—— Medical-Surgical Nursing[RESPIRATORY SYSTEM OXYGENATION etabolism, Process of acquiring, transporting, utilizing 02 to support cellular ™ body function thereby maintaining COMPONENTS: here to the cells and carbon dioxide Respiration~ process in which oxygen is transported from atmosp! camed from the cells to the atmosphere. Function: + Primary functions: 1. Provides oxygen for metabolism in the tissues 2. Removes carbon dioxide, the waste product of metabolism ~ Secondary functions: 1, Facilitates sense of smell 2. Produces speech 3. Maintains acid-base balance 4, Maintains heat balance 5. Maintains body water levels Process: — movement of air to and from the alveoli which has 2 aspects: inhalation and exhalation which is controlled byffMiBAllla and)PBAR - exchange of oxygen and carbon dioxide between alveoli and blood from an area of high concentration to low concentration with out ATP expenditure. - - availability and movement of for transport of gases, nutrients and metabolic waste products ‘Structures: 1. Airways — Upper Airway * Functions of Upper Airways - Transports gases to lower airway = Serves as a protection of the lower airways - Warming, filtration and humidification of inspired air © Nares ~ Opening of the nose 1. Nostrils + (Anterior/ External Nares) - Leading from the nasal cavity to the outside 2. Chonae + (Posterior/ Internal Nares) ~ Opening leading from nasal Cavity to pharynxPharynx = Funnel shape tube that extends from nose to larynx = _ Serves as a common opening between respiratory and digestive system = Composed of three parts: 1. Nasopharynx 2. Oropharnx 3. Laryngopharynx Larynx - voice box - Located above the trachea = contains 2 pairs of vocal cord, the true and false cords - the opening between the true vocal cords is the GLOTT!: role in @BUBhINg, the Paranasal Sinuses = Airfilled spaces lined with mucous membrane, the skull. = Itprovides resonance during speech = Named according to their location: 5, which plays an important is located within some of the bones of © Frontal © Ethmoidal © Sphenoidal © Maxillary Epiglottis Leaf-shaped elastic flap structure at the top of the larynx ‘od from entering the tracheobronchial tree by closing over the glottis - Prevents fo during swallowing — Lower Airways (Tracheobronchial tree) Trachea - Windpipe = Located in front of the esophagus = Conduets air towards the lungs Its mucosa is lined up with mucus and cilia to trap particles and carry them towards the upper airway. Contains cilia which are microscopic hair like projections that is needed to remove foreign particles through their rapid, coordinated, unidirectional upward motion. Bronchi = The right and left primary bronchi begin at the carina = The function is for air passage = Divide into secondary or lobar bronchi that enter each of the 5 lobes of the lung = Are lined with cilia, which propel mucus up and away from the lower airway to the trachea where it can be expectorated or swallowed+ The primary bronchus: TERT BRONCHUS | RIGHT BRONCHUS Narrower, Wider Longer Shorter, More horizontal More Vertical * Bronchioles tertiary then into bronchioles. > The primary bronchus further divides into secondary, = The terminal bronchiole is the last part of the conducting Bee ochre = The terminal bronchiole contains no cilia and do not partici: for patency - Contain no cartilage and depend on the elastic recoil of the lung for P: irway * Respiratory Acinus ~The chief respi an - ae isa ae indicate all structures distal to the terminal bronchiole - Functions for gas exchange through the respiratory membrane - Consists of: 1. Respiratory bronchiole 2. Alveolar duct 3. Alveolar sac (the basic units of gas exchange) © Lungs = Located in the pleural cavity in the thorax ~ _ Extend from just above the clavicles to the diaphragm, the major muscle of inspiration ~ The respiratory structures are innervated by the phrenic nerve, the vagus nerve and the thoracic nerve = sides of the lungs: RIGHT LUNG LEFT LUNG Larger Narrower 3 lobes (upper, middle, and lower) 2 lobes - Two types of pleura © Parietal Pleura -linésith@linside of the:thoraeielavity, includi , including the of the diaphragm eames * Visceral pleura - covers the pulmonary surfaces - Athin fluid layer, which is produced by the cell the visceral pleura and the parietal pleura, and ~ Blood flows throughout the lungs via the pulmonary circulation syst system s lining the pleura, lubricates allowing them to glide smoothly © Thoracic cavity ~The chest wall composed of the sternum and the ri oy i cage ~_Tresnyieseertey he HRRRGEM the mest mportantrespatony muscleRespiratory Membrane The respiratory membrane is composed of two epithelial cells: = Type 1 pneumocyte * Most abundant, thin and flat. * This is where SERS ccurs, * Lines the alveoli - Type 2 pneumocyte * — Secretes the lung surfactant * Surfactant is a phospho! rotein that reduces the surface tension in the alveoli; without surfactant, the avea would collapse - Type 3 pneumocyte © The A@GRSBREGETh at ‘estsforeignimaterBlhd acts as an important defense mechanism Accessory Muscles of Respiration = Scalene muscles: Elevate the first 2 ribs - _ Sternocleidomastoid muscles: Raise the sternum - Trapezius and Pectoralis muscles: Fix the shoulders The Respiratory Process 1, Diaphragm descends into the abdominal cavity during inspiration causing negative pressure in the lungs Negative pressure draws air from the atmosphere (greater pressure) to the lungs (lesser pressure) 2 3, Inthe lungs, air passes through the terminal bronchioles (alveoli) capillaries the rest of the bod to oxygenate the body tissues 4. At the end of inspiration, the diaphragm and intercostal muscles relax and the lungs recoil 5, As the lungs recoil, pressure within the lungs becomes higher than the atmospheric pressure, causing the air, which now contains carbon dioxide and water (cellular waste products), to move from lungs to the atmosphere Effective gas exchange depends on the distribution of gas (ventilation) and blood (perfusion) in all 6. portions of the lungs Functions of Lower Airways: & * Clearance Mexhanism * Cough ~Mucociliary System * Macrophages © lymphatics General functions of the Respiratory System * For Gas Exchange * Acid Base Balance - imbalance can cause alterations in arterial pH © Elimination of CO2 * Fluid Balance * Temperature RegulationSo i ——V3—nrK——— ee REVIEW ACADEMY Diagnostic Tests 2 Chest xRay anata lean! appearance ofthe lungs Provides information regarding the Preprocedure: * Remove all metal objects ner breath * Assess client's ability to breathe and hold his/her ru petareperorming rodlographi * Question women regarding pregnancy or its possibil studies Postprocedure Help client to get dressed Sputum Specimén Ke ldenttfying organisms or Obtained by QRBSHSHsHh or RRGHBAYSUEHOP in order to assist in identifying orga abnormal cells Preprocedure * Determine the specific purpose * Early morning sterile specimen * Rinse mouth with water + Obie SESSA * Instruct client to take several deep breaths and then cough deeply to obtain sputum Postprocedure * Mouth care . sain ASAP. Dire the larynx, trachea and bronchi with a fiber opticy Preprocedure * Informed consent Maintain PO) . © Obtain in © Assess results of * Remove dentures and eyeglasses * IlVaccess as necessary and SE08HGH)s prescribed © Prepare’ -quipment . available Postprocedure * Monitor vital signs especially after deep sedation : # brechial son = : ~wihen airwans go ito 5 i lonitor bloody sputum, respiratory status and complications Signa ak > whaerieg, of * Complications: bronchospasm or bronchial Perforation, indicated by facial or i i) crepitus, dysrhythmias cane hypoxemia and pneumothorax1s ee _ . 