NCMB312 LECTURE:
06
BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Bachelor of Science in Nursing 3YA
Professor: Dr. Potenciana A. Maroma
Prelim Topics:
• Disturbance in Oxygenation
• Coronary artery diseases
• Obstructive disorders
• Restrictive disorders
• Hematologic Disorders - Peripheral Vascular
Disorders
ANTOMY OF THE HEART
Introduction
- The heart is a hollow, muscular organ located in the
center of the thorax
- Mediastinum – where it occupies the space between the
lungs and rests on the diaphragm. weighs approximately
300 g (10.6 oz)
- the weight and size of the heart are influenced by age,
gender, body weight, extent of physical exercise and
conditioning, and heart disease.
- The heart pumps blood to the tissues, supplying them with
oxygen and other nutrients.
Three (3) layers of the Heart
• Endocardium – Inner layer consists of endothelial tissue
and lines the inside of the heart and valves.
• Myocardium – middle layer made up of muscle fibers and
is responsible for the pumping action.
• Epicardium – The exterior layer of the heart
CODE: E.M.E
Heart Chambers
• Diastole – relaxation phase
• Systole – refers to the events in the heart during
contraction of the two top chambers (atria) and two
bottom chambers (ventricles).
• Apical pulse – the pulsation created during normal
ventricular contraction. Also called Point of Maximal
Impulse (PMI)
J.A.K.E 1 of 57
Exam Week
Heart Valves
- The four valves in the heart permit blood to flow in
only one direction. The valves, which are composed of
thin leaflets of fibrous tissue, open and close in
response to the movement of blood and pressure
changes within the chambers. There are two types of
valves: atrioventricular and semilunar.
Atrioventricular Valves
- The atrioventricular valves separate the atria from the
ventricles.
- The tricuspid valve, so named because it is composed of
three cusps or leaflets, separates the right atrium from the
right ventricle. The mitral or bicuspid (two cusps) valve lies
between the left atrium and the left ventricle
Semilunar Valves
- The two semilunar valves are composed of three leaflets,
which are shaped like half-moons. The valve between the
right ventricle and the pulmonary artery is called the
pulmonic valve. The valve between the left ventricle and
the aorta is called the aortic valve.
- The semilunar valves are closed during diastole. At this
point, the pressure in the pulmonary artery and aorta
decreases, causing blood to flow back toward the
semilunar valves.
Coronary Arteries
- These arteries originate from the aorta just above the
aortic valve leaflets
- The heart has high metabolic requirements, extracting
approximately 70% to 80% of the oxygen delivered (other
organs extract, arteries are perfused during diastole.
- The artery rom the point of origin to the first major branch
is called the left main coronary artery. Two branches arise
from the left main coronary artery: the left anterior
descending artery, which courses down the anterior wall
of the heart, and the circumflex artery, which circles
around to the lateral left wall of the heart.
- The right side of the heart is supplied by the right coronary
artery, which leads to the inferior wall of the heart. The
posterior wall of the heart receives its blood supply by an
additional branch from the right coronary artery called the
posterior descending artery
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Myocardium
- The myocardium is the middle, muscular layer of the atrial
and ventricular walls. It is composed of specialized cells
called myocytes, which form an interconnected network
of muscle fibers. These fibers encircle the heart in a
figure-of eight pattern, forming a spiral from the base (top)
of the heart to the apex (bottom). During contraction, this
muscular configuration facilitates a twisting and
compressive movement of the heart that begins in the
atria and moves to the ventricles.
Function of the Heart
Cardiac Electrophysiology
- cardiac conduction system generates and transmits
electrical impulses that stimulate contraction of the
myocardium. Under normal circumstances, the
conduction system first stimulates contraction of the atria
and then the ventricles. The synchronization of the atrial
and ventricular events allows the ventricles to fill
completely before ventricular ejection, thereby
maximizing cardiac output. Three physiologic
characteristics of two types of specialized electrical cells,
the nodal cells
Purkinje cells, provide this synchronization:
- Automaticity: ability to initiate an electrical impulse
- Excitability: ability to respond to an electrical impulse
- Conductivity: ability to transmit an electrical impulse
from one cell to another
- Sinoatrial Node – primary pacemaker
- Atrioventricular Node – secondary pacemaker (kapag
wala or hindi kayang mag function ng SA taga salo si AV
but cannot give the best function like SA, in short second
option ganurn (awts beh saetttt djk HAHAHA)
Cardiac Cycle
- It refers to the events that occur in the heart from one
heartbeat to the next.
- During atrial and ventricular diastole, the heart chambers
are relaxed. As a result, the atrioventricular valves are
open, whereas the semilunar valves are closed. Pressures
in all of the chambers are the lowest during diastole,
which facilitates ventricular filling.
- Venous blood returns to the right atrium from the superior
and inferior vena cava, then into the right ventricle. On the
left side, oxygenated blood returns from the lungs via the
four pulmonary veins into the left atrium and ventricle.
Cardiac Output
- refers to the amount of blood pumped by each ventricle
during a given period
Resting adult – 5 L/min
- but varies greatly depending on the metabolic needs of
the body
- Cardiac output is computed by multiplying the stroke
volume by the heart rate
Stroke volume
- is the amount of blood ejected per heartbeat. The average
resting stroke volume is about 70 mL, and the heart rate is
60 to 80 bpm.
- Cardiac output can be affected by changes in either
stroke volume or heart rate.
J.A.K.E 2 of 57
Control of Heart Rate
- Cardiac output must be responsive to changes in the
metabolic demands of the tissues.
- For example, during exercise the total cardiac output may
increase fourfold, to 20 L/min. This increase is normally
accomplished by approximately doubling both the heart
rate and the stroke volume.
- Changes in heart rate are accomplished by reflex controls
mediated by the autonomic nervous system, including its
sympathetic and parasympathetic divisions.
- The parasympathetic impulses, which travel to the heart
through the vagus nerve, can slow the cardiac rate,
whereas sympathetic impulses increase it.
(Parasympathetic = PARA, unti unti mong pinapabagal.
Sympathetic = urge to do the action)
- These effects on heart rate result from action on the SA
node, to either decrease or increase its inherent rate. The
balance between these two reflex control systems
normally determines the heart rate.
Baroreceptors
- are specialized nerve cells located in the aortic arch and
in both right and left internal carotid arteries (at the point
of bifurcation from the common carotid arteries). This is
sensitive to changes in BP.
Hypertension
- during this state cells increase their rate of discharge,
transmitting impulses to the cerebral medulla.
- This initiates parasympathetic activity and inhibits
sympathetic response, lowering the heart rate and the
BP
Hypotension
- results in less baroreceptor stimulation, which
prompts a decrease in parasympathetic inhibitory
activity in the SA node, allowing for enhanced
sympathetic activity.
- The resultant vasoconstriction and increased heart
rate elevate the BP.
Control of Stroke Volume
- Stroke volume is primarily determined by three
factors: preload, afterload, and contractility.
Preload
- refers to the degree of stretch of the ventricular
cardiac muscle fibers at the end of diastole.
commonly referred to as left ventricular end-diastolic
pressure (LVEDP).
- Taandaan lang na ang PRELOAD nagbibigay or nagsu
supply ng blood sa chambers ng heart. Sa madlaing
salita nagkakarga ka.
Frank-Starling (or Starling) law
- within limits, the greater the initial length or stretch of
the cardiac muscle cells (sarcomeres), the greater the
degree of shortening that occurs.
- Diuretics, venodilating agents (eg, nitrates), excessive
loss of blood, or dehydration (excessive loss of body
fluids from vomiting, diarrhea, or diaphoresis) reduce
preload.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Afterload
- resistance to ejection of blood from the ventricle, is
the second determinant of stroke volume
- systemic vascular resistance - resistance of the
systemic BP to left ventricular ejection
- pulmonary vascular resistance - resistance of the
pulmonary BP to right ventricular ejection
- Pinagkaiba naman dito nag e excrete ka ng blood.
Meaning PALABAS sa heart.
Contractility
- refers to the force generated by the contracting
myocardium.
Ejection Fraction
- percentage of the end-diastolic blood volume that is
ejected with each heartbeat
- ejection fraction of the normal left ventricle is 55% to
65%.
- right ventricular ejection fraction is rarely measured
- Ito yung amount ng blood na nilalabas ng heart sa
kada parts nya (aorta, ventricle, artery, veins)
Assessment
- the key components of the cardiovascular assessment
remain the same, the assessment priorities vary
according to the needs of the patient
- For example, an emergency department nurse performs a
rapid and focused assessment of a patient in which acute
coronary syndrome (ACS), rupture of an atheromatous
plaque in a diseased coronary artery, is suspected.
- Diagnosis and treatment must be started within minutes
of arrival to the emergency department.
Physical Assessment
1) Common Symptoms
- Chest pain or discomfort (angina pectoris, ACS,
dysrhythmias, valvular heart disease)
- Shortness of breath or dyspnea (ACS, cardiogenic
shock, HF, valvular heart disease)
- Peripheral edema, weight gain, abdominal distention
due to enlarged spleen and liver or ascites (HF)
- Palpitations (tachycardia from a variety of causes,
including ACS, caffeine or other stimulants,
electrolyte imbalances, stress, valvular heart disease,
ventricular aneurysms)
- Vital fatigue, sometimes referred to as vital
exhaustion (an early warning symptom of ACS, HF, or
valvular heart disease, characterized by feeling
unusually tired or fatigued, irritable, and dejected)
- Dizziness, syncope, or changes in level of
consciousness (cardiogenic shock, cerebrovascular
disorders, dysrhythmias, hypotension, postural
hypotension, vasovagal episode)
2) Chest Pain
- Chest pain and discomfort are common symptoms
that may be caused by a number of cardiac and
noncardiac problems. When a patient experiences
chest symptoms, the nurse asks questions that aid in
differentiating among these sources of chest
symptoms. During the assessment the patient is asked
to identify the quantity of pain using a 0 (no pain) to 10
J.A.K.E 3 of 57
(worst pain) scale. Next, the nurse asks the patient to
describe the character or quality of the pain or
discomfort and its location. The nurse should keep the
following important points in mind when assessing
patients reporting chest pain or discomfort:
3) Past Health, Family, and Social History
- What type of health concerns do you have? Are you
able to identify any family history (Chart 26-2) or
behaviors (risk factors) that put you at risk for this
health condition?
- What are your risk factors for heart disease? What do
you do to stay healthy and take care of your heart?
- How is your health? Have you noticed any changes
from last year? From 5 years ago?
- Do you have a cardiologist or primary health care
provider? How often do you go for checkups?
- Do you use tobacco or consume alcohol?
4) Medications
- Nurses collaborate with physicians and pharmacists to
obtain a complete list of the patient’s medications
including dose and frequency.
- Vitamins, herbals, and other over-the-counter
medications are included on this list. During this aspect of
the health assessment, the nurse solicits answers to the
following questions to ensure that patients are safely and
effectively taking their medications.
o Is the patient independent in taking medications?
o Are the medications taken as prescribed?
o Does the patient know what side effects to report to
the prescriber?
o Does the patient understand why the medication
regimen is important?
o Are doses ever forgotten or skipped, or does the
patient ever decide to stop taking a medication?
5) Nutrition
- Dietary modifications, exercise, weight loss, and
careful monitoring are important strategies for
managing three major cardiovascular risk factors:
hyperlipidemia, hypertension, and diabetes mellitus.
Diets that are restricted in sodium, fat, cholesterol, or
calories are commonly prescribed.
6) Elimination
- Typical bowel and bladder habits need to be identified.
Nocturia (awakening at night to urinate) is common in
patients with HF.
- Fluid collected in gravity-dependent tissues
(extremities) during the day (ie, edema) redistributes
into the circulatory system once the patient is
recumbent at night.
- The increased circulatory volume is excreted by the
kidneys (increased urine production). .
7) Activity and Exercise
- As the nurse assesses the patient’s activity and
exercise history, it is important to note that decreases
in activity tolerance are typically gradual and may go
unnoticed by
8) Blood Pressure
- Systemic arterial BP is the pressure exerted on the
walls of the arteries during ventricular systole and
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
diastole. It is affected by factors such as cardiac
output; distention of the arteries; and the volume,
velocity, and viscosity of the blood.
- A normal BP in adults is considered a systolic BP less
than 120 mm Hg over a diastolic BP less than 80 mm
Hg.
- High blood pressure or hypertension is defined by
having a systolic blood pressure that is consistently
greater than 140 mm Hg or a diastolic BP greater than
90 mm Hg.
- Hypotension refers to an abnormally low systolic and
diastolic blood pressure that can result in
lightheadedness or fainting.
9) Pulse Pressure
- The difference between the systolic and the diastolic
pressures is called the pulse pressure.
- It is a reflection of stroke volume, ejection velocity,
and systemic vascular resistance. Pulse pressure,
which normally is 30 to 40 mm Hg, indicates how well
the patient maintains cardiac output.
- The pulse pressure increases in conditions that
elevate the stroke volume (anxiety, exercise,
bradycardia), reduce systemic vascular resistance
(fever), or reduce distensibility of the arteries
(atherosclerosis, aging, hypertension).
10) Arterial Pulses
- Factors to be evaluated in examining the pulse are rate,
rhythm, quality, configuration of the pulse wave, and
quality of the arterial vessel.
11) Pulse Rate
- The normal pulse rate varies from a low of 50 bpm in
healthy, athletic young adults to rates well in excess of
100 bpm after exercise or during times of excitement.
- Anxiety frequently raises the pulse rate during the
physical examination.
- If the rate is higher than expected, it is appropriate to
reassess it near the end of the physical examination,
when the patient may be more relaxed.
12) Pulse Rhythm
- The rhythm of the pulse is as important to assess as
the rate. Minor variations in regularity of the pulse are
normal.
- The pulse rate may increase during inhalation and slow
during exhalation.
- This phenomenon, called sinus arrhythmia, occurs
most commonly in children and young adults.
- For the initial cardiac examination, or if the pulse
rhythm is irregular, the heart rate should be counted by
auscultating the apical pulse, located at the PMI, for a
full minute while simultaneously palpating the radial
pulse.
a) Aortic area — second intercostal space to the
right of the sternum. To determine the correct
intercostal space, the nurse first finds the angle of
Louis by locating the bony ridge near the top of
the sternum, at the junction of the body and the
manubrium. From this angle, the second
intercostal space is located by sliding one finger
to the left or right of the sternum. Subsequent
J.A.K.E 4 of 57
intercostal spaces are located from this reference
point by palpating down the rib cage.
b) Pulmonic area — second intercostal space to the
left of the sternu
c) Erb’s point — third intercostal space to the left of
the sternum
d) Tricuspid area — lower half of the sternum along
the left parasternal area
e) Mitral (apical) area — left fifth intercostal space at
the midclavicular line
f) Epigastric area — below the xiphoid process.
13) Pulse Quality
- The quality, or amplitude, of the pulse can be
described as absent, diminished, normal, or bounding.
It should be assessed bilaterally.
14) Heart Inspection and Palpation
- The heart is examined by inspection, palpation, and
auscultation of the chest wall. A systematic approach
is used to examine the chest wall in the following six
areas.
15) Heart Auscultation
- A stethoscope is used to auscultate each of the
locations identified in Figure 26-5, with the exception
of the epigastric area.
- The purpose of cardiac auscultation is to determine
heart rate and rhythm and evaluate heart sounds. The
apical area is auscultated for 1 minute to determine
the apical pulse rate and the regularity of the
heartbeat.
- Normal and abnormal heart sounds detected during
auscultation are described in the following section.
16) Normal Heart Sounds
- Normal heart sounds, referred to as S1 and S2, are
produced by closure of the AV valves and the
semilunar valves, respectively.
- The period between S1 and S2 corresponds with
ventricular systole (Fig. 26-7).
- When the heart rate is within the normal range,
systole is much shorter than the period between S2
and S1 (diastole). However, as the heart rate
increases, diastole shortens.
- Normally, S1 and S2 are the only sounds heard during
the cardiac cycle.
• S1—First Heart Sound. Tricuspid and mitral
valve closure creates the first heart sound (S1).
- The word ―lub‖ is used to replicate its sound.
S1 is usually heard the loudest at the apical
area.
- The intensity of S1 from beat to beat due to
lack of synchronized atrial and ventricular
contraction.
• S2—Second Heart Sound. Closure of the
pulmonic and aortic valves produces the second
heart sound (S2), commonly referred to as the
―dub‖ sound. The aortic component of S2 is
heard the loudest over the aortic and pulmonic
areas.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
• Abnormal Heart Sounds develop during systole
or diastole when structural or functional heart
problems
- These sounds are created by the vibration of
the ventricle and surrounding structures as
blood meets resistance during ventricular
filling. The term gallop evolved from the
cadence that is produced by the addition of a
third or fourth heart sound, similar to the
sound of a galloping horse.
- Gallop sounds are very low-frequency sounds
and are heard with the bell of the stethoscope
placed very lightly against the chest.
• S3—Third Heart Sound. An S3 occurs early in
diastole during the period of rapid ventricular
filling. It is heard immediately after S2. ―Lub-dub
DUB‖ (S3) is used to imitate the sound of the
beating heart with this gallop sound. It represents
a normal finding in children and adults up to 35 or
40 years of age.
• S4—Fourth Heart Sound. S4 occurs late in
diastole. An S4 occurs just before S1 and is
generated during atrial contraction as blood
forcefully enters a noncompliant ventricle. This
resistance to blood flow is due to ventricular
hypertrophy caused by hypertension, CAD,
cardiomyopathies, aortic stenosis, and numerous
other conditions. ―LUB (S4) lub-dub‖ is used to
imitate this gallop sound. During tachycardia, all
four sounds combine into a loud sound, referred
to as a summation gallop.
17) Murmurs. Murmurs
- are created by turbulent flow of blood. The causes of
the turbulence may be a critically narrowed valve, a
malfunctioning valve that allows regurgitant blood
flow, a congenital defect of the ventricular wall, a
defect between the aorta and the pulmonary artery, or
an increased flow of blood through a normal structure
(eg, with fever, pregnancy, hyperthyroidism).
18) Friction Rub.
- A harsh, grating sound that can be heard in both
systole and diastole is called a friction rub.
- It is caused by abrasion of the inflamed pericardial
surfaces from pericarditis. Because a friction rub may
be confused with a murmur, care should be taken to
identify the sound and to distinguish it from murmurs
that may be heard in both systole and diastole.
- A pericardial friction rub can be heard best using the
diaphragm of the stethoscope, with the patient sitting
up and leaning forward.
Auscultation Procedure
- During auscultation, the patient remains supine and
the examining room is as quiet as possible.
- A stethoscope with both diaphragm and bell functions
is necessary for accurate auscultation of the heart.
- Using the diaphragm of the stethoscope, the examiner
starts at the apical area and progresses upward along
J.A.K.E 5 of 57
the left sternal border to the pulmonic and aortic
areas.
- Alternatively, the examiner may begin the examination
at the aortic and pulmonic areas and progress
downward to the apex of the heart.
- Initially, S1 is identified and evaluated with respect to
its intensity and splitting.
- Next, S2 is identified, and its intensity and any
splitting are noted.
- After concentrating on S1 and S2, the examiner listens
for extra sounds in systole and then in diastole.
Sometimes it helps to ask the following questions:
• Do I hear snapping or clicking sounds?
• Do I hear any high-pitched blowing sounds?
• Is this sound in systole, or diastole, or both?
Laboratory Tests
• To assist in diagnosing the cause of cardiac-related signs
and symptoms
• To determine baseline values before initiating therapeutic
interventions
• To screen for modifiable CAD risk factors
• To ensure that therapeutic levels of medications (eg,
antiarrhythmic agents and warfarin) are maintained
• To evaluate the patient’s response to the therapeutic
regimen (eg, effects of diuretics on serum potassium
levels)
• To identify abnormalities that affect the prognosis of a
patient with CVD
- Normal values for laboratory tests may vary
depending on the laboratory and the health care
institution. This variation is due to the differences in
equipment and methods of measurement across
organizations.
• Cardiac Biomarker Analysis
• Blood Chemistry, Hematology, and Coagulation Studies
- Lipid Profile
- Cholesterol Levels
- Triglycerides
• Brain (B-Type) Natriuretic Peptide
• C-Reactive Protein
• Homocysteine
• Chest X-Ray and Fluoroscopy
• Electrocardiography
- Traditional Echocardiography
- Transesophageal Echocardiography
• Magnetic Resonance Angiography
• Cardiac Catheterization
• Angiography
• Continuous Electrocardiographic Monitoring
• Telemetry
• Central Venous Pressure Monitoring
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

DISTURBANCES IN OXYGENATION
Discussed by: Dr. Potenciana A. Maroma
Components involved in Oxygenation
• Heart
• Lungs
• Red Blood Cells
• Blood Vessels

Anatomy and Physiology Review

• Heart
- cone-shaped hollow muscular organ located in the
mediastinum between the lungs
- Pumps about 60ml/beat or 5L/min
- Pericardium – protective covering of the heart
3 layers of cardiac muscle tissue:
• Epicardium – outermost layer
• Myocardium – middle layer
• Endocardium – innermost layer
Chambers
- Right atrium (0-5 mmHg)
 SVC, IVC, Coronary sinus
- Right Ventricle (25 mmHg)
- Left atrium
- Left ventricle
Valves
• AV valves - Semilunar valves
Coronary Arteries
Left Coronary Artery
- Left anterior descending – LV, Ventricular septum,
chordae tendinae, papillary muscle, RV (lesser extent)
- Circumflex coronary artery – LA, lateral & posterior
surfaces of LV, portion of interventricular septum, SA
node, AV node
Right Coronary Artery
- RA, RV, inferior portion of LV
- Branching pattern of the coronary arteries varies
considerably among individuals
Electrophysiologic Properties of the Heart
• Automaticity
- initiate an impulse spontaneously & repetitively
• Excitability (depolarization)
- respond to a stimulus
• Conductivity
- Transmit electrical impulses
• Contractility
- Contract
• Refractoriness
- Inability to respond until repolarization
Conduction System of the Heart
• SA node (60-100 times/min)
• AV node (40-60 beats/min)
• Bundle of His
• R & L bundle branches
• Purkinje fibers (20-40 beats/min)

