GNRS 555 Case Study Upper Respiratory Diseases Questions With Answers, Exams of Nursing

Download GNRS 555 Case Study Upper Respiratory Diseases Questions With Answers and more Exams Nursing in PDF only on Docsity! GNRS 555 Case Study Upper Respiratory Diseases Questions With Answers • Mr. Davidson is a 24-year old boxer. He had a boxing game and received with a nose injury. Due to heavy nosebleed, he was transferred to ER. Health Assessment and Physical Exam: Diagnostic Test: Deviated septum is observed. X-ray is done to confirm the diagnosis. • Patient is alert and oriented. He didn't lose his consciousness. The patient reports severe nose pain. No other symptoms. • Nursing Care: • What should be your highest priority when you plan the care of this patient? o Vent airway, BCs • Which position should you assist the patient to and why? o Up right position, head slightly forward • How do you differentiate between anterior nasal bleeding and posterior nasal bleeding? o Posterior: secondary to hypertension, older people, coughing, more dangerous, back of throat o Anterior: stops spontaneously, not life threatening, able to see • What are some of the nursing interventions that can help control the bleeding of this patient? Provide rationale. o High fowlers, pinch nose, head tilt forward, acetaminophen, nasal sponges, nasal packing, medication for pain, Tylenol (no NSAIDS) • What is the appropriate way to apply pressure to stop the epistaxis? How and for how long? o Pinch nose against septum 10-15 mins, up right, lean forward, ice • Would you insert gauze into the bleeding nostril in this case? Why? o NO because patient has a fx. If stops in 10-15 mins then no gauze • Considering the bleeding, what medications would be contraindicated? o NSAIDS, (aleve, advil, ibuprofen) anticoagulants (warfarin, heparin, Lovenox) ▪ Heparin-IV, SC Lab: aPPT Need: sulfate ▪ Coumocin- PO Lab: PT, INR Need: vit K ▪ Lovenox- • If you notice a clear liquid draining from the patient's left ear, what should you do next? o Worried about CSF from skull fx, check fluid for glucose, send to lab • What do you expect the vital signs of this patient to be? Explain. o Increased HR, high RR, increase BP patient is in distress and anxious • The ENT specialist applies nasal ointment that includes topical Lidocaine and epinephrine. What are the indications and desired outcomes of these two agents? o Lidocaine pain, epi is vasoconstrictor • The bleeding continues, so the ENT decides to use a Pledget (nasal tampon) impregnated with cocaine. Why cocaine? o Cocaine- potent anesthetic and vasoconstrictor • How long should the pledgets remain in the nose? o 2-3 days o Need ENT to place and remove pladget • While the pledgets inside the nose, the patient needs to sneeze, what should tell the patient? o Sneeze with mouth open • Remember the pre-op management (consent, precautions (bleeding and infection), etc). o Consent- patientneeds to consent unless unconscious o Precautions- know about bleeding and risk infection • Formulate a nursing diagnosis with highest priority post-op. o Airway clearance effective o Edema • Sulfamethoxazole/Trimethoprim (Bactrim) antibiotic was prescribed for the patient to take for 2 weeks. What teaching should you provide regarding the indication and the administration of this antibiotic? o Finish antibiotic in entirety ▪ Side effect: drowsiness –crosses blood brain barrier, sedation effect on brain ▪ Nursing consideration: no driving ▪ 2nd Gen- Zyrtec, Claritin, allegra ▪ Pros: non-sedative, ▪ Con: not as strong as 1st • How can the patient manages the dry mouth/mucosa results from antihistamines? o Ice chips, hydration • Flunisolide spray, an intranasal corticosteroid, is prescribed for Mrs. Jones. For the best results, when should Mrs. Jones start using Flunisolide? o Couple weeks before allergy season o Take every day, no prn • Mrs. Jones says "I should take Flunisolide when I need"? How should you responds? o False, need a few weeks to kick in • Mrs. Jones says "Flunisolide relieves symptoms within minutes". How should you respond? o no • Mrs. Jones asks "I usually get a sinus infection once a year, should I continue flunisolide if I get a sinus infection or quit?" How should you responds? o Keep taking • In October, Mrs. Jones' symptoms become worse and Singulair (monteLUKAST), a leukotriene receptor antagonist inhibitor was added. Before Mrs. Jones can start using Singulair, what should the prescriber check first? o Liver function- AST and ALT labs • It is safe for Mrs. Jones to use Singulair, what time of the day should she take it? o evening • Few months after using Singulair, Mrs. Jones calls and reports that her eyes are "turning yellow". What should you tell her? o Stop med, liver damage • Due to some life events, Mrs. Jones develops depression. Phenelzine (Nardil), an monoamine oxidase inhibitor (MAOI), was prescribed for her. How will Nardil affect the allergy medications of Mrs. Jones? o Interacts with other medications, stop allergy med • Mrs. Jones tells you that her mother-in-law has developed nasal congestion and she is going to get her Sudafed (pseudoephedrine) over-the-counter (OTC). Sudafed would be contraindicated if the patient has what medical conditions? o Table 26-2: Heart issues, hypertension, • Phenylephrine (Neo-Synephrine), an alpha-1 adrenergic agonist topical decongestant, is prescribed to use PRN. What cautions regarding the use of this decongestant should you include in the teaching plan? o Do not take more than 3 times daily, able to get rebound congestion • Mrs. Jones tells you that her pulmonologist mentioned to her a therapy called "immunotherapy" and ask you to tell her more about. o Intro allergen to body slowly so get get used to allergen (desensitize) o Allergy shots • Provide patients with education based on table 27-1. • KNOW!!! Antihistamines, singulair, corticosteroids, decongestants o Know typical med, generic and brand name, nursing consid, side effects, who cant use # 3: Acute Viral Rhinitis (Common Cold) • Mr. Richards has developed a common cold. He tells you that last week he worked 7 days in a row 14 hours a day. He asks you if there was a connection between working "to much" and getting the cold. What should your response be? o Yes, stress increases chances of getting sick • What are the latent viruses? and where do they live? o Dormant, live inside body • Mr. Richards says "I'm going to see my doctor to get an antibiotic", what do you think? o No, virus are not effective • What does Mr. Richards need to treat the symptoms of his cold? o Rest, fluids, decongestants • Five days later, Mr. Richards informs you that his symptoms got worse and now he has fever of 104.0 F and greenish discharge. Explain what happened and how will the treatment change now o 2nd bacterial infection, may need antibiotics, high Fever and discharge bacterial o Viral: no green discharge, low grade fever # 4: Influenza (flu) You are participating in setting up a "Flu Clinic" to vaccinate the local community. The following patients are present and you need to decide who should receive the inactivated vaccine and who should receive live attenuated vaccine Live: nasal spray age 2-64 Inactivated: shot, older people, immunocompromised 1. A 65 years old with COPD. Dead 2. A 9 months old. dead 3. A 71 years old who lives in a nursing home. Dead 4. A 45 years old who is diagnosed with AIDS. dead 5. A 26 years old nursing students who is healthy. either 6. A 27 years old who is 30 weeks pregnant. dead • How will you administer the inactivated vaccine? What route? Location? What's the volume of the vaccine? o Intramuscular, deltoid, 0.5ml • The mother of the 9 months old is requesting that her child receive the vaccine via nasal spray because it is less painful. How should you respond? o No, patient is too young and not immunity mature • The 65 years old says "the vaccine will make me infecious so I have to avoid people for 2-3 days". How should you respond? o Dead virus is not infectious • During physical exam of a patient with the flu, it is expected to hear crackles on asuculation. True/False. o Crackles- pneumonia • What is the most common complication of influenza? What are the signs and symptoms that indicate poor prognosis (=flu becomes pneumonia)? o Pneumonia, better and then worse, cough, fever, crackles, sputum purulent, SOB, dyspnea • The treatment of uncomplicated influenza infection should include antibtioics. True/False? o Chemo- use meds to kill cancer, IV or PO, need special certification to give chemo, controversial o Radiation- high dose X-ray to kill cancer cells, skin reaction (red and sensitive), special skin care needed, intense sun screen, dehydration • What is brachytherapy? What are some of the cautions? • Teach Mr. Ghali