7 issue sampl re obtained from b i Central lung ma: ry using Tonchoscope with the help of utrasound guidance nn housewives = Monitor for signs of Pe et * An invasive fluoroscopic procedure ~ Acatheter is inserted throu; one of its branches, 1 ONCE 2n injection EGG? o SSA - Preprocedure ‘gh the antecubital or femoral vein into the pulmonary artery or Obtained informed consent * Maintain NPQ © Get initial © Assess results Establish IV access 4 Administer sedation as prescribed Instruct patient tolfigSH Instruct patient that he or she MSH, RaUSEa, or salt) ‘* “Have emergency resuscitation equipment available Monitor any reaction to the dye Assess insertion site for bleeding nd "pleural space via transthoracic aspiration — - Preprocedure ‘© Obtain informed consent ¢ Obtain vital signs Prepare the client «© Assess results of coagulation 5 oor he arms and shoulder supported by iti jent should b ch thé arm: Note position of patient s! erupted a table at the bedside or an wore (eH Preprocedure * Determine i ill be administered * Consult with the HCP if * Instruct client to void and to wear Jopserlot!i@) * Remove dentures * Instruct the client to * Instruct client to ~ Postprocedure May resume a normal diet and any bronchodilators that were withheld before the procedure é A trasnsbronchial biopsy and a transbfonchial needle aspiration may be performed to by culture or cytological examination ~ Preprocedure * Obtained informed consent * MaintaidiNB@istatus * Inform patient that a (GESIBGEEEHA Will be used but a sensation of pressure during needle insertion and aspiration may be felt. . Administe fSialgasigs andiSdativéajas prescribed - Postprocedure * Apply a dressing to the biopsy site * Monitor for drainage, bleeding, signs of respiratory distress, signs of pneumothorax and air emboli ees ient for chest gaeeee if prescribed , - Winjection of ae is used. If not, a ventilation-perfusion V/Q sean will be done ~ Perfusion scan: evaluates blood flow to the lungs ~ Ventilatory scan: determines the patency ofthe pulmonary airways ~ RAGORTUEIaE|HSyBELIN|eCLEY for the procedure = Preprocedure + Assess for * Remove jewelry * Review breathing methods © Establish arllMiaeeaey” s + Administeisedation if presefibel - Postprocedure ® Monitor the client for reaction “Instruct the client that the TSE Ot mtcuee ns)+ Anintraden | \n intradermal injection to help diagnose various infectious diseases ~ Special Considerations: ¢_Usea shin ste that fre of excessive body hal dermatitis and blemishes. Advise patient not to scratch the test site to prevent infection and possible abscess formation. = Measurement of the dissolved oxygen and carbon dioxide inthe arterial blood to indicate acid-base state and! ‘sample because the suctio procedure will deplete the client's oxygen, resulting in inaccurate ABG results = Arnoninvasive test that registera oxygen saturation ofthe client's hemoglobin ~ Reems NOT | psensor fe placed on the cent fing G69? GH, EERIE o HSTEREBAIR measure oxygen saturation which then is displayed on a monitor. ae if the reading A pulse oximetry reading | and a reading lower than Measure clot formation and lysis Normal level: Less than or equal to 250 mg/ml D- Normal fibrinogen: 200-400 mg/ml Respiratory Treatments . (pursed lip breathing and diaphragmatic breathing) 0 Inhale through the nose ‘and exhale through the mouth © Place a hand over the abdomen while inhaling; the abdomen should expand with inhalation and contract during exhalation © Client should exhale 3 times longer than inhalation . Pe © Percussion, vibration, and postural drainage to loosen secretions in the affected area of the central airways lungs and move them into more Place a layer of material between the hands and the client’s skin Contraindications: © Unstable vital signs © Increased intracranial pressure © Bronchospasm ec 0000* History of Pathological Fractures © Rib Fractures © Chest incisions © Procedure: * Position client appropriately + ViBFStEHERe area while the ¢ ‘* Monitor for respiratory tolerance * Provide * Incentive Spirometry f © Sitting or upright position © Place mouth tightly around the mouthpiece EIS ea he © Inhale slowly to raise and maintain the flow rate indicator between t marks © Hold breath fdflsyseconds and then exhale through pursed lips © Instruct to repeat TORIES * Nasal cannula for low flow © For client with GhroniealNewAintioR and for SRRRERMOMBENIUSE) o fitekipn! ° : * Nasal-high flow respiratory therapy © ForiiYPGXEMIePlients in mild to moderate (fESBiRatORVaIseaSs + Simple face mask © For SHOFEtEFRA|oxygen therapy or to deliver oxygen in an SmereenEy © Used to delive AOE60%6IIf concentration © Minimum offSipm) © Venturi Mask ° For at risk for or experiencing (EUteirespIratOry fallGFe? © High-flow oxygen delivery system © Anadapter is located between the bottom of the maskand the oxygen ‘© Partial rebreather mask © Apartial rebreather mask consists of mask with a reservoir ba concentration of ith flow rates When the oxygen concentration needs to be raised; i that provided an oxygen 5 not usualprescribed for a client with COPD« Nonrebreather mask o Foraclienta Is whe ee ay eae o Can deliver an Fi02 higher thar : lepending on the Tracheostomy collar and T-bar or T-plece e160 somber 20 © To deliver high humidity and the desired Pract ioral ‘oxygen to the client with a tracheostomy; ead the T-bar or T-piece is used to deliver the desired FiO2 cote ef + Facetent sy © Used instead of a tight-fitting mask from the _ cient who es RUNS peudd-up of Corin care heen sho SSE RSESTERSORSER | 29 (COPD) requires low levels of oxygen delivery atte (Uitiffbecause a low arterial oxygen level is the client’s primary drive for breathing. RTE 2 ee © Types ‘© Pressure-cycled ventilator Gate ger he ur op Wetting her a foo vet atle-te forarhe each on “fait wh = The ventilator pushes air into the lungs until a specific airway pressure is reached. = Itis used for SHOPEBERERS © Time-cycled ventilator = The ventilator pushes air into the lungs until a FIRESBKILIME has elapsed © Volume-cycled Ventilator ‘The ventilator pushes air into the lungs until a preset volume is delivered ‘Aconstant tidal volume is delivered regardless of the changing compliance of the lungs and chest wall or the airway resistance in the client or ventilator © Modes: © Controlled = Client receives a set tidal volume at a set rate Used for clients who cannot initiate respiratory effort | © Assist-Control if the client attempts to initiate a breath, the ventilator blocks the effort Tidal volume and ventilator rate are preset on the ventilator Takes over the work of breathing for the client.Fie = * Delivers the preset tidal volume when the client initiates a breath while allowing the cling to control the rate of breathing. dotintor continues to detiver a * Ifthe client’s spontaneous ventilatory rate increases, the rane Preset tidal volume with each breath, which may cause hyperventilation and respiratory alkalosis. ° Simetroniedintermitent mandatory venison SIM) * Similar to assist-control ventilation in that the tidal volume and ventilatory rate are preset n the ventilator. * Allows the client to breath spontaneously at her or his own rate and tidal volume between the ventilator breaths 5 Gan be used as = ieamninigOey "When SiMv i the © Nursing Considerations: © Assess vital signs, lung sounds, respiratory status, breathing patterns and chest for bilateral expansion Monitor skin color Obtain Pulse oximetry reading Monitor ABG Results Assess the need for suctioning and observe the type, color, and amount of secretions. Assess ventilator settings. Assess the level of water in th@lHUngiMgeand the because extremes in temperature can damage the mucosa in the airway. 220000 © Ensure that the. o Ifa o Empty the ventilator tubing when moisture collects. © Have resuscitation equipment available at the bedside [ Cause of Ventilator Alarms Low-Pressure Alarm High-Pressure Alarm ‘© Increased secretions are in the airway ° Decorate ak poo rear © Wheezing or bronchospasm causes Client's airway cuff occurs. decreased airway size. © The client © The endotracheal tube is displaced. SERRE brpeeife. ‘©. The ventilator tube is obstructed because of water or a kink in the tubing. Client coughs, gags, or bites on the oral endotracheal tube. Client is anxious or fights the ventilator. co Possible Complications: : - used by the application of positive pressure, which increases intrathoracic ° hypomgy pressure and inhibits blood return to the heart i complications such as, 7 oe o Respiratory comp! eemeeaees wee? Cac ibe foe ge ha ing aie= (© Gastrointestinal alterations such as nif nutrition is not maintained Muscular deconditioning ~ reduction of wichiting, Wied glow Hhetefad mausele Ventilator dependence or in ‘Weaning: Process of going from ventilator dependence to spontaneous breathing ° creased gradually until the client is breathing on his or her own without the use of the ventilator. © (HBIEES clients taken off the ventilator and the ventilator is replaced with a T-plece OF continuous postive airway pressure, which delivers humidified oxygen so that client will be allowed to breathe spontaneously © Pressure support: predetermined pressure set on the ventilator to assist the client in respiratory effort which will be decreased gradually. (CPAP vs BIPAP ‘© Continuous positive airway pressure (CPAP) © Maintains a set positive airway pressure during inspiration and expiration; beneficial in clients who have acute e + Bilevel positive airway pressure (BIPAP) ‘0 Provides positive airway pressure during inspiration and ceases aifway support during expiration; there is only enough pressure provided during expiration to keep the airways opens ive «Both CPAP and BiPAP impove oxygnenation through airway support ° ° ° ° RESPIRATORY CONDITIONS CONDITIONS OF THE UPPER AIRWAY e " © Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus membrane + Most common site- anterior sepfurn Causes: = Trauma — Infection = Hypertension = Blood dyscrasia ~ diver of Be Gord (Kenoyil = Cancer : - Rheumatic Heart Disease Collaborative Management Focus: ia SOBSIUEHORY 1. Position patient UBRH® @AAIRENORNSTE. RE and afitatia 2._Apply direct pressure. 