J.A.K.E 6 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

 Sequence of events during cardiac cycle

- Systole (contraction) – emptying
- Diastole (relaxation) – filling

Mechanical Properties of the Heart

• Cardiac Output
- Heart rate
o ANS,  endogenous cathecolamines
o Parasympathetic NS (vagus nerve), beta blockers,
Ca++-channel blockers
- SV
o Preload – volume of blood distending the
ventricles at the end of diastole just before
contraction
o Afterload – resistance that the ventricles must
overcome to eject blood
o Contractility – contract
Formula: Cardiac Output = HR x SV

Assessment
- History (focus: obtaining information about client’s risk
factors & symptoms of cardiovascular disease)
o Demographic data – age, gender, ethnic origin
Vascular System o Family history & genetic risk
Functions: o Personal history
- Provide conduits for blood to travel from the heart to o Diet history
nourish the various tissues of the body Socioeconomic status
- Carries cellular waste to the excretory organs - History
- Allows lymphatic flow to drain tissue fluid back into the • Modifiable
circulation - Cigarette smoking
- Returns blood to the heart for recirculation - Physical inactivity
- Obesity
- Psychological variables
- Chronic diseases
J.A.K.E 7 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

• Non-modifiable risk factors • Serum lipids

- Age, gender, ethnic background, family history - Cholesterol (122-200mg/dl)
• Cigarette smoking – major risk factor for the devp’t of cad - TGL (40-160 or 35-135mg/dl)
& pvd - HDL (45-50 or 55-60mg/dl)
• Obesity – strong indicator of cvd especially when - LDL (60-180mg/dl)
abdominal obesity is present - HDL:LDL ratio (3:1)
Physical Assessment Laboratory Tests II
• Major symptoms of cardiovascular disease (CVD) o C-Reactive Protein (<1.0mg/dl)
- Pain or discomfort o Blood coagulation tests (evaluate the ability of the blood
- Dyspnea (DOE, Orthopnea, Paroxysmal Nocturnal to clot- thrombi)
Dyspnea) o ABG
- Fatigue o Serum electrolytes (K+, Ca++, Na+, Magnesium)
- Palpitations o CBC
- Weight gain – best indicator of fluid retention (edema)
- Syncope – transient loss of consciousness ( cerebral Radiographic Examinations
perfusion) • Chest radiography
- Extremity pain – due to ischemia & venous - Determine the size, silhouette & position of the heart
insufficiency • Angiography (arteriography)
Physical assessment II - Invasive procedure involving fluoroscopy & the use of
- Skin color – pallor (anemia), cyanosis (late sign of contrast media
decreased perfusion) • Cardiac Catheterization
-  skin temperature – due to  blood flow - Most definitive, most invasive test used in the
- Clubbing of fingers – chronic tissue hypoxia diagnosis of heart disease
- Edema o Right-sided heart catheterization
- BP changes o Left-sided heart catheterization
o Hypertension
o Postural
- Hypotension
o Pulse pressure (30-40mmHg)
- Precordium (area over the heart)
• Other assessment involves
o Inspection
- Apical impulse
o Palpation
o Percussion
o Auscultation
- Normal heart sounds
- Abnormal heart sounds
Normal Heart Sounds
• S1 – closure of AV valves
- Low pitch, long; best heard at the apex of the heart
- Palpate the carotid pulse while listening
- Marks the beginning of ventricular systole
• S2 – closure of semilunar valves
- High pitch, short; best heard at the base of the heart
Abnormal Heart Sounds
• Murmurs
- Reflection of turbulence of blood flow through the
normal or abnormal valves
• Pericardial friction rub
- Sign of inflammation, infection or infiltration
Laboratory Tests
• Serum markers of myocardial damage (cardiac
markers)
- Troponin (T=<0.2ng/ml, I=<0.03ng/ml)
- Creatine Kinase (CK-MB)
- Myoglobin (<90mcg/L)

J.A.K.E 8 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

Measures electrical current from 12 different views or

leads
• Bipolar limb leads
- Lead I
- Lead II
- Lead III
• Unipolar augmented leads
- aVR
- aVL
- aVF
• Unipolar precordial leads
- V1
- V2
- V3
- V4
- V5
- V6
• Angiography
- Angiography in action: The beating heart and its
surrounding blood vessels can be watched and
recorded in extraordinary detail as a catheter injects
a contrast dye into a patient's coronary arteries
• Coronary arteriography
- Technique is the same for left-sided heart
catheterization
- Complications: MI, Stroke, Arterial bleeding,
Thromboembolism, Lethal dysrhythmias, Death
• Intravascular ultrasonography (IVUS)
- Catheter with miniature transducer (soundwaves) at
the distal tip to visualize the coronary arteries

• Electrocardiography (ECG)
- Graphically measures & records the electrical current
traveling through the conduction system generated by
the heart
- Measured by electrodes placed on the skin &
connected to an amplifier & strip chart recorder
- In a standard 12-lead ecg:
o Five electrodes attached to the arms, legs, &
chest

J.A.K.E 9 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Electrocardiographic Paper
- Electrocardiogram (ECG) strip: each
measures 1 mm in height & width
- Standard speed:25mm/sec
• P wave – represents atrial depolarization
• PR segment – represents the time required for the
impulse to travel through the AV node, where it is delayed,
and through the Bundle of His, Bundle branches, &
Purkinje fiber network, just before ventricular
depolarization
• PR interval – represents the time required for atrial
depolarization as well as impulse travel through the
conduction system and Purkinje fiber network, inclusive of
the P wave and PR segment. It is measured from the
beginning of the P wave to the end of the PR segment
(0.12-0.20 sec)
small block • QRS complex – represents ventricular depolarization and
is measured from the beginning of the Q (or R) wave to the
end of the S wave (0.04 - 0.10 sec)
• ST segment – represents early ventricular repolarization
• T wave – represents ventricular repolarization
• U wave – represents late ventricular repolarization
• QT interval – represents the total time required for
ventricular depolarization and repolarization and is
measured from the beginning of the QRS complex to the
end of the T wave
J.A.K.E 10 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

Characteristics of the Normal rhythm: Disturbances in O2 Transport Mechanism

• HR is 60-100 bpm • Infectious Disorders
• P waves are found before the QRS complex - Pericarditis, Myocarditis, Endocarditis, RHD
• PR interval is 0.12 to 0.20 seconds duration • Coronary Artery Disease
• QRS complex is 0.04 to 0.10 seconds duration - Atherosclerosis
• conduction is forward and cyclical - Angina pectoris
• The rhythm is regular with no delay - Myocardial infarction
• Various forms of ECG • Congestive Heart Failure
• Resting ECG • Pulmonary edema
• Ambulatory ECG (Holter monitoring) – 24 hrs. • Arrythmias
• Exercise ECG (Stress test)

• Echocardiography
- uses ultrasound waves to assess cardiac structure &
mobility, particularly at the valves

• Hemodynamic Monitoring
- Use to assess the volume & pressure of blood in the
heart & vascular system by means of a surgically
inserted catheter
- Methods:
o Direct BP monitoring
- Artery used: radial, brachial, femoral
- Catheter tip contains sensor that measures &
transmits the fluid pressure to a transducer
o CVP monitoring
o Pulmonary artery pressure monitoring
• CVP monitoring
– Pressure produced by venous blood in the RA
– NV: 2-7 mmHg or 4-10cm H2O
• Pulmonary artery pressure monitoring

J.A.K.E 11 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

• Antibiotics
• Pericardial drainage
• Radiation or chemotherapy if caused by malignancy
• Hemodialysis (uremic pericarditis)
• Assist to assume position of comfort
• Pericardiectomy (chronic constrictive pericarditis)
• Monitor for complications: pericardial effusion
Monitor for complications:
• pericardial effusion  cardiac tamponade
- Findings:
• Jugular distention
• Paradoxical pulse (systolic BP 10mmHg or more
on expiration than on inspiration)
•  cardiac output
Pericarditis • Muffled heart sounds
- Inflammation of the pericardium • Circulatory collapse
- Associated w/ the following: • emergency care: pericardiocentesis
• Malignant neoplasms
• Idiopathic cause
• Infective organisms (bacteria, viruses, fungi)
• Post-MI syndrome (Dressler’s syndroe) – pericarditis,
fever, pericardial & pleural effusion 1-12 weeks after
MI)
• Postpericardiotomy syndrome
• Systemic connective tissue disease
• Renal failure
- Chronic pericardial inflammation causes fibrous
thickening of the pericardium
- “Chronic Constrictive Pericarditis” → rigid pericardium
→ inadequate ventricular filling → Heart Failure

Myocarditis
- Causes:
• Viral, bacterial, fungal & parasitic infection
• Chronic alcohol & cocaine abuse
• Radiation therapy
• Autoimmune disorders
• Bulimic patients taking ipecac syrup to facilitate
purging (myocardial damage)
- Due to inflammation  abnormal function
Assessment: •  cardiac output, impaired blood circulation,
• PAIN radiating to the neck, shoulder & back predispose client to CHF
- aggravated by inspiration, coughing & swallowing • Due to ischemia: tachycardia, dysrhythmias
- worst in supine position (relieved by sitting up & • Cardiomyopathy
leaning forward) Assessment:
• Pericardial friction rub (scratchy high pitch sound) • Pain, Fever, Tachycardia, Dysrhythmias, Dyspnea, Malaise,
• If w/ chronic constrictive pericarditis: Signs of RSHF Fatigue, Anorexia, Pale or cyanotic skin, signs of RSHF
• Echocardiography, CT scan – reveals thickening of • WBC count, elevated CRP, elevated cardiac isoenzymes,
pericardium abnormal ECG
• WBC count • Abnormal chest radiography, echocardiography
• Atrial fibrillation is also common Intervention:
Interventions: • Treatment of underlying cause (antibiotic)
• NSAIDs for PAIN
• Corticosteroids
J.A.K.E 12 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

• Promote bed rest, Na+-restricted diet, cardiotonic drugs

(digitalis) are prescribed
• Monitor cardiopulmonary status and complications (CHF,
dysrhythmias)
- VS
- Daily weight
- I&O
- Heart & lung sounds
- Pulse oximetry measurements
- Cardiac monitoring
- Dependent edema

Rheumatic Fever
– A systemic inflammatory disease that usually develops
after an URTI
– group A ß-hemolytic streptococci
– Rheumatic carditis (Rheumatic endocarditis)

Rheumatic Carditis/ Endocarditis

1) Antibodies are formed to destroy the group A ß-hemolytic
strep microorganism
2) Antibodies “mistakenly” cross-react against the proteins
in the connective tissue of the heart, joints, skin & nervous
system
3) Pan CARDITIS (all layers) due to inflammation, WBC
migrate to endocardium causing accumulation of Assessment:
inflammatory debris “vegetations” around the valve • Major/ Classic symptoms
leaflets - Carditis
o Characterized by formation of Aschoff’s bodies
o Murmur (valve damage)
o pericardial friction rub (pericarditis)
o CHF
- Polyarthritis
o Swelling of several joints (knees, ankle, hips,
shoulders) that is warm, red and painful
- Chorea (Sydenham’s chorea, St. Vitu’s dance)
o Involuntary grimacing & inability to use skeletal
muscles in a coordinated manner
o Involvement of CNS
- Subcutaneous nodules
o Sometimes marble-sized nodules appear around
the joints
- Erythema marginatum
o Red, spotty rashes on the trunk that disappears
rapidly leaving irregular circles on the skin

J.A.K.E 13 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

• Minor symptoms - Types:

- Reliable history of RF or evidence of pre-existing • Left-sided heart failure
rheumatic heart disease • Right-sided heart failure
- Arthralgia- pain in one or more joints without evidence - Causes:
of inflammation, tenderness, or limited movement • Damage to muscular wall (M.I.), Cardiomyopathy,
- Fever (38.9 - 40°C or 101 - 104°F) Hypertension, CAD, Valvular defects, Infections
- Diagnostic tests:  in ESR and ASO titer, (+) C-
reactive protein
- ECG changes: prolonged P-R interval

• Diagnosed clinically through the use of the JONES criteria

- presence of 2 major manifestation or
- 1 major + 2 minors with supporting evidence of a
recent streptococcal infection
Management/ Intervention:
• PREVENTION - ideal management
• RHD is prevented through early identification & adequate
treatment of streptococcal infection
• A nurse should be familiar with the signs & symptoms of
streptococcal pharyngitis
Signs & symptoms of streptococcal pharyngitis:
• Fever (38.9 - 40°C or 101 - 104°F)
• Chills
• Sore throat (sudden onset)
• diffuse redness of throat with exudates on oropharynx
• Enlarge & tender lymph nodes
• Abdominal pain (common in children)
• Acute sinusitis & acute otitis media
Management/ Intervention:
• Antibiotic: DOC – penicillin
• Aspirin (control blood clot formation around the valves)
• Steroids (suppresses inflammation)
• Fever (antipyretics, hydration)
• Antibiotic prophylaxis to prevent recurrence
• Provide bed rest; provide diversional activities that require
minimal activity (reading, putting puzzles together)
• Assess for progression or improvement of heart
involvement

Heart Failure
- “Pump failure”, inadequacy of the heart to pump blood
throughout the body Diagnostic Findings:
- Congestive Heart Failure • Chest x-rays: reveals cardiomegaly (hypertrophy)
• accumulation of blood & fluid in organs & tissues due • Pleural effusions develops
to impaired circulation • ECG: abnormal findings (ventricular hypertrophy,
dysrhythmias)
J.A.K.E 14 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

• Echocardiography – reveals cardiac valvular changes, - Nonproductive cough

pericardial effusions, chamber enlargement, ventricular - Hiccough.
hypertrophy • Dyspnea and other signs and symptoms of heart failure
• Multigraded angiographic (MUGA) scans – information (HF) may occur.
about ejection fraction
Medical Management:
• Low-sodium diet, fluid restriction
• Inotropic agents:
- Digitalis: Digoxin (Lanoxin)
o  contractility,  HR,  conduction (AV node)
o (-) sympa. activity, (+) parasympa. Activity
o Watch out for DIGITALIS toxicity: loss of apetite,
N&V, rapid, slow, irregular heart rate, disturbance
in color vision
- Dopamine (Intropin), Dobutamine (Dobutrex)
• Diuretics: Furosemide (Lasix), Chlorothiazide (Diuril)
• Vasodilators (Nitroglycerin), ACE inhibitors (pril)