about supraglottic swallow. • Discuss the post-op diet progression for Mr. Ghail (from NPO- IV- liquid-pureed!). o Go from Npo to IV (TPN[need central line, total parenteral nutrition], PPN [need peripheral IV, peripheral parental nutrition]) to clear liquid to full liquid to puree food to mechanical soft to regular diet ABG Exercise: 1. pH 7.31, PaO2 80 mmHg, PaCO2 55 mmHg, HCO3 24 mEq. Respiratory acidosis 2. pH 7.30, PaO2 85 mmHg, PaCO2 40 mmHg, HCO3 18 mEq. Metabolic acidosis 3. pH 7.53, PaO2 90 mmHg, PaCO2 29 mmHg, HCO3 25 mEq. Respiratory alkalosis 4. pH 7.50, PaO2 82 mmHg, PaCO2 37 mmHg, HCO3 30 mEq. Metabolic Alkalosis Memorize Normal: pH 7.35-7.45, PCO2 35-45 mmHg (respiratory compensation), HCO3 22-26 mEq/ml (renal system) metabolic *Memorize CBC (Complete Blood Count): Normal: WBC- 4000-11000, Hemoglobin Male 13-18 Female 12- 15, Hct Men 38-50, female 35-45, platelets 150-450 PT, INR (Normal 0.8-1.2, no coumodin)- monitered when on coumodin PT(11-14) PTT (125-135) *Memorize BMP- chem 7, Na (135-145), K(3.5-5), Cl (101-111), CO2 (20-29), BUN (7-20) (renal, increase with exercise or high protein diet), SrCr (renal, not interfered by diet/exercise) (0.8-1.2), Glu (70-110) CMP: comprehensive metabolic panel (chem 12) X-ray- radiation, fx CT- radiation, computerized tomography, is basically a 3D x-ray, contrast v no contrast (renal impairment no IV contrast), MRI – no radiation, sound waves, no metals (pacemaker, transplant) Lower Respiratory Tuberculosis Case Study Nursing Science: Physiological Integrity Case Study: History Mr. B is a 38 year old homeless male consults presents to ED c/o cough, sputum production and mild hemoptysis. He has had evening rise of temperature for the past one month and claims to have lost 30 lbs. over a three month period. 1. What can you identify in this patient's history that put him at high risk for this present illness? • Cough • Sputum production • Mild hemoptysis • Unexplained weight loss • Comes from an at risk population - homeless 2. Based on the clinical presentation, the MD suspects tuberculosis (TB). Assuming the diagnosis is accurate, what microorganism causes TB? How did Mr. B get infected with TB (think from the route of acquiring causing microorganism)? • Organism - Mycobacterium tuberculosis • Route of Infection - TB is released as droplet nuclei into the air from an infected person when they cough, sneeze, sing, or speak. These nuclei are inhaled by others who then become infected. 3. Based on the history of Mr. B, it is very likely that he was exposed to TB many years ago but until recently became active. What are the difference between active and inactive TB? Why Mr.B's inactive TB became active? • Active TB - Positive TB test with symptoms present. Highly infectious. • Inactive TB - Positive TB test indicating that an individual has the bacteria in their system, but no symptoms are present. 5-10% of those with a positive TB test will go on to develop the disease at some point in their life. Not infectious. • Reinfection can occur when the patient becomes immunocompromised. Mr. B's Physical Exam Findings On exam, Mr. B appeared to be chronically ill and wasted. Cavernous breath sounds are heard over the right apex. 4. The MD suspects TB and orders a series of tests. Place the interventions in the order that they should be performed. 1. Perform a PPD intradermal skin test 2. Have a CXR performed 3. Institute airborne precautions 4. Obtain sputum culture 5. Notify the Department of Health 5. After the PPD skin test. The result of Mr. B will be considered positive if, after 48-72 hours, he develops an induration that measures over mm? What is the rationale? Think from different patient populations. • Mr. B is homeless and therefore categorized in the “at risk” population. In addition, based on the history he provided, he is suspected to be immunocompromised. Those who are immunocompromised have developed a decreased response to tuberculin, so smaller indurations are graded as positive. Therefore, if the induration measures over 5mm, Mr. B tests positive for the PPD test. 6. How to conduct a PPD skin test? route? read time window? how to interpret? Clinical significance? False positive in what kinds of populations? • Intradermal injection of 0.1 mL tuberculin in ventral side of forearm. Patient must wait a read time window of 48-72 hours before having the test read. If the injection has a reaction, it will show an “induration” at the site, described as a hardened, raised (maybe swollen) bump, the diameter of the induration is measured and graded according to the patient’s risk-level. o Healthy, no-risk → positive if induration > 15mm o Immune but high-risk (IV drug users) → positive if induration >10mm o Immunocompromised → positive if induration > 5mm • An induration of a certain size means the patient is sensitive to tuberculin (have already encountered in and developed antibodies that react to it) testing positive, and likely has a TB infection. • A false positive PPD test can occur in low risk populations that have previously received a BCG (Bacillus Calmette Guerin) vaccine. 7. What's the isolation precaution for Mr. B? Criteria to discontinue isolation? Visitor education? • TB is an airborne precaution isolation. This means that the germs are so small that they can travel through the air and affect you. People with TB need to be in a negative pressure room. The patient should wear a mask. The staff who enter the room need to wear a fitted N95 mask, a gown, and gloves. A patient could discontinue this isolation once there are no signs or symptoms of infection, and has 3 negative AFB smears. This can be confirmed by a chest x-ray and blood tests. Visitors should be limited, and if they do enter the room, they need to be informed of the risk. Immunocompromised people should not visit someone who is on airborne isolation. 8. What's the best time to collect sputum culture? Clinical significance? Protocol for sputum specimen collection? • Before collecting sputum, have the patient rinse his or her mouth out with water. It is best to collect specimen in the early morning before breakfast to get all of the overnight secretions in the sample. Collect sample from a coughing secretion (sputum only). • A sputum sample collection is clinically significant because it is the best way to diagnose active TB. You can also test the effectiveness of the medications you are taking by collecting a sputum sample daily to see is the infection is reducing. • Obtain doctor’s orders to collect the sample. Make sure the container that your patient will be spitting into is not contaminated. Collect the sample before administering any form of antibiotics. Protocol would be to adequately label the container to ensure that the sample is from the desired patient. A smear and culture will be done on the sample to determine the degree, or presence of infection. • Need 3 consecutive negative sputum 9. What's the clinical significance of having CXR in Mr. B? What would you see on CXR on a confirmed TB patient? What diagnostic exams are used to confirm the diagnosis of active TB? • A chest x-ray is beneficial for this patient because TB usually resides in the lungs. Though the scan the doctor can visualize the infection. A CXR of an active TB patient should show consolidation in the lungs. The picture below shows what a positive chest x-ray for a patient with active TB would look like: • The TB skin test can show that a person has been infected with TB, but it does not tell whether the person has latent or active TB. The skin test can also be a false-positive. The blood test does the same, it only will show if the person has been in contact with the virus, not if it is latent or active. The chest x-ray and sputum culture will confirm active TB. Nursing Science: Pharmacological Considerations o Both lungs are resonant by percussion with one exception: the right mid-anterior and right mid-lateral lung fields are dull. o Auscultation reveals bilateral diminished vesicular breath sounds. Bronchial breath sounds, rhonchi and late inspiratory crackles (are heard) in the area of the right mid-anterior and right mid-lateral lung fields. The remainder of the lung fields is clear. Nursing Science : Physiological Integrity • 6. The MD orders CBC with differentials. What would you find from CBC to confirm the diagnosis of pneumonia? What else lab results will you find from CBC? What are the normal ranges? From the CBC, results showing elevated white blood cells–particularly elevations in neutrophils and neutrophil bands– would help confirm a diagnosis of pneumonia. Other lab results that you would find from a CBC include red blood cell count, white blood cell count, hemoglobin, hematocrit, mean corpuscular volume (MCV: average