3. unrelieved, administe help decrease bleeding and to prevent aspiration 4. Assist in BCUORSUKEH) and ABBBNPAEKINE (rminimun of 3-5 days) for posterior bleeding |, silver nitrate, gel foams tooe He Oey, Upper airway infections \lanwel- depos? wo Saeed ° Feute and chronic Allergic, non-allergic and infectious | Acute and chronic 5/5 cae een, ©. Fiery-red pharyngeal io, nnnottee Facial pain nan © Nasal congestion ‘0 Tenderness over the oer purpe ecked exudates ° Sreaing paranasal sinuses : d and tender cervical Scien © Purulent nasal Enlarge ° Headache discharges Iymph nodes . 0 Ear pain, headache, Fever malaise, sored roat dental pain © Difficulty swallowing o Deereaved sense ofsmell|o _Cough may be absent Laboratory tests 1. CBC. 2. Nasal Swab/Throat Culture - To (SAR MNGSusaEVESEESHICN) ‘Nursing Management Positioning: HOB elevated Increase'fluid intake to loosen seeretiRs is Utilize room vaporizers onsteam inhalation Administe! e000 © Warin garglé for the relief of soretthroa® Provide oral hygiene ‘0 Instruct patient to refrain from'speaking as much as possible © Provide writingimaterials Medical Management Pharmacotherapy: — Administer medications to relieve nasal congestion 0 Decongesant- EISEN ASESR Administer prescribed analgesics © DOC:(BBAIEIIM (complete dose as prescribed) , Administer lozenges (to soothe throat) o BEGUSGIEy stepsisy Assist in surgical Interventions: > Monitor for AGSSIOTECOMPNANS like FRGRIRBIR, GERI, an SBSEEECETOn aS___c_coXx“—_ Infection and inflammation of the tonsils Can be viral or bacterial (most complicated) infection jpeta hemolytic streptococcus ‘Most common organism- Group A- Clinical Manifestations Difficulty swallowing : ‘© Sore throat and mouth breathing 0 Enlarged, reddish tonsils Smee waitin eae : Es teat SU fase ne an sorry Byes WNL s Medical Management = Antibiotics: DOC: = Surgery: nd ABBRBUBEROMIr chronic cases and abscess formation) Nursing Management = Pre-operative care © Informed Consent (0 ‘Routine pre-op surgical care Uncoaccrds - (Reve — Post-operative care cassie CCAS = ALR Maintain Patent Airway «Position: Most comfortable sama head turned to side (unconscious patient right after surgery). If patient is 4 onselw Maintain oral airway, ‘AppIVIGERGBl to the neck to ‘Advise patient to refrain from talking and coughing “are given when there is no bleeding and gag reflex returns © Prevent Bleedin; © Patient sWallowsifreawently Vomiting of large amount of bright red or dark blood © Pihinereased, restlessand Temperaturesisincreased” © Promote Rest© Diet ° TE ..rcsuce © Farthe fst 2¢hours + Genera SoR OAT ate -7 aay er the surgery. Sudden an Ing deterioration ofthe wate weeds i Occur hc eee eet ihe bo) re eaRETEBTIORES = Occurs when, ‘CAUSES: ‘+ CNS depression- Head trauma, edatives + CVS diseases- i : iseases- MI, CHF, pulmonary emboli adie : ‘© Airway irritants- Smoke, fumes < * Endocrine and metabolic disorders- Myxedema, metabolic alkalosis * Thoracic abnormalities- Chest trauma, pneumothorax PATHOPHYSIOLOGY 1. Decreased Respiratory Drive > Brain injury, sedatives, metabolic disorders -> Impair the normal response of the brain to normal respiratory stimulation» Dysfunction of the chest wall -> Dystrophy, MS disorders, peripheral nerve disorders disrupt the impulse transmission from the nerve to the diaphragm > Abnormal ventilation 3. Dysfunction of the Lung Parenchyma > Pleural effusion, hemothorax, pneumothorax, > Obstruction interfere ventilation and prevent lung expansion SS I Manifestations Dyspnea Cyanosis Restlessness Headache Altered respirations and breath sounds Altered mentation Tachycardia Hyperfension Cardide arrhythmias Respiratory arrest Interventions Identify and treat the cause of the respiratory failure to maintain the, P2200 CDG Oe Place the client ina - Encourage!- Administer Prepare the client for The acute episode of is characterized by away hyperactivity to various im that results in recurrent Is marked Episodes of wheezing, breathlessness, chest tightness, and coughing ass¢ obstruction that may resolve spontaneously Itis often! It. Mechanism: Hypersensitivity (allergy) Mediator: Histamine (trigger) Jociated with airflow PATHOPHYSIOLOGY Immunologic/allergic reaction histamine release produces three main airway responses: ‘© Edema of mucous membranes ‘# Spasm of the smooth muscle of bronchi and bronchioles © Accumulation of tenacious secretions Assessment Findings Family’ 0 Client HistBRWiOReezeHT 2 Clinical Manifestations © Respiratory distress: slow onset of shortness of breath, expiratory whee72, expiratory phase, air trappin ugh, diaphoresis, increase in ( p absent or diminished lung respiratory rate: acute sounds, hyper resonance, tachypnea with hyperventilation, decreased oxygen saturation ‘olonged I: E (Inhalation: crackles, prolonged f respiration, inspiratory retractions, pr Exhalation) ratio» : tachycardia, ECG changes, hypertension, decreased cardiac contractility, pulsus paradoxus, cyanosis s: anxiety, restlessness, fear and disorientation ° Nursing Management . (leaning forward) Positioning: © Bed rest « Administer{O2tolmalitainyPa0zatmorethansOmmigy «Suction airways as required « (Deep\Breathing’ExerciBe to divert patient's attention to illness 0 Client education «© Onthe intermittent nature of symptoms and need for long term management ind measures to prevent episodes ‘the management of medication and proper administration r * To © About © About the correct use of] ‘About developing an asthma action plan with the primary HCP and what to do if an asthma episode occurredNEVIEW ACADE Medical Management Pharmacotherapy © Administe - B—Agonist (Epinephrin' = Methylxanthines (aminophy = Corticosteroids . lar a the bronchial wall i i ; congenit © Caused by, er respiratory tract fections; cons (altered bronchial structures); lung tumors as prescribed , Albuterol, te! lline and d rbutaline) jerivatives) and elastic structure of ral defects recurrent lows Pathophysiology tly the lower Bronchiectasis is usually locali lobes. 1. Inflammation. The inflammatory process associated with pulmonary infection damages the ture and resulting i bronchial wall, causing a loss of its supporting stru ultimatel f stended and distorted, impairing mucociliary 2. Distention. The walls become permanently di clearance. Collapse. Th distal to the obstruction collapse. 4, Scarring. Inflammatory scarring or fibro: 5, Symptoms. In time, the patient develop: n, and an increased ratio of residual volume to total lung capacity. 6. Impairment. There is impairment in the tmatch of ventilation to perfusion and hypoxemia Clinical Manifestations fatigue, weight loss ed, affecting a segment or lobe of 2 1unB» most frequen e retention of secretions and subsequent obstruction ultimately cause the alveoli sis replaces functioning lung tissue. o Anore: Diagnostic tests 1. eveals sources and sites of secretions 2. CB Nursing Management © Nursing management focuses on alleviating the symptoms and helping patients ear? is.Chronic Bronchitis RS” ay (Cyanosis/ Duskiness + Edema) Inflammation of the bronchioles characterized by the presence of cough and sputum production for at least 3 months in each 2 consecutive years. ‘S/sx: 0 Persistent, 2B ewaaHFE sone on exertion Scattered rales and rhonchi Feeling of eis, ankle oil) Elastin — causes elasticity of the alveoli (rec © Elastase- remove/ destroys elastin . counteracts elastase i er ake Bi 44 S/sx: o With increase rate and de of nostrils, decrease expiratory excursion mean perfor dss enh ‘sounds with prolonged expiration, normal/ decrease fremitus — nm ~aic Ftd lwo, weg n, dyspnea, pth of breathing, flaring o Feeling of (@Dirtyuung” appearance upon X-ray Over distended Y” appearance of the lungs upon X-ray a Dx test: PCO2/ Normal and PO2 slightly / Normal PERIPHERAL EDEMA RHONCH AND WHEEZING Copyright 2013 Jorge Muniz {wawrmedcomic.com) “EMPHYSEMA PATHOLOGIC DIAGNOSIS: PERMANENT ENLARGEMENT AND DESTRUCTION OF AIRSPACES DISTAL TO THE TERMINAL BRONCHIOLECOPD Management | Nursing Management inst the gravity causing — Positioning ungs is pulled 262 © HOBIBIEVEREUIFro decrease exertion: In supine, exertion — Rest o To — DBE: © To increase airway co2 — Increase fluid intake © Encourage fluid intake up to[B90Qmmiidayy - Good oral care oo SNE” lmao — Diet low dilation of bronchioles and to increase expel of ‘to allow dil provides source of energy ° ° lps maintain integrity of alveolar walls o Moderate fats © Low carbohydrate diet limits carbon dioxide production (natural end product). The client has diffiéulty exhaling carbon dioxide. ° to maintain nutrition and|preventayspnee — 02 therapy 1 to 3 Ipm ) ° n. The drive for breathing may be depressed. Avoid cigarette smoking, alcohol, and environmental pollutants. These inhibit mucociliary ay 7 — Bronchial hygiene measures Medical Management Pharmacotherapy Administer