INFLAMMATORY/INFECTIOUS DISORDERS OF THE HEART

Discussed by: Dr. Potenciana A. Maroma
Pericarditis (Cardiac Tamponade)
- Inflammation of the pericardium, the membranous sac
enveloping the heart. It may be primary or may develop in
the course of a variety of medical and surgical disorders.
- Cause: Unknown
- Others causes:
• Infection (usually viral, rarely bacterial or fungal)
• Connective tissue disorders
• Hypersensitivity states
• Diseases of adjacent structures
• Neoplastic disease, radiation therapy trauma
• Renal disorders
• Tuberculosis (tb).
- Frequent or prolonged episodes of pericarditis may lead to
thickening and decreased elasticity that restrict the
heart’s ability to fill properly with blood (constrictive
pericarditis).
- The pericardium may also become calcified, which
restricts ventricular contraction. Pericarditis can lead to
an accumulation of fluid in the pericardial sac (pericardial
effusion) and increased pressure on the heart, leading to
cardiac tamponade.
- Calcification – accumulation of calcium salts in the body
Clinical Manifestations of Pericarditis
• Pain – which is felt over the precordium or beneath the
clavicle and in the neck and left scapular region.
Aggravated by breathing, turning in bed, and twisting the
body
- It is relieved by sitting up (or leaning forward).
- creaky or scratchy friction rub heard most clearly at
the left lower sternal border.
• Other signs
- Mild fever
- Increased wbc count
- Anemia
- An elevated erythrocyte sedimentation rate (esr)
- C-reactive protein level
J.A.K.E 15 of 57
Clinical Manifestations of Cardiac Tamponade
• Falling blood pressure
• Rising venous pressure (distended neck veins)
• Distant (muffled) heart sounds with pulsus paradoxus
Assessment
- Assess pain by observation and evaluation while having
patient vary positions to determine precipitating or
intensifying factors.
- (Is pain influenced by respiratory movements?)
- Assess pericardial friction rub (a pericardial friction rub is
continuous, distinguishing it from a pleural friction rub).
- Ask patient to hold breath to help in differentiation:
audible on auscultation, synchronous with heartbeat, best
heard at the left sternal edge in the fourth intercostal
space where the pericardium comes into contact with the
left chest wall, scratchy or leathery sound, louder at the
end of expiration and may be best heard with patient in
sitting position.
- Monitor temperature frequently, because pericarditis
causes an abrupt onset of fever in a previously afebrile
patient.
Nursing Diagnoses
- Acute pain related to inflammation of the pericardium
- Collaborative Problems/Potential Complications
o Pericardial effusion
o Cardiac tamponade
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Planning and Goals
- The major goals of the patient may include relief of pain
and absence of complications.
Nursing Interventions Relieving Pain
- Advise bed rest or chair rest in a sitting-upright and
leaning- forward position.
- Instruct patient to resume activities of daily living as chest
pain and friction rub abate.
- Administer medications; monitor and record responses.
- Instruct patient to resume bed rest if chest pain and
friction rub recur.
Monitoring and Managing Potential Complications
- Observe for pericardial effusion, which can lead to cardiac
tamponade: arterial pressure falls; systolic pressure falls
while diastolic pressure remains stable; pulse pressure
narrows; heart sounds progress from being distant to
imperceptible.
- Observe for neck vein distention and other signs of rising
CVP.
- Notify physician immediately upon observing any of the
above symptoms and prepare for diagnostic
echocardiography and pericardiocentesis.
- Reassure patient and continue to assess and record signs
and symptoms until physician arrives.
Myocarditis
- inflammatory process involving the myocardium.
- Causes: results from an infectious process (eg, viral,
bacterial, rickettsial, fungal, parasitic, metazoal, protozoal,
spirochetal).
- cause heart dilation, thrombi on the heart wall (mural
thrombi), infiltration of circulating blood cells around the
coronary vessels and between the muscle fibers, and
degeneration of the muscle fibers themselves.
Clinical Manifestations
• Clinical features depend on the type of infection, degree
of myocardial damage, and capacity of the myocardium to
recover.
• Symptoms may be moderate, mild, or absent.
• fatigue and dyspnea, palpitations, and occasional
discomfort in the chest and upper abdomen.
• The most common symptoms are flulike.
• Patient may develop severe congestive heart failure or
sustain sudden cardiac death.
Assessment
- Cardiac enlargement, faint heart sounds (especially S1)
- a gallop rhythm
- a systolic murmur may be found
Diagnostic Findings
- Cardiac MRI with contrast may be diagnostic and can
guide clinicians to sites for endocardial biopsies.
Medical Management
- Patients are given specific treatment for the underlying
cause if it is known (eg, penicillin for hemolytic
streptococci) and are placed on bed rest to decrease
cardiac workload, myocardial damage, and complications.
- young patients, activities, especially athletics, should be
limited for a 6-month period or at least until heart size and
J.A.K.E 16 of 57
function have returned to normal; physical activity is
increased slowly.
- If heart failure or dysrhythmia develops, management is
essentially the same as for all causes of heart failure and
dysrhythmias
- beta-blockers are avoided
Endocarditis, Infective
- a microbial infection of the endothelial surface of the
heart. A deformity or injury of the endocardium leads to
accumulation on the endocardium of fibrin and platelets
(clot formation).
- Infectious organisms, usually staphylococci, streptococci,
enterococci, pneumococci, or chlamydiae invade the clot
and endocardial lesion.
- Other causative microorganisms include fungi (eg,
Candida, Aspergillus) and rickettsiae
Risk Factors
• Prosthetic heart valves or structural cardiac defects (eg,
valve disorders, hypertrophic cardiomyopathy [HCM]).
• Age: More common in older people, who are more likely to
have degenerative or calcific valve lesions, reduced
immunologic response to infection, and the metabolic
alterations associated with aging.
• Intravenous (IV) drug use: There is a high incidence of
staphylococcal endocarditis among IV drug users.
• Hospitalization: Hospital-acquired endocarditis occurs
most often in patients with debilitating disease or
indwelling catheters and in those receiving hemodialysis
or prolonged IV fluid or antibiotic therapy.
• Immunosuppression: Patients taking immunosuppressive
medications or corticosteroids are more susceptible to
fungal endocarditis.
Clinical Manifestations
• Primary presenting symptoms are fever and a heart
murmur: Fever may be intermittent or absent, especially
in elderly patients, patients receiving antibiotics or
corticosteroids, or those who have heart failure or renal
failure.
• Vague complaints of malaise, anorexia, weight loss,
cough, and back and joint pain.
• A heart murmur may be absent initially but develops in
almost all patients.
• Small, painful nodules (Osler nodes) may be present in
the pads of fingers or toes.
• Irregular, red or purple, painless, flat macules (Janeway
lesions) may be present on the palms, fingers, hands,
soles, and toes.
• Hemorrhages with pale centers (Roth spots) caused by
emboli may be observed in the fundi of the eyes. Splinter
hemorrhages (ie, reddish brown lines and streaks) may be
seen under the fingernails and toenails.
• Petechiae may appear in the conjunctiva and mucous
membranes.
• Cardiomegaly, heart failure, tachycardia, or splenomegaly
may occur.
• Headache
• Temporary or transient cerebral ischemia
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
• Strokes
• Embolization may be a presenting symptom
Assessment and Diagnostic Methods
- A diagnosis of acute infective endocarditis is made when
the onset of infection and resulting valvular destruction
are rapid, occurring within days to weeks.
o Blood cultures
o Doppler or transesophageal echocardiography
Complications
- Complications include heart failure, cerebral vascular
complications, valve stenosis or regurgitation, myocardial
damage, and mycotic aneurysms.
Nursing Management
• Provide psychosocial support while patient is confined to
hospital or home with restrictive IV therapy.
• Monitor patient’s temperature; a fever may be present for
weeks.
• Assess heart sounds for new or worsening murmur.
• Monitor for signs and symptoms of systemic embolization,
or, for patients with right heart endocarditis, signs and
symptoms of pulmonary infarction and infiltrates.
• Assess for signs and symptoms of organ damage such as
stroke (cerebrovascular accident [CVA], brain attack),
meningitis, heart failure, myocardial infarction,
glomerulonephritis, and splenomegaly.
• Instruct patient and family about activity restrictions,
medications, and signs and symptoms of infection.
• Reinforce that antibiotic prophylaxis is recommended for
patients who have had infective endocarditis and who are
undergoing invasive procedures.
• If patient received surgical treatment, provide postsurgical
care and instruction.
• Refer to home care nurse to supervise and monitor IV
antibiotic therapy in the home. For additional nursing
interventions.
J.A.K.E 17 of 57
Heart Failure
- HF is a clinical syndrome characterized by signs and
symptoms of fluid overload or inadequate tissue perfusion.
- The underlying mechanism of HF involves impaired
contractile properties of the heart (systolic dysfunction) or
filling of the heart (diastolic) that leads to a lower- than-
normal cardiac output.
- The low cardiac output can lead to compensatory
mechanisms that cause increased workload on the heart
and eventual resistance to filling of the heart. HF is a
progressive, life-long condition that is managed with
lifestyle changes and medications to prevent episodes of
acute decompensated HF, which are characterized by an
increase in symptoms, decreased CO, and low perfusion.
- Causes: Variety of heart disorders
Clinical Manifestations
Left-Sided HF
- Most often precedes right-sided cardiac failure
• Pulmonary congestion: dyspnea, cough, pulmonary
crackles, and low oxygen saturation levels; an extra
heart sound, the S3, or ―ventricular gallop, may be
detected on auscultation.
• Dyspnea on exertion (DOE), orthopnea, paroxysmal
nocturnal dyspnea (PND).
• Cough initially dry and nonproductive; may become
moist over time.
• Large quantities of frothy sputum, which is sometimes
pink (blood-tinged).
• Bibasilar crackles advancing to crackles in all lung
fields.
• Inadequate tissue perfusion.
• Oliguria and nocturia.
• With progression of HF: altered digestion; dizziness,
lightheadedness, confusion, restlessness, and
anxiety; pale or ashen and cool and clammy skin.
• Tachycardia, weak, thready pulse; fatigue.
Right-Sided HF
• Congestion of the viscera and peripheral tissues
• Edema of the lower extremities (dependent edema),
hepatomegaly (enlargement of the liver), ascites
(accumulation of fluid in the peritoneal cavity),
anorexia and nausea, and weakness and weight gain
due to retention of fluid
Assessment and Diagnostic Methods
- Assessment of ventricular function
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
- Echocardiogram, chest x-ray, electrocardiogram (ECG)
- Laboratory studies: serum electrolytes, blood urea
nitrogen (BUN), creatinine, thyroid-stimulating hormone
(TSH), CBC count, brain natriuretic peptide (BNP), and
routine urinalysis
- Cardiac stress testing, cardiac catheterization
Medical Management
• Oral and IV medications, major lifestyle changes,
supplemental oxygen, implantation of assistive devices,
and surgical approaches, including cardiac
transplantation.
• Lifestyle recommendations include restriction of dietary
sodium; avoidance of excessive fluid intake, alcohol, and
smoking; weight reduction when indicated; and regular
exercise.
Pharmacologic Therapy
- Alone or in combination: vasodilator therapy
(angiotensinconverting enzyme [ACE] inhibitors),
angiotensin II receptor blockers (ARBs), select beta-
blockers, calcium channel blockers, diuretic therapy,
cardiac glycosides (digitalis), and others
• IV infusions: nesiritide, milrinzne, dobutamine
• Medications for diastolic dysfunction
• Possibly anticoagulants, medications that manage
hyperlipidemia (statins)
Surgical Management
- Coronary bypass surgery, percutaneous transluminal
coronary angioplasty (PTCA)
Assessment
- Signs and symptoms of pulmonary and systemic fluid
overload are recorded and reported immediately.
- Note report of sleep disturbance due to shortness of
breath, and number of pillows used for sleep.
- Ask patient about edema, abdominal symptoms, altered
mental status, activities of daily living, and the activities
that cause fatigue.
- Respiratory: Auscultate lungs to detect crackles and
wheezes. Note rate and depth of respirations.
- Cardiac: Auscultate for S3 heart sound (sign heart
beginning to fail); document heart rate and rhythm.
- Assess sensorium and LOC.
- Periphery: Assess dependent parts of body for perfusion
and edema and the liver for hepatojugular reflux; assess
jugular venous distention.
- Measure intake and output to detect oliguria or anuria;
weigh patient daily.
Nursing Diagnoses
- Activity intolerance and fatigue related to decreased CO
- Excess fluid volume related to the HF syndrome
- Anxiety related to breathlessness from inadequate
oxygenation
- Powerlessness related to chronic illness and
hospitalizations
- Ineffective therapeutic regimen management related to
lack of knowledge
Complications
• Hypotension, poor perfusion, and cardiogenic shock
• Dysrhythmias
J.A.K.E 18 of 57
• Thromboembolism
• Pericardial effusion and cardiac tamponade
Planning and Goals
- Promoting activity and reducing fatigue, relieving fluid
overload symptoms, decreasing anxiety or increasing the
patient’s ability to manage anxiety, encouraging the
patient to verbalize his or her ability to make decisions
and influence outcomes, and teaching the patient about
the self-care program.
Nursing Interventions Promoting Activity Tolerance
- Monitor patient’s response to activities. Instruct patient to
avoid prolonged bed rest; patient should rest if symptoms
are severe but otherwise should assume regular activity.
- Encourage patient to perform an activity more slowly than
usual, for a shorter duration, or with assistance initially.
- Identify barriers that could limit patient’s ability to perform
an activity, and discuss methods of pacing an activity (eg,
chop or peel vegetables while sitting at the kitchen table
rather than standing at the kitchen counter).
- Take vital signs, especially pulse, before, during, and
immediately after an activity to identify whether they are
within the predetermined range; heart rate should return
to baseline within 3 minutes. If patient tolerates the
activity, develop short-term and long-term goals to
increase gradually the intensity, duration, or frequency of
activity.
- Refer to a cardiac rehabilitation program as needed,
especially for patients with a recent myocardial infarction,
recent open-heart surgery, or increased anxiety.
Reducing Fatigue
- Encourage patient to alternate activities with periods of
rest and avoid having two significant energy- consuming
activities occur on the same day or in immediate
succession.
- Explain that small, frequent meals tend to decrease the
amount of energy needed for digestion while providing
adequate nutrition.
- Help patient develop a positive outlook focused on
strengths, abilities, and interests.
Managing Fluid Volume
- Administer diuretics early in the morning so that diuresis
does not disturb nighttime rest.
- Monitor fluid status closely: Auscultate lungs, compare
daily body weights, and monitor intake and output.
- Teach patient to adhere to a low-sodium diet by reading
food labels and avoiding commercially prepared
convenience foods.
- Assist patient to adhere to any fluid restriction by planning
the fluid distribution throughout the day while maintaining
dietary preferences.
- Monitor IV fluids closely: contact physician or pharmacist
about the possibility of double concentrating any
medications.
- Position patient, or teach patient how to assume a
position, that facilitates breathing (increase number of
pillows, elevate the head of bed), or patient may prefer to
sit in a comfortable armchair to sleep.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

- Assess for skin breakdown, and institute preventive - Ulceration

measures (frequent changes of position, positioning to - Thrombosis
avoid pressure, leg exercises).
Controlling Anxiety
- Decrease anxiety so that patient’s cardiac work is also
decreased.
- Administer oxygen during the acute stage to diminish the
work of breathing and to increase comfort.
- When patient exhibits anxiety, promote physical comfort
and psychological support; a family member’s presence
may provide reassurance; pet visitation or animal-
assisted therapy can also be beneficial.
- When patient is comfortable, teach ways to control
anxiety and avoid anxiety-provoking situations (relaxation
techniques) Risk Factors Modifiable
- High blood cholesterol (hyperlipidemia)
CORONARY ARTERY DISEASE - Cigarette smoking, tobacco use
Discussed by: Ma’am Maria Sheila Mujemulta - Elevated blood pressure
- the major blood vessels that supply your heart become - Hyperglycemia (diabetes mellitus)
damaged or diseased. - Obesity
- Cause: Cholesterol-containing deposits (plaques) and - Physical inactivity
inflammation Non-Modifiable
- Plaque – the buildup of plaque can narrow these arteries, - Positive family history (a first-degree relative with
decreasing blood flow to your heart. cardiovascular disease at age 55 years or younger for
- Reduced blood flow causes: chest pain (angina) & males and at age 65 years or younger for females)
shortness of breath. Complete blockage: Heart attack - Age (more than 45 years for men, more than 55 years for
women)
Arteriosclerosis - Gender (men develop cardiovascular disease at an earlier
- Thickening or hardening of the arterial wall age than do women)
- abnormal accumulation of lipid or fatty substances and - Race (higher incidence
fibrous tissue in the vessel wall.
- involves a repetitious inflammatory response to injury of
the artery wall and subsequent alteration in the structural
and biochemical properties of the arterial walls.
- A type of arteriosclerosis caused by formation of PLAQUE
(chiefly composed of cholesterol)
- Leading contributor to coronary artery and
cerebrovascular disease
- Cause: unknown

Clinical Manifestations
- Ischemia
- Chest pain: angina pectoris
- Atypical symptoms of myocardial ischemia (shortness of
breath, nausea, and weakness)
- Myocardial infarction
- Dysrhythmias, sudden death
Assessment
Pathophysiology
- BP (hypertension)
o Vascular damage (cause inflammation) - Elevated cholesterol & triglycerides
o Fatty streak development (intimal layer) - Elevated homocysteine (risk if level > 15mmol/L)
o Plaque (partial or complete occlusion of blood flow)
o Complications
- Calcifications
J.A.K.E 19 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

• Blocks the production of nitric oxide on the - Progressive - Chest pain of

endothelium making cell wall less elastic & permitting worsening of increased frequency,
plaque to build up stable angina severity & duration
Unstable
• Diet: B-complex vitamin rich diet (folic acid) - with >90% poorly relieved by
homocysteine coronary rest or oral nitrates
- Presence of abdominal obesity occlusion
- Elevated FBS - Arterial spasm -chest pain that occurs
Interventions in normal or at rest (usually bet.
- Cholesterol screening Variant diseased 12 & 8am), sporadic
- Diet (Prinzmetal’s) coronary over 3-6 mos &
- Smoking cessation artery diminishes over time
- Exercise (ECG: ST – elevation)
- Drug therapy
• What is the most serious acute coronary syndrome???
- HMG-CoA reductase inhibitors “Statins”. In combination
- Subendocardial MI & Transmural MI
with other substances, LDLs can lead to plaque formation,
greatly increasing the chances for myocardial infarction
and stroke. HDLs work to remove harmful LDLs from the
blood, thereby preventing fatty buildup and formation of
plaque in arterial walls.
- The American Heart Association (AHA) now suggest the
term Acute Coronary Syndrome to describe any group of
clinical symptoms compatible with acute myocardial
ischemia
 Ischemia – insufficient supply – decrease O2
 Atherosclerosis  ischemia Angina Pectoris Clinical Manifestations
 Ischemia led to Myocardial Infarction - Pain – choking or heavy sensation in the upper chest
ranging from discomfort to agonizing pain.
Angina Pectoris - Angina is accompanied by severe apprehension and a
- “Chest pain” of cardiac origin feeling of impending death.
- Most common clinical manifestation of myocardial - The pain is usually retrosternal, deep in the chest behind
ischemia the upper or middle third of the sternum.
- Myocardial ischemia causes chemical and mechanical - Discomfort is poorly localized and may radiate to the neck,
stimulation of sensory afferent nerve endings in the jaw, shoulders, and inner aspect of the upper arms
coronary vessels and myocardium (usually the left arm).
- A feeling of weakness or numbness in the arms, wrists,
and hands, as well as shortness of breath, pallor,
diaphoresis, dizziness or lightheadedness, and nausea
and vomiting, may accompany the pain. Anxiety may
occur with angina.
- An important characteristic of anginal pain is that it
subsides when the precipitating cause is removed or with
nitroglycerin.
Gerontologic Considerations
NOTE: The elderly person with angina may not exhibit the
typical pain profile because of the diminished responses of
neurotransmitters that occur with aging.
• Presenting symptom (elderly) – dyspnea.
Types Cause Symptoms - Elderly patients should be encouraged to recognize their
- 75% coronary - Chest pain (15mins chest pain–like symptom (eg, weakness) as an indication
occlusion that or less) and may that they should rest or take prescribed medications.
accompanies radiate Assessment and Diagnostic Methods
exertion - Similar pain severity, - Evaluation of clinical manifestations of pain and patient
Stable
- Elevated HR or frequency & duration history
BP with each episode - Electrocardiogram changes (12-lead ECG), stress testing,
- Eating a large blood tests
meal - Echocardiogram, nuclear scan, or invasive procedures
such as cardiac catheterization and coronary angiography