volume of red cells), mean corpuscular hemoglobin (MCH: average amount of hemoglobin per red blood cell), mean corpuscular hemoglobin concentration (MCHC: the average concentration of hemoglobin in the cells), and platelet count. With differentials, each group of white blood cells is broken down into a percentage. Differentials give the percentages of: neutrophils and neutrophil bands, lymphocytes, monocytes, eosinophils, and basophils. Normal Lab Values: • HB: o 13.2-17.3 g/dL in males o 11.7-15.5 g/dL in females • Hct: o 39-50% males o 35-47% females • WBC: 4-11x103 µL • Platelet: 150-400x103 µL • RBC: o male 4.3-5.7x106/µL o female 3.8-5.1x106/µl • MCV: 80-100 fL • MCH: 27-34 pg • MCHC: 32-37 % • Neutrophils: 50-70% • L: 20-40% • M: 4-8% • E: 0-4% • B: 0-2% • Neutrophil Bands: 0-8% a. b. c. d. • 7. The MD orders CXR. Which CXR would confirm the diagnosis of pneumonia? What is the difference between Xray, CT scan and MRI? What will be different in regarding to patients' preparation (think from radiation, contrast, claustrophobia, medications to hold)? CXR B would confirm the diagnosis of pneumonia. X-ray CT: Computed Tomography MRI: Magnetic Resonance Imaging Uses radiation Uses radiation Does not use radiation. Patient Preparations: X-ray: - Remove jewelry and metal objects from area being imaged. Patient must remain motionless during the exam (excessive movement could alter results). CT: - If intravenous contrast is used, patient needs to be NPO 4-8 hours before the test - Can cause mild claustrophobia or anxiety - Remove all jewelry/metal in the CT field - Pregnant women cannot have a CT scan - Renal impairment: cannot have scan with contrast - Stop taking diabetic drugs like Metformin MRI: - Contraindications: ferromagnetic metal implants or other magnetic fragments within a patient’s body (ie. sharpnel or bullets). Implants such as aneurysm clips, vascular stents, pacemakers, cochlear implants, surgical screws and staples, joint implants, and intrauterine devices. - Patient can become claustrophobic so provide sedatives before hand if necessary. • 8. You are about to collect a sputum culture from this patient. What is the common nursing protocol regarding sputum culture collection? Rationale? Common nursing protocol regarding sputum culture collection is as follows: * Take sputum sample before starting patient on antibiotics (taking sample after antibiotics can cause inaccurate/inconclusive results, as the organisms that would normally be detected may not grow after exposure to the antibiotic). 1. Instruct the patient to expectorate sputum into container after coughing deeply 2. Obtain sputum not saliva 3. Obtain specimen in early morning after mouth care because secretions collect during the night 4. Collect sputum in sterile container (sputum trap) during suctioning or by aspiration secretions from the trachea 5. If unsuccessful, try increasing oral fluid intake unless fluids are restricted 6. Send specimen to laboratory promptly 7. Results take 48-72 hours • 9. What's the common causing organisms for hospital or community acquired pneumonia? What are the differences in regards to treatments? The common causative organism for community acquired pneumonia (CAP) is Streptococcus pneumoniae. The common causative organisms for hospital acquired pneumonia (HAP) are Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Acinetobacter species. Treatment for CAP includes empiric antibiotic therapy which is the initiation of treatment before a definitive diagnosis or causative agent is confirmed (this should be started as soon as CAP is suspected). Empiric antibiotic therapy is based on experience and knowledge of drugs known to be effective for the most likely causative agent (in this case Streptococcus pneumoniae). With CAP, the decision to treat the patient at home or in the hospital depends on the patient’s age, vital signs, mental status, presence of co-morbidities, and physiological condition. Treatment for HAP is initiated based on known risk factors, onset of pneumonia (early or late stage), and most likely causative organism (in this case E. coli, K. pneumoniae, A. species). Antibiotic therapy is adjusted once the causative agent is confirmed through sputum culture. • CXR: Right lower and middle lobe infiltrates, suggests pneumonia. • Sputum culture: Pending. • The diagnostic finding confirm the diagnosis of right lung pneumonia. The physician decides to admit Mr. A and orders the following: o 1.Bed rest; o 2. Specimens for C&S; o 3. Oxygen via nasal cannula; o 4. Administration of an antibiotic. Nursing Science : Management of Care • 10. What will be the isolation precautions for Mr. A? What kinds of patient you may place in the same room with Mr. A? Mr. A will be placed on isolation for droplet precautions, meaning that he can only be placed in the same room as other patients with pneumonia as well. All who enter the room must wear PPE consisting of gloves, gown, and mask as well. They must also practice strict medical asepsis, wash their hands before and after entering the patient’s room, wash or gel hands before and after providing care or upon removing gloves. Handling any respiratory devices must be done with sterile aseptic care. • Dyspnea absent except during exacerbation • Clinical symptoms intermittent • Smoking not cause • Stable disease course • Infrequent sputum 2. In order to expedite M.B. admission, you delegate some nursing actions to the nursing assistive personnel (NAP). What are the possible relevant actions can be delegated? • Obtain patient's vital signs • Obtain patient’s height and weight • Apply telemetry monitor • Orient patient to call bell system, TV controls, and bed controls • Able to suction tracheostomy with supervision 3. This patient's ABG results are: pH 7.31; PaO2 68mmHg; PaCO2 58mmHg; HCO3- 32mEq/L; SaO2 85%. You would interpret that these findings indicate what respiratory status? Respiratory acidosis Patient has CO2 trapping hypo ventilating (keep CO2 inside) Asthma hyperventilating (exhale lots CO2) repiratory alkalosis brown back 3. Based on the results of ABG, what high priority nursing interventions should be implemented? Encourage patient to pursed lip breathing and deep breathing with effective coughing which will help clear secretions to increase oxygen delivery to the lungs, and pursed-lip breathing will prevent bronchiolar collapse and air trapping, reducing carbon dioxide retention. The oxygen rate should not be increased because in patients with chronic hypercapnia, the stimulus for breathing becomes low oxygen levels, and higher oxygen administration may cause respiratory arrest. Give patient Oxygen (goal 88-92 O2 sat) Negative pressure helps CO2 to be eliminated. 3. When you review the results of other lab tests (esp. CBC and BMP) and CXR, what you would expect to find as a result of M.B's exacerbation of COPD? (Hint: think from XCR, HCO3-, RBC counts etc) *Elevated Hct above normal range which is 37-48 % due to low availability of oxygen and possibly enlargement of right side of heart. *hypercapnia *RBC elevated An increased number of red blood cells (erythrocytosis). This occurs when the person has had low oxygen levels in the blood (hypoxemia) for a long period of time. Red blood cells carry oxygen in the blood. Because of damage to the lungs, a person with COPD often cannot get enough air. The body reacts by producing more red blood cells to try to increase the amount of oxygen in the blood. PaCo2 will go up. *hypoxemia (PaO2<60mmHg, SaO2<88%) and then hypercapnia (PaCO2>45mmhg) later in disease. *Polycythemia develops as a compensation for hypoxemia (HgB>20g/dl) *chest x-ray might reveal barrel chest, hyperinflation, cardiac enlargement and flat diaphragm. 6. What kinds of diet will be appropriate for M.B to meet his nutritional needs? The diet that is recommended is a high-calorie, high-protein diet. Around 3L/day recommended of fluids. It is recommended to eat 5-6 small meals daily to avoid bloating and satiety. Nursing Science : Pharmacological Considerations 7. How should you teach M.B about using MDI? (Hint: open mouth, hold breath, shake, rinse mouth, spacer, how to know it is empty etc) Step 1: take off cap and shake inhaler Step 2: Breathe out all the way Step 3: hold inhaler the way your doctor says. (Pics below) Step 4: Start breathing in slowly through your mouth, and press down 1 time on inhaler. Keep breathing in slowly as deep as possible Step 5: Hold your breath as you count to 10 slowly (if you can). Step 6: For inhaled quick relief medicine (B-agonists) wait 1 minute between puffs. Usually 2 puffs recommended. Step 7: rinse mouth after done to prevent candida Clean inhaler: look at hole and see if there is powder around the hole. If so clean inhaler. Remove the metal canister. Rinse only the mouthpiece and cap in warm water. Let them dry overnight. Know when empty: For medications that are used every day, calculate the number of days the inhaler should last by dividing the number of puffs in the canister by the number of puffs taken daily. For quick release or prn medication, count each puff. Never put canister in water to see if it is empty. 