ERBBERORAMES — vechce ides ot vicos ‘al counts ' © Guaiafenessin fio hebaw os cue! Sy eta Me Wwowearing weve AdministerfUNE) ~ ‘eattoun oe cheica) nue © Mucosolvan hecel ede) Toco nat Sie Sage Re vwas wena Adminis + ordered o Dextrometorphan © Codeine SPS Coughing given at wtyliy Ke el - Observe for drowsiness ~ Avoid activities that involve mental alertness, e.g drivin : ~ Causes decrease peristalsis thereby constipation 8 OPerating electrical machinesi from which can cause potential intrathoracic fe most comm. ctured ribe mn fractured because chest muscles least protect them. Splintered or HDS may penetrate the pleura and lungs. Clinical Manifestations ° especially SRINSBINGn ° an = eae © Fractures noted on chest x-ray Diagnostic tests L reveals area and degree of fracture 2 (later) Nursing Management * Provide BainiIiBH/controt * Place client in fo ease pain associated with breathing. © Instruct the client t ith the hands, arms or pillow Monitor client closely for complications. Assess for Observe for signs and symptoms of Administer orderediSRSRESI nj * Compleat of Seen: 20 or ore sites, resulting in free-floating rib segments. * Fracture of several ribs and resultant instability of the affected chest wall, * Chest wall is no longer able to provide the bony structure necessary to maintain adequate ventilation; Consequently, the flail portion and underlying tissue move Paradoxically (in opposition) to the rest of the chest cage and lungs. +The lil portion s sucked non inspiration and bulges ot on ea © The chest is pulled INWARD during inspiration, ° The 2 Bulges OUTWARD during expiration because the intrathoracic pressure exceeds atmospheric pressure. The patient has impaired exhalation ‘ autiously and monitor effects Clinical Manifestations Severe dyspnea; rapid, shallow, grunty breathing, diminished breath sounds © The chest will sans wages ‘on inhalation and OUTWARDS on exhalation also known as * Cyanosis, possible neck vein distension, tachycardia, hypotension ‘© Severe pain in the chestDiagnostic tests ABG Analysis 7 Nursing Management * Maintain an §B@HSIAWay and via endotracheal Bes + aeons economy Gs. SBP = '* Note changes in amount, color, and characteristi Maintain the client in FOIE BBIEE » Administer distressed Monitor increased respiratory demands Maintain bed rest and limit activity to reduce oxygen Monitor mechanical ventilation é sipeeRor severe ail ches * Prepare for intubation with mechanical ventilation, wit associated with respiratory failure and shock ‘ cous © Encourage turi * Prepare patient for S0RBen ‘© Partial or complete collapse of the lung due to an accumulation of air or fluid in the pleural space © Accumulation of atmospheric air in the pleural space, whichtresults in a rise in intrathoracic pressure and reduced vital capacity Types: Spontaneous pneumothorax: The most common type of air accumulates within the pleural space without an obvious cause. Rupture of a small bleb on the visceral pleura most frequently produces this type Of pneumothorax. —Yanef Criy Hsin Hic Open pneumothorax: Air enters the pleural space through an opening in the chest wall; usually cused SSRI NSeRCUNY — Tension pneumothorax: Air enters the pleural space with each inspiration but increased intrathoracic pressure and shifting of the mediastinal content, to th Sener € unaffected side (mediastinal shift). Rlewol Guity ayure “7 Afnasiteic Prsnure ‘The pleural cavity pressure is eatects \ Diagnostic tests Hui in feured space oes g ul hs oar at sin Re conity, { prowl gqaee 1 showin, : away from the fluid if greater than 250 ce pleural fluid 2 ‘may reveal bronchogenic carcinoma cc pleural flui 3. RR 21 conn Goo} If cause is cancer, pulmonary infarct positive for specific organismy empyema, ion, or tuberculosis; Nursing Management: Vary depending on etiology. In general: © Promote! Positioning: sitioy ‘0 promote ventilation! . : —$—Medical Management Pharmacotherapy © Admini 2 St RT 2s ordered to decrease pain. instillation of medication into pleural space (! ‘Assist with repeated thoracentesis. © Monitor ABG's (arterial blood gas) ‘© Monitor for shock! + Fortension pneumothorax: @GEIETRBRICEREEEN done if chest tube insertion 708 immediately done * «For open pneumothorax, SR BSS: and tape on tree a sides; of ‘* Forhemothorax, prepare for To prevent hypovolemic SHOCK, «day ix vcd Sion Oy, + Pleurectomy © Consists of surgically stripping the parietal pleura away from the visceral pleura 2 a produces am intense nammatary reaction thet rORTGReSSORESON erase) © Pleurodesis «© Involves the instillation of a sclerosing substance into the pleural space 18 2 thoracotomy tube the ‘A form of pulmonary insufficiency commonly encounteréd in adults with no previous lung disorders than in those with existing lung disease. ‘Aform of acute respiratory failure that occurs as a complication of some othe! ‘caused by a diffuse lung injury and leads to extravascular lung fluid initial damage to the alveolar-capillary membrane with subsequent leakage of fluid into the interstitial spaces and alveoli, resulting injpulmenary edema)ond There is cell damage, decreased surfactant production, and atelectasis, The ABG level: Pee been called SBRINEIFeNd the cause are the followin = Shock, Aspiration — Inhalation of toxic agentO2 toxicity = Narcotic abuse, Drugs (ASA) _ Alesierowning, Trauma, neurological injuries = Infection, Sepsis pic (Disseminatell Intravascular coagulation) —« mre wh ming ceudtinn fang ours alerted = Fat emboli cletfeg Yeroghoct He echt) Wed wsek. — Pancreatitis = Radiation = Pneumonitis condition; it is ‘which in turn producesClinical Manifestations og bas ably“ Heth 6 cepa ocr i 0 \d pulmonary compli a © Hypoxemia despite high concentration of delivered oxyBt ration, scattered to diffuse rales © Dyspnea, cough, tachypnea with intercostal suprasternal f= 4 or rhonchi © Changes in orientation, tachycardia, cyanosis (rare) Laboratory tests 1. PCO2 increased and PO2 decreased 3. AGB aha HCT decreased” : nd interstitial edema may not 4. Chest X-ray showing bilateral interstitial and alveotar infiltrates 3 be noted until there is a 30% increase in fluid content Nursing Management © Promote Patent Airway + 02 therapy (HOH RSDESIOLEN © (PRORBIBRSIFION) evidenced Based Practice) Lung compression is less which improves lung function as compat © Redistributes blood and air flow more evenly * Secretions produced by the disease process it and nose are facing down in the prone position. * Chest Pulmophysiotherapy + (REStriet|Fldidjintakd (Balanced with diuretic due to Pulmonary Edema) © Administer‘didiretis) antiGOagUlaits or COPRICSREFER. ‘© Administer Morphing/ Ativai/ Oiprivant © Prepare client for intubation ani with BEEBBetting © Ifon PEEP (Positive End Expiratory Pressure) * Administer Pavulon to reduce resistance to PEEP (to keep the collapsed alveoli open) ‘© Monitor patient . © Provide Comfort Administer Pain medication as prescribed iance red to supine the lung may drain better because mouth @ This refers to the obstruction of the pulmonary artery or one of its branches by a blood clot (Gtiombus) shat originates somewhere in the venous system or in the right side of the heart Common Risk Factor © Multiple trauma - Especially from a fracture ofthe femur (Fat Emboli) © Obesity, Pregnancy Congestive Heart Failure History of thromboembolism— Taroabar —Steticnony eumbolus = Ov Hypercoagulability —tadency + hase iva ° i 7 Fluid and septic thrombus from a bacterial invasion, Clinical Manifestations ; | sere xd by anginal and pleuritic pain, exacerbated by inspiration