J.A.K.E 20 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Nursing Diagnoses
- Ineffective cardiac tissue perfusion secondary to CAD as
evidenced by chest pain or other prodromal symptoms
- Death anxiety
- Deficient knowledge about underlying disease and
methods for avoiding complications
- Noncompliance, ineffective management of therapeutic
regimen related to failure to accept necessary lifestyle
changes
Potential Complications
• ACS and/or MI
• Dysrhythmias and cardiac arrest
• Heart failure
• Cardiogenic shock
• Awareness of the disease process and understanding of
the prescribed care
• Adherence to the self-care program
• Absence of complications
Planning and Goals
- Prevention of angina
Reduction of anxiety
Nursing Interventions
Treating Angina
- Take immediate action if patient reports pain or if the
person’s prodromal symptoms suggest anginal ischemia
- Direct the patient to stop all activities and sit or rest in bed
in a semi-Fowler’s position to reduce the oxygen
requirements of the ischemic myocardium.
- Measure vital signs and observe for signs of respiratory
distress.
- Administer nitroglycerin sublingually and asses the
patient’s response (repeat up to three doses).
- Administer oxygen therapy if the patient’s respiratory rate
is increased or if the oxygen saturation level is decreased.
- If the pain is significant and continues after these
interventions, the patient is further evaluated for acute MI
and may be transferred to a higher-acuity nursing unit.
Reducing Anxiety
- Explore implications that the diagnosis has for patient.
- Provide essential information about the illness and
methods of preventing progression. Explain importance of
following prescribed directives for the ambulatory patient
at home.
- Explore various stress reduction methods with patient (eg,
music therapy).
Preventing Pain
- Review the assessment findings, identify the level of
activity that causes the patient’s pain or prodromal
symptoms, and plan the patient’s activities accordingly
(Box A-1).
- If the patient has pain frequently or with minimal activity,
alternate the patient’s activities with rest periods.
Balancing activity and rest is an important aspect of the
educational plan for the patient and family.
Factors that Trigger Angina Episodes
- Sudden or excessive exertion
- Exposure to cold
- Tobacco use
J.A.K.E 21 of 57
- Heavy meals
- Excessive weight
- Some over-the-counter drugs, such as diet pills, nasal
decongestants, or drugs that increase heart rate and
blood pressure.
Medical Management
- Decrease the oxygen demand
- Increase the oxygen supply
Pharmacologic therapy
• Nitrates, the mainstay of therapy (nitroglycerin)
• Beta-adrenergic blockers (metoprolol and atenolol)
• Calcium channel blockers/calcium ion antagonists
(amlodipine and diltiazem)
• Antiplatelet and anticoagulant medications (aspirin,
clopidogrel, heparin, glycoprotein [GP] IIb/IIIa agents
[abciximab, tirofiban, eptifibatide])
• Oxygen therapy
• Eperfusion procedures – restore blood supply
Percutaneous Coronary Interventions Procedures:
• Percutaneous transluminal coronary angioplasty
[PTCA]
• Intracoronary stents,
• Atherectomy
• Coronary Artery Bypass Graft (CABG)
Myocardial Infarction
- an emergent situation characterized by an acute onset of
myocardial ischemia resulting myocardial death
- educed blood flow in a coronary artery often due to
rupture of an atherosclerotic plaque
- Plaque rupture and subsequent thrombus formation
result in complete occlusion of the artery
- Vasospasm (sudden constriction or narrowing) of a
coronary artery
- Decreased oxygen supply (eg, from acute blood loss,
anemia, or low blood pressure)
- Increased demand for oxygen (eg, from a rapid heart rate,
thyrotoxicosis, or ingestion of cocaine)
Etiology & Genetic Risk
- Primary Factor: Atherosclerosis
- Nonmodifiable risk factors
- Modifiable risk factors
• Elevated serum cholesterol levels
• Cigarette Smoking
• Hypertension
• Impaired glucose tolerance
• Obesity
• Physical inactivity
• Stress
Assessment and Diagnostic Methods
- Patient history (description of presenting symptom;
history of previous illnesses and family health history,
particularly of heart disease). Previous history should also
include information about patient’s risk factors for heart
disease.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
- Electrocardiography (ECG) within 10 minutes of pain
onset or arrival at the emergency department;
echocardiography to evaluate ventricular function.
- Cardiac enzymes and biomarkers (creatine kinase
isoenzymes, myoglobin, and troponin).
Clinical Manifestations
- Chest pain that occurs suddenly and continues despite
rest and medication is the primary presenting symptom.
- Some patients have prodromal symptoms or a previous
diagnosis of coronary artery disease (CAD), but about half
report no previous symptoms.
- Patient may present with a combination of symptoms,
including chest pain, shortness of breath, indigestion,
nausea, and anxiety.
- Patient may have cool, pale, and moist skin; heart rate
and respiratory rate may be faster than normal. These
signs and symptoms, which are caused by stimulation of
the sympathetic nervous system, may be present for only
a short time or may persist.
Physical assessment/ Clinical Manifestations:
Medical Management
- Reperfusion via emergency use of thrombolytic
medications or percutaneous coronary intervention (PCI).
- Reduce myocardial oxygen demand and increase oxygen
supply with medications, oxygen administration, and bed
rest.
- Coronary artery bypass or minimally invasive direct
coronary artery bypass (MIDCAB).
- The goals of medical management are to minimize
myocardial damage, preserve myocardial function, and
prevent complications such as lethal dysrhythmias and
cardiogenic shock.
Pharmacologic Therapy
• Nitrates (nitroglycerin) to increase oxygen supply
• Anticoagulants (aspirin, heparin)
• Analgesics (morphine sulfate)
• Angiotensin-converting enzyme (ACE) inhibitors
• Beta-blocker initially, and a prescription to continue its
use after hospital discharge
• Thrombolytics (alteplase [t-PA, Activase] and reteplase [r-
PA, TNKase]): must be administered as early as possible
after the onset of symptoms, generally within 3 to 6 hours
Interventions
- Pain management: MONA
J.A.K.E 22 of 57
• Morphine
o 2- to 10-mg IV q 5-15 minutes
o AE: respiratory depression, hypotension,
bradycardia, severe vomiting
o Antidote: Naloxone (Narcan) 0.2 – 0.8 mg IV
o Oxygen: 2-4L/min by nasal cannula
o Nitroglycerin
o Aspirin
- Positioning – semifowler’s
- Provide a quiet & calm environment
Medications
• Nitrates
- Nitroglycerine, Isosorbide dinitrate (Isordil), Isosorbide
mononitrate (Imdur)
• Beta Blockers
• Calcium Channel Blockers
• Thrombolytics/ Fibrinolytics
Nursing Process
Assessment
- Assess level of consciousness.
- Evaluate chest pain (most important clinical finding).
- Assess heart rate and rhythm; dysrhythmias may indicate
not enough oxygen to the myocardium.
- Assess heart sounds; S3 can be an early sign of impending
left ventricular failure.
- Measure blood pressure to determine response to pain
and treatment; note pulse pressure, which may be
narrowed after an MI, suggesting ineffective ventricular
contraction.
- Assess peripheral pulses: rate, rhythm, and volume.
- Evaluate skin color and temperature.
- Auscultate lung fields at frequent intervals for signs of
ventricular failure (crackles in lung bases).
- Assess bowel motility; mesenteric artery thrombosis is a
potentially fatal complication.
- Observe urinary output and check for edema; an early sign
of cardiogenic shock is hypotension with oliguria.
- Examine IV lines and sites frequently.
Nursing Diagnoses
- Ineffective cardiac tissue perfusion related to reduced
coronary blood flow
- Risk for imbalanced fluid volume
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
- Risk for ineffective peripheral tissue perfusion related to
decreased cardiac output from left ventricular dysfunction
- Death anxiety
- Deficient knowledge about post-ACS self-care
Potential Complications
• Acute pulmonary edema
• Heart failure
• Cardiogenic shock
• Dysrhythmias and cardiac arrest
• Pericardial effusion and cardiac tamponade
Planning and Goals
- The major goals of the patient include relief of pain or
ischemic signs (eg, ST-segment changes) and symptoms,
prevention of myocardial damage, absence of respiratory
dysfunction, maintenance or attainment of adequate
tissue perfusion, reduced anxiety, adherence to the self-
care program, and absence or early recognition of
complications.
Nursing Interventions
Relieving Pain and Other Signs and Symptoms of Ischemia
- Administer oxygen in tandem with medication therapy to
assist with relief of symptoms (inhalation of oxygen
reduces pain associated with low levels of circulating
oxygen).
- Assess vital signs frequently as long as patient is
experiencing pain.
- Assist patient to rest with back elevated or in cardiac chair
to decrease chest discomfort and dyspnea.
Improving Respiratory Function
- Assess respiratory function to detect early signs of
complications.
- Monitor fluid volume status to prevent overloading the
heart and lungs.
- Encourage patient to breathe deeply and change position
often to prevent pooling of fluid in lung bases.
Promoting Adequate Tissue Perfusion
- Keep patient on bed or chair rest to reduce myocardial
oxygen consumption.
- Check skin temperature and peripheral pulses frequently
to determine adequate tissue perfusion.
Reducing Anxiety
- Develop a trusting and caring relationship with patient;
provide information to the patient and family in an honest
and supportive manner.
- Ensure a quiet environment, prevent interruptions that
disturb sleep, use a caring and appropriate touch, teach
relaxation techniques, use humor, and provide spiritual
support consistent with the patient’s beliefs. Music
therapy and pet therapy may also be helpful.
- Provide frequent and private opportunities to share
concerns and fears.
- Provide an atmosphere of acceptance to help patient
know that his or her feelings are realistic and normal.
Monitoring and Managing Complications
- Monitor closely for cardinal signs and symptoms that
signal onset of complications.
- Promoting Home- and Community-Based Care
J.A.K.E 23 of 57
Teaching Patients Self-Care
- Identify the patient’s priorities, provide adequate
education about heart-healthy living, and facilitate the
patient’s involvement in a cardiac rehabilitation program.
- Work with the patient to develop a plan to meet specific
needs to enhance compliance.
Continuing Care
- Provide home care referral if warranted.
- Assist the patient with scheduling and keeping follow-up
appointments and with adhering to the prescribed cardiac
rehabilitation regimen.
- Provide reminders about follow-up monitoring, including
periodic laboratory testing and ECGs, as well as general
health screening.
- Monitor the patient’s adherence to dietary restrictions and
to prescribed medications.
- If the patient is receiving home oxygen, ensure that the
patient is using the oxygen as prescribed and that
appropriate home safety measures are maintained.
- If the patient has evidence of heart failure secondary to an
MI, appropriate home care guidelines for the patient with
heart failure are followed.
Evaluation
• Experiences relief of angina
• Has stable cardiac and respiratory status
• Maintains adequate tissue perfusion
• Exhibits decreased anxiety
• Complies with self-care program
• Experiences absence of complications
Surgical Procedure: Coronary Artery Revascularization
- CAD has been treated by myocardial revascularization
since the 1960s, and the most common CABG techniques
have been performed for more than 35 years.
- CABG is a surgical procedure in which a blood vessel is
grafted to an occluded coronary artery so that blood can
flow beyond the occlusion
The major indications for CABG are:
• Alleviation of angina that cannot be controlled with
medication or PCI
• Treatment of left main coronary artery stenosis or
multivessel CAD
• Prevention and treatment of MI, dysrhythmias, or heart
failure
• Treatment for complications from an unsuccessful PCI
Traditional Coronary Artery Bypass Graft
- the surgeon performs a median sternotomy and connects
the patient to the cardiopulmonary bypass (CPB) machine.
- Next, a blood vessel from another part of the patient’s
body (eg, saphenous vein, left internal mammary artery) is
grafted distal to the coronary artery lesion, bypassing the
obstruction
- CPB is then discontinued, chest tubes and epicardial
pacing wires are placed, a critical care unit.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Cardiopulmonary Bypass
- The procedure mechanically circulates and oxygenates
blood for the body while bypassing the heart and lungs.
CPB maintains perfusion to body organs and tissues and
allows the surgeon to complete the anastomoses in a
motionless, bloodless surgical field.
- Accomplished by placing a cannula in the right atrium,
vena cava, or femoral vein to withdraw blood from the
body.
- The cannula is connected to tubing filled with an isotonic
crystalloid solution. Venous blood removed from the body
by the cannula is filtered, oxygenated, cooled or warmed
by the machine, and then returned to the body.
- The cannula used to return the oxygenated blood is
usually inserted in the ascending aorta, or it may be
inserted in the femoral artery
Alternative Coronary Artery Bypass Graft Techniques
- OPCAB involves a standard median sternotomy incision,
but the surgery is performed without CPB. A beta-
adrenergic blocker may be used to slow the heart rate.
- The surgeon also uses a myocardial stabilization device to
hold the site still for the anastomosis of the bypass graft
into the coronary artery while
- the heart continues to beat
J.A.K.E 24 of 57
DISTURBANCE IN OXYGEN EXCHANGE AND UTILIZATION:
OBSTRUCTIVE DISORDERS
Discussed by: Dr. Potenciana A. Maroma
Obstructive Disorder
- a category of respiratory disease characterized by airway
obstruction. Many obstructive diseases of the lung result
from narrowing (obstruction) of the smaller bronchi and
larger bronchioles, often because of excessive
contraction of the smooth muscle itself. It is generally
characterized by inflamed and easily collapsible airways,
obstruction to airflow, problems exhaling and frequent
medical clinic visits and hospitalizations.
- Types of obstructive lung disease include; asthma,
bronchiectasis, bronchitis and chroni c obstructive
pulmonary disease (COPD). Although COPD shares
similar characteristics with all other obstructive lung
diseases, such as the signs of coughing and wheezing,
they are distinct conditions in terms of disease onset,
frequency of symptoms and reversibility of airway
obstruction. Cystic fibrosis is also sometimes included in
obstructive pulmonary disease.
1) Chronic Obstructive Pulmonary Disorder (COPD)
2) Emphysema
3) Chest Physiotherapy
4) Chronis Bronchitis
5) Bronchiectasis
6) Bronchial Asthma
Physiology of Respiration
1. There is adequate O2 in the ambient air
2. Airway is patent
3. Respiratory muscles and rib cage are functioning
well
4. There is negative intrapleural pressure
5. Diffusion between alveoli and pulmonary
6. Heart is an effective pump
7. Blood vessels are patent and elastic
- arteiole, capillary, vein
- Kapag makipot ang daan mabilis sumabit ang RBC
8. There is adequate RBC and hemoglobin to carry
O2
9. Tissues utilize O2
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
- cause airway obststruction is mucus secretions
- kaya kapag may ganun ginagawa natin is bumubwelo
para umubo
- Allergy: Broncholaryngo spasm
- 760 mmHG
- 755 mmHG
- Right lungs = 3 lobes
- Left lungs = 2 lobes
- Diaphragm = Contract: Lungs = expanded
- <760 mmHg (negative); 755> mmHg (positive)
- Ventilation – gas exchange
- Diffusion – higher to lower concentration
J.A.K.E 25 of 57
- One = alveolus
- Many = alveoli
- Increase of CO2 in pulmonary capillary = there will
be exchange of gases between the PC and Alveoli
- External respiration
- Internal respiration
- Perfusion – the amount of blood in pleural space
- Thrombus
- Air embolism
- There’s a problem in cardiovascular system
- Mismatched perfusion ratio – increase of secretions
hindi maka expand ang lungs ng maayos
- Pneumothorax or Hemothorax
- Cyanotic ang patient kapag bumalik ang CO2
- Shunted – left side of the heart
- May bara sa pulmonary artery may thrombus,
therefore no blood will flow to the capillary artery
- The lungs will die = pulmonary infarction
- Thrombolytic medication
- Laryngeal tumor = shunted unit
- Pneumothorax, Hemothorax = shunted unit
- Atelectasis = Silent unit
- Internal respiration = exchanges of gas bet. alveoli
and capillary bed
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

Chronic Airflow Limitations (CAL) - Endotracheal suctioning if the patient is under

- A group of chronic lung diseases that includes: endotracheal tube
- Don’t wait the patient to give the specimen dapat yung
• Asthma – reversible
nurse mismo ang kukuha
• Chronic Bronchitis - Low hematocrit
• Emphysema – pwedeng maka accumulate kahit - High hemoglobin
hindi nag s smoke, this is also genetic (Alpha-1) – Interventions
affects the alveoli, normal ABG Mainstays of COPD management:
 Airway maintenance
• Bronchiectasis
 Monitoring
- Board exam: COPD (chronic bronchitis and  Drug Therapy
emphysema)  O2 therapy
- Most common cause: smoking Airway maintenance:
- Medication – suctioning, chest physiotherapy, • Keep the client’s head, neck and chest in alignment
bronchodilators • Assist the client to liquefy secretions and clear the
airway of secretions
Chronic Obstructive Pulmonary Disease (COPD) Breathing Techniques
- a disease characterized by airflow limitation that is not
fully reversible.
- Risk factors
• Cigarette smoking
• air pollution
• occupational exposure (coal, cotton, grain)

Clinical Manifestations
- General appearance
- RR of 40-50 breaths/min
Psychosocial assessment
- Socialization may be reduced when friends avoid the
client with COPD because of annoying coughs, excessive
sputum, or dyspnea
Laboratory assessment
- Abnormal ABG results (hypoxemia, hypercarbia), Sputum
C/S, Hgb./Hct., serum electrolyte levels are examined
because phosphate, K+, Ca++ & Mg++ reduces muscle
strength
- CXR to rule out other chest diseases & to check the Controlled coughing
progress of clients with respiratory infections or chronic - advise client to cough on arising on the morning, before
disease mealtimes, before bedtimes
- Pulmonary Function Test (Vital capacity, Residual volume, - to cough effectively, the client sits in a chair or on the side
Total lung capacity) of a bed with feet placed firmly on the floor. Instruct the
- Sa umaga kukunin ang sputum pero mouth wash muna client to turn the shoulders inward and to bend the head
with plain water slightly downward hugging a pillow against the stomach.
- Cough the phlegm The client then takes a few deep breaths. After the 3rd to
J.A.K.E 26 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
5th deep breath ( pursed-lip breathing), instruct the client
to bend forward slowly while coughing two or three times
from the same breath
Postural Drainage
• Monitoring:
- Assess COPD client at least q2°
• O2 Therapy:
- The need for O2 therapy & its effectiveness can be
determined by ABG values & O2 saturation by
pulse oximetry
- usually, 2-4 L/min or even 1-2 L/min via nasal
cannula or up to 40% via venturi mask
- Low-flow O2 because low arterial oxygen level is
the COPD client’s primary drive for breathing
 Drug Therapy:
• involves the same inhaled and systemic drugs for
asthma
- mucolytics [acetylcysteine (Mucomyst),
Guaifenesin]
• Pneumonia
- one of the most common complications of COPD
NOTE: Teach clients to avoid large crowds and stress the
importance of receiving a pneumonia vaccination and a
yearly influenza vaccine “flu shot”
• Complications (copd)
- Hypoxemia & acidosis – due to impaired exchange
of gases
- Respiratory Infections – due to  mucus & poor
oxygenation (most common: S. pneumoniae, H.
influenzae, Moraxella catarrhalis)
• due to infection, COPD manifestations
worsens due to increasing inflammation &
mucus production
- Cardiac Dysrhythmias – results from O2 supply
to the heart, other cardiac disease, drug effects, or
acidosis
- Cor Pulmonale – RSHF caused by pulmonary
disease
J.A.K.E 27 of 57
Canvas:
Clinical Manifestations
- COPD is characterized by chronic cough, sputum
production, and dyspnea on exertion; often worsen over
time.
- Weight loss is common.
Symptoms are specific to the disease.
o Asthma
o Bronchiectasis
o Bronchitis
o Emphysema
Medical Management
- Smoking cessation, if appropriate.
- Bronchodilators, corticosteroids, and other drugs (eg,
alpha1-antitrypsin augmentation therapy, antibiotic
agents, mucolytic agents, antitussive agents, vasodilators,
narcotics). Vaccines may also be effective.
- Oxygen therapy, including nighttime oxygen.
- Varied treatments specific to disease.
o Asthma
o Bronchiectasis
o Bronchitis
o Emphysema
- Surgery: bullectomy to reduce dyspnea; lung volume
reduction to improve lobar elasticity and function; lung
transplantation.
Nursing Management Assessment
Achieving Airway Clearance
- Monitor the patient for dyspnea and hypoxemia.
- If bronchodilators or corticosteroids are prescribed,
administer the medications properly and be alert for
potential side effects.
- Confirm relief of bronchospasm by measuring
improvement in expiratory flow rates and volumes (the
force of expiration, how long it takes to exhale, and the
amount of air exhaled) as well as by assessing the
dyspnea and making sure that it has lessened.
- Encourage patient to eliminate or reduce all pulmonary
irritants, particularly cigarette smoking.
- Instruct the patient in directed or controlled coughing.
- Chest physiotherapy with postural drainage, intermittent
positive-pressure breathing, increased fluid intake, and
bland aerosol mists (with normal saline solution or water)
may be useful for some patients with COPD.
Improving Breathing Patterns
- Inspiratory muscle training and breathing retraining may
help improve breathing patterns.
- Training in diaphragmatic breathing reduces the
respiratory rate, increases alveolar ventilation, and
sometimes helps expel as much air as possible during
expiration.
- Pursed-lip breathing helps slow expiration, prevent
collapse of small airways, and control the rate and depth
of respiration; it also promotes relaxation.
Improving Activity Tolerance
- Evaluate the patient’s activity tolerance and limitations
and use teaching strategies to promote independent
activities of daily living.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

- Determine if patient is a candidate for exercise training to

strengthen the muscles of the upper and lower extremities
and to improve exercise tolerance and endurance.
- Recommend use of walking aids, if appropriate, to
improve activity levels and ambulation.
- Consult with other health care professionals
(rehabilitation therapist, occupational therapist, physical
therapist) as needed.
Monitoring and Managing Complications
- Assess patient for complications (respiratory insufficiency
and failure, respiratory infection, and atelectasis).
- Monitor for cognitive changes, increasing dyspnea,
tachypnea, and tachycardia.
- Monitor pulse oximetry values and administer oxygen as
prescribed.
- Instruct patient and family about signs and symptoms of
infection or other complications and to report changes in
physical or cognitive status.
- Encourage patient to be immunized against influenza and
Streptococcus pneumonia.
- Caution patient to avoid going outdoors if the pollen count
is high or if there is significant air pollution and to avoid
exposure to high outdoor temperatures with high humidity.
- If a rapid onset of shortness of breath occurs, quickly
evaluate the patient for potential pneumothorax by
assessing the symmetry of chest movement, differences
in breath sounds, and pulse oximetry.
- Airflow limitation that is not fully reversible
• Risk factors:
o s`
o Environmental pollutants
o Occupational exposure
o Genetic predisposition
• Three Primary Symptoms:
o Chronic cough
o Sputum production
o Dyspnea on exertion

Bronchial Asthma
- Allergic in nature
- Intermittent & reversible airflow obstruction affecting
the lower airway
- Bronchial edema causes obstructions mucus
secretions cannot get through
- Obstructions – inflammation Physical assessment findings:
- Airway hyper-responsiveness – bronchospasm - Audible wheezing & RR (acute episode)
- Constriction of bronchial smooth muscle due to • Wheezing is louder during exhalation – inspiratory and
stimulation of the nerve fibers expiratory inhalation
- Dyspnea, cough, use of accessory muscle of
Etiology:
respiration, barrel chest (chronic severe asthma)
- Allergens, cold air, dry air, airborne particles, - Cyanosis, poor O2 saturation (pulse oximetry) –
microorganism, aspirin  inflammation 95% - 100%
- Pollens, dust mites, mold, pet dander - Change of LOC & tachycardia due to hypoxemia
- Saan dapat ang mga domestic pets? – dapat outside - Increase mucus secretions = reproductive cough
home - Magalaw ang patient – panget ang O2 circulation
sa brain
- Exercise induced asthma

J.A.K.E 28 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

• inhaler – Budesonide, Fluticasone, Beclomethasone,

Triamcinolone, Flunisolide
• Corticosteroid = indirect
- Mast cell stabilizer
• Cromolyn sodium (Intal); helps prevent atopic asthma
attacks (prevent mast cell membranes from opening
when an allergen binds to IgE) but are not useful
during an acute episode – hindi ito ibibigay kapag
during ng attack
- Monoclonal antibodies
• Omalizumab (Xolair), approved in 2003 only – binds to
IgE receptor sites on mast cells & basophils
preventing the release of chemical mediators for
inflammation
Exercise/ Activity
- Aerobic exercise (recommended)
Laboratory assessment:
• assist in maintaining cardiac health, enhancing
- ABG, elevated eosinophil count, elevated IgE levels
skeletal muscle strength, and promoting ventilation
- Pulmonary function tests – most accurate test for asthma
and perfusion
- Normal – Eupnea (500mL)
- Total lung capacity – the maximal volume of gas in the • Swimming
lungs after a maximal inhalation (10 to 12 L) – fibrosis - Oxygen Therapy
kapag nag low 3 to 4 L • Often used during an acute asthma attack
- Residual Volume – 1,200mL
- VC - 4-6 L Bronchitis
- FRC – 2.0 L Acute Bronchitis
- FRC – 0.5 L - Inflamed primary and
Nursing interventions: - Typically begins as an URTI (viruses, bacteria)
Goals: • H. influenzae, S. pneumoniae, M. pneumoniae
- To improve airflow - Chemical irritants (noxious fumes, gases, air
- Relieve symptoms contaminants)
- Prevent episodes - Assessment Findings
Management plan includes - Fever, chills, malaise, headache, dry irritating
- Client education nonproductive cough (initial)  mucopurulent
- Drug therapy sputum
- Lifestyle management including exercise Medical Management
Client Education Guide - Usually self-limiting
- Avoid factors that triggers asthma attack - Bedrest, antipyretics, expectorants (stimulate coughing -
- Use bronchodilator 30 minutes before exercise to prevent papaubuhin), antitussives (suppress the coughing reflex),
or reduce exercise-induced asthma Fluids, humidifiers, antibiotics
- Proper technique & correct use of metered dose inhalers
- Adequate rest & sleep, reduce stress & anxiety; learn
relaxation techniques
- Failure of medications to control worsening symptoms,
seek immediate emergency care
Bronchodilators:
- β2 agonist: Albuterol (Ventolin), Bitolterol, Pirbuterol,
Salmeterol, Formoterol – Bronchial dilatation, relax the
lungs muscles “rol”. Inhalers
- Methylxanthines
• Theophylline, Aminophylline, Oxtriphylline]
• Monitor for SE: excessive cardiac & CNS stimulation
(check pulse & BP)
- Cholinergic antagonist
• Ipratropium (Atrovent)
Anti-inflammatory Agents:
- Corticosteroids
• oral – Prednisolone, Prednisone

J.A.K.E 29 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

Assessment Findings
- Chronic productive cough – thick white mucus
(earliest symptom)  yellow, purulent, copious,
blood-streaked sputum
- Bronchospasm, Acute respiratory infections,
cyanosis, DOE, RSHF (cor pulmonale)

Promoting Home- and Community-Based Care: Teaching

Patients Self-Care
• Teach patient and family about asthma (chronic
inflammatory), purpose and action of medications,
triggers to avoid and how to do so, and proper inhalation
technique.
• Instruct patient and family about peak-flow monitoring.
• Teach patient how to implement an action plan and how
and when to seek assistance. Medical Management
• Obtain current educational materials for the patient based - Smoking Cessation
on the patient’s diagnosis, causative factors, educational - Bronchodilators, fluid intake, Well-balanced diet,
level, and cultural background. Postural drainage, Steroid therapy, Antibiotic therapy
• Continuing Care Nursing Management
• Emphasize adherence to prescribed therapy, preventive - Focus: educating clients in managing their disease
measures, and need for follow-up appointments. - Smoking cessation, occupational counseling, monitoring
• Refer for home health nurse as indicated. air quality & pollution levels, avoiding cold air & wind
• Home visit to assess for allergens may be indicated (with exposure (triggers bronchospasm)
recurrent exacerbations). - Preventing infection, avoid others with RTI, immunizations,
• Refer patient to community support groups. monitor sputum for signs of infection, proper use of
• Remind patients and families about the importance of metered-dose inhaler (MDIs)
health promotion strategies and recommended health - flu vaccine = pneumococcal vaccine
screening. Emphysema
Nursing Management - Abnormal distention of the airspaces beyond the terminal
• Auscultates breath sounds, monitors VS q 4 hrs especially bronchioles and destruction of the walls of the alveoli
if client has fever - Pink Puffer
• Encourage client to cough & deep breath q 2 hrs while - Signs & symptoms:
awake & to expectorate rather than swallow sputum • Barrel chest
• Provide humidification of surrounding (loosens bronchial • Severe dyspnea
secretions) • Thin-framed body
• Changes the bedding & client’s clothes if they become - Diagnosis
damp with perspiration • Spirometry
• Offers fluid frequently • CXR: hyperinflation with FLATTENED diaphragm
• Prevent infection (teach to wash hands frequently) • ABG:
• Teach to cover the mouth when sneezing & coughing o mild-mod hypoxemia
• Discard soiled tissues in a plastic bag; avoid sharing of o Respiratory acidosis
eating utensils & personal articles