8. You formulate a nursing diagnosis of imbalanced nutrition: less than body requirements for this patient. What appropriate nursing interventions should you implement? Assess dietary habits, recent food intake. Note degree of difficulty with eating. Evaluate weight and body size. Patient in acute respiratory distress is often anorectic because of dyspnea, sputum production, and medications. In addition, many COPD patients habitually eat poorly, even though respiratory insufficiency creates a hypermetabolic state with increased caloric needs. Encourage a rest period of 1 hr before and after meals. Provide frequent small feedings. Avoid gas-producing foods and carbonated beverages. Avoid very hot or very cold foods Administer supplemental oxygen during meals as indicated. Table 5-48 COPD Drugs LABA (take regularly) serevent SABA (rescue) albuterol (CNS activation, palpitations), xopinex, Cortcosteroid cortisone, prednisone, Medrol SAMA-atrovent (COPD) LAMA- Spiriva (COPD) COMBO meds: Advair (corticosteroid and LABA)- rinse mouth after use Rinse mouth out after corticosteroids. Know side effects, nurse action, medications ASTHMA • Case Study: History o C.J., a 20-year-old female college student, is admitted to the emergency department (ED) with a severe asthma attack after engaging in a tennis match . She is accompanied by her tennis partner, who drove her to the ED. On an initial assessment you see that she is sitting in an upright position , using her accessory muscles to breathe. She appears restless and anxious . Her vital signs are T 98.4° F (36.9° C), P 128, R 34, BP 160/82. Auscultation indicates faint wheezing on inspiration and expiration , and her expiration is prolonged . Hyperresonance is noted upon percussion. C.J. manages to tell you that she has a long history of asthma but that this is the worst attack she has ever experienced. She cannot identify any triggers that she may be sensitive to and has never been tested for allergens. She does not smoke or use alcohol. She uses a bronchodilator metered-dose inhaler about once a day but has misplaced it. She also has a peak flow meter but has never used it. • Nursing Science : Physiological Integrity and Adaptatio • 1. What is the pathophysiology nature of asthma? What's the difference between asthma and COPD in pathophysiology? Asthma reversible, younger group 2. What ABG results you may expect to find during C.J's early attack? (Hint: In the early stages of an acute asthma attack, hypoxemia with hypocapnia (decreased PaCO2) occurs as the patient attempts to hyperventilate and maintain adequate oxygenation and ventilation. The hyperventilation and hypocapnia cause an initial respiratory alkalosis reflected by an increase in pH. As the attack increases in severity, the ABGs deteriorate to normocapnia and then ultimately to hypercapnia, hypoxemia, and respiratory acidosis) Hyperventilate, respiratory alkalosis • Nursing Science : Safe and Effective Care • 3. What nursing actions/interventions have the highest priority for C.J. at this point? • O2 sat, give oxygen comfy position 4. Treatment for C.J. will be initiated immediately. What initial interventions that you would anticipate to be implemented for this patient? (Think from nursing actions, medication treatments) SABA, albuterol, oxygen, solumedrol, duo neb, IV fluids The diagnostic study used to properly diagnose a pleural effusion would be that of a chest x-ray and/or a chest CT scan. These images can give a picture of what is going on in the pleural space, checking for a variety of problems such as masses, air or fluid (pleural effusion). A chest scan can show if there is abnormal volumes of fluid build up and where the fluid build up is located in the pleural space. • 4. What procedure is used to remove fluid/air from pleural space to alleviate respiratory distress or obtain a specimen for diagnostic purposes? The proper procedure for the removal of air/fluid in the pleural space is called a thoracentesis. A thoracentesis is a procedure in which a physician will insert a needle into the intercostal space to alleviate fluid/ air out of the pleural space into a sterile container. The contained fluid can be then sent to laboratory or pathology to be tested for diagnostic purposes. Typically between 1000 -1500 ml of fluid are removed at one time. Able to check fluids to see what is causing pleural effusion • Management o Right pleural effusion has been confirmed with CXR and CT scan. o Thoracentesis is ordered. • 5. What positions should the patient assume for the procedure of thoracentesis? The patient should be sitting upright at the edge of the bed, leaning forward, with their arms placed on top of the table. This allows the fluid to accumulate at the base of the lung, and make it easier to locate and remove. 6. What are the serious complications from thoracentesis? What may patient present if you suspect some serious complication develop after the procedure? Serious complications can include hemothorax, intra abdominal organ injury, air embolism, and post- expansion pulmonary edema. Some signs include chest or abdominal pain, coughing, or localized infection. Indications for an x-ray would be if air was aspirated during the procedure, dyspnea, or hypoxemia. Pulmonary Embolism Lower Respiratory Case Study- Pulmonary Embolism 1. What can you identify from the patient's history that put her at high risk for the present illness? Oral contraceptives pose a great risk for PE. Smoking additionally puts a person at high risk for PE. Finally, as a computer programmer, I suspect she spends much of her day sitting. Although this patient was otherwise healthy, these risk factors may explain her illness. 2. Based on the clinical presentation, pulmonary embolism is suspected as a result of DVT. What is the non-invasive diagnostic study that can identify DVT? Venous doppler can be used to diagnose DVTs. This test is essentially an ultrasound that is used along the major veins of the extremities (mainly lower extremities). A doppler can diagnose superficial or deep venous thrombosis. 3. What types of patient population have the highest risks for developing a PE? The patients with the highest risk of pulmonary embolism are patients who have post op, cancer, bariatric,left sided heart failure, patients who are immobile, patients who had surgery within the last 3 months, patients with a history of DVT, obese patients, childbirth, cancer patients, and patients who have a clotting disorder. 4. A patient has a total hip replacement. What clinical presentations from the patient indicate that the plan to prevent postoperative thrombus formation has been ineffective? Clinical presentations would be SOB, dyspnea, cyanosis, tachycardia, sudden chest pain, hemoptysis, hypoxemia, and tachypnea. Additionally, DVT symptoms might include unilateral calf pain or swelling. 5. What blood work would you be expected to find in Mr.D's case? (Hint: D-dimer, aPTT, PT/INR?) What's the clinical significance of D-dimer? D-dimer is a lab test that measures the amount of crosslinked fibrin fragments. These fragments are the result of clot degradation. Disadvantage is that it is neither sensitive or specific. If D-Dimer is elevated, may be a clot. If it is normal, rule out DVT. Monitoring lab results to insure therapeutic ranges of INR if pt is taking Warfarin. aPTT for IV heparin. Anticoagulant therapy should continue for at least 3 months. INR levels are drawn at intervals and Warfarin dosage is adjusted. 