” only part of a segment of lung tissue; For ae Basal =e We) excision of small nodules oF sy 2 feelers ae _Yeto-fbicl_ Nursing Management:SREGPERATIVES = (ake ose] — Informed Consent Provide routine pre-op care. — Perform a complete physical assessment of the lungs to obtait . EERO TERRE 32 orion sts ‘oxygen, suctioning, chest tubes {except if pneumonectomy performed) = Teach client adequate sBIREREGRMIESIGM th hands or pillow for turning, coughing, and deep breathing. = Demonstrate AON ERB GR aMeREUBE. = Provide to help emove secretions. Nursing Management: ‘+ Provide routine post-op care. + Promote Beaune Enh a perform complete physical assessment of lungs and €Ohiparewith BRESOP NINGINgS. = Ehcouroe fuming, ough, reap Bane V A= NOs rps ih obtained, 7 shat Rabe ~ Peto feheobORERTSUCRRe needed. cos 00). = Assess for proper maintenance of chest drainage system (except after priéumonect «+ Montor Abr and repr significant hangs omens Place client in is performed, follow surgeon's orders about positioning, often on back oF pete side ade” Hl [aE or operative side, but not turned to unoperative side), 2 epee de -—BBEeROMYPatient is usualy positioned on the UNOPERATIVE SIDE USE OF INHALERS © Iftwo different inhaled medications are prescribed and one of the medications contains a glucocorticoid (corticosteroid), and th (© Instruct the client ti i>, TO AACE YR — 1e mouth but hElG|Swaue TWO FRREHWERREy The METERED-DOSE INHALER should not be put in th h ice can be used. Patients should breathe deeply EVI ‘ nds. Patient: ° Alt ER WITH A SPACER DI for about 5 seco! nts once before stvatng ~ inhaler and then continue breathing in then shoul VASCULAR SYSTES Anatomy and Physiology * The heart is located in the MIDDLE mediastinum, tilted forward to the left ~ Consists of Three layers: * Epicardium: covers the outer surface of the heart * Myocardium: is the middle muscular layer of the heart * Endocardium: lines the chambers and the valves, * The layer that covers the heart is the PERICARDIUM 4 ~ Consist of two Parts; * Parietal pericardium * Visceral pericardium * The space between the two pericardial layers is the pericardial space © The heart also has four chambers- two atria and two ventricles * The Left atrium and the right atrium * The left ventricle and the right ventricle * The heart chambers are guarded by valves * Atrio-ventricular valves- Tricuspid and bicuspid (nqiTRaLy * _ Semi-lunar valves- Pulmonic and Aortic valves * The Blood supply of the heart comes from the Coronary arteries * Right coronary artery supplies the RIGHT atrium and RIGHT ventricle, inferior portion of the LEFT Wentricle, the POSTERIOR septal whit and the two nodes. ay and SA node * Left coronary artery- branches into the LAD and the circumflex branch * The LAD supplies blood to the anterior wall ofthe LEFT Ventricle, the anterior septum and the Apex of the left ventricle * The CIRCUMFLEX branch supplies the left atrium and the posterior The CONDUCTING SYSTEMS OF THE HEART + GAURGEIB the primary Physiologic cardiac Pacemaker, with a firing rate of Iti located at the junction of the superior vena cave and right atrium 60-100 bp. do + AVIRBUBls the secondary cardiac Pacemaker. it ca i located at the lower aspect of the atrial septum, tai" ® heartbeat $fROESOIEBHT and itis * Bundle of His is located at the interventricular septum and bra branch and terminates at the Purkinje fibers * Purkinje fibers are a diffuse network of, conducting Strands locat ted . endocardium. They spread the wave of depolarization theousq ned eeeath the ventricular igh the i pacemaker with ate between 20440 bom when to peceriateeecd And can act as the SA ode AV node (50 bom) Rid ota funnyHeart rate . © Normal range is 60-100 beats per minute : is greater than 100 bpm . is less than 60 bpm Atrioventricular (AV) node Bundle of His Left bundle branch Left anterior division Right bundle Left posterior branch division Purkinje fibres Cardiac Conduction System Blood pressure = Cardiac output X Total Peripheral Resistance = Control is neural (central and peripheral) and hormonal — Baroreceptors in the carotid and aorta Vasocauterictian — bp Hormones vanditetion = yup ‘© ADH, aldosterone, epinephrine can increase BP © ANP can decrease BP ‘Angiotensin Il stimulates the release of aldosterone which promotes water and sodium retention by the kidneys; this action increases blood volume and BP a - a of the SHf@#les, (Bing and GSBNGHE? ~ Thelaitafieslare vessels that carry blood away from the heart to the periphery ‘ — The re the vessels that carry blood to the heart e — The are lined with squamous cells, they connect the veins and arteries Iso is part of the vascular system and the function of this system is to Heart Sounds © Si:Heard as the AV valves close. Heard loudest at the SPOMOPUNG NGS ‘+ 82: Head when the semilunar valves close, Heard loudest at the Bas@lOFEREIHESNtectictlar gay ® $3: May be heard if ventricular wall com he gelop ce is decreased and structures in the ventricular wal) i I Vibrate such as in heart failure or valvular regurgitation. May be normal in individuals younger than 30 years :auetwas | (D) Rein wy ts 0 m5 -) frequant-;MtNletet ‘ i \ : | ‘* $4: May be heard on atrial systole if resistance to. ventricular filling is re Abnormal finding usually found in cardiac hypertrophy, disease or injury to the ventricular wall. “tyerteusion LABORATORY PROCEDURES Rationale: To assist in diagnosing disease, identify abnormalities, assess inflammation, determine baseline values, monitor serum level of medications and assess the effects of medications ARDC PORES. CK-MB Myoglobin (Creatine Kinase) > Elevates in MI within 4 hours, ~ Rises within 1-3 hours Peaks in 18 hours and then - Peaks in 4-12 hours declines within 24 hours - Returns to normal in a day > Normal Ck MB - Not used alone © Female: 2-5 ng/ml = Muscular and RENAL disease can have elevated © Male: 2-6 ng/ml myoglobin Lactic Dehydrogenase (LDH) Troponin ~ Elevates in MI in 24 hours, peaksin|- Composed of 3 proteins: Troponin C, Cardiac Troponin! 48-72 hours and Cardiac Troponin T - Normal value is 70-200 IU/L ~ Troponin 1s usually utilized for MI ~ _ Elevates within 3-4 hours, peaks in 4-24 hours and persists for 7 days to 3 weeks! - _ Normal value for Troponin | is less than 0.6 ng/mL ~ Normal value for Troponin T is less than 0.2 ng/mL - REMEMBER to| ~__Early and late diagnosis can be made — Lipid profile measures the serum cholesterol, triglycerides and lipoprotein levels - Cholesterol: /d = Lipoprotein-a is a modified form of LDL which increases atherosclerotic plaques and increases clots = Preparation: NBO SIGART CRIS 82 FOUR)? Rec, WBC, HeT Ho ‘in RHD and infective endocarditis; RBC increases in conditions characterized by el~ WBIIHEFESEES in RSE RATATRRARARRSR/RIGSHEERBT the heart and ater Ml because vB from the infarction numbers of WBCs are needed to di i hea eeded to dispose ofthe necrotic tissue resulting ' ti = wa en ob ee I 7 ‘and hematocrit can indicate ima ° ae el = Increase in coagulation factors can occur during and after Mi, which places the client at greater risk for thrombophlebitis and extension of clots in the coronary arteries = Elevated levels may increase the risk of cardiovascular disease; level should be less than 14mmol/dt i Cale iniketes Gurdise cm inc Ss TT Geeue erin maintains confrecion ° SiséS Increased cardiac electrical instability, ventricular dysrhythmias, and increased risk of digoxin toxicity; The ECG shows , the appearance of a (WAVE an ° causes asystole and ventricular dysrhythmias. The ECG may show tall peaked 7 omplexes, BROIONESAPR| tervals or MARPWAVES? ‘0 Decreased with the use of diuretics © Decreased in heart failure indicating water excess ° ee cause ventricular dysrhythmia, fRBIGRBSUIS Mane Gnintenvals andjearaiae) © Hyperealeemif can cause os fGRREREAS SSERGERENMEREDTWANE, AV block, tachycardia or bradycardia, digitalis hypersensitivity and cardiac arrest ~ PsesBR ‘0 Should be interpreted with calcium levels because the kidneys retain or excrete one electrolyte in an inverse relationship to the other ~ Magnesium 7 © Low level can cause ventricular tachycardia and fibrillation. May show (@INSEWBVESIaq lepressed ST segments ‘© High level can cause muscle weakness, hypotension and bradycardia, May show a Prolonged ” and widened QRS complex Sayre narmunenicrePrioe = Released in response to atrial and ventricular stretch; it serves as ~ Should bell6WeFERaREOOIpE/M; the higher the lever, the more severe the heart failure aaa cgsiey ~ Reflects the electrical activity of cardiac cells and records electrical acti tivity at a 5 fee: peed of 25 mm/om SSA IN Tylaxe — AD oes Bo R n Each small square represents 0.04 second Each large square represents 0.20 second P wave represents ATRIALDEPOLARIZATION i PR interval represents the time it takes an impulse to travel from the aura bitin oo node, bundle of His and to the Purkinje fibers. Shows! be = ee second i QRS complex represents {JENTRICULARBEFOIARIZATION. Normal range is 0.04-0.2 second ST segment represents early EWTRICUUARIREPOLARIZATION Twave represents ventricular repolarization and ventricular diastole QT interval represents ventricular refractory tome or the total time required for ventricular depolarization and repolarization. Normally lasts 0.32-0.40 second oot Ty mm 0.2 sec | 5mm — i tH R Ei O.smv | 4p : [ imm 0.04 sec 1mm 0.1 mv) 25 mamiseo 1Ommimv) | | |_| [ | | | |e oe le—s-ttof | | 7 Jot 4 ee segment vl | [ | CPR @ interval s inte interval Patt Fe ORS “le, interv | | kT Q-T interval\V-Fib Reel aL Coe V-Tach Mati tae) avo er PTicenters | AI Saas Regular, Peas Wide QRS: Irregular, Rela Rea Torsade de Pointes Pence mre) re>rxznory Coad Peele un Drei) Ota el STEMI Beer MO eMC oa ree LLL ia Peas cas AT eravewaves 1 “RS normaty narrow but not aways eas Read Ort hel io eauc Cavey STElevated Irregular, Nac Mee tey om a Rate: Slow (<60 b Normal QRS: ace 4 ‘ate: Fast 100 0pm) nels a a ase — need the client wears 2 holter monitor and an ECG tracing wmemneiegt - Nursing Management: © Instruct client to and and any symptoms that may develop for correlation with electrocardiographic tracing © Instruct client tolaVSidlEUBIBAthS or SEWERbecause they will interfere with the Electrocardiographic