Chronic Bronchitis
- Prolonged inflammation of the bronchi accompanied by a
chronic cough & excessive production of mucus for at
least 3 months each year for 2 consecutive years
- Chronic cough - Halos sa isang buwan may ubo ang
patient
- Etiology:
- Cigarette Smoking
- Long history of bronchial asthma, RTI, air pollution

J.A.K.E 30 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

- A chronic disease characterized by loss of lung elasticity &

hyperinflation of the lung
- most common COPD

Classification:
• Panlobar or panacinar
– destruction of the entire alveolus uniformly; diffuse &
Etiology/ Genetic Risk: more severe in the lower lung areas
• Major cause: Smoking • Centrilobular or centriacinar
• Alpha1-Antitrypsin Deficiency (AAT) – openings occur in the bronchioles and allow spaces
• Air pollution (minimal) to develop as tissue walls breakdown; upper lung
sections
• Paraseptal or distal acinar
– only the alveolar ducts and alveolar sacs are affected;
upper half of the lung
“Each type can occur alone or in combination in the same lung”
Assessment Findings
• Exertional dyspnea - 1st symptom
• shortness of breath with minimal activity
• Chronic productive cough with mucopurulent sputum
• Decreased breath sounds, wheezing, crackles
• “Barrel shaped chest”
• Use of accessory muscle of respiration
Alpha1 – Antitrypsin Deficiency (AAT) • Toxic CO2 levels Lethargy, stupor, coma (carbon
• AAT is made by the liver and is normally present in the dioxide narcosis)
lungs
• Function: regulates proteases from working on lung
structures
• If AAT is deficient, COPD develops even if the person
is not exposed to cigarette smoke or other irritants
Pathophysiology
• Loss of elasticity
• Air trapping
• Impaired gas exchage
Signs/ symptoms
- Bullae/ blebs
- Pneumothorax

Medical management
- Meds: Bronchodilators, mucolytics, antibiotics,
corticosteroids (limited basis to assist with broncho
dilation & removal of secretions)
- Physical therapy: deep breathing, CPT, postural drainage
- NCLEX: The nurse went to patient with emphysema and
saw the O2 in just 2mL because the patient cannot
breathe properly what she did is she increased the O2
- use of accessory muscles in the process of breathing due saturation and loss drive results to respiratory distress.
to flattening of the diaphragm - Take note 2mL lang ang need sa O2
- disequilibrium Nursing Management
- Administer O2 via nasal cannula (2-3 L/min)

J.A.K.E 31 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
• High flow of O2 may lead to lost of hypoxic drive
- Teach abdominal breathing (using the diaphragm
effectively), pursed-lip breathing
• Most important risk factor for COPD is smoking
• Chest physiotherapy & postural drainage
Postural Drainage
• Monitoring: Assess COPD client at least q2°
• O2 Therapy:
– The need for O2 therapy & its effectiveness can be
determined by ABG values & O2 saturation by pulse
oximetry
– usually, 2-4 L/min or even 1-2 L/min via nasal cannula
or up to 40% via venturi mask
– Low-flow O2 because low arterial oxygen level is the
COPD client’s primary drive for breathing
Drug Therapy:
• involves the same inhaled and systemic drugs for asthma
- mucolytics [acetylcysteine (Mucomyst), Guaifenesin]
• Pneumonia
- one of the most common complications of COPD
NOTE: Teach clients to avoid large crowds and stress the
importance of receiving a pneumonia vaccination and a yearly
influenza vaccine “flu shot”
Complications (copd)
- Hypoxemia & acidosis – due to impaired exchange of
gases
- Respiratory Infections – due to  mucus & poor
oxygenation (most common: S. pneumoniae, H.
influenzae, Moraxella catarrhalis)
• due to infection, COPD manifestations worsens due
to increasing inflammation & mucus production
- Cardiac Dysrhythmias – results from O2 supply to the
other cardiac disease, drug effects, or acidosis
- Cor Pulmonale – RSHF caused by pulmonary disease
Bronchiectasis
- An abnormal and permanent dilatation of bronchi &
bronchioles
- It results from inflammation and destruction of the
structural components of the bronchial wall brought
about by:
• chronic pulmonary infection (P. aeruginosa, H.
influenzae)
J.A.K.E 32 of 57
• tumor or foreign body
• congenital abnormalities
• exposure to toxic gases
- The structure of the wall tissue changes, resulting in the
formation of saccular dilatations which collects purulent
materials causing more dilatation, structural damage &
more infection
Assessment Findings
- Chronic cough (copious, purulent, blood-streak sputum)
• Coughing worsens when the client changes position
• Sputum collected settles in three distinct layers (top
layer is frothy & cloudy, middle layer is clear saliva,
bottom layer is heavy, thick & purulent)
- Fatigue, weight loss, anorexia, dyspnea
- CXR & bronchoscopy – reveals increased size of
bronchioles, atelectasis & changes in the pulmonary
tissues
- Sputum C/S identify causative microorganism
Medical Management
• Drainage of purulent material from the bronchi
• Antibiotics
• Bronchodilators
• Mucolytics
• Humidification
• Surgery removal of bronchiectasis if confined to a small
area
- kapag one lobe lang ang naapektuhan yun lang ang
tatanggalin
Nursing Management
• Instruct client in postural drainage techniques
• CPT
• Oral hygiene
DISTURBANCE IN OXYGEN EXCHANGE AND UTILIZATION -
RESTRICTIVE DISORDERS
Discussed by: Dr. Potenciana A. Maroma
Pneumonia
- An inflammatory process affecting the bronchioles &
alveoli
- Most common cause of death from an infection in the US
(Smeltzer & Bare, 2004)
Causes
• Usually Infection
- Bacterial pneumonia “Typical pneumonia”
• S. pneumoniae, P. carinii, S. aureus, K. pneumoniae, P.
aeruginosa, H. influenzae
- Atypical pneumonia
• Mycoplasma pneumonia, Chlamydia pneumoniae,
Chlamydia psittaci, Legionella pnemophila,
Mycobacterium tuberculosis, viruses, parasites, fungi
• Radiation Therapy (Radiation pneumonia)
- Damage to the normal lung mucosa during radiation
therapy for Breast CA, Lung CA
• Chemical ingestion or inhalation (Chemical pneumonia)
- Ingestion of kerosene, gasoline or other chemical
- Inhalation of volatile hydrocarbons
• Aspiration of foreign bodies or gastric contents
(Aspiration pneumonia)
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

- Inhalation of foreign object or gastric contents during • Pain during breathing (patient exhibits shallow breathing)
vomiting or regurgitation
• Bronchopneumonia
- Infection is patchy, diffuse & scattered throughout
both lungs
• Lobar pneumonia
- Inflammation is confined to one or more lobes of the
lung

Four (4) General Categories of Pneumonia
• CAP (Community-acquired pneumonia)
- Illness is contracted in a community setting or within
48 hrs of admission to a healthcare facility
• HAP (Hospital-acquired pneumonia)/ Nosocomial
pneumonia
- Occurs in healthcare setting >48 hrs after admission
• Opportunistic Pneumonia (immunocompromised host)
- P. carinii pneumonia (Pneumocystis jirovecii ), Fungal
pneumonia, pneumonia related to TB
• Aspiration Pneumonia
Pathophysiology
Microorganism
- inhalation of droplets
- aspiration of organism from upper airways
- Seeding from the bloodstream
Alveoli
- Inflammatory reaction takes place
- Exudate formation
- Impaired gas exchange
- Atelectasis, consolidation (inflammation & exudates),
hypoxemia, bronchitis, CHF, empyema, pleurisy
(inflammation of the pleura), septicemia, hypotension,
shock, death
Diagnostic Findings
• Wheezing, crackles, decreased breath sounds
• Cyanosis (nail beds, lips, oral mucosa)
• Sputum culture reveals infectious microorganism
• CXR shows areas of infiltrates & consolidation
• WBC
Medical Management
• Prompt initiation of antibiotic therapy for bacterial
pneumonia
• Hydration to thin secretions
• Supplemental O2 to alleviate hypoxemia
• Bed rest, CPT, bronchodilators, analgesics, antipyretics, &
cough expectorants or suppressants
• F&E replacement 2° to fever, dehydration & inadequate
nutrition
• Severe respiratory difficulty – intubation along with
mechanical ventilation
Nursing Management
• Auscultate lung sounds & monitor the client for signs of
respiratory difficulty
• Check oxygenation status (pulse oximetry) & monitor
ABGs
• Position: semi fowler’s position
• Encourage  fluid intake
• Monitor I&O, skin turgor, VS & serum electrolytes
• Administer antipyretics as indicated
• Encourage at-risk & elderly clients to receive vaccination
against pneumococcal & influenza infections
-
Pleural Effusion
• Abnormal collection of fluid between the visceral &
parietal pleurae as a complication of
- Pneumonia
- Lung CA
- TB
- Pulmonary embolism
- CHF
• Normal: 5-15ml

Assessment Findings
• Fever
• Chills
• Productive cough, sputum (rust colored)
• Discomfort in the chest wall muscles
• General malaise

J.A.K.E 33 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

General Classification
• Transudative effusion (protein-poor, cell-poor)
- Hydrothorax- accumulation of water/serous fluid
• Exudative effusion (protein rich fluid)
- Pyothorax or Empyema- accumulation of pus
- Hemothorax- accumulation of blood
- Chylothorax- accumulation of lymph and lipoprotein
Assessment Findings
• Fever
• Pain
• Dyspnea Nursing Management
• Dullness over the involved area during chest percussion - If with CTT, monitor the function of the drainage system &
• Diminished or absent breath sounds the amount & nature of the drainage
• Friction rub
• CXR & CT scan – shows fluid accumulation

Medical management
- Main goal: eliminate the cause & relieve discomfort
• Antibiotics
• Analgesics
• Cardiotonic drugs to control CHF if present
• Thoracentesis
• Insertion of a CTT
• Surgery if cause by CA
Nursing Guidelines
• Explain the procedure to the client
• Reassure the client that he or she will receive local
anesthesia. Explain that the client will still experience a
pressure-like pain when the needle pierces the pleura &
when fluid is withdrawn
• Assist client to an appropriate position (sitting with arms
and head on padded table or in side-lying position on
unaffected side)
• Instruct the client not to move during the procedure,
including no coughing or deep breathing
• Provide comfort, Inform client about what is happening
• Maintain asepsis
• Monitor VS during the procedure – also monitor pulse
oximetry if client is connected to it
• During removal of fluid, monitor for respiratory distress,
dyspnea, tachypnea or hypotension
NOTE: When caring for a client with chest tubes, the nurse
• Apply small sterile pressure dressing to the site after the
should be aware of the following:
procedure
- Fluctuation of the fluid in the water-seal chamber is
• Position the client on the unaffected side. Instruct client
initially present with each respiration. Fluctuations cease
to stay in this position for at least 1 hour and to remain on
when the lung re-expands. The time for lung re-expansion
bed rest for several hours
varies. Fluctuations also may cease if:
• Check that chest radiography is done after the procedure
• The chest tube is clogged
• Record the amount, color and other characteristics of
• The wall suction unit malfunctions
fluid removed
J.A.K.E 34 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
• A kink or dependent loop develops in the tubing
- Bubbling in the water-seal chamber occurs in the early
postoperative period. If bubbling is excessive, the nurse
checks the system for leaks. If leaks are not apparent, the
nurse notifies the physician
- Bloody drainage is normal, but drainage should not be
bright red or copious
- The drainage tube(s) must remain patent to allow fluids to
escape from the pleural space
- Clogging of the catheter with clots or kinking causes
drainage to stop. The lung cannot expand, and the heart
and great vessels may shift (mediastinal shift) to the
opposite side. The nurse must be alert to the proper
functioning of the drainage system. Malfunctions need
immediate correction
- If a break or major leak occurs in the system, the nurse
clamps the chest tube immediately with hemostats kept
at the bedside. He or she notifies the physician if this
occurs
Clinical Manifestations
- Some symptoms are caused by the underlying disease.
Pneumonia causes fever, chills, and pleuritic chest pain.
Malignant effusion may result in dyspnea and coughing.
- The size of the effusion, the speed of its formation, and
the underlying lung disease determine the severity of
symptoms.
• Large effusion: shortness of breath to acute
respiratory distress.
• Small to moderate effusion: Dyspnea may not be
present.
• Dullness or flatness to percussion over areas of fluid,
minimal or absence of breath sounds, decreased
fremitus, and tracheal deviation away from the
affected side.
Assessment and Diagnostic Methods
- Physical examination
- Chest x-rays (lateral decubitus)
- Chest CT scan
J.A.K.E 35 of 57
- Thoracentesis
- Pleural fluid analysis (culture, chemistry, cytology)
- Pleural biopsy
Medical Management
- Objectives of treatment are to discover the underlying
cause:
o to prevent reaccumulating of fluid
o to relieve discomfort
o dyspnea
o respiratory compromise
- Specific treatment is directed at the underlying cause.
• Thoracentesis is performed to remove fluid, collect
specimen for analysis, and relieve dyspnea.
• Chest tube and water-seal drainage may be necessary
for drainage and lung re-expansion.
• Chemical pleurodesis: Adhesion formation is
promoted when drugs are instilled into the pleural
space to obliterate the space and prevent further
accumulation of fluid.
• Other treatment modalities include surgical
pleurectomy (insertion of a small catheter attached to
a drainage bottle) or implantation of a
pleuroperitoneal shunt.
Nursing Management
- Implement medical regimen: Prepare and position patient
for thoracentesis and offer support throughout the
procedure.
- Monitor chest tube drainage and water-seal system;
record amount of drainage at prescribed intervals.
- Administer nursing care related to the underlying cause of
the pleural effusion.
- Assist patient in pain relief. Assist patient to assume
positions that are least painful. Administer pain
medication as prescribed and needed to continue
frequent turning and ambulation.
- If the patient is to be managed as an outpatient with a
pleural catheter for drainage, educate the patient and
family about management and care of the catheter and
drainage system.
Chest Injuries
- occur alone or in combination with multiple other injuries
- is classified as either blunt or penetrating
- Penetrating trauma occurs when a foreign object
penetrates the chest wall.
Fractured Ribs/ Sternum
- Common injury resulting from a hard fall or a blow to the
chest
- Automobile & household accidents (frequent cause)
- Sharp end of the broken rib may tear the lung or thoracic
blood vessels
- Signs & Symptoms: Pain at the site (increases with
respiration)
- Management:
• Unite spontaneously
• High fowler’s position
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

Flail Chest Pneumothorax

- Complication of chest trauma occurring when 2 or more • Accumulation of air
adjacent ribs are fractured at two or more sites, resulting - in the pleural space it can lead to partial or complete
in free-floating rib segments collapse of the lung
- Signs & Symptoms: PARADOXICAL BREATHING Types:
- Management - Spontaneous pneumothorax
• Oxygen - Open pneumothorax
• WOF respiratory distress - Tension pneumothorax
• High fowler’s position
Paradoxic movement of the chest
- The chest is pulled INWARD during inspiration, reducing
the amount of air that can be drawn into the lungs
- The chest Bulges OUTWARD during expiration because
the intra-thoracic pressure exceeds atmospheric pressure.
The patient has impaired exhalation
- The chest is pulled INWARD during inspiration, reducing Spontaneous pneumothorax
the amount of air that can be drawn into the lungs - Most common type of closed pneumothorax
- The chest Bulges OUTWARD during expiration because - Air accumulates within the pleural space without an
the intra-thoracic pressure exceeds atmospheric pressure. obvious cause (no antecedent trauma to thorax)
The patient has impaired exhalation - Rupture of a small bleb on the visceral pleura most
frequently produces this type of pneumothorax
Open pneumothorax
- usually caused by stabbing or gunshot wound

 This paradoxical movement will lead to:

- Reduced gas exchange
- Decreased lung compliance, retained airway secretions
- Atelectasis, Hypoxemia Tension pneumothorax
Assessment findings - pressure in the pleural space is POSITIVE throughout the
- Severe pain on inspiration & expiration & obvious trauma respiratory cycle
- Shortness of breath - occurs in mechanical ventilation or resuscitation
- Hypotension & inadequate tissue perfusion 2° to  CO - air enters the pleural space with each inspiration but
- Respiratory acidosis cannot escape
- CXR – confirms the diagnosis - causes  intra-thoracic pressure & shifting of the
Medical Management mediastinal contents to the unaffected side (mediastinal
- Immobilize the fractured ribs shift)
o rib belt or elastic bandage is used especially in Sign & Symptoms:
multiple rib fractures o Dyspnea
o it can lead to decreased lung expansion followed by o Dec. or Absent breath sound on the affected side
pulmonary complications (pneumonia & o Dec. chest expansion
atelectasis) o Tracheal deviation to the unaffected side (CXR)
- Pain: Analgesics (codeine), regional nerve block ! Exclusive for tension pneumothorax
- Support ventilation, clear lung secretions Management
- Antibiotics - Thoracentesis
- ET intubation & mechanical ventilation • Chest tubes and drainage system
Nursing Management - Aims to restore negative pressure of the pleural cavity and
- Apply the immobilization device drain collected fluid/blood
- Stress the importance of taking deep breaths every 1-2° Components
even though breathing is painful
• Suction control chamber
- Assess, monitor the client for signs of respiratory
• Water seal chamber
distress, infection & pain
J.A.K.E 36 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

• Closed collection chamber - Diminished/absent breath sounds on affected side

Assessment - respiratory excursion on affected side
• At least every 4 hours for: - Hyper resonance on percussion
- Excessive or abnormal drainage - Tracheal shift to the opposite side (tension pneumothorax
- Cracking sound upon palpation for subcutaneous accompanied by mediastinal shift)
emphysema - Weak, rapid pulse; anxiety; diaphoresis
! If lying on the affected side  Diagnostic tests
- put a rolled towel beside the tubing - Chest x-ray reveals area and degree of pneumothorax
• Remember: - ABG
- Keep the collection device below the client’s chest Nursing interventions
level • Provide nursing care for the client with an ET tube
Oscillations or fluctuations on water seal: - suction secretions, vomitus, blood from nose, mouth,
• Normal throat,
• Absence: - monitor mechanical ventilation
- Re-expansion of the lungs • Restore/promote adequate respiratory function
- Obstruction - Assist with thoracentesis and provide appropriate
Management nursing care
- Notify the MD for CXR - Assist with insertion of a CTT to water- seal drainage
- Obstruction: (no milking and stripping) and provide appropriate nursing care
o Squeeze hand-over-hand) • Continuously evaluate respiratory patterns and report any
• Presence of bubbling: changes.
- Drainage bottle: no bubbling • Provide relief/control of pain.
- Water seal bottle: intermittent bubbling - Administer narcotics/ analgesics/ sedatives as
- Suction control bottle: continuous gentle bubbling ordered and monitor effects
• Abnormal bubbling: - Position client in high-Fowler’s position.
- water seal bottle: continuous bubbling Lung Resections
- suction control bottle: vigorous bubbling • Lobectomy
! Alert: leakage!!! - removal of one lobe of a lung; treatment for
Management bronchiectasis, bronchogenic carcinoma,
- Clamp the tube and tape the leak (allowed for short emphysematous blebs, lung abscesses
periods) • Pneumonectomy
- Prolonged clamping: can cause tension pneumothorax - removal of an entire lung; most commonly done as
• Absence of bubbling treatment for bronchogenic CA
- Water Seal Bottle
• Segmentectomy/ Segmental resection
- Suction Control Bottle
- segment of lung removed; most often done as
• May mean: treatment for bronchiectasis
- Lung Re-expansion
• Wedge resection
- Obstruction
- removal of lesions that occupy only part of a segment
Management
of lung tissue; for excision of small nodules or to
- The same (pareho sa unang management sa taas)
obtain a biopsy
! Points to remember:
• Tube pulled from the site
o Cover with DRY STERILE dressing
o If air is leaking ensure that the dressing is not
occlusive
o If not available in the choices:
• Vaselinized gauze
• Petrolatum gauze
• Tube disconnected or water seal bottle breaks:
- Submerge the end in 1 in. of sterile saline or water
- Reconnect

Hemothorax
- Accumulation of blood in the pleural space
- frequently found w/ an open pneumothorax resulting in a
hemopneumothorax
Assessment findings
- Pain, Dyspnea