6. The MD orders heparin IV drip and Coumadin (Warfarin) after the sign of PE and DVT have subsided. What are the mechanism differences between heparin and Coumadin treatment in Mr.D's case? What are the antidote to each medication? What lab values should you monitor for each medication? Heparin is an anticoagulant that prevents the formation of blood clots by binding to antithrombin III to make it more actively bind to thrombin which then inhibits thrombin from forming clots. This mechanism differs from the mechanism of Coumadin which involves the interference of the vitamin K cycle, which is involved in the coagulation factors needed to form clots. The antidote to heparin is protamine sulfate while the antidote to Coumadin is vitamin K. The lab values we would monitor for heparin are activated partial thromboplastin time (aPTT), and for coumadin, the international normalized ratio (INR) which both measure how long it takes for the blood to clot. Monitor aPTT and INR for therapeutic dose not prophylaxis. Hypertension Case Study Questions 1-7 ● J. G. is a 50-year-old African American man who comes monthly to the community health screening for blood pressure checkups. He says he had some headaches lately and a little dizziness. ● Initial Objective Data ● Alert and oriented and cooperative ● 5 feet 10 inches, 240 pounds ● Blood pressure 172/94, pulse 90, respirations 24, temperature 97.0° F ● Subjective Data ○ Is a truck driver and eats a lot of fast foods ○ It is hard to eat healthy on the road ○ Smokes one-half pack of cigarettes per day for 30 years ○ Drinks at least a 6-pack of beer a day when he is not working ○ States that he feels fine and is not a “hyper” person ○ Has heard that BP drugs “make you impotent” 1. What misconceptions about hypertension should be corrected? a) “Hyper” and hypertension are the same diagnosis. Being hyper and having hypertension are two completely, unrelated topics. Having a diagnosis of hypertension does not have anything to do with what type of characteristics you have as an individual, such as being calm, passive, hyper or energetic. Being Hyper just means you are hyperactive or have a lot of energy. Hypertension is the diagnosis of having high blood pressure, meaning that the force of your blood against your artery walls is too high. This diagnosis is based on certain body characteristics and habits, but none having to do with your personality. b) Hypertension is called the “silent” killer because it does not always cause visible symptoms. Hypertension is often called the “silent killer.” This is because it is frequently asymptomatic until it becomes severe and target organ disease occurs. c) Erectile dysfunction is something all men have to deal with when taking antihypertensive medications. 13. What information should the nurse include in discharge education for this patient? side effects, what to look for, when to call DR. 14. Whats the difference between hypertensive urgency and Hypertensive emergency? Hypertensive urgency has severe symptoms and need to be managed right away Loop directics lasix Beta blocker (lol) Ace inhibitor lisino(pril) ARBS cozaar, benapril KNOW!!!! representative med, side effects, relevant teaching Chest Pain Mr. Cameron is a 66-year old Caucasian gentleman who has a history of CAD. This morning while he was gardening, he felt “some chest pain.” He drove himself to the ED. ● 1. Is every chest pain of a cardiac origin? If not, how to differentiate a chest pain of cardiac origin from non-cardiac origin based on clinical presentations? What are the clinical significance? In approximately half of the cases, chest pain is of cardiac origin, either ischemic cardiac or nonischemic cardiac disease. The other half is due to non-cardiac causes, primarily esophageal disorder. Pain from either origin may occur in the same patient. Classic coronary pain--or angina--involves a substernal pressure that commonly begins with exertion and is relieved by rest. However, some patients experience angina in the absence of physical exertion or emotional stress, and not all chest pain that begins after exertion is angina. Atypical chest pain must be differentiated from other types of chest pain, including chest wall pain, pleurisy, gallbladder pain, hiatal hernia, and chest pain associated with anxiety disorders. Careful examination of the chest wall is essential, and abnormal heart sounds can tell you a great deal. ● 2. Did this patient make the right decision driving himself to ED? What would you advise him for future reference? This patient made the right decision in driving himself to the ED. Pain presenting to the chest region may impact breathing and circulation. For future reference, I would advise that pt is more aware of when and what causes onset of chest pain. If pt feels pain growing than he should drive to the hospital or possibly call 911 if he is unable to operate a vehicle. ● 3. What are the risk factor you anticipate this patient has which may contribute to this scenario? Age, High cholesterol, smoking, obesity, stress, lack physical activity, diabetes ● 4. Based on the clinical presentation, what diagnostic tests you anticipate this patient may have? What is the clinical significance for each test? EKG- checks for signs of heart disease, able to see if abnormalities in heart contraction, past heart attacks CXR- reveals abnormalities that may affect heart (size of heart, lung issues, condensed areas) ECHO- tests for cardiac function and hyperdynamics (blocked arteries, fatty material) Cardiac/Nuclear stress test- how heart performs when on treadmill or under chemical agents. EKG, heart rate, and blood pressure are continuously monitored and will have abnormal results if a blockage is present. Results of blockage will show up as decreased blood flow to a part of the heart. C-reactive Protein- tests for inflammation inside blood vessels Cholesterol panel (total, HDL, LDL, triglycerides)- hypercholesterolemia is an additional risk factor Glucose, Hemoglobin A1c- tests for diabetes, additional risk factor Troponin I- rule out Heart attack, tests for cardiac muscle damage, every 8 hours x3 Myoglobin-cardiac ● Mr. Cameron indicated that his pain is in the middle of his chest and radiates to his left arm. It is about 6/10. He added that this was not the first time he had this pain. He said that the pain usually starts few minutes after gardening or climbing stairs and is relieved by rest. Angina is suspected. ● 5. What type of angina did Mr. Cameron just described? Chronic stable angina, which refers to chest pain that occurs intermittently over a long period of time with a similar pattern of onset, duration, and intensity of symptoms. It is often provoked by physical exertion (e.g. gardening or climbing stairs), stress, or emotional upset. Although most angina pain occurs substernally, it may radiate to other locations, including the law, neck, shoulders, and/or arms. The pain of chronic angina usually lasts only a few minutes and commonly subsides when the precipitating factors are resolved (e.g. resting). ● 6. Based on the pathophysiology of Mr. Cameron&#39;s conditions, his coronary artery had been blocked by at least ? (hint: a percentage number) Since Cameron has a history of CAD his ischemia was most likely secondary to atherosclerotic plaque in which the artery is usually blocked (stenosed) 70% or more (50% or more for the left main coronary artery). ● 7. Which diagnostic test can be utilized to confirm or visualize the occlusion/obstruction of the coronary arteries? ECG, chest xray, exercise stress test, coronary computed tomography, echocardiogram, electron beam CT scan, ECHO. Angiogram ● 8. What&#39;s the pathophysiology cause of Mr.Cameron&#39;s chest pain? (hint: think from O2 demand and supply) The pain is caused by increased demand for O2 or a decrease supply of o2. Could be caused by narrowing of one or more coronary arteries by atherosclerosis, so in this case could be due to the lack of O. Chest Pain Mr. Cameron is a 66-year old Caucasian gentleman who has a history of CAD. This morning while he was gardening, he felt “some chest pain.” He drove himself to the ED. Mr. Cameron indicated that his pain is in the middle of his chest and radiates to his left arm. It is about 6/10. He added that this was not the first time he had this pain. He said that the pain usually starts few minutes after gardening or climbing stairs and is relieved by rest. Angina is suspected. You connect Mr. Cameron to ECG and observe the following rhythm: 9. How do you interpret the above rhythm? • T wave is inverted , indicating myocardial ischemia . (yellow) T wave shows ventricles “repolarizing”/ relaxing, so an inverted T wave is showing them depolarizing. • P wave present (pink). P wave shows atrial contraction, originating in the SA node. o P wave is on the smaller side • QRS present, ventricles are contracting. (green) • PR interval is 4-5 boxes, good finding. Note no widened PR interval. (light pink) 10. T-wave inversion on EKG indicate ? • The inverted T wave can mean anything from a normal life to sudden death. Some people are able to function with this heart rhythm, while it causes others to die suddenly. Acute coronary ischemia, CNS injury, and a pulmonary embolism can all cause an inverted T wave. • In this situation, the T-wave inversion indicates acute coronary disease resulting from myocardial ischemia, or a myocardial infarction. 