recorder device — Noninvasive procedure which is based on the principles of ultrasound andieyaluatesistructural afd — Heart chamber size is measured, ejection fraction is calculated, and flow gradient across the valves contans is HO FOUNDATION FOR MEDICAL EDUCATION ANDRESEAROH is determined — Instruct the client tofu N /e test that ind detects and @aliates eoronarylarteryy - en RED — Nursing Management: © Instruct the client to eat alight ealTtS2 NOUS BEFSrSNESPERGGFe and to avoid smoking, an © Instruct the client to ask the HCP about taking prescribed medication on the day of the procedure; ‘and Cay (Ghianinelitocls anc Beblockerg are usually Withheld thie day OFEHBYEE to allow, the heart rate to increase during the stress portion of the test © Instruct client to wear comfortable clothing and supportive rubber-soled shoes © instruct lento CEE ASB eeu itRSS Es An Renny ig Insertion of a catheter into the heart and surrounding vessels. = Obtains information about thelstfietitland . : th sBiaiesp Preprocedure intervention: © Obtain informed consent. © Assess for 5d, iodine) or fGIOBSqUSEVE:, is allergic, the client may be ~ Cortcosteois to prevent a reaction,© Withhold solid food for 6 to 8 hours 3 n dGUBERSER RUB prescribed to prevent vomiting and aspiration during the procedure. © Document the client’ jecause these data will 4 ed. 9 Document baseline vital signs and note the quality and presence of peri postprocedure comparison. % ° In i . = i form the client that a [SESISHESHEHE will be administered before catheter insertion. © Prepare the insertion site by shaving commonly on SE andigfBinjares and cleaning with an antiseptic solution if prescribed. © Administer preprocedure medications such a ‘0 _ Insert an IV line if prescribed which is usually MBMGIRinEkthe@ABH yer o ne procedure because of te FORBES? e needed to determine the ipheral pulses for © Usually Loch acid built up the Yeedshcmn CA produced whan or Cevely w iy cot, in ante: where = Postprocedure Intervention: ‘ Ve meteioldzer © Monitor yiaIsiBi, jias, peripheral pulses and the color, warmth, and sensation of the extremity distal to the insertion site ° if the client complains} /andiRIAglINg, if the extremity becomes o ori occurs. © Monitor the pressure dressing for bleeding or hematoma formation. co Apply al if prescribed) to the insertion site to provide additional pressure if required. 0 EncouragelfiWl@IREak®, if not contraindicated, to promote renal excretion of the dye and to replace fluid loss caused by the osmotic diuretic effect of the dye. © Monitor for nausea, vomiting, rash, or other signs of hypersensitivity to the dye. Vv © Anticipate to administer prescribed medications such as - aN EON aN ES Invaeive, nonsurgical tect seat in piesa ‘arteries is (are) dilateaWithaIbaNloOn cc = May coincide during Coronary angiography = PTCA may be used for erent ath an evan mivcrdiainfrtion (M), alone or in combination with medications to achieve reperfusion. ion: — Preprocedure interventi ae intain ABO totus SERA. sere assesment to fog, nf hi metformin fo for cardiac © Obtain informed consent, catheterization). 0. Prepare th ith antiseptic soap and shave per institutional procedure and as prescri ‘ibed. © Instruct the client that and to SSE it does ~ Postprocedure interventions: Jy and distal pulses in both extremities © Monitor vital signs closelagents as prescribeg an 2d STIRS to © Administer anticoagulants such as intravenou: ° if not contraindicated, to enhance RBLREReHOROREVED © Assist the client with planninglifestylemonifieatiOns rene ous or arterial blood ve: The occluded coronary arteries are bypassed with the client’s own ven! Ssels, a or other arteries may be used to bypass lesions in The Saphenous vein, In ternal mammary artery, the coronary arteries. Coronary artery bypass grating is SHAE WREO IMBREwOREROEFespord KOImecisT I” ‘anageTEAL coronary artery disease or when vessels are S6VBREly OceIUGEE: 7 ‘CORONARY ARTERY DISEASE (cab)! a.k.a Ischemic Heart (7 Prratteh of Yoque ;ease/Atherosclerotic Heart Disease * CAD results from the focal faRROWIRBIOHENe large and medium-sized T-cells and monocytes ingest lipids in the area of deposition > atheroma -> narrowing of the arterial lumen -> reduced Coronary blood flow > Normal conditon of Beginning of Increased plac eee ER MEE ernie Soe Coronary Artery Disease "m8 fom wor monteops. org= = 150% of the left coronary arterial lumen s reduced or 75% ofthe other coronary artery: ths becomes significant = ‘here deceased perfusion of mycad ive sn adequate myocar EEN APP — RSREASITORTFOMBSSS onc Emborsmy Glinical Manifestations ‘* possibly normal findings during asymptomatic periods + Chest pain ~ + Palpitation ~ + Dyspnea ~ «Syncope ~ ‘© Coughor hemoptysis ~ © Excessive fatigue ~ Diagnostic Findings + ECG: ST segment depression, T wave inversion o both is noted: if with infarction, there is ST segment elevation followed by T-wave inversion and an abnormal Qwave ™ shows the presence of Nursing Management «Health teaching fo* [tis a myocardial ischemia without cell death, * Caused by a and increasing workload. S/sx: © Substernal, anterior chest {0 te should, ms eck an Burning like/and| indigestion, Sightness, moderate pressure, shortness of breath. Increased heart rate, diaphoresis, nausea, (for STABLE ANGINA) S-ubsternal pain A- nterior chest V - ague (radiates) E-xertion related R - elieve by rest S~ hort Duration (commonly 5-15 mins) pallor, in regions ofthe © Heart with SK: o Chest pain is described as severe, persistent, ° Radiates to thelfigck, nd Bake Occurs without cause, primarily Dyspnea Diaphoresis, cold clammy skin NA, restlessness, sense of doom Tachycardia or bradycardia, hypotension eoooo G08 (chest hand clutching) universal symptom of distress of both angina and MI © MURR ERE (chest hana clutching) universal ‘Ymptom of distress of both angina and MI Pathophysiology: * Myocardial cells become ischemic -> Coronary artery occlusion -> Decrease Pumping action of the heart -> After several mins decreased blood flow -> Decrease ATP -> Anaerobic metabolism -> Lactic acid Production -> Pang Pathophysiology: * Interrupted corona ischemia > Anaer, for several hours Depressed cardia ry blood flow -> Myocardial ‘obic myocardial metabolism > Myocardial death -> ic function -> Triggers autonomic nervous system Fesponse -> Further Imbalance Of myocardial 02 demand Predictable severity, pattern and duration, * Unstable Angina: (Pre-infarction Angina) © Chest pain last for ASIRSSGIARGR but ° = frequent recurrence © _ Occurs with minimal rest and exertion and supply, Types: Laboratory findings: * Stable Angina: Chest pain ~ ECG: ST sey . ment elevation: Results from the * Twave inve: Developed from the "sion: Originates from the * Pathologic Q wave; eee—_—_—_—_—_—S—— + Prinzmetal Angina: (Variant Angina) = Myocardial enzymes i © Caused by a coronary artery spasm ‘s Elevated CK-MB: Most reliable cardiac (© Angina at rest after long exertion specific enzyme exercises and even sleep «Elevated, LDH: Increase only with cardiac ‘* Nocturnal Angina: Occurs only at night damage 3-6 hrs after onset of MI associated with REM «Elevated Troponin levels: Most definitive Angina Decubitus: Paroxysmal chest pain | CBC: may show elevated WBC count that occurs during sitting and standing _ Test after the acute stage: Exercise © Intractable Angina: Chronic and severe tolerance test, thallium scans, and cardiac incapacitating chest pain with no response catheterization. to intervention. ‘* Post Infarction Angina: Occurs after MI when residual ischemia may cause episodes of angina Te Te M/MGT: mymer: 1504 specific to MI - SEES) ‘Administer via IV not 1M (can increase «Stored in dark container - photosensitive | troponin levels due to symphatetic effect Toke tablet maximum of 3x with 15 mins | GReeRIpH, promote rest interval, pain last for 3 mins/subside, | - ot relieved by NTG orrest bring the drug at all times!! © Inform patient that stinging / burning sensation and lightheadedness is expected, g__|S-tool Softeners, soft diet, prevents straining : eg + Apo} one SSP Points to remember «Rotate site of application ¢ Advise patient taking nitroglycerine not to take sildenafil (viagra) because both drugsare «Remove old before applying new patch = for VARIANT. vasodilators ’ ANGINA. | feveametal «Patient must be able tofimiby2Mighits/OF Stairs) Nsg mgt: A- spirin, anticoagulant, 02 therapy N- itroglycerin G - ive appropriate diet 1 -ncrease patient knowledge (health teaching) N- ormalize BP (Beta blockers, calcium channel blockers) A- void cigarettes, control cholesterol and DM L- ifestyle modificationuate circulation to meet the metabolic a Inability of the heart to pump sufficiently to maintain ade needs of the body " Right * Classified according to the major ventricular dysfunction- Left or Rig! Congestive heort AU Normol heart opotiy ond ejection of blood Etiology of CHF ‘ + caD ‘ * Cardiomyopathy ‘+ Valvular heart diseases * Lung diseases * Hypertension * Pulmonary Hypertension - om * Pericarditis and cardiac tamponade Left Sided Heart Failure Right Sided Heart Failure Manifestation: Pulmonary (Primary) Manifestation: Systemic . * Results from increase venous pressure xia ai = _ initially seen as Pathophysiology Pathophysiology LEFT Ventricular pump failure > Back up of blood | RIGHT ventricular failure -> Blood pooling into the pulmonary veins > Increasedpulmonary | in the venous circulation - Inereased capillary pressure > hydrostatic pressure | a LEFT ventricular fallure > Decreased cardiac output | RIGHT ventricular failure > Blood pooling decreased perfusion to the brain, kidney and other a. congestion in the kidney, liver an tissuessisx: s/sxz Dyspnea on exertion, cough, nasal flaring, Peripheral dependent [piRIREeSERay orthopnea ° ° Paroxysmal Nocturnal Dyspnea 7 Geass” ° © Ascites ough with Pinkish, frothy sputum 0 Body weakness ° ° ° Hepatosplenomegaly Tachycardia Anorexia, nausea » Cool extremities Pulsus alternans Cyanosis Decreased peripheral pulses Fatigue Oliguria © Signs of cerebral anoxia e@eoooeooo 6 Diagnostic Test 1. CXR- May reve 2. ECG - May identify cardiac hypertrophy 3. Echocardiogram - May show hypokinetic heart 4. ABG and Pulse Oximetry - May show decreased 02 saturation 5. PCWP is increased in LEFT sided CHF and CVP is increased in RIGHT sided CHF uae 2 postion on SERSURSTIATSNIE fo adequate ches expansion Assess patient’s cardio-pulmonary status © Assess VS, CVP and PCWP. — . ‘to monitor fluid retention = TST «Administer medications - usually cardiac glycosides are given - ISOMMONDIGIOXIN (OTUREEESY and fBBIBIEBBI are prescribed * Provide Monitor accurate intake and output and © Monitor daily weight to assess for fluid retent + Provide adequate fESE\BEHOUS to prevent fatigue Prevent complications of immobility + Administer as preserib + Monitor digoxin levels and for GGS@FBIGGRIMONERY, Including anorexia, poor feeding, nausea, vomiting, bradycardia, and ‘ea 7 aS * Administer iiotensi- converting enzymlhhibtors as prescribed. Nursing Management after Acute Stage «Provide opportunities for verbalization of feelings «Instruct the patient about the medication regimen — Digitalis, vasodilators and diuretics © Instruct to avoid OTC drugs, stimulants, smoking and alcohol + Provide a LOWE an * Provide|CET AC AOE YL —— * Instruct about iMate, * Provide adequate rest periods and schedule activities * Monitor daily weight and report signs of fluid retention ceuremnes and dURPEaRea aie dequately resulting to a s a result of occlusion of major ; "ore han ROSGERTERRR ous, sua 2 coronary vessels oe BERET 2nd improve the pumping * The! al ability of the heart Etiology * Massive MI © Severe CHF * Cardiomyopathy ° Cal trauma * Cardiac tamponade Clinical Manifestations Ayo Tad “chy pee ° ° ° © Tachypnea © Narrow pulse pressure © Weak peripheral pulses y ee e a ' ° © Continuing chest discomfort LABORATORY FINDINGS 1. CVP-elevated - Normal value: 5-10 cmH20 4-8 mmHg ¢ Nursing Management © Place patient ina ) © Administer IVE; an uch a and SosuTaMINe Administer 02 is administered to decreased pulmonary congestion and to reli Assist in intubation, mechanical ventiation, PTCA, CABG, insertion opener e IABP Monitor urinary output, BP and pulses "of Swan-Ganz cath and . Cautiously administe M@iuretigs and iiRraRERY Monitor client’s hemodynamics© Central venous pressure © Pressure with thin the suj — Perior vena cava; it reflects the pressure which blood is returned to vena cava and right atrium ° as tes an increase in blood volume as a result of sodium and water : . excessive IV fluids, alterations in fluid balance or kidney failure cic aati $2 decrease in circulating blood volume and may be a result of » hemorrhage, or sever i iineeees re vasodilation, with pooling of blood in extremities Pulmonary artery pressures ° eae right heart and indirect left heart pressures 7 " tained during momentary balloon inflation of the pulmonary artery catheter and is reflective of left ventricular end-diastolic pressure ‘* Pulmonary artery wedge pressure normal range: 4-12 mmHg © Normal RA pressure: 1-8 mmhg ‘0 Normal pulmonary artery pressure: 15-26 mmHg systolic/5-15 mmHg diastolic © Elevations may indicate left ventricular failure, hypervolemia, mitral regurgitation, or intracardiac shunt ‘ © Decreases may indicate hypovolemia or afterload reduction © Mean Arterial pressure ‘ . co Approximation of the average pressure in the systemic circulation throughout the cardiac 0 cycle used in hemodynamic monitoring ‘ MAP must be between 60-70 mmHg for adequate organ perfusion — Pulmonary capillary wedge pressure (PCWP) e 0 It is reflective of left ventricular end-diastolic pressure. © Decreased PCWP indicates hypovolemia © Increased PCWP indicates hypervolemia, left ventricular failure, or mitral regurgitation. . ‘ : ‘ccamilation of uid inthe) deere. Moa asvn where the hearts is6R6 RS BUMBEIDSE ue to «hs condition restricts ventricular filing resulting to decreased cardiac output. © Acute tamponade may happen when there is 2 sudden accumulation of aboutaBOminiieyClinical Manifestations ° Jugular Vein Distention * Hypotension 4 * _ Distant/muffied heart sound © Pulsus paradoxus ® © Increased Cvp © Decreased cardiac output Nursing Management © Assist in pericardiocentesis © Administer ve a © Monitor ECG, urine output and BP © Monitor for recurrence of tamponade REND? tener tan 20 mg and» ABH pressure eater tha BO mH over a Sustained period based on two or more BP measurements. * Foran adult (ages 18 and older), a(RBERBEIB? is a systolic BP below 120 mm Hg and a diastolic below 80 mmHg. * An individual classified with §RBIBEREREER has a systolic BP between 120 and 139 mm Hgora diastolic pressure between 80 and 89 mm Hg. ° GSEBWRVBEHEREBn can be classified as a systolic BP between 140 and 159 mm Hg or a diastolic Pressure between 90 and 99 mm. He. . (StSEEZ hypertension Can be classified as a systolic BP equal to or greater than 160 mm Hgora iastolic pressure equal to or greater than 100mmHg. © Hypertension is a major risk factor for coronary, cerebral, renal, and peripheral vascular disease. The disease is nd preventing rE REESE . lapproaches, such ai may be prescribed initially; if the BP cannot be decreased after a reasonable time p ) the client may require ‘Types of Hypertension: © Primary or ESSENTIAL © Most common type © Causes unknown, but with presence of risk factors © Aging * Family history * Black race, with higher prevalence in males * Obesity * Smoking * Stress * Excessive alcohol © Hyperlipidemia ‘* Increased intake of salt or caffeine© Secondary © Due to other conditions like Pheochromocytoma, renovascular hypertension, Cushing's, Crofin’ 's, SIADH, cardiovascular disorders, renal disorders, endocrine disorders, pregnancy and medications such as estrogens, glucocorticoids, mineralocorticoids : 3 Major Conditions Concerns Secondary Hypertension ~ Kidney disease - DM ’ - Dyslipidemia PATHOPHYSIOLOGY . punecor es er: Any increase in the above parameters will increase BP: Increased sympathetic activity Increased absorption of Sodium, and water in the kidney Increased activity of the RAAS Increased vasoconstriction of the peripheral vessels ~ [insulin Fesistance Clinical Manifestations ' © Maybe asymptomatic Fatigue ° © Palpitations 0 Visual changes o Epistaxis © Chest pain © Tinnitus 0 Dizziness © Flushed face o NN © Chest pain Major Risk factors: «Smoking © Age older than 60 © Hyperlipidemia © Gender « DM Family History Diagnostic Test : § 1, Health history and PE 2. Routine laboratory - urinalysis, ECG, lipid profile, BUN, creatinine, FBS 3, Other lab - CXR, creatinine clearance, 24-huour urine protein Medical Management © Goal: To reduce BP and to prevent or lessen the extent of organ damage ‘* Promote lifestyle modification © Drug therapy 1. BIUREMIES}-1 ine of rugs for treatment of mild hypertension) = Loop - Furosemide - Osmotic - Mannitol — Thiazide - Hydrochlorothiazide — Potassium-sparing - Spironolactone (Aldactone) 2 [ReEnNHIBETORS- nibs vasoconstriction, suppressed conversion of Angiotensin Ito — Captopril (capoten) = Quinapril (Accupril)Coe REVIGM ACAD EN (errr corte to bradycardia (SOUREARIBERGRD a a Sew decreases heart rate may le =" To watch out for hypotension, hein eases HHEEEET 7 = Propranolol (inderal) = Metoprolol (lopressor) — event peripheral vasoconstriction and secretion of 4 aldosterone and — Losartan (Cozaar = Telmisartan (Micardis) — Candesartan (Candez) camaesioaieea blocks entry of calcium into smooth muscle cells causing a decrease in contractility and arteriolar constriction — Verapamil — Diltiazem (Dilzem) — Nifedipine — Amlodipine (Norvasc/Amvasc) Nursing Management * Promote Home care management ‘* Instruct regular monitoring of BP Involve family members in care ‘+ Instruct regular follow-up ‘Manage hypertensive