J.A.K.E 37 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

Thoracentesis - Inform the client not to cough while the needle is

 Pleural Tap inserted in order to avoid puncturing the lung
- it is a procedure in which a needle is inserted through Before the procedure:
the back of the chest wall into the pleural space to - The patient may have diagnostic procedure, such as a
remove fluid or air chest x-ray, chest fluoroscopy, ultrasound, or CT scan,
 Purposes performed prior to the procedure to assist the
- Diagnostic physician in identifying the specific location of the
- Therapeutic fluid in the chest that is to be removed.
Indications - The patient may receive a sedative prior to the
- pleural effusion which needs diagnostic work-up procedure to help the patient relax
symptomatic treatment of a large pleural effusion - Asked the patient to remove any clothing, jewelry, or
- size other objects that may interfere with the procedure.
- The area around the puncture site may be shaved
Contraindications
- Vital signs
- Uncooperative patient After the procedure:
- Uncorrected bleeding diathesis (blood clothing problem, - The dressing over the puncture site will be monitored
hemophilia) for bleeding or other drainage
- Chest wall cellulitis at the site of puncture - Monitor patient’s blood pressure, pulse, and
Procedure breathing until are stable
1) Position patient in the sitting position with arms and head Canvas:
resting supported on a bedside adjustable table - Removal of excess air and fluid from the pleural cavity
2) If unable to sit, the patient should lie at the edge of the Prevent infection:
bed on the affected side with the ipsilateral arm over the - Sterile technique
head and the midaxillary line accessible for the insertion Site of insertion:
of the needle. Elevating the head of the bed to 30 deg. may - Depending on the MD’s assessment
help. (lumbar region) - Chest X-ray: best method to pinpoint the site
3) Listen to the chest to confirm the site and size of pleural Position:
effusion - Sitting on the edge of the bed with feet supported and
4) Percuss to determine the upper border of the effusion arms on a padded over- bed table
5) Penetrate site is 1-2 intercostal spaces below the fluid - Straddling a chair with arms and head resting on the
level back of the chair
6) Penetration site is 1-2cm below the upper border dullness ! If the patient cannot sit:
area on percussion o Lying on the unaffected side with the head of the bed
7) Go directly above upper edge of corresponding rib elevated 30-450
8) Mark a penetration site at least 2 inches below the o Kozier: sitting with arms above the head
scapular tip Secure the consent:
9) Start cleaning the area from the center in a spiral direction - Obtained by: MD
using iodine swab - Given by: patient
10) Clean the area away from the central in a spiral direction Instruction upon insertion:
using iodine swab (inner to outer) - Exhale and hold
11) Use largest needle to penetrate pleural space and ! Watch out for:
aspirate fluid. Needle to 1-L vacuum bottle. Aspiration o Respiratory distress
syringe. (to withdraw the fluid) o Hypotension
Complications Prevent hypotension:
• Pneumothorax (3-30%) - Do not remove >1000 mL for the first 30 mins
• Hemopneumothorax Post-procedure:
• Hemorrhage - Apply vaselinized or petrolatum gauze
• Hypotension Position post-procedure:
• Pulmonary edema due to lung re expansion - Side-lying on the unaffected side
• Spleen or liver puncture ! Emergency
• Air embolism - If the client expectorate blood (may mean accidental
• Introduction of infection puncture of the lungs) NOTIFY the MD!
Nursing Responsibilities - Rule-out pneumothorax: Chest X-Ray
- Sign consent Health teaching post procedure:
- Mild pain on the site where the needle was pricked • Avoid coughing
- Procedure takes only few minutes, depending • Deep breathing
primarily on the time it takes for fluid to drain from the • Straining
pleural cavity

J.A.K.E 38 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Pleurisy
- refers to inflammation of both the visceral and parietal
pleurae.
- When inflamed, pleural membranes rub together, the
resulting to:
• severe sharp
• knifelike pain with breathing that is intensified on
inspiration
Causes:
• conjunction with pneumonia or an upper respiratory tract
infection
• TB
• collagen disease
• after trauma to the chest
• pulmonary infarction or pulmonary embolism (PE)
• patients with primary or metastatic cancer
• after thoracotomy.
Clinical Manifestations
• Pain usually occurs on one side and worsens with deep
breaths, coughing, or sneezing.
• Pain is decreased when the breath is held. Pain is
localized or radiates to the shoulder or abdomen.
• As pleural fluid develops, pain lessens. A friction rub can
be auscultated but disappears as fluid accumulates.
Assessment and Diagnostic Methods
• Auscultation for pleural friction rub
• Chest x-rays
• Sputum culture
• Thoracentesis for pleural fluid examination, pleural biopsy
(less common)
Medical Management
- Objectives of management are to discover the
underlying condition causing the pleurisy and to relieve
the pain.
• Patient is monitored for signs and symptoms of
pleural effusion: shortness of breath, pain,
assumption of a position that decreases pain, and
decreased chest wall excursion.
• Prescribed analgesics, such as NSAIDs, are given to
relieve pain and allow effective coughing.
• Applications of heat or cold are provided for
symptomatic relief.
J.A.K.E 39 of 57
• An intercostal nerve block is done for severe pain.
• Nursing Management
• Enhance comfort by turning patient frequently on
affected side to splint chest wall.
• Teach patient to use hands or pillow to splint rib cage
while coughing.
Pulmonary Edema
- Abnormal accumulation of fluid in the interstitial spaces
of the lungs that diffuses into the alveoli
- An acute event that results from left ventricular failure.
- With increased resistance to left ventricular filling, blood
backs up into the pulmonary circulation. The patient
quickly develops pulmonary edema, sometimes called
“flash pulmonary edema,” from the blood volume
overload in the lungs.
- Caused by noncardiac disorders, such as renal failure and
other conditions that cause the body to retain fluid.
- The rapid increase in atrial pressure results in an acute
increase in pulmonary venous pressure, which produces
an increase in hydrostatic pressure that forces fluid out of
the pulmonary capillaries into the interstitial spaces and
alveoli. Lymphatic drainage of the excess fluid is
ineffective.
Clinical Manifestations
- As a result of decreased cerebral oxygenation, the patient
becomes increasingly restless and anxious.
- Along with a sudden onset of breathlessness and a sense
of suffocation, the patient’s hands become cold and
moist, the nail beds become cyanotic (bluish), and the
skin turns ashen (gray).
- The pulse is weak and rapid, and the neck veins are
distended.
- Incessant coughing may occur, producing increasing
quantities of foamy sputum.
- As pulmonary edema progresses, the patient’s anxiety
and restlessness increase; the patient becomes confused,
then stuporous.
- Breathing is rapid, noisy, and moist-sounding; the
patient’s oxygen saturation is significantly decreased.
- The patient, nearly suffocated by the blood-tinged, frothy
fluid filling the alveoli, is literally drowning in secretions.
The situation demands emergent action.
Assessment and Diagnostic Methods
- Diagnosis is made by evaluating the clinical
manifestations resulting from pulmonary congestion.
- Abrupt onset of signs of left-sided HF (eg, crackles on
auscultation of the lungs) may occur without evidence of
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
right-sided HF (eg, no jugular venous distention [JVD], no
dependent edema).
- Chest x-ray reveals increased interstitial markings.
- Pulse oximetry to assess ABG levels.
- Medical Management
- Goals of medical management are to reduce volume
overload, improve ventricular function, and increase
respiratory exchange using a
- combination of oxygen and medication therapies.
- Oxygenation
- Oxygen in concentrations adequate to relieve hypoxia and
dyspnea
- Oxygen by intermittent or continuous positive pressure, if
signs of hypoxemia persist
- Endotracheal intubation and mechanical ventilation, if
respiratory failure occurs
- Positive end-expiratory pressure (PEEP)
- Monitoring of pulse oximetry and ABGs
- Pharmacologic Therapy
- Morphine given intravenously in small doses to reduce
anxiety and dyspnea; contraindicated in cerebral vascular
accident, chronic pulmonary disease, or cardiogenic
shock; have naloxone
- hydrochloride (Narcan) available for excessive respiratory
depression
- Diuretics (eg, furosemide) to produce a rapid diuretic
effect
- Vasodilators such as IV nitroglycerin or nitroprusside
(Nipride) may enhance symptom relief
Nursing Management
- Assist with administration of oxygen and intubation and
mechanical ventilation.
- Position patient upright (in bed if necessary) or with legs
and feet down to promote circulation. Preferably position
patient with legs dangling over the side of bed.
- Provide psychological support by reassuring patient. Use
touch to convey a sense of concrete reality. Maximize time
at the bedside.
- Give frequent, simple, concise information about what is
being done to treat the condition and what the responses
to treatment mean.
- Monitor effects of medications. Observe patient for
excessive respiratory depression, hypotension, and
vomiting. Keep a morphine antagonist available (eg,
naloxone hydrochloride).
- Insert and maintain an indwelling catheter if ordered or
provide bedside commode.
- The patient receiving continuous IV infusions of vasoactive
medications requires ECG monitoring and frequent
measurement of vital signs.
Pulmonary Embolism
- Obstruction of the pulmonary artery or one of its branches
by a thrombus (or thrombi) that originates somewhere in
the venous system or in the right side of the heart.
- Gas exchange is impaired in the lung mass supplied by the
obstructed vessel. Massive PE is a life- threatening
emergency
J.A.K.E 40 of 57
- death commonly occurs within 1 hour after the onset of
symptoms.
- common disorder associated with trauma, surgery
(orthopedic, major abdominal, pelvic, gynecologic),
pregnancy, HF, age more than 50 years, hypercoagulable
states, and prolonged immobility
- It also may occur in apparently healthy people. Most
thrombi originate in the deep veins of the legs.
Clinical Manifestations
- Symptoms depend on the size of the thrombus and the
area of the pulmonary artery occlusion.
o Dyspnea is the most common symptom. Tachypnea is
the most frequent sign.
o Chest pain is common, usually sudden in onset and
pleuritic in nature; it can be substernal and may
mimic angina pectoris or a myocardial infarction.
o Anxiety, fever, tachycardia, apprehension, cough,
diaphoresis, hemoptysis, syncope, shock, and
sudden death may occur.
o Clinical picture may mimic that of bronchopneumonia
or HF.
o In atypical instances, PE causes few signs and
symptoms, whereas in other instances it mimics
various other cardiopulmonary disorders.
o Assessment and Diagnostic Methods
o Because the symptoms of PE can vary from few to
severe, a diagnostic workup is performed to rule out
other diseases.
o The initial diagnostic workup may include chest x-ray,
ECG, ABG analysis, and ventilation– perfusion scan.
o Pulmonary angiography is considered the best
method to diagnose PE; however, it may not be
feasible, cost-effective, or easily performed,
especially with critically ill patients.
o Spiral CT scan of the lung, D-dimer assay (blood test
for evidence of blood clots), and pulmonary
arteriogram may be warranted.
o Prevention
o Ambulation or leg exercises in patients on bed rest
o Application of sequential compression devices
o Anticoagulant therapy for patients whose hemostasis
is adequate and who are undergoing major elective
abdominal or thoracic surgery
Medical Management
- Immediate objective is to stabilize the cardiopulmonary
system.
- Nasal oxygen is administered immediately to relieve
hypoxemia, respiratory distress, and central cyanosis.
- IV infusion lines are inserted to establish routes for
medications or fluids that will be needed.
- A perfusion scan, hemodynamic measurements, and ABG
determinations are performed. Spiral (helical) CT or
pulmonary angiography may be performed.
- Hypotension is treated by a slow infusion of dobutamine
(Dobutrex), which has a dilating effect on the pulmonary
vessels and bronchi, or dopamine (Intropin).
- The ECG is monitored continuously for dysrhythmias and
right ventricular failure, which may occur suddenly.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
- Digitalis glycosides, IV diuretics, and antiarrhythmic
agents are administered when appropriate.
- Blood is drawn for serum electrolytes, complete blood
cell count, and hematocrit.
- If clinical assessment and ABG analysis indicate the need,
the patient is intubated and placed on a mechanical
ventilator.
- If the patient has suffered massive embolism and is
hypotensive, an indwelling urinary catheter is inserted to
monitor urinary output.
- Small doses of IV morphine or sedatives are administered
to relieve patient anxiety, to alleviate chest discomfort, to
improve tolerance of the endotracheal tube, and to ease
adaptation to the mechanical ventilator.
Anticoagulation Therapy
- Anticoagulant therapy (heparin, warfarin sodium
[Coumadin]) has traditionally been the primary method for
managing acute DVT and PE (numerous specific options
for treatment are available).
- Patients must continue to take some form of
anticoagulation for at least 3 to 6 months after the
embolic event.
- Major side effects are bleeding anywhere in the body and
anaphylactic reaction resulting in shock or death. Other
side effects include fever, abnormal liver function, and
allergic skin reaction.
- Thrombolytic Therapy
- Thrombolytic therapy may include urokinase,
streptokinase, and alteplase. It is reserved for PE affecting
a significant area and causing hemodynamic instability.
- Bleeding is a significant side effect; nonessential invasive
procedures are avoided.
- Surgical Management
- A surgical embolectomy is rarely performed but may be
indicated if the patient has a massive PE or hemodynamic
instability or if there are contraindications to thrombolytic
therapy.
- Transvenous catheter embolectomy with or without
insertion of an inferior vena caval filter (eg, Greenfield).
Nursing Management
- The nurse must have a high degree of suspicion for PE in
all patients, but particularly in those with conditions
predisposing to a slowing of venous return.
Preventing Thrombus Formation
o Encourage early ambulation and active and passive leg
exercises.
o Instruct patient to move legs in a “pumping” exercise.
o Advise patient to avoid prolonged sitting, immobility, and
constrictive clothing.
o Do not permit dangling of legs and feet in a dependent
position.
o Instruct patient to place feet on floor or chair and to avoid
crossing legs.
o Do not leave IV catheters in veins for prolonged periods.
o Monitoring Anticoagulant and Thrombolytic Therapy
o Advise bed rest, monitor vital signs every 2 hours, and
limit invasive procedures.
J.A.K.E 41 of 57
o Measure international normalized ratio (INR) or activated
partial thromboplastin time (PTT) every 3 to 4 hours after
thrombolytic infusion is started to confirm activation of
fibrinolytic systems.
o Perform only essential ABG studies on upper extremities,
with manual compression of puncture site for at least 30
minutes.
Minimizing Chest Pain, Pleuritic
- Place patient in semi-Fowler’s position; turn and
reposition frequently.
- Administer analgesics as prescribed for severe pain.
Managing Oxygen Therapy
- Assess the patient frequently for signs of hypoxemia and
monitors the pulse oximetry values.
- Assist patient with deep breathing and incentive
spirometry.
- Nebulizer therapy or percussion and postural drainage
may be necessary for management of secretions.
- Alleviating Anxiety
- Encourage patient to express feelings and concerns.
- Answer questions concisely and accurately.
- Explain therapy, and describe how to recognize untoward
effects early.
Monitoring for Complications
- Be alert for the potential complication of cardiogenic
shock or right ventricular failure subsequent to the effect
of PE on the cardiovascular system.
Providing Postoperative Nursing Care
- Measure pulmonary arterial pressure and urinary output.
- Assess insertion site of arterial catheter for hematoma
formation and infection.
- Maintain blood pressure to ensure perfusion of vital
organs.
- Encourage isometric exercises, antiembolism stockings,
and walking when permitted out of bed; elevate foot of
bed when patient is resting.
- Discourage sitting; hip flexion compresses large veins in
the legs.
Pulmonary Tuberculosis
- an infectious disease primarily affecting the lung
parenchyma, is most often caused by Mycobacterium
tuberculosis.
- It may spread to almost any part of the body, including the
meninges, kidney, bones, and lymph nodes.
- The initial infection usually occurs 2 to 10 weeks after
exposure. The patient may then develop active disease
because of a compromised or inadequate immune system
response.
- The active process may be prolonged and characterized
by long remissions when the disease is arrested, only to
be followed by periods of renewed activity.
- TB is transmitted when a person with active pulmonary
disease expels the organisms. A susceptible person
inhales the droplets and becomes infected. Bacteria are
transmitted to the alveoli and multiply.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
- An inflammatory reaction results in exudate in the alveoli
and bronchopneumonia, granulomas, and fibrous tissue.
Onset is usually insidious.
Risk Factors
• Close contact with someone who has active TB
• Immunocompromised status (eg, elderly, cancer,
corticosteroid therapy, and HIV)
• Injection drug use and alcoholism
• People lacking adequate health care (eg, homeless or
impoverished, minorities, children, and young adults)
• Preexisting medical conditions, including diabetes,
chronic renal failure, silicosis, and malnourishment
• Immigrants from countries with a high incidence of TB (eg,
Haiti, southeast Asia)
• Institutionalization (eg, long-term care facilities, prisons)
• Living in overcrowded, substandard housing
• Occupation (eg, health care workers, particularly those
performing high-risk activities)
Clinical Manifestations
o Low-grade fever
o Cough
o Night sweats
o Fatigue
o Weight loss
o Nonproductive cough, which may progress to
mucopurulent sputum with hemoptysis
Assessment and Diagnostic Methods
- TB skin test (Mantoux test); QuantiFERON-TB Gold (QFT-
G) test
- Chest x-ray
- Acid-fast bacillus smear
- Sputum culture
Gerontologic Considerations
- Elderly patients may have atypical manifestations, such
as unusual behavior or disturbed mental status, fever,
anorexia, and weight loss. TB is increasingly encountered
in the nursing home population.
- In many elderly people the TB skin test produces no
reaction.
Medical Management
- Pulmonary TB is treated primarily with antituberculosis
agents for 6 to 12 months.
- A prolonged treatment duration is necessary to ensure
eradication of the organisms and to prevent relapse.
Pharmacologic Therapy
- First-line medications: isoniazid or INH (Nydrazid),
rifampin (Rifadin), pyrazinamide, and ethambutol
(Myambutol) daily for 8 weeks and continuing for up to 4
to 7 months
- Second-line medications: capreomycin (Capastat),
ethionamide (Trecator), para aminosalicylate sodium, and
cycloserine (Seromycin)
- Vitamin B (pyridoxine) usually administered with INH
Nursing Management Promoting Airway Clearance
- Encourage increased fluid intake.
- Instruct about best position to facilitate drainage.
J.A.K.E 42 of 57
Advocating Adherence to Treatment Regimen
- Explain that TB is a communicable disease and that taking
medications is the most effective way of preventing
transmission.
- Instruct about medications, schedule, and side effects;
monitor for side effects of anti-TB medications.
- Instruct about the risk of drug resistance if the Blunt chest
trauma results from sudden compression or positive
pressure inflicted to the chest wall.medication regimen is
not strictly and continuously followed.
- Carefully monitor vital signs and observe for spikes in
temperature or changes in the patient’s clinical status.
- Teach caregivers of patients who are not hospitalized to
monitor the patient’s temperature and respiratory status;
report any changes in the patient’s respiratory status to
the primary health care provider.
Promoting Activity and Adequate Nutrition
- Plan a progressive activity schedule with the patient to
increase activity tolerance and muscle strength.
- Devise a complementary plan to encourage adequate
nutrition. A nutritional regimen of small, frequent meals
and nutritional supplements may be helpful in meeting
daily caloric requirements.
- Identify facilities (eg, shelters, soup kitchens, Meals on
Wheels) that provide meals in the patient’s neighborhood
may increase the likelihood that the patient with limited
resources and energy will have access to a more
nutritious intake.
Preventing Spreading of TB Infection
- Carefully instruct the patient about important hygiene
measures, including mouth care, covering the mouth and
nose when coughing and sneezing, proper
- disposal of tissues, and handwashing.
- Report any cases of TB to the health department so that
people who have been in contact with the affected patient
during the infectious stage can undergo screening and
possible treatment, if indicated.
- Instruct patient about the risk of spreading TB to other
parts of the body (spread or dissemination of TB infection
to nonpulmonary sites of the body is known as miliary TB).
- Carefully monitor patient for military TB: Monitor vital
signs and observe for spikes in temperature as well as
changes in renal and cognitive function; few physical
signs may be elicited on physical examination of the chest,
but at this stage the patient has a severe cough and
dyspnea. Treatment of miliary TB is the same as for
pulmonary TB.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

OXYGEN EXCHANGE AND UTILIZATION: HEMATOLOGIC

DISORDERS
Discussed by: Dr. Potenciana A. Maroma
Components of Blood

Anemia
- Deficiency of RBCs, Hgb, Hct
• Hct -percentage of PRBCs/ dl of blood
- Anemia results from:
• Blood loss
• Inadequate or abnormal RBC production
• Destruction of RBCs

Iron Deficiency Anemia

- Microcytic, Hypochromic anemia caused by:
• Inadequate intake of iron
• Decreased absorption of iron in GIT
• Excessive loss of iron (excessive bleeding or blood
loss)