11. The ED MD examines this patient and based on the ECG findings diagnosed him angina. The MD orders MONA, what does MONA stand for? • MONA stands for morphine, oxygen, nitroglycerin, and aspirin. Its an acronym used to help medical professionals treat acute coronary syndrome. • Aspirin- anticoagulent 12. Before you administer Nitroglycerin, what should you assess? What's the interaction of NTG with Viagra? What are the two most common side effects of NTG? Rationale and how to treat these side effects? • Before administering nitro, nurse should screen for: o low blood pressure - nitro causes vasodilation and therefore further lowers BP o orthostatic hypotension - same reason as above o use of Viagra - nitro interacts with Viagra, causing severe hypotension o headaches – nitro causes a redirection of blood to brain, if there is already an increased, treat with Tylenol o intracranial pressure it could cause bleeding o keep for light and moisture o ASK are you taking any other medications? Viagra (as for men and women)? Able to take if after 24 hours after taking Viagra o Will know its working if it starts burning Major pathology of (AMI) acute myocardial infarction - indicates irreversible myocardial injury resulting in necrosis of a significant portion of myocardium - "acute" denotes infarction less than 3-5 days old Nonreperfusion type: in which case the obstruction to blood flow is permanent Reperfusion type: in which the obstruction or lack of blood flow is long enough in duration (generally hours) but is reversed or restored after myocardial cell death occurs. TPA treatment- dissolve clot PCA- Goal of treatment - Reperfusion of the partially blocked or completely occluded artery • 29. What are the treatment options of AMI? Interventional Management (To open the occluded artery) Fibrinolytic Therapy - works by dissolving clots which are obstructing blood flow. The goal is to open the blocked artery through lysis of the clot. PCI (Percutaneous Cardiac Intervention) - Invasive diagnostic and therapeutic procedure that is used to visualize and establish coronary reperfusion. - Uses a catheter (thin, flexible tube) and small balloon threaded through a blood vessel in the groin or arm and guided to heart to open a blocked or narrowed coronary artery - Catheter is placed in/performed via the femoral or the radial artery and less commonly performed via the brachial or ulnar artery. Conservative Management (If patient is not a candidate for the options above) Treat Symptoms - morphine, O2, aspirin, and heparin drip (to prevent another MI and thrombi from being formed) Prevent recurrence • 30. What is fibrinolytic therapy? How does it work? The administration of a fibrinolytic agent results in lysis of the acute thrombus, resulting in recanalization or opening of the obstructed coronary artery and restoration of blood flow to the affect tissue. How does it work: used to lyse acute blood clots by activating plasminogen, resulting in the formation of plasmin, which cleaves the fibrin cross-links causing thrombus breakdown. Most common agents used: tPA (tissue plasminogen activator), alteplase, reteplase, streptokinase, tenecteplase, urokinase • Mr. Cameron has a history of atrial fibrillation and has been taking Coumadin (Warfarin) and therefore he is not a candidate for fibrinolytic therapy. Instead, urgent cardiac catheterization is scheduled. • 31. You are preparing to care for Mr. Cameron after the cardiac catheterization performed through the femoral artery. Which position and activity level should the patient assume? Bed rest for 6-12hrs, maintain leg straight, apply sand bag over IV insertion site (at least 5lbs), do not bend for about 6hrs, do not elevate head of bed more than 15 degrees • 32. Mr. Cameron is diabetic. Which medications should you hold after the procedure? (hint: insulin, glipizide, metformin?) Metformin, hold for 48 hours (for kidney function) but monitor blood sugar levels and provide insulin if needed Heart Failure  Mrs. M. H. developed 5/10 substernal chest pain (on a 0-10 pain scale) and shortness of breath. Admitting Data: • Name: M. H. • Age: 60-year-old. • Gender: Female. • Medical History: o HTN x 15 years. o MI in 2012. o Atrial fibrillation in 2012. o Hyperlipidemia x 7 years. • Surgical History: o Appendectomy in 2000. • Allergies: o PNC (skin rash). o Lisinopril (angioedema). • Psychosocial History: o Marital status : married. o Education level : some college. o Social resources : none. o Spiritual resources : attending Church on holidays. o Occupation : administrative assistant. o Employment : retired due to disability . o Smoking : smoked for 5 years; quit in 2012. o Alcohol : social drinker (only on holidays, soft liquor). o Recreation drugs : during high school only.  1. Substernal pain is highly associated with cardiovascular events. True OR False? true 2. Notice how many pillows the patient is using and what that may indicate? Paroxysmal nocturnal dyssnpea ??? 2. From this patient's history, what are the modifiable and non-modifiable cardiovascular risk factors? Age, gender, ethnicity, family hx, smoking, alcohol use, 4. Knowing that Mrs. M.H developed HF after MI. Her MI was most likely Q-wave MI or non Q- wave MI? Q-wave MI deeper and longer Q wave, deprived of circulation for more than 2 hours MI cell going into necrosis 5. Since the patient is allergic to Penicillin, she should not receive Amoxil (Amoxicillin) Vancomycin Cefepime (Maxipime) Levofloxacin (Levaquin) 6. Since the patient is allergic to Lisinopril, her alternative would be: Lisinopril (ace inhibitor) if can’t tolerate use ARB; Statin-check liver enzymes to monitor function, assess for muscle pain Atenolol (Tenormin) Simvastatin (Zocor) Amlodipine (Norvasc) hypoactive o Vital signs: A, A, O x 4. No neuro. deficit. PEERLA. o Head, Face, & Neck: Head normocephalic; no facial droop; neck supple; no lymphadenopathy; JVD is noticed with head of bed at 45o. o ENT: No significant findings . o Cardiovascular: skin evenly warm; PMI at6th ICS ; S4 and S3 and murmur. auscultated. 1+ pitting edema to mid shin bilaterally. o Pulmonary: mild dyspnea , tachypnea , and orthopnea . Fine crackles bilaterally. Dullness on percussion at lower bases. o Gastrointestinal: bowel sounds; last bowel movement was 2 days ago. o Genitourinary: urine output 300 mL during day shift. (normal 30ml per hour) o o no muscle weakness; fatigue . • Diagnostic findings on the day of care: Hematology: Test Normal Range Patient's Result Hemoglobin Male: 13.2-17.3 g/dL Female: 11.7-15.5 g/dL 10.5 g/dL Hematocrit Male: 39% - 50% Female: 35% - 47% 31% RBC Male: 4.3 - 5.7 x 106/mm3 Female: 3.8 - 5.1 x 106/ mm3 3.6 x 10 6 /UL Platelets 150 - 400 x 103/mm3 210 x 103/mm3 WBC 4.0 - 11.0 x 103/mm3 8.8 x 103/mm3 HGh and HCT stroke volume and cardac output decreased, not enough blood circulation, kidney not enough blood- kidney produces erytheroprotein which affects HnH and HCT Complete Metabolic Panel (Chemistry): Test Normal Range Patient's Result Sodium 135 - 145 mEq/L 131 mEq/L Potassium 3.5 - 5.0 mEq/L 3.3 mEq/L Chloride 96 - 106 mEq/L 100 mEq/L Magnesium 1.5 - 2.5 mEq/L 2.0 mEq/L Phosphate 2.4 - 4.4 mg/dL 3.4 mg/dL Calcium 8.6 - 10.2 mg/dL 8.1 mEq/L Creatinine 0.6 - 1.2 mg/dL 1.9 mg/dL BUN 6 - 20 mg/dL 28 mg/dL Ammonia 15 - 45 mcg/dL 20 mcg/dL Albumin 3.5 - 5.0 g/dL 3.6 g/dL Bilirubin 0.2 - 1.2 mg/dL 1.0 mg/dL Glucose 70 - 100 mg/dL 130 mg/dL CO2 22 - 28 mEq/L 24 mEq/L Creatinine most sensitive for renal function, high level renal impairment BUN can be affected by high protein diet Time Temp. HR BP RR SpO2 Pain 08:00 99.1 oF 92 irregular 110/70 22 92% on NC 2 L/min 0 o Neurological and Pupils: Skin: edema ; no pressure ulcers. Musculoskeletal: Coagulation: Test Normal Range Patient's Result PTT 25 - 35 seconds 37 seconds PT 25 - 35 seconds 44 seconds INR 1.0 2.0 INR elevated on purpose due to taking coumodin, 2 is therapeutic dose Coagulation: Test Normal Range Patient's Result BNP <100 pg/L 200 pg/L Troponin <0.1 ng/mL <0.1 ng/mL Lipid Panel: Test Normal Range Patient's Result Cholesterol < 200 mg/dL 256 mg/dL HDL Male: > 40 mg/dL Female: > 50 mg/dL 40 mg/dL LDL 140 - 280 mg/dL 280 mg/dL Triglycerides <150 mg/dL 210 mg/dL  16. Discuss the pathophysiology of abnormal lab values and physical assessments. • Discuss above Medications: • CHF after IMI- Ace inhibitor drug of choice • Digoxin- hypokalemia- may experience toxicity, too much hyperkalemia- normal dose digoxin not effective ( need stronger dose) Analysis and Synthesis: Mrs. M. H. is a patient who has cardiovascular risk factors (i.e. HTN, smoking, MI) that lead to heart failure. Based on her symptoms, the patient is having stage III (or stage C) heart failure. She is hospitalized for acute decompensated heart failure as evidenced by her significant cardiovascular (edema, JVD) and pulmonary (dyspena, crakcles, desaturation) symptoms as well as diagnostic tests (high BNP, cardiomegaly and infiltration on CXR). Based on the findings from the history, physical exam, and diagnostic studies, the patient's prioritized needs are: 1. Physiological Needs (High Priority) ▪ Oxygenation : as evidenced by dyspean, orthopnea, desaturation, and crackles. ▪ Circulation: as evidenced by edema, JVD, extra heart sounds, cardiomegaly, fatigue, low EF, murmur, high BNP. 2. Physiological Needs (low Priority) ▪ Fatigue : as evidenced by activity intolerance. Drug Dose Route Classification Specific Indica Lasix (Furosemide) 40 mg x once IV Loop diuretic Edema Lasix (Furosemide) 20 mg BID PO Loop diuretic Edema Hydrochlorothiazide 25 mg daily PO Diuretic thiazide HTN Capoten (Captoril) 12.5 mg daily PO ACE-inhibitor HF/remodeling Warfarin (Coumadin) 2 mg daily PO Anticoagulant Thromobosis Digoxin (Lanoxin) 0.125 mg Q 8 hours IV push over 3 min Inotropic agent Impaired contract Potassium 2 tabs daily PO Supplement Hypokalemia Zocor (Simvastatin) 2 mg HS PO Antilipids Hyperlipidemia Morphine 2 mg PRN Q 6 hours for pain IV push over 3 min Opiod analgesic Chest pain ▪ Skin Integrity : as evidenced by edema. 