emergency and urgency properly * Provide health teaching to patient * Teach about the disease process * Elaborate on lifestyle changes ‘* Assist in meal planning to lose weight * Provide list of COWiag, Los et des hn ams * Limit alcohol intake to 30 mi/day © Limit 3s prescribed © Regular aerobic exercise * Stop smoking * Provide information about anti-hypertensive drugs Encourage client to express feeling about daily stress * Teach relaxation techniques that may include into the cient’ daly vin * Instruct proper compliance and not abrupt cessation of drugs even peer asymptomatic/ improved condition nifpatient bécomes | * Instruct to avoid over-the-counter drugs that may interf ‘ere with the curr ‘ent medication = Any clinical condition requiring immediate reduction in ap - AnAssessment - An - Headache — Blurred vision ith diastolic pressure AiGREERESRASO — Drowsiness and confusion — Changes in neurological status - Tachycardia - Tachypnea = Dyspnea = Cyanosis Management = Maintain SERED — Administer antihypertensive medications IV - Monitor VS, asses: - Maintain bed rest, — Place client in al if hypotension occurs — Have emergency medications and resuscitation equipment readily available = Monitor IV therapy, 1&0; i — Insert RBIBWRSERBEP® as prescribed ARTERIAL VS lENOUS DIS‘ ARTERIAL DISORDER: VENOUS DISORDER Mechanisr Ischemia * Stasis — clot formation Appearance: © Pallor (early) Erythematous © Cyanotic (late) © Brown pigments © Thin shiny skin in the legs « Edematous © Loss of hair in the legs * Normal toenails * Thick toe nails Temperature: * Cold to touch Warm to touch . (thrombophlebitis) Pa + (iii |= eae © Aggravated by walking and elevation | of legs Sensation: ‘Numbness, paresthesia * Itching Pulse: + Diminished/ absent . Ulcer: © Grayish - occur on toes with © Pinkish - occur on ankles gangrene without gangrene Types: Raynaud's disease - Age: 15-40y/o OvT SVT Females Buerger’s disease - Age: 30-50y/o Males Varicose veins2 DISEASE (PVP) CULA\ PERIPHERAL WAC" “7ENOUS ULCERS Porn mage om pining.com VENOUS & ARTERIAL ULCERS Arterial ulcer Venous ulcer © Refers t usualh : 'Y Secondary to peripheral atherosclerosis. * Usually found in . Thellegspre most often affected Risk factors for Peripheral Arterial occlusive disease . fennel - Age Gender Family predispositioni Clinical Manifestations ° = This is PAIN described as aching, cramping or fatiguing discomfort consistently reproduced with the same degree of exercise or activity = The pain is > This aera eres he mul eupbow he aal ocea 0 Progressive pain on the extremity as the disease advances 9. Sensation of o Skin igfB@l@Wwhen elevated and hen placed on a dependent position ‘0 Muscle atrophy, leg ulceration and gangrene Diagnostic Test 1 GRRRURIBURE between the extremities 2. Duplex ultrasonography 3, Doppler flow studies ‘Medical Management ‘* Pharmacotherapy * * & ° reduces blood viscosity and improves supple of O}blood to muscles ° inhibits platelet aggregation and increases aseuilationyy * Surgery Nursing Management © Maintai 9 Evaluate regularly peripheral pulses, temperature, sensation, motor function and capillary refill time © Administer post-operative care to patient who underwent surgery Monitor and manage| Note for 7 to dit edema ° ° ° Encourag@ERSIeBe/of ‘the extremity while on bed ° ° Teach patent 0G SES Access for signs of ulcer formation offiGRBlBEaREReRe . * Promote home management © Encourage lifestyle changes Instruct ° @ Instruct to avoid leg crossing 0 Inftruct to ye extremities and to wear socks insulated shoes for warmth at all times ¥ oInetuct never apply direct heat tthe limb Wine arena ‘* A.K.A Thromboangitis obliterans © Adisease characterized by t! . ee erento are affected most commonly ofTOPERANK I PATHOPHYSIOLOGY peat TN arteriolar VASOCONST! RICTION th: at results ins ey REVIEW ACAD! od supply causes cath of tissue ‘Occurs in Cause is} Probably an Autoimmune disease Inflammation of the arteries ) Thrombus formation —\ Occlusion of the vessels Clinical Manifestations ° e Foot cramps in the arch (insteP — claudication) after exercise © Relieved by rest disturbance and © Intens redaish-blue discoloration» progresses to disease advances 0 gator ping nies Raresthesta burtitg) peteg ower mwadestgsiton Extremities that are cold and red in the dependent position 0 Development cfuesratC# in the extremities Diagnostic Test 1. Duplex ultrasonography 2. Contrast angiography Nursing Management ‘Assist in the medical and surgical management = Strongly advise to — Manage complications appropriately — Post-operative care (AMPUTATION) ‘to minimize edema and to] ‘Assess skin for ‘© Wrap the extremity with ‘* Monitor pulses) in coldness, pain and pallor of eet finger tips or toes roma e\vasospasm of the arterioles and arteries of the up, constriction of the cutaneous vessels er and lower extremiti wht Cause: 's which causes — OO=> i No ¢ Attacks are intermittent and occur wit + Affects primarily HiNgets, £085, 898 and| Clinical Manifestations © Raynaud's phenomenon: ~ _ Alocalized episode of vasoconstriction of the small arteries of the hands and feet that ‘causes color and temperature change Pallot Due to vasoconstriction, then @lue Due to pooling of Deoxygenated blood Whitd,- From severe vasospasm ~ Ged) due to exaggerated renowffyperemid) ; ‘© Tingling sensation ° Medical Management - Se ~povtle Novation ~ (asbaatorg Aaalgesiesy ‘Nursing Management — _ Instruct patient to avoid situations that may te SRS — Instruct to ind remain indoors when theglimate iscold — Instruct to avoid all kinds of = Instruct about safety. Fingers become white @Fingors turn be as @ Fingers nay tun eo ‘v9 tolack of Blood flow _-veseals diate to Keep {88 blood flow returns blood in issues, aynauds Disease Information Pamphlet Ia photograph by Gwen Shockey which was uploaded on September 0th, 2015 /Fineartamerica.com . epee by dilation of an artery secondary to weakness and stretching of an arterial wall. The dilation may involve one or all layers of the arterial wall, ‘An aneurysm, usually fusiform or dissecting, in the descending, ascending, or transverse section of the thoracic aorta © The spalotthe treatment: to limit the progression of the disease by_fHSUINUMEMERTEO) controlling the BP to prevent strain on the aneurysm, recognizing symptoms early and|pfeV@Btingy © Usually occurs ingmemages 50-70} caused by artetiosclerotis, infection, syphilis) hypertensionClassification * Fusiform: Both sides of arterial wall dilate | of the arterial circumference + Saccular: Outpouching on one side only, affecting part + cavity that fills with blood ‘+ Dissecting: Separation of the arterial wall layers to form i ea but is held in p} * False: The vessel wallis disrupted, blood escapes into surrounding 2 place by surrounding tissue Clinical Manifestations saccular fusiform giant ° GRRernaSyAABROREER: deep, diffuse chest pain; hoarseness; dysphagia ; dyspnea © Pallor, diaphoresis, distended neck veins © THOREOTEDR Ay = * Pain extending to neck, shoulders, lower back or abdomen * Syncope * Dyspnea * Increased Pulse a . + Cyanosis * Weakness ° . rominent, pulsating mass in abdomen at or above umbilicus * Systolic bruit over the aorta * Tenderness on deep palpation * Abdominal or lower back pain * Increased Pulse rate Diagnostic tests 1. Aortography shows exact location of the aneurysm. 2. X-rays: Chest film reveals abnormal widening of aorta; within walls of aneurysm Nursing Management * Obtain information regarding back or abdominal pain ‘© Check peripheral circulation * Observe signs of rupture * Note any tenderness over the abdomen Monitor for abdominal Medical Management ¢ Control of underlying hypertension ’ # Surgery: Resection of the aneurysm and replacement with need extracorporeal circulation > TENORIO REFORaRG cient will Abdominal film may show calcification> O _ _ inflammation of the vessel wall withifoPfistiORlGHlalORABFEMBUB May affect superficial or deep veins «Most frequent veins affected are thelS@BHEHOUS, ee © can result in damage to the surrounding tissues {SEHR an Risk Factors Obesity CHE prolonged immobility MI Pregnancy, oral contraceptive eee trauma Clinical Manifestations indurations along course of the vein | tenderness, redness, imb, tenderness over involved vein, (+) swelling, venous distension of I Homan’s sign —> pois wien Aesighecion oF taf (ouis is 48> cep) Diagnostic Tests 1. Elevated WBC and ESR 2.. Venography (phlebography): inc. uptake of radioactive material 3. Doppler ultrasonography: impairment of blood flow ahead of thrombus 4. Venous pressure measurements: high in affected limb until collateral circulation i Nursing Management - Provid t, involved extremity — Apply continuous Wat to decrease lymphatic congestion - Administer OBR ors Mronttor for chest pain or $08 (SSi6KISUlmionanyemBSIEn nt teaching and discharge planning: ’ 1 Ranting rossng le =e is developed importance of planned rest with