Normal Values
 RBC count SI units
12
 Female: 4.2 – 5.4 million/uL 4.2-5.4 x 10 cells/L
12
 Male: 4.7 – 6.1 million/uL 4.7-6.1 x 10 cells/L
 Hgb
 Female 12-16 g/dL 120-160 g/L
 Male 14-18 g/dL 140-180 g/L Assessment Findings
 Hct
• Reduced energy, Cold sensitivity, Fatigue, DOE
 Female 37 – 47% 0.37 – 0.47 fraction
 Male 42 – 52% 0.42 – 0.52 fraction
• HR even at rest
 WBC count • decreased CBC, Hgb, Hct, serum Fe
9 • Blood smear reveals microcytic & hypochromic RBCs
 5,000-10,000/uL 5.0-10 x 10 cells/L
• Complete hematologic studies (eg, hemoglobin,
 Platelets
3 9 hematocrit, reticulocyte count, and red blood cell (RBC)
 150,000-400,000mm 150-400 x 10 /L
J.A.K.E 43 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
indices, particularly the mean corpuscular volume [MCV]
and RBC distribution width [RDW])
• Iron studies (serum iron level, total iron-binding capacity
[TIBC], percent saturation, and ferritin)
• Serum vitamin B12 and folate levels; haptoglobin and
erythropoietin levels
• Bone marrow aspiration
• Other studies as indicated to determine underlying illness
Clinical Manifestations
- The rapidity with which the anemia has developed
- The duration of the anemia (ie, its chronicity)
- The metabolic requirements of the patient, other
concurrent disorders or disabilities (eg, cardiac or
pulmonary disease)
- Complications or concomitant features of the condition
that produced the anemia
- In general, the more rapidly an anemia develops, the more
severe its symptoms. Pronounced symptoms of anemia
include the following:
• Dyspnea, chest pain, muscle pain or cramping,
tachycardia
• Weakness, fatigue, general malaise
• Pallor of the skin and mucous membranes
(conjunctivae, oral mucosa)
• Jaundice (megaloblastic or hemolytic anemia)
• Smooth, red tongue (iron-deficiency anemia)
• Beefy, red, sore tongue (megaloblastic anemia)
• Angular cheilosis (ulceration of the corner of the
mouth)
• Brittle, ridged, concave nails and pica (unusual
craving for starch, dirt, ice) in patients with iron-
deficiency anemia
Medical Management
• Treat & eliminate the cause
• Correction of faulty diet, oral supplement or parenteral
administration of iron is prescribed
• Blood Transfusion in severe case
• Search for the cause, which may be a curable GI cancer or
uterine fibroids.
• Test stool specimens for occult blood.
• People aged 50 years or older should have periodic
colonoscopy, endoscopy, or x-ray examination of the GI
tract to detect ulcerations, gastritis, polyps, or cancer.
• Administer prescribed iron preparations (oral,
intramuscular [IM], or IV).
• Have patient continue iron preparations for 6 to 12
months.
Nursing Management
• Monitor for signs and symptoms of abnormal bleeding
especially from the GIT
• Provide for adequate rest: plan activities so as not to
overtire
• Provide a thorough explanation of all diagnostic tests used
to determine sources of possible bleeding (helps allay
anxiety and ensure cooperation)
• Administer iron preparations as ordered.
• Oral iron supplements for mild iron losses (FeSO4)
J.A.K.E 44 of 57
• prophylactic use:300-325mg therapeutic use- 600-
1200mg daily in divided dose
• Take iron with or immediately after a meal to avoid GI
upset
• Take with orange juice or vitamin C source ( absorption)
• Use straw (elixir preparations) to prevent staining of teeth
• Expect iron to color stool dark green or black
• Causes constipation
• Parenteral: used in clients intolerant to oral preparations,
who are noncompliant with therapy, or who have severe
iron deficiency anemia
• Use one needle to withdraw and another to administer
iron preparations as tissue staining and irritation are a
problem
• Use the Z-track injection technique to prevent leakage into
tissues
- Do not massage injection site but encourage ambulation
as this will enhance absorption; advise against vigorous
exercise and constricting garments
- Provide dietary teaching regarding foods high in iron
• Liver especially pork & lamb
• Red meat, Organ meats, Kidney beans
• Whole-wheat breads and cereals
• Leafy green vegetables
• Carrots, Egg yolk, Raisins
- Encourage ingestion of roughage and increase fluid intake
to prevent constipation if oral iron preparations are being
taken
Pernicious Anemia
- Caused by a deficiency of intrinsic factor (substance
normally secreted by the gastric mucosa)
- Intrinsic Factor is necessary for absorption of Vitamin B12
- Vitamin B12 is needed for the maturation of erythrocytes
- without Vitamin B12
- precursor cells undergo improper DNA synthesis (few are
released from the bone marrow)
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
- increased in size: MEGALOBASTIC or MACROCYTIC cells
- Paresthesia: Vitamin B12 is needed for normal nerve
function
Assessment Findings
- Usually seen in elderly (production of IF decreases with
age & gastric mucosal atrophy) & in client’s w/ history of
surgical removal of stomach, bowel resection (ileum)
- Stomatitis, glossitis (a smooth, beefy-red tongue)
- Pallor, fatigue, DOE
- Severe cases: jaundice, irritability, confusion,
- Numbness & tingling in the arms & legs & difficulty with
gait or balance (neurologic involvement)
Diagnostic Findings
- Client’s history, Symptoms, Blood & BM studies
• Microscopic exam: large & immature erythrocytes
• Schilling test
- measures absorption of radioactive Vitamin B before and
after parenteral administration of intrinsic factor
- Definitive test for pernicious anemia
- used to detect lack of intrinsic factor
- The Schilling test is performed by administering 58Co-
labeled cobalamin and collecting urine for 24 h and is
dependent upon normal renal and bladder function. As a
consequence, cobalamin absorption may be abnormal in
Pernicious anemia
- The Schilling test is performed to evaluate vitamin B12
absorption. B12 helps in the formation of red blood cells,
the maintenance of the central nervous system, and is
important for metabolism. Normally, ingested vitamin B12
combines with intrinsic factor, which is produced by cells
in the stomach. Intrinsic factor is necessary for vitamin
B12 to be absorbed in the small intestine. Certain
diseases, such as pernicious anemia, can result when
absorption of vitamin B12 is inadequate.
J.A.K.E 45 of 57
Medical Management
- Administration of Vitamin B12 (IM) weekly & monthly for
maintenance
Nursing Management
- Provide a Vitamin B12-rich diet
- Liver, Organ meats, Dried beans, Nuts, Green leafy
vegetables, Citrus fruit, Brewer’s yeast
- Avoid highly seasoned, coarse, or very hot foods if client
has stomatitis & glossitis
- Provide mouth care before & after meals using a soft
toothbrush and nonirritating rinses
- Bed rest may be necessary if anemia is severe
- Provide safety when ambulating (especially if carrying
hot items, etc.)
- Provide client teaching and discharge planning
concerning
o Dietary instruction
o Importance of lifelong Vitamin B12 theraphy
o Rehabilitation and physical therapy for neurologic
deficits, as well as instruction regarding safety
Folic Acid Anemia
- Folic acid deficiency can also cause megaloblastic
anemia
- Manifestations are similar to those of Vitamin B12
deficiency except for the nervous system involvement
(folic acid does not affect nerve function)
- Absence of neurologic problems in FADA
- 3 main causes of FADA:
1) Poor nutrition
• Beef liver, organ meats, eggs, green leafy
vegetables, cabbage, broccoli, yeast, citrus fruits,
peanut butter, oatmeal, asparagus
2) Malabsorption
• Crohn’s disease
• Chronic alcohol abuse (malnutrition)
3) Drugs
• Anticonvulsants, oral contraceptives
• prevent absorption & conversion of folic acid to
its active form leading to folic acid deficiency &
anemia
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Assessment and Diagnostic Findings
• Severe fatigue, sore & beefy red tongue
• Dyspnea, nausea, anorexia, headaches, weakness,
lightheadedness
• Hgb/Hct, serum folate
• Schilling test – differentiates pernicious anemia & FADA
• Schilling test (primary diagnostic tool)
• Complete blood cell count (Hgb value as low as 4 to 5
g/dL, WBC count 2,000 to 3,000 mm3, platelet count
fewer than 50,000 mm3; very high MCV, usually exceeding
110 _m3)
• Serum levels of folate and vitamin B12 (folic acid
deficiency and deficient vitamin B12)
Medical management
• Oral or parenteral folic acid supplements
• Well-balanced diet
• Increase intake of folic acid in patient’s diet and
administer 1 mg folic acid daily.
• Administer IM folic acid for malabsorption syndromes.
• Prescribe additional supplements as necessary, because
the amount in multivitamins may be inadequate to fully
replace deficient body stores.
• Prescribe folic acid for patients with alcoholism as long as
they continue to consume alcohol.
Nursing Management
• Encourage to eat soft, bland & high in folic acid foods
• Good oral hygiene, adequate rest periods (fatigue)
• Assess patients at risk for megaloblastic anemia for
clinical manifestations (eg, inspect the skin, sclera, and
mucous membranes for jaundice; note vitiligo and
premature graying).
• Perform careful neurologic assessment (eg, note gait and
stability; test position and vibration sense).
• Assess need for assistive devices (eg, canes, walkers) and
need for support and guidance in managing activities of
daily living and home environment.
• Ensure safety when position sense, coordination, and gait
are affected.
• Refer for physical or occupational therapy as needed.
• When sensation is altered, instruct patient to avoid
excessive heat and cold.
• Advise patient to prepare bland, soft foods and to eat
small amounts frequently.
• Explain that other nutritional deficiencies, such as alcohol
induced anemia, can induce neurologic problems.
• Instruct patient in complete urine collections for the
Schilling test. Also explain the importance of the test and
of complying with the collection.
• Teach patient about chronicity of disorder and need for
monthly vitamin B12 injections even when patient has no
symptoms. Instruct patient how to self-administer
injections, when appropriate.
• Stress importance of ongoing medical follow-up and
screening, because gastric atrophy associated with
pernicious anemia increases the risk of gastric carcinoma.
J.A.K.E 46 of 57
Clinical Manifestations
• Symptoms of folic acid and vitamin B12 deficiencies are
similar, and the two anemias may coexist. Symptoms are
progressive, although the course of illness may be marked
by spontaneous partial
• Gradual development of signs of anemia (weakness,
listlessness, and fatigue).
• Possible development of a smooth, sore, red tongue and
mild diarrhea (pernicious anemia).
• Mild jaundice, vitiligo, and premature graying.
• Confusion may occur; more often, paresthesias in the
extremities and difficulty keeping balance; loss of position
sense.
• Lack of neurologic manifestations with folic acid
deficiency alone.
• Without treatment, patients die, usually as a result of
heart failure secondary to anemia.
• remissions and exacerbations.
Vitamin B12 Deficiency
- A deficiency of vitamin B12 can occur in several ways.
Inadequate dietary intake is rare but can develop in strict
vegetarians who consume no meat or dairy products.
Faulty absorption from the GI tract is more common, as
with conditions such as Crohn’s disease or after ileal
resection or gastrectomy. Another cause is the absence of
intrinsic factor. A deficiency may also occur if disease
involving the ileum or pancreas impairs absorption. The
body normally has large stores of vitamin B12, so years
may pass before the deficiency results in anemia.
- Same sila ng folic acid deficiency ng assessment,
manifestation at nursing management pero sa medication
magka – iba
Medical Management
• Provide vitamin B12 replacement: Vegetarians can
prevent or treat deficiency with oral supplements with
vitamins or fortified soy milk; when the deficiency is due to
the more common defect in absorption or the absence of
intrinsic factor, replacement is by monthly IM injections of
vitamin B12.
• A small amount of an oral dose of vitamin B12 can be
absorbed by passive diffusion, even in the absence of
intrinsic factor, but large doses (2 mg/day) are required if
vitamin B12 is to be replaced orally.
• To prevent recurrence of pernicious anemia, vitamin B12
therapy must be continued for life.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Aplastic Anemia
- Deficiency of circulating rbcs usually accompanied by
leukopenia & thrombocytopenia
- There is PANCYTOPENIA in aplastic anemia
- Causes:
- Failure of he BM to produce cells (pluripotent stem cell
injury)
- Long-term exposure to toxic agents (drugs, chemical)
- Ionizing radiation
- Viral infection
- Autoimmune
- 50% of cases unknown
Assessment Findings
• Weakness & fatigue (typical for any type of anemia)
• Frequent opportunistic infections
• Coagulation abnormalities (unusual bleeding, petechiae &
ecchymoses “bruises”)
• Splenomegaly
• accumulation of client’s blood cells destroyed by
lymphocytes that failed to recognize them as normal cells
• CBC – macrocytic anemia, leukopenia, thrombocytopenia
• BM aspiration/ biopsy
• Bone marrow aspirate that shows an extremely
hypoplastic or even aplastic (very few to no cells) marrow
replaced with fat.
Medical Management
• Blood Transfusion: MAINSTAY of treatment
• Discontinued if client’s own marrow begins to produce
blood cells
• Antibiotic for infection
• Corticosteroids (if autoimmune)
• Bone marrow transplantation
• Identification and withdrawal of offending agent or drug
• Those who are younger than 60 years, who are otherwise
healthy, and who have a compatible donor can be cured
of the disease by a bone marrow transplant (BMT) or
peripheral blood stem cell transplant (PBSCT).
• In others, the disease can be managed with
immunosuppressive therapy, commonly using a
combination of ant thymocyte globulin (ATG) and
cyclosporine or androgens.
• Supportive therapy plays a major role in the management
of aplastic anemia. Any offending agent is discontinued.
The patient is supported with transfusions of PRBCs and
platelets as necessary.
J.A.K.E 47 of 57
Nursing Management
• Administer blood transfusions as ordered
• Provide nursing care for client with BM transplantation
• Administer medications as ordered
• Monitor for signs of infection and provide care to minimize
risk
• Implement special isolation procedures
• Encourage high-protein, high-Vitamin diet to help reduce
incidence of infection
• Provide mouth care before and after meals.
• Monitor for signs of bleeding and provide measures to
minimize risk
• Use a soft toothbrush and electric razor
• Avoid IM injection
• Check for occult blood in urine and stool (Hematest)
• Observe for oozing from gums, petechiae, or ecchymoses.
• Assess patient carefully for signs of infection and bleeding,
as patients with aplastic anemia are vulnerable to
problems related to erythrocyte, leukocyte, and platelet
deficiencies.
• Monitor for side effects of therapy, particularly for
hypersensitivity reaction while administering ATG.
• If patients require long-term cyclosporine therapy,
monitor them for long-term effects, including renal or liver
dysfunction, hypertension, pruritus, visual impairment,
tremor, and skin cancer.
• Carefully assess each new prescription for drug–drug
interactions, as the metabolism of ATG is altered by many
other medications.
• Ensure that patients understand the importance of not
abruptly stopping their immunosuppressive therapy.
Clinical Manifestations
• Infection and the symptoms of anemia (eg, fatigue, pallor,
dyspnea).
• Retinal hemorrhages.
• Purpura (bruising).
• Repeated throat infections with possible cervical
lymphadenopathy.
• Other lymphadenopathies and splenomegaly sometimes
occur.
Hemolytic Anemia
- Anemia cause by increase destruction of RBCs
- Acquired
- Cardiopulmonary bypass surgery, arsenic or lead
poisoning, malarial infection, toxins & hazardous
chemicals, transfusion reactions
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

- Hereditary
- Hereditary spherocytosis, G6PD deficiency, sickle cell
anemia, thalassemia
Assessment Findings
- Clinical manifestations vary depending on severity of
anemia and the rate of onset (acute vs chronic)
• Dyspnea, Pallor, Fatigue, Jaundice (chronic)
• Chills, Fever, Irritability, Precordial pain
• Abdominal pain, N&V, diarrhea, melena, hematuria
• Splenomegaly, hepatomegaly & symptoms of
cholelithiasis
• Laboratory tests
•  Hgb/Hct
•  Retic count
• Coombs’ test (direct): positive if autoimmune features
present
• Bilirubin (indirect): elevated unconjugated fraction
Medical Management
• Identify & eliminate the cause (if possible)
• Administration of corticosteroids (autoimmune)
• Blood transfusion
• Splenectomy (fails to respond to medical treatment)
Nursing Management
• Monitor for signs and symptoms of hypoxia including
confusion, cyanosis, shortness of breath, tachycardia,
and palpitations
• presence of jaundice may make assessment of skin color
in hypoxia unreliable • Platelet plug formation triggers the blood clotting cascade
• If jaundice and associated pruritus are present, avoid mechanism
soap during bathing and use cool or tepid water  Intrinsic pathway
• Frequent turning and meticulous skin care are important - Intrinsic factors are problems or substances directly in
as skin friability is increased the blood itself that first make platelets clump & then
activate the blood-clotting cascade
Hemostasis / Blood Clotting - Example: Ag-Ab reaction, circulating debris, prolonged
- Blood clotting mechanism involves 3 sequential process: venous stasis, bacterial toxins
• Platelet aggregation with formation of a platelet plug  Extrinsic pathway
• Blood clotting cascade - Outside the blood: Trauma
• Formation of a complete fibrin clot

J.A.K.E 48 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Idiopathic Thrombocytopenic Purpura/
Autoimmune Thrombocytopenic Purpura
- Destruction of platelets causing a slow blood clotting
process
- Cause: autoimmune
- Autoantibodies directed towards own platelets
- Assessment Findings:
- Ecchymoses (Bruises), petechial rashes on the arms, legs,
upper chest & neck
- Mucosal bleeding occurs easily
- Significant blood loss  anemia
- Intracranial bleed-induced stroke (very rare)
- Assess for neurologic function & mental status
Diagnostic Findings
• Decrease platelet count
• Large amount of megakaryocytes in the bone marrow
• Presence of antiplatelet antibodies
• Decrease Hgb/Hct (due to bleeding)
• Medical Management:
• Treatment of underlying condition & protection from
trauma-induced bleeding episodes
• Corticosteroids & Azathioprine (Imuran)
• Suppresses immune function
J.A.K.E 49 of 57
• Platelet transfusion (not performed routinely because they
will be destroyed also)
• Maintain a safe environment & protect the client from
conditions that can lead to bleeding
Nursing interventions
- Control bleeding
- Administer platelet transfusions as ordered.
- Apply pressure to bleeding sites as needed.
- Position bleeding part above heart level if possible.
- Prevent bruising.
- Provide support to client and be sensitive to change in
body image.
- Measure normal circumference of extremities for baseline.
- Administer medications orally, rectally, or IV, rather than
IM; if administering immunizations, give subcutaneously
(SC) and hold pressure on site for 5 minutes.
- Administer analgesics (acetaminophen) as ordered; avoid
aspirin
- Disseminated Intravascular Coagulation
- Diffuse fibrin deposition within arterioles and capillaries
with widespread coagulation all over the body and
subsequent depletion of clotting factors
- Hemorrhage (kidneys, brain, adrenals, heart, and other
organs)
- Cause: UNKNOWN
- Clients are usually critically ill with an obstetric, surgical,
hemolytic, or neoplastic disease
- May be linked with entry of thromboplastic substances
into the blood
- Mortality rate is high, usually because underlying disease
cannot be corrected
Pathophysiology
Pathophysiology: Underlying disease
(e.g., toxemia of pregnancy, cancer)
Release of thromboplastic subs that promote clot
deposition throughout the microcirculation (microthrombi
causes microinfarcts and tissue necrosis)
RBCs are trapped in fibrin strands and are hemolysed;
Platelets, prothrombin, and other clotting factors are
destroyed leading to bleeding
Excessive clotting activates fibrinolytic system, which
inhibits platelet function, causing further bleeding
Assessment Findings
- Petechiae and ecchymoses on the skin, mucous
membranes, heart, lungs, and other organs
- Prolonged bleeding from breaks in the skin (e.g., IV or
venipuncture sites)
- Severe and uncontrollable hemorrhage during childbirth
or surgical procedures
- Oliguria and acute renal failure
- Convulsions, coma, death
Laboratory findings
- PT/ PTT/ Thrombin prolonged
- Fibrinogen level & Platelet count usually depressed
- Factor assays (II, V, VII) depressed
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

- Medical Management: Assessment

- Identification and control of underlying disease is key - History (review client’s risk factors for hypertension)
- Blood transfusions: WB, PRBC, platelets, plasma, Physical assessment
cryoprecipitates, & volume expanders - most clients have no symptoms; however, they may
- Heparin administration experience headaches, dizziness, fainting
- Somewhat controversial!!! - Check for Orthostatic hypotension (decrease in BP of
- Inhibits thrombin thus preventing further clot formation, 20mmHg systolic &/or 10mmHg diastolic when the client
allowing coagulation factors to accumulate changes position from lying to sitting in 2 minutes interval)
Nursing Interventions - tachycardia, sweating & pallor suggest a
- Monitor blood loss and attempt to quantify pheochromocytoma or adrenal medulla tumor
- Observe for signs of additional bleeding or thrombus - Psychosocial assessment
formation - assess for psychosocial stressors (job-related, economic
- Monitor appropriate laboratory data & other life stressors)
- Prevent further injury Diagnostic assessment
- Avoid IM injections - No laboratory tests are diagnostic of essential
- Apply pressure to bleeding sites hypertension, but several laboratory tests can assess
- Gently turn & position client frequently possible causes of secondary hypertension
- Provide frequent nontraumatic mouth care (soft - presence of CHONs, RBCs, pus, BUN & CREA indicate
toothbrush or gauze sponge) renal disease
- Provide emotional support to client and significant others - CXR reveals cardiomegaly, ECG determines the degree of
- Administer blood transfusions and medications as cardiac involvement
ordered. Interventions
- Lifestyle modifications
Blood Vessels Disturbances - Sodium restriction –  sodium intake from the average of
Arteriosclerosis 150mEq/L to <100mEq/L
- Thickening or hardening of the arterial wall - Weight reduction – weight loss is encouraging if BMI is 25
Atherosclerosis or higher
- A type of arteriosclerosis that involves the formation of - Moderation of alcohol intake – limit alcohol to no >1
plaque within the arterial wall ounce of ethanol (2 ounces of liquor, 8 ounces of wine or
Pathophysiology: 24 ounces of beer daily). Excessive alcohol intake
Vascular damage; Inflammation elevates BP & can add “empty” calories
- Exercise – start an exercise program slowly & gradually
Fatty streak formation
work up to more rigorous activities
Plaque - Tobacco & caffeine avoidance
Hypertension Drug therapy
- New classification (2003) “Normal adult BP”: - Diuretics – DOC for hypertensive clients who have asthma,
o <120mmHg systolic chronic airway limitation (CAL) & chronic renal disease
o <80mmHg diastolic - Mc SE: hypokalemia (monitor K+ level, assess for irregular
pulse & muscle weakness)
Prehypertension
- Thiazide (low-ceiling) diuretics – prevent Na+ & water
o 120-139/80-89mmHg reabsorption in the distal tubules while promoting K+
Stage 1 hypertension: excretion
o 140-159/90-99mmHg - Loop (high-ceiling) diuretics – depress Na+ reabsorption in
Stage 2 hypertension the ascending loop of henle & promote K+ excretion (ex;
o >160/>100mmHg Lasix)
- K+-sparing diuretics – inhibits reabsorption of Na+ in DCT
Etiology
in exchange for K+, thereby retaining K+ [Spironolactone
Essential (primary) Secondary
- No known cause - Due to specific disease (aldactone)]
- Associated risk factors:
 Age >60 years of age
states & some - Calcium channel blocking agents
medications
 Family history  Renal vascular & renal - Lower Bp by interfering with transmembrane flux of Ca++
 Excessive calorie parenchymal disease
consumption  Primary aldosteronism ion resulting to vasodilation & subsequent  in BP
 Physical inactivity  Pheochromocytoma
 Excessive alcohol intake  Cushing’s syndrome
(Verapamil, Amlodipine, Diltiazem)
 Hyperlipidemia
 African-american ethnicity
 Coarctation of aorta - ACE inhibitors – inhibits conversion of angiotensin I to II,
 Brain tumors
 High intake of salt or
caffeine; reduced intake of
 Encephalitis one of the most powerful vasoconstrictors in the body
 Psychiatric disturbances
K+, Ca++, Mg++  Pregnancy (Captopril, Enalapril, Lisinopril)
 Obesity
 SMOKING!!!
 Medications
• Estrogen (oral contraceptives)
- Angiotensin II receptor blockers (Candesartan, Losartan,
 Stress • Glucocorticoids Telmisartan)
• Mineralocorticoids
• Sympathomimetics - Aldosterone receptor antagonist