3. Basic Care and Comfort ▪ Mobility: ▪ Skin care ▪ anti-embolic ▪ positioning ▪ Elimination: ▪ Strick intake and output ▪ Nutrition: ▪ Adjust diet ▪ Rest and Sleep 4. Pharmacological and Parenteral Therapies ▪ Adverse effect of medications: ▪ Allergic reaction to medications: ▪ Dosage calculation: ▪ Physiologic response (i.e.VS, lab): 5. Health Promotion and Maintenance ▪ Immunization: ▪ Slowing disease progression: ▪ Risk factors modification: ▪ Sexuality: ▪ Self-Care: 6. Safety and Infection Control: ▪ Allergies: 7. Psychosocial Needs: ▪ Anxiety: ▪ Nonadherence: EKG Chest Pain Please interpret the following strip and regularity, calculate heart rate and explain relevant nursing care accordingly. 1. This looks like normal sinus rhythm-no nursing intervention necessary. Regularity:R-R intervals are constant Rate:The atrial and ventricular rates are equal P wave:P waves are uniform. There is one P wave in front of every QRS complex. PRI: PR interval is 0.12 sec QRS: QRS complex measures less than 0.12 sec Heart rate calculation method( count number of R-R intervals in 6 Seconds -6 seconds is 30 big boxes on ECG and then multiply by 10) In this case we have 10R-R X 10=100 is the HR. 2. Sinus Bradycardia Regularity: R-R are constant HR: 50 Nursing Care: Treatment for bradycardia depends on the type of electrical conduction problem, the severity of symptoms and the cause of your slow heart rate. If you have no symptoms, treatment might not be necessary. If symptomatic: Atropine is the drug of choice. 3. • The inverted T wave can mean anything from a normal life to sudden death. Some people are able to function with this heart rhythm, while it causes others to die suddenly. Acute coronary ischemia, CNS injury, and a pulmonary embolism can all cause an inverted T wave. • In this situation, the T-wave inversion indicates acute coronary disease resulting from myocardial ischemia, or a myocardial infarction. 11. The ED MD examines this patient and based on the ECG findings diagnosed him angina. The MD orders MONA, what does MONA stand for? • MONA stands for morphine, oxygen, nitroglycerin, and aspirin. Its an acronym used to help medical professionals treat acute coronary syndrome. 12. Before you administer Nitroglycerin, what should you assess? What's the interaction of NTG with Viagra? What are the two most common side effects of NTG? Rationale and how to treat these side effects? • Before administering nitro, nurse should screen for: o low blood pressure - nitro causes vasodilation and therefore further lowers BP o orthostatic hypotension - same reason as above o use of Viagra - nitro interacts with Viagra, causing severe hypotension o headaches – nitro causes a redirection of blood to brain, if there is already an increased intracranial pressure it could cause bleeding 13. For ASA treatment, what are the common route? dosage? Nursing consideration? • The common route is oral, initial dose is 162-325 mg, then usually baby aspirin is given (81 mg, 3-4 times a day) or up to 325 mg (ED dose) daily. Complication of higher doses include gastrointestinal bleeding (dangerous because can go undetected). • Since it is an antiplatelet agent. Nurse should check for any anticoagulation disorders before administering aspirin, and aspirin shouldn’t be given before or after surgeries (might cause internal bleeding). • Do not give NSAIDs with aspirin, can exacerbate bleeding. 14. For Morphine, what are the commonly used dosage? Route? Rationale of giving morphine? • In the emergency department, doses range based on HCP preference, but morphine is usually given 2-4 mg IVP Q5-15 minutes PRN for immediate relief of chest pain unrelieved by nitroglycerin, reduction of anxiety, and to help vasodilate vessels, reducing the preloading (strain on ventricles of the heart). 15. Knowing this patient also has COPD, how will that impact the oxygen therapy decision? • The COPD patient is used to a hypoxic environment, and needs the hypoxic state to passively drive them to breathe. Therefore, we should not try to administer too much O2 for dyspnea and provide enough therapy to maintain O2 sat at > 90% or PaO2 > 60 mmHg The ED physician orders the following tests: CBC, BMP, 12-lead ECG, cardiac enzymes, coagulation panel, and CXR. 16. What cardiac enzymes that are routinely tested in ACS? • Myocardial fraction of creatine kinase (CKMB) - The amount of creatine kinase in the blood. Used to monitor the amount of damage to cardiac muscle over time. CK-MB is found at 25-30% in cardiac muscle as opposed to skeletal muscle 1%. • Troponin T - a relatively poorer cardiac marker than CK-MB because it is less sensitive and less specific for myocardial injury. Cardiac regulatory protein that controls the calcium mediated interaction between actin and myosin. • Troponin I - a better cardiac marker than CK-MB for myocardial infarction because it is equally sensitive yet more specific for myocardial injury. An elevated level denotes positive for an AMI. • Myoglobin - It is released more rapidly from infarcted myocardium than troponin and CK-MB and may be detected as early as two hours after an acute myocardial infarction. Found in skeletal muscles so it is not specific to the heart and is rarely use. • C-Reactive Protein (CRP) indicates acute inflammation and predicts risks of MI. 17. Which cardiac enzyme is the most sensitive and specific for myocardial damage? How often does it get tested? Other clinical significance? • Troponin I is the most sensitive and specific for myocardial injury. • In the hospital these levels are checked 3 times over 24 hours, so every 8 hours. The values will continue to go up in the amount of time. • Troponins are a class of regulatory proteins that control muscle contraction. Testing troponin levels helps in the diagnosis and prognosis of AMI. • Troponin Values: o Troponin I < 0.4 ng/mL o Troponin T < 0.2 ng/mL 18. Why another 12-lead ECG is ordered here? • A repeat ECG may be necessary to assess the effectiveness of drug therapy at one point in time. Deviations from the normal sinus rhythm can also indicate heart problems. 19. When you reassess Mr. Cameron. He says the pain is now 4/10 but not complete relieved, BP 90/50, HR 110, SaO2 92%, RR 22. Why patient's BP dropped? • Nitroglycerin, which is a medication given for angina, helps to relieve chest pain but it is also a vasodilator so low blood pressure is a side effect. 20. Mr. Cameron tells you that he is not sure that the NTG is still good. How can you tell if NTG has expired or still active? Where should NTG be stored? • Active NTG should have a slight burning sensation if placed under the tongue. It should also be replaced every 6 months. Nitroglycerin should be in a dark, air-tight container (brown bottle) because it is photosensitive to light and air. Endocarditis Mr. Kobe Bryant is a 35 y/o African-American male who was admitted with fever and hypotension. A CBC was drawn and showed WBC = 13,000/mm3. His Echo showed "aortic valve vegetation" and "low ejection fraction". Vegetation- Plaque growing on valve, can visualize from echo, could break off and cause PE Ejection fraction: normal 50-70 The admitting physician updates the admitting diagnosis as "Infective Endocarditis". Once you know Mr. Bryant's diagnosis, you look to see if the Emergency Department RN did which of the following? Blood cultures * most relevant, positive staph or strep, negative- cant simply rule out IE due to slow growing, keep specimen growing x2 weeks, clean area, draw 2 different sides, 30 mins apart Sputum cultures * clean area Urinalysis* Occult Blood test * True or False. It is possible for someone with IE to come back with negative blood cultures. True* False Which one of the following reveals a risk factor / etiology for Mr. Bryant's condition? 2 congenital birth marks on backside A single episode of diarrhea about one month ago Family history of maternal and fraternal grandfathers with HTN Medical history of strep throat about 4 months ago* bacteria could move to heart Decreased Cardiac output related to valvular dysfunction manifested by low EF* Ejection fraction measures 65% normal 50-70 splinter hemorrhages* Cant stop antibiotics mid-way through b/c rheumatic heart disease, resistance to meds, and bacteria flow to kidneys Mr. Bryant is concerned about his diagnosis. He tells you, "I have no medical background - I play basketball. The doctor didn't explain this to me - Can you please tell me what is going on in my body?" Based on your understanding of the pathophysiology of infective endocarditis (IE), the following is an appropriate nursing diagnosis? Endocarditis related to pharyngitis manifested by hypotension and fever. Risk for infection related to group A beta-hemolytic streptococci infection Fluid volume excess related to decrease contractility manifested by hypotension https://youtu.be/vNuijvjGZBE On Day 2, you return for your second 12-hour shift. Which of the following findings indicates that the patient's endocarditis has worsened? Why? Serum potassium 4.8mEq/L normal 3.5- 5 Absent of murmur good WBC increases to 18,000/mm3* Clinical manifestations of IE could include which of the following? Select ALL that apply. Osler's nodes* Janeway's Lesions* Hemorrhagic retinal lesions* Onset of new aortic or mitral murmur* Low-grade fever* True.* auscultation of friction rub that correlates with patient's pulse.* True or False: Most cases of acute pericarditis are idiopathic. False. Chest Pain gets worse with breathing in and out b/c lung field has more pressure on pericardial sac Which of the following are classical symptoms of pericarditis? Select ALL that apply. auscultation of friction rub that correlates with patient's breathing. Prominent heart sounds. ST elevation in most leads in ECG.* Pleuritic pain that gets worse with inspiration.* Pain that worsens in supine position* Pericarditis & Chest Pain https://www.youtube.com/embed/eCbF9G2qt80?wmode=opaque What is the hallmark sign of acute pericarditis? Pericardial friction rub Pericardial Friction Rub https://www.youtube.com/watch?v=J1R8Oxgqhfk - Louder, can use computer. Which tests are useful in diagnosis of pericarditis? √ ECG ST elevation √ Echocardiogram pleural effusion, cardiac tamponade √ CBC √ ESR √ CRP Urinalysis Where would you best hear a pericardial friction rub? How would you describe it? What position would you put the patient in to hear this sound best? The pericardial friction is best heard with the stethoscope placed at the lower left sternal border of the chest with the patient leaning forward. It sounds like a scratching, grating, high-pitched sound. Sitting position. Outer layer of pericardial sac rubbing. Even if they hold their breathe you can hear this. Two major complications that may result from acute pericarditis are what? The 2 major complications are pericardial effusion and cardiac tamponade. Pericardial effusion is a buildup of fluid in the pericardium. Cardiac tamponade occurs as the pericardial effusion increases in volume which results in compression of the heart. Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess presence of pulsus paradoxus, you should: subtract the diastolic bp from the systolic bp. √ note when Korotkoff sounds are audible during both inspiration and expiration. auscultate for a pericardial friction rub that increases in volume during inspiration check the electrocardiogram (ECG) for variations in rate pericardial effusion may be there- need to use pericardialcentesis You understand that pericardiocentesis is possible with your patient. As you prepare yourself for this, you remember that this procedure involves what steps? 1. Prepare your access site. As with most procedures in the cath lab, there is more than one way to do it, but commonly used is method of the subxyphoid approach . 2. Position the patient in the catheterization laboratory at a 30 to 45 degree, head-up angle to permit pericardial fluid to pool on the inferior surface of the heart. Palpate the subxyphoid process, about a finger- width below the edge of the rib. This location avoids difficulty in advancing the catheter through fibrous tissue closer to the lower part of the sternum itself. 3. Sterilely prepare the site and drape, covering everything but a small area around the subxyphoid process. Give local anesthesia, usually lidocaine over the anticipated needle puncture site. 4. Insert the pericardial needle. Advance the needle through the skin at first perpendicularly to chest, then angled lower to a plane nearly parallel with the floor, moving under the subxyphoid process toward the left shoulder. More lidocaine can be given gently through the pericardial needle as it is advanced. If the patient is obese, a longer needle and some force may be required to tip the syringe under the subxyphoid process toward the heart. To measure pericardial pressures, a stopcock on the needle is connected to a pressure line and transducer. 5. Advance the needle into the pericardial space. Passage of the needle through the skin may block the needle with subcutaneous tissue. Flush any tissue that may have accumulated during passage before entering the pericardium, a tough fibrous membrane. Use caution when advancing the needle through the diaphragm, as excessive forward pressure may result a sudden jump through the pericardium into a cardiac chamber. 6. Confirm intra-pericardial position with hemodynamics or echo contrast imaging. 7. Place the pericardial drainage catheter. The needle is exchanged over a guide wire for a multiple side- hole catheter. Pericardial and RA pressures are measured again, the effusion is aspirated, and pressures are measured once more after the pericardial space is empty . 8. Obtain serial echocardiograms before and after removal of the pericardial drainage catheter to confirm the absence of fluid re-accumulation. Remove the pericardial drain after 24-48 hours. Should fluid recur, consider a surgical pericardial window. You realize that anxiety and acute pain are two major nursing diagnoses relevant for your patient. What intervention would aid your patient with anxiety? Select ALL that apply. √ Simple, complete explanations of all procedures √ Simple, complete explanations of possible causes of pain * Alleviate pain with anti inflammatory medications as prescribed Position patient at 30 degrees Position patient at 45 degrees* Positive Homan's sign shiny taut appearance on skin of lower legs, ankles, and feet* True. False.* (PAD) Provide an overbed table for support Leave the patient alone as often as possible See a real patient with Pericarditis https://www.youtube.com/embed/Edtxhc4Rixk?wmode=opaque Peripheral artery disease What is the difference between Peripheral artery disease and peripheral venous disease? How do the wounds differ? Which is more superficial? PAD- arthrosclerosis plaque, cold feet and toes, no hair distribution, palor, dry, no enough nutrients, edema, dangle leg, numbness, lose sensation, prevent injuries, no bare foot, Diagnose: Pallor, pale, prosthesis, uselessness, pain, intermittent pain while walking (cortication) rest and walk in a little bit Test: Doppler, segmental BP- if drop from above the knee to below knee is less than 30 degrees It is PAD Systolic BP from brachial to radial should drop PAD or DVT- elevate leg, warm to touch, wet, hair growth, wet ulcer, edema, more superficial Skin temp, pulse, color to check patency under bypass is fine Your patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe. You would expect to find which of the following? swollen dry scaly ankles a large amount of drainage from the ulcer prolonged capillary refill in all the toes * Intermittent claudication is peripheral venous problem. True or False. Mitral- stenosis, regurgitation MRS ASS Mitral regurgitation (systoic murmur) mitral stenosis (diastolic murmur) Aortic- S1 S2 S1 S2 AV valve Semilunar valves Systolic murmur (btw S1 and S2) Diastolic Murmur (after S1 and before S2) Normally: mitral valve opens blood goes to ventricle Mitral stenosis- not enough blood flowing through Mitral stenosis- Left atrium blood to Left ventricle not enough blood flows from LV so pressure in LA is higher Mitral regurgitation- no blood should flow back from LV-LA, but the blood does flow to LA so the pressure in LA increases Mitral Valve- apex 5th intercostal space midclavicular line Aortic- semilunar valves; stenosis- Aortic not able to open completely, not enough blood so it pools in LA All physicians take money Regurgittaion- L ventricular hypertophy