikinase A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse’s first action? a. Irrigate the Foley. b. Administer an antibiotic. c. Clamp the Foley. d. Notify the health care provider********************************* Surgical Management Embolectomy Rarely performed If pt has contraindication to thrombolytic therapy IVC filter Prevention Encourage ambulation Active & passive leg exercises Not to sit or lie in bed for prolonged periods Do not cross legs No constrictive clothing SCDs No leg dangling while sitting hydration Monitoring thrombolytic therapy Pt on bedrest immed. After Vital signs q2 hrs Invasive procedures avoided Check INR or PTT 3-4 hrs after VALVULAR HEART DISEASE • Description o Valvular heart disease occurs when the heart valves cannot open fully (stenosis) or close completely (insufficiency or regurgitation) o Valvular heart disease prevents efficient blood flow through the heart • Types o Mitral stenosis ▪ Valvular tissue thickens and narrows the valve opening, preventing blood from flowing from the left atrium into the left ventricle o Mitral insufficiency, regurgitation ▪ Valve is incompetent, preventing complete valve closure during systole o Mitral valve prolapses ▪ Valve leaflets protrude into left atrium during systole o Aortic stenosis ▪ Valvular tissue thickens and narrows the valve opening, preventing blood from flowing from the left ventricle into the aorta o Aortic insufficiency ▪ Valve is incompetent, preventing complete valve closure during diastole • Aortic valve disorders o Aortic stenosis ▪ Symptoms • Dyspnea on exertion • Angina • Syncope on exertion • Fatigue • Orthopnea • Paroxysmal nocturnal dyspnea • Harsh systolic crescendo-decrescendo murmur o Aortic insufficiency ▪ Symptoms • Dyspnea • Angina • Tachycardia • Fatigue • Orthopnea • Paroxysmal nocturnal dyspnea • Blowing decrescendo diastolic murmur • Tricuspid valve disorders o Tricuspid stenosis ▪ Symptoms • Easily fatigued • Effort intolerance • Reports fluttering sensations in the neck (obstructed venous flow) • Cyanosis • Signs of right ventricular failure o Ascites o Hepatomegaly o Peripheral edema o Jugular vein distention o Clear lung fields • Symptoms of decreased cardiac output • Rumbling diastolic murmur o Tricuspid insufficiency ▪ Asymptomatic in mild situations ▪ Signs of right ventricular failure ▪ Pleural effusion ▪ Systolic murmur heard at the left sternal border at the fourth intercoastal space • Pulmonary valve Disorders o Pulmonary stenosis ▪ Asymptomatic in mild condition ▪ Dyspnea ▪ Fatigue ▪ Syncope ▪ Signs of right ventricular failure ▪ Systolic thrill heart at the left sternal border o Pulmonary insufficiency ▪ Asymptomatic in mild condition ▪ Dyspnea ▪ Fatigue ▪ Syncope ▪ Signs of right ventricular heart failure ▪ Systolic thrill heard at left sternal border • Repair procedures o Percutaneous balloon valvuloplasty ▪ A balloon catheter is passed from the femoral vein through the atrial septum to the mitral valve or through the femoral artery to the aortic valve. ▪ The balloon is inflated to enlarge the orifice ▪ Monitor for bleeding from the catheter insertion site ▪ Institute precautions for arterial puncture if appropriate, site care and monitoring is similar to that after cardiac catheterization ▪ Monitor for signs of systemic emboli ▪ Monitor for signs of a regurgitant valve by monitoring cardiac rhythm, heart sounds and cardiac output o Mitral annuloplasty ▪ Tightening and suturing the malfunctioning valve annulus to eliminate or greatly reduce regurgitation, percutaneous or open surgical approach o Commissurotomy, valvotomy ▪ Thrombi are removed and calcium deposits are debrided, the valve is incised and widened ▪ Risk of clot formation is high as the body reacts to the artificial materials, anticoagulation is required ▪ Lifetime anticoagulant therapy is required with any valve replacement o Bioprosthetic valves ▪ Biological grafts are xenografts (valves from other species)-porcine valves (pig), bovine valves (cow) or homograft (human cadavers). These valves are less durable than mechanical prosthetic valves ▪ The risk of clot formation is small, therefore, long term anticoagulation may not be indicated o Open heart surgical approach o Preoperative interventions ▪ Consult with the PCP regarding discontinuing anticoagulants 72 hours before surgery o Post op ▪ Monitor closely for signs of bleeding ▪ Monitor cardiac output and for signs of heart failure ▪ Administer digoxin as prescribed to maintain cardiac output an prevent a fib o Education ▪ Rest is important and fatigue is common ▪ Anticoagulant therapy is necessary if a mechanical prosthetic valve has been inserted ▪ Hazards related to anticoagulants ▪ Brush teeth twice daily using a soft bristle toothbrush, followed by oral rinses ▪ Avoid irrigation devices, electric toothbrushes and flossing they can cause the gums to bleed allowing bacteria to enter the mucous membranes and bloodstreams. ▪ Monitor incision and report any drainage or redness ▪ Avoid any dental procedures for 6 months ▪ Lifting more than 10lbs is to be avoided and exercise caution when in an automobile to prevent injury to the sternal incision ▪ If a prosthetic valve was inserted a soft audible clicking sound may be heard ▪ Obtain and wear a medic alert bracelet VALVULAR DISORDERS Mitral valve prolapse ❑ Usually produces no symptoms ❑ Few clients may have: Fatigue, SOB, syncope ❑ Leaflets balloon into right atrium and cause regurgitation ❑ May hear a mitral click on assessment ❑ Diagnosed via echo Mitral valve regurgitation Backflow of blood from left ventricle into left atrium Most common cause is from changes in mitral valve such as mitral valve prolapse Mitral valve leaflets are thought to be fibrosed and thickened which does not allow them to close completely. Left atrium strained and stretched from backflow  lung congestion -- Strain on right ventricle  systolic HF Mitral valve regurgitation: assessment and diagnostics ■ Manifestations: ■ Manifests as severe congestive HF ■ Dyspnea, fatigue, weakness ■ Pulse may be regular or irregular from atrial fibrillation ■ A systolic murmur may be heard on assessment ■ Diagnostics: Definitively diagnosed via echocardiogram ■ Medical management: ■ Managed similarly to HF ACE inhibitors Mitral Valve Stenosis ❑ Obstruction of blood flowing from left atrium to left ventricle ❑ Decreased filling in the left ventricle which Causes decrease cardiac output ❑ Left atrium hypertrophy due to not being able to get out blood. ❑ Dyspnea on exertion ❑ Generalized fatigue ❑ Dry cough/wheezing ❑ Hemoptysis ❑ Palpitations/tachycardia/ possible atrial fibrillation ❑ Frequent respiratory infections ❑ Weak pulse on assessment Aortic Regurgitation ■ Flow of blood back into the left ventricle from the aorta ■ Due to aortic valve failing to close for various reasons (lesions on aorta, failing aortic valve replacement, various diseases) ■ Left ventricle accepts blood from left atrium AND received backup from aorta- hypertrophy of left ventricle occurs ■ Echo for diagnosis  cardiac catheterization for further information ■ Many patient’s do not have noticeable symptoms ■ Forceful heartbeat ■ “Water hammer” / “corrigans” pulse on assessment ■ “high-pitched, blowing murmur ■ Widened pulse pressure Management ■ Avoid sports and vigorous physical activity if left ventricle is failing ■ Symptomatic patients should restrict intake of salt ■ Reduce afterload  calcium channel blockers / ACE inhibitors ■ Aortic valve replacement / valvuloplasty (preferred treatment before LV failure occurs) ■ Narrowing of the opening between LV & aorta ■ Result of degenerative calcifications ■ Progressive narrowing ■ LV hypertrophy Diagnosis Via echo Management Aortic valve replacement / valvuloplasty Signs and Symptoms Most patient’s asymptomatic but if symptoms occur, patients may experience: -exertional dyspnea -orthopnea -syncope -angina -narrow pulse pressure due to the lessened blood flow (due to narrowed valve) -murmur over aortic area DROWNING What is Drowning Drowning defined as: death secondary to asphyxia and within 24 hours of submersion which may be immediate or follow resuscitation Submersion injury: Survival after more than 24 hr is termed regardless the victim later dies or recovers EPIDEMIOLOGY Age: < 5 years & > 85 years = greatest risk Prevalence:372,000 drownings occur globally More drownings happen to males Those who live near water/often travel on water at greater risk Educate your patients! PREVENTION IS KEY Do not swim without inflatable devices/life jacket if unable to swim Do not ingest alcohol and swim/travel on water Do not dive in shallow water Do not leave child unattended near water Do not leave child unattended in bathtub no matter height of water Discuss water safety with children Learn CPR especially if pool at home or swim often Pay attention to children when near water with them MANAGEMENT Cardiopulmonary resuscitation Determine brain functioning/damage Management of hypoxia/acidosis Management of hypothermia Endotracheal intubation if necessary Decompress stomach – NG TUBE Monitor patient even if they feel/appear fine INVASIVE MONITORING CVP monitoring (central venous pressure)-usually done in ICU or open-heart surgery Measurement of the pressure from the right atrium or superior vena cava CVP = Right atrium pressure Normal CVP – 2-6 mm Hg-high pressure means hypervolemia Measurement at phlebostatic axis Subclavian is the spot to put it in xray will be done to see if its in the right spot Doctor will tell you how often they want the measurement Transducer is what does the measuring and it is at the phlebostatic axis, number can be off if the transducer is in the wrong place, like the top or bottom of the pole Pulmonary artery Pressures AKA Swan Ganz Catheter Measures R heart pressure & indirect L heart pressure Pulmonary artery wedge pressure- Normal 4-12 mm Hg Evaluates response to medical interventions Balloon tip put at the end of it –in the atrial gives left atrial pressure, if you do not take the air out, it could be a major problem, when removing it Elevations mean left ventricular failure, mitral valve regurgitation, hypervolemia At the height of the patients clavicle to get the right measurements Intra-Arterial Blood Pressure Monitoring Direct and continuous BP measurements Useful when frequent ABGS or blood samples needed Allen test-compress the radial and ulnar simultaneous in order to make it blanche after they open the fist, they release the pressure, if the pressure comes back in less than 6 seconds, they can put the line in Assess perfusion distal to site Zero an A line once a shift Minute by minute blood pressure medication, no cuff needed but still do it once a shift to make sure they match, may not be zeroed right