J.A.K.E 50 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

- Beta blockers – DOC for hypertensive clients with • Surgical Management

ischemic heart disease because the heart is the most - Abdominal Aortic Aneurysm Resection – excision of
common target of end-organ damage w/ hypertension aneurysm from the abdominal aorta to prevent or repair
the rupture
Aneurysm - Goal: to secure a stable aortic integrity & tissue perfusion
- A permanent localized dilation of an artery, which throughout the body
enlarges the artery to at least 2 times its normal diameter
Types:
• Fusiform – diffuse dilation affecting the entire
circumference of the artery
• Saccular – an outpouching affecting only a distinct
portion of the artery

Peripheral Vascular Disease

- Disorders that alter the natural flow of blood through the
arteries & veins of the peripheral circulation
- most frequently affected are the lower extremities
Peripheral Arterial Disease
- chronic partial or total arterial occlusion resulting from
- Aneurysm tends to occur at specific anatomic sites but systemic atherosclerosis leading to deprivation of O2 &
most commonly in the abdominal aorta nutrients
- Aneurysm forms when the middle layer (T. media) of the - PAD of lower extremities is also called “Lower Extremity
artery is weakened, producing a stretching effect in the Arterial Disease” (LEAD)
inner layer (T. intima) and outer layers (T. adventitia) of the
artery
- As the aneurysm grows, the risk of arterial rupture
increases
Etiology
- Atherosclerosis is the most common cause of all
aneurysm with hypertension & cigarette smoking being
contributing factors
Assessment Findings
- Most are asymptomatic until discovered by routine
examination or during radiographic study performed for
another reason
- Steady with a gnawing quality abdominal, flank, or back Classification
PAIN especially if its AAA • Inflow obstruction – involves the distal end of the aorta &
- With a rupturing AAA, signs include hypotension, the common, internal, external iliac arteries (located
diaphoresis, mental obtundation, oliguria & dysrhythmias above the inguinal ligament)
(S/S of hypovolemic shock) • Outflow obstruction – involves femoral, popliteal & tibial
Diagnostic Assessment arteries (below the superficial femoral artery)
• X-ray – reveals “eggshell” appearance in cases of AAA Etiology & risk factors
• Standard tool:
• Atherosclerosis – most common cause
- CT scan (determines the size and location)
Risk factor
• Ultrasonography: noninvasive technique that provides
o hypertension
accurate diagnosis, as well as information about the size
o hyperlipidemia
& location of AAA
o DM
Interventions
o cigarette smoking
• Nonsurgical management: goal is to monitor the growth
o obesity & familial predisposition
of the aneurysm (frequent CT scanning) and maintenance
of BP at a normal level to  risk of rupture
- w/ hypertension; treated with anti-hypertensive agents
J.A.K.E 51 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Assessment
- Clients initially seek treatment for a characteristic leg pain
known as intermittent claudication (usually they can walk
only a certain distance before a cramping, burning muscle
discomfort or pain forces them to stop)
- presence of Rest Pain – numbness or burning sensation
often describe as a feeling like a toothache, that is severe
enough to awaken clients at night located in the distal
portion of the extremities (heal, toes)
- Inflow disease – discomfort in the lower back, buttocks or
thighs
- Outflow disease – burning or cramping in the calves,
ankles, feet & toes
- Loss of hair on the lower calf, ankle & foot; dry, scaly,
dusky, pale or mottled skin; thickened toenails
- Cold extremity & cyanotic; pallor occurs when the
extremity is elevated
- Palpate all pulses in both legs – most sensitive & specific
indicator of arterial function is the quality of the posterior
tibial pulse (not palpable)
- Note for early signs of ulcer formation
J.A.K.E 52 of 57
Radiographic assessment
- Arteriography – not commonly performed today because
this procedure involves injecting contrast medium into the
arterial system and can have risks which include
hemorrhage, thrombosis, embolus & death
Segmental Systolic BP measurements
- Inexpensive, noninvasive method of assessing PAD using
a Doppler probe.
- Normally, BP readings in the thigh and calf are higher than
those in the upper extremities; with the presence of
arterial disease, these pressures are lower than the
brachial pressure
- Ankle-Brachial Index – an ABI of <0.9 in either leg is
diagnostic of PAD (derived by dividing the ankle BP by the
brachial BP)
Exercise Tolerance Testing
- Done by stress test or treadmill and gives valuable
information about claudication (muscle pain) without rest
pain
Interventions
- Exercise
- Improve arterial blood flow to the affected limb through
buildup of the collateral circulation
- Exercise is individualized for each client, but people with
severe rest pain, venous ulcers or gangrene should not
participate
- Positioning
- Positioning of the client to promote circulation has been
somewhat controversial
- Refrain from raising the legs above the heart level because
extreme elevation slows arterial blood flow to the feet
- In severe cases, clients with PAD & swelling may sleep
with the affected limb hanging from the bed or they may
sit upright in a chair for comfort
- Avoid crossing the legs and refrain from wearing restrictive
clothing which interferes with blood flow
Promote Vasodilation
- Provide warmth to the affected extremity & prevent long
periods of exposure to cold
- Never apply direct heat to the limb (sensitivity might be 
to the affected limb: burn injury)
- Drink adequate fluids to prevent increased blood viscosity
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
- Emotional stress, caffeine, nicotine causes
vasoconstriction (1 cigarette = 1 hour vasoconstriction)
Drug Therapy
- Hemorheologic agent
- Pentoxifylline (Trental):  flexibility of RBCs;  blood
viscosity by inhibiting platelet aggregation &  fibrinogen
thus increasing blood flow to the extremities
- Antiplatelet agents – ASA
- Percutaneous Transluminal Angioplasty (PTA)
- Invasive procedure; arteries are dilated with a balloon
catheter advanced through a cannula, which is inserted
into or above an occluded or stenosed artery
- Stents (wirelike devices) may be used along with the PTA
to help keep the vessel open
Laser-Assisted Angioplasty
- Invasive procedure; laser probe is advanced through a
cannula similar to that used for PTA
- Reserved for clients with smaller occlusions in the distal
superficial femoral, proximal popliteal & common iliac
arteries
- Heat from the laser vaporizes the arteriosclerotic plaque
to open the occluded or stenosed artery
- Surgical Management
- Arterial revascularization – most commonly performed
procedure that  arterial blood flow in an affected limb
- Bypass procedures; grafts preferred are saphenous vein,
cephalic or basilic arm veins, synthetic materials such as
polytetrafluoroethylene, Gore-Tex & Dacron
Interventions
Buerger’s Disease
- “Thromboangitis obliterans”
- Cause: unknown
- An occlusive disease limited to the medium & small
arteries & veins; distal upper & lower limbs are the most
frequently affected
J.A.K.E 53 of 57
- Identified in young adult men who smoke; cessation of
cigarette smoking usually arrests the disease process, but
persistence in smoking causes occlusion in the most
proximal vessels
Assessment
• 1st clinical manifestation: claudication of the arch of the
foot
• Increased sensitivity to cold, coldness & numbness
• Diminished pulses
• Diagnosis of Buerger’s disease is commonly based on a
physical finding of Peripheral ischemia leading to
ulceration, gangrene
Interventions
• Complete abstinence from tobacco in all forms
• Avoid to extreme cold & prolonged exposure to cold to
prevent vasoconstriction
• Treatment: similar to that for PAD
Raynaud’s Disease
- Caused by vasospasm of the arterioles and arteries of the
upper & lower extremities
- Usually occurs in people older than 30 years of age; but
can occur between the ages of 17 & 50 years of age; more
common in women
- Etiology: unknown
Assessment
• As a result of vasospasm, the cutaneous vessels are
constricted & blanching of the extremities occurs followed
by cyanosis
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
• Numbness, coldness, pain swelling, ulcers may also be
present
Management
• Treatment involves relieving or preventing the
vasoconstriction by drug therapy; help relieve symptoms
but they can cause uncomfortable side effects such as
facial flushing, headaches, hypotension, & dizziness
• For severe symptoms not relieved by drug: Lumbar
sympathectomy is performed
• Health teaching & education
Venous Thromboembolism
- Thrombus – a blood clot usually as a result of:
• Virchow’s triad
o endothelial injury
o venous stasis
o Hypercoagulability
Embolus
- a blood clot/ air/ fat that has move from its place of origin
that can obstruct the circulation in a blood vessel
Thrombophlebitis
- a thrombus that is associated with inflammation
Phlebothrombosis
- a thrombus without inflammation
Deep Vein Thrombophlebitis/ Thrombosis (DVT)
- Affects the deep vein of the lower extremities which
presents a greater risk for pulmonary embolism
- Etiology: highest incidence of clot formation occurs in
clients who have
• undergone hip surgery, total knee replacement,
• open prostate surgery, pregnancy
• ulcerative colitis, heart failure, immobility
• invasive procedures such as IV therapy
• SLE, polycythemia vera, oral contraceptives
• trauma, adenocarcinoma of the visceral organs
Assessment Findings
- Classic S/Sx: Calf or groin tenderness & pain & sudden
onset of unilateral swelling of the leg
- Checking of Homan’s sign is not advised!!! (pain in the calf
on dorsiflexion of the foot) because only 10% of clients
appears to be positive from this test
- Localized edema in one extremity may suggest
thrombophlebitis
J.A.K.E 54 of 57
- contrast venography (GOLD STANDARD), duplex
ultrasonography, Doppler flow studies, impedance
plethysmography, MRI
Management
- Focus of treatment: prevent complications such as
pulmonary emboli, prevent further thrombus formation &
prevent an increase in size of the thrombus
- Rest – supportive therapy; bed rest & elevation of the
extremity: DO NOT MASSAGE THE AFFECTED
EXTREMITY!!!
• Drug therapy – DOC: anticoagulant
- Unfractionated Heparin Therapy
- prevent formation of other clots & prevent enlargement of
the existing clot
- discontinued if there is severe heparin-induced
thrombocytopenia & thrombosis (due to platelet
aggregation)
- SE: Bleeding
- Antidote: Protamine sulfate
- Warfarin Therapy
o Works in the liver to inhibit synthesis of the four
vitamin K-dependent clotting factors
o Takes 3-4 days before it can exert therapeutic
anticoagulation
- Thrombolytic Therapy
o recombinant tissue plasminogen activator, Alteplase,
Reteplase
o effective in dissolving clots or preventing new clots
o serious complication: intracerebral bleeding
Health Teaching
• Avoid & stop smoking!!!
• Avoid the use of oral contraceptives to  the risk of
recurrence
• Usually, clients are discharged on a regimen of warfarin or
heparin so instruct clients & their families to avoid
potentially traumatic situations (contact sports)
• Watch out for S/Sx of bleeding
Varicose Veins (Varicosities)
- Dilated tortuous veins
- Commonly affected:
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

o
saphenous leg veins (lack support from surrounding • Exercise (walking, swimming)
muscles) • Losing weight
- also occurs in: • Wearing elastic support stockings
• Rectum – Hemorrhoids • Avoidance of prolonged sitting & standing
• Esophagus – Esophageal varices • Severe or multiple varicose veins
• Surgery
• Vein ligation
• Veins are tied off above & below the area of incompetent
valves, but the dysfunctional vein remains
• Vein stripping
• Ligated veins are severed & removed
Nursing Management
• Assessment: skin, distal circulation, peripheral edema
- Postoperative: nurse monitors for swelling in the
operative leg(s) & its effect on circulation
- Nurse can removes & rewrap the roller bandage to
facilitate blood flow
- Nurse inspects the dressing for signs of active
Pathophysiology and Etiology bleeding
- Familial tendency - Immediate post operative period: nurse elevates the
- Incompetent valves (early adulthood) foot of the bed to aid venous circulation to the heart &
- Anything that constricts or interferes with venous return reminds the client to alternately contract & relax the
(venous congestion or pooling) lower leg muscles
- Prolonged standing, obesity, pregnancy, abdominal
tumor Disseminated intravascular coagulation (DIC)
- Thrombophlebitis (may damage the valves) - Is a coagulation disorder that prompts overstimulation of
the normal clotting cascade and results in simultaneous
thrombosis and hemorrhage.
- The formation of microclots affects tissue perfusion in the
major organs, causing hypoxia, ischemia, and tissue
damage.
- Coagulation occurs in two different pathways: intrinsic
and extrinsic.
- Responsible for the formation of fibrin clots and blood
clotting, which maintains homeostasis.
- Intrinsic pathway – endothelial cell damage commonly
occurs because of sepsis or infection.
- Extrinsic pathway – Is initiated by tissue injury such as
from malignancy, trauma, or obstetrical complications.
Assessment Findings
- Dic may present as an acute or chronic condition.
• Legs feel heavy & tired particularly after prolonged
standing (patient will say that activity or elevation of the Signs and Symptoms of Excessive Blood Clotting
legs relieves the discomfort) - blood clots form throughout the body's small blood
• Leg veins look distended & tortuous seen under the skin vessels
as dark blue or purple, snakelike elevations • Chest pain and shortness of breath if blood clots form
• Feet, ankles, legs may appear swollen in the blood vessels in your lungs and heart.
Diagnostic Findings • Pain, redness, warmth, and swelling in the lower leg if
- Brodie-Trendelenburg test blood clots form in the deep veins of your leg.
- client lie flat & elevates the affected leg to empty veins, • Headaches, speech changes, paralysis (an inability to
tourniquet is then applied to the upper thigh, & the client move), dizziness, and trouble speaking and
is ask to stand understanding if blood clots form in the blood vessels
- if blood flows from upper part of the leg into the in your brain. These signs and symptoms may indicate
superficial veins a stroke.
- Incompetent valves • Heart attack and lung and kidney problems if blood
o Ultrasonography clots lodge in your heart, lungs, or kidneys. These
o Venography organs may even begin to fail.
Medical Management
• Mild varicose veins

J.A.K.E 55 of 57
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022
Signs and Symptoms of Bleeding
Internal Bleeding
- can occur in your body's organs, such as the kidneys,
intestines, and brain. This bleeding can be life threatening
• Blood in your urine from bleeding in your kidneys or
bladder.
• Blood in your stools from bleeding in your intestines
or stomach. Blood in your stools can appear red or as
a dark, tarry color. (Taking iron supplements also can
cause dark, tarry stools.)
• Headaches, double vision, seizures, and other
symptoms from bleeding in your brain.
External Bleeding
- occur underneath or from the skin, such as at the site of
cuts or an intravenous (IV) needle.
- External bleeding also can occur from the mucosa. (The
mucosa is the tissue that lines some organs and body
cavities, such as your nose and mouth.)
- External bleeding may cause purpura (PURR-purr-ah) or
petechiae (peh-TEE-key-ay).
- Purpura are purple, brown, and red bruises. This bruising
may happen easily and often. Petechiae are small red or
purple dots on your skin.
Assessment and Diagnostic Findings
- Clinically, the diagnosis of DIC is often established by a
drop in platelet count, an increase in PT and activated
partial thromboplastin time (aPTT), an elevation in fibrin
degradation products, and measurement of one or more
clotting factors and inhibitors (eg, antithrombin [AT]).
- The International Society on Thrombosis and Haemostasis
has developed a highly sensitive and specific scoring
system using the platelet count, fibrin degradation
products, PT, and fibrinogen level to diagnose DIC. This
system is also useful in predicting the severity of the
disease and subsequent mortality.
Medical Management
- correct the secondary effects of tissue ischemia by
improving oxygenation, replacing fluids, correcting
electrolyte imbalances, and administering vasopressor
medications.
- If serious hemorrhage occurs, the depleted coagulation
factors and platelets may be replaced (cryoprecipitate to
replace fibrinogen and factors V and VII; fresh-frozen
plasma to replace other coagulation factors).
- A heparin infusion, which is a controversial management
method, may be used to interrupt the thrombosis process.
Other therapies include recombinant activated protein C
and AT infusions.
Nursing Management Maintaining Hemodynamic Status
- Avoid procedures and activities that can increase
intracranial pressure, such as coughing and straining.
- Closely monitor vital signs, including neurologic checks,
and assess for the amount of external bleeding.
- Avoid medications that interfere with platelet function, if
possible (eg, beta-lactam antibiotics, acetylsalicylic acid,
nonsteroidal anti-inflammatory drugs).
- Avoid rectal probes and rectal or intramuscular injection
medications.
J.A.K.E 56 of 57
- Use low pressure with any suctioning.
- Administer oral hygiene carefully: use sponge-tipped
swabs, salt or soda mouth rinses; avoid lemon-glycerine
swabs, hydrogen peroxide, commercial mouthwashes.
- Avoid dislodging any clots, including those around IV sites,
injection sites, and so forth.
Maintaining Skin Integrity
• Assess skin, with particular attention to bony
prominences and skin folds.
• Reposition carefully; use pressure-reducing mattress and
lamb’s wool between digits and around ears and soft
absorbent material in skin folds, as needed.
• Perform skin care every 2 hours; administer oral hygiene
carefully.
• Use prolonged pressure (5 minutes minimum) after
essential injections.
Monitoring for Imbalanced Fluid Volume
• Auscultate breath sounds every 2 to 4 hours.
• Monitor extent of edema.
• Monitor volume of IV medications and blood products;
decrease volume of IV medications if possible.
• Administer diuretics as prescribed.
• Assessing for Ineffective Tissue Perfusion Related to
Microthrombi
• Assess neurologic, pulmonary, and skin systems.
• Monitor response to heparin therapy; monitor fibrinogen
levels.
• Assess extent of bleeding.
• Stop epsilon-aminocaproic acid if symptoms of
thrombosis occur.
• Reducing Fear and Anxiety
• Identify previous coping mechanisms, if possible;
encourage patient to use them as appropriate.
• Explain all procedures and rationale in terms that the
patient and family can understand.
• Assist family in supporting patient.
• Use services from behavioral medicine and clergy, if
desired.
Idiopathic thrombocytopenic purpura (ITP)
- is a disease affecting all ages but is more common in
children and young women.
- Although the precise cause remains unknown, viral
infection sometimes precedes the disease in children.
- Other conditions (eg, systemic lupus erythematosus,
pregnancy) or medications (eg, sulfa drugs) can also
produce ITP. In patients with ITP, antiplatelet
autoantibodies
- that bind to the platelets are found in the blood. When the
platelets are bound by the antibodies, the
reticuloendothelial system (RES) or tissue macrophage
system ingests the platelets, destroying them.
- The body attempts to compensate for this destruction by
increasing platelet production within the marrow. There
are two forms: acute (primarily in children) and chronic.
 NCMB 312 LECTURE: BSN 3RD YEAR 1ST SEMESTER PRELIM 2022

Clinical Manifestations • Provide information about medications (tapering schedule,

- Many patients have no symptoms. if relevant), frequency of platelet count monitoring, and
- Petechiae and easy bruising (dry purpura). medications to avoid.
- Heavy menses and mucosal bleeding (wet purpura; high • To minimize bleeding, instruct patient to avoid all agents
risk of intracranial bleeding). that interfere with platelet function. Avoid administering
- Platelet count generally below 20,000/mm3. medications by injection or rectal route; rectal
- Acute form self-limiting, possibly with spontaneous temperature measurements should not be performed.
remissions. • Instruct patient to avoid constipation, the Valsalva
Assessment and Diagnostic Findings maneuver, and tooth flossing.
- Usually the diagnosis is based on the decreased platelet • Encourage patient to use electric razor for shaving and
count and survival time and increased bleeding time and softbristled toothbrushes instead of stiff- bristled brushes.
ruling out other causes of thrombocytopenia. • Advise patient to refrain from vigorous sexual intercourse
- Key diagnostic procedures include platelet count, when platelet count is less than 10,000/mm3.
complete blood cell count, and bone marrow aspiration, • Monitor for complications, including osteoporosis,
which shows an increase in megakaryocytes (platelet proximal muscle wasting, cataract formation, and dental
precursors). caries.
- Many patients are infected with Helicobacter pylori. To
date, effectiveness of H. pylori treatment in relation to
management of ITP is unknown. GOOD LUCKK!! KAKAYANIN NATIN TOOO GUYS
Medical Management SENDING HUGS TO ALL
- Primary goal of treatment is a safe platelet count.
Splenectomy is sometimes performed (thrombocytopenia
may return months or years later).
Pharmacologic Therapy
- Immunosuppressive medications, such as corticosteroids,
are the treatment of choice.
- The bone mineral density of patients receiving chronic
corticosteroid therapy needs to be monitored. These
patients may benefit from calcium and vitamin D
supplementation or bisphosphonate therapy to prevent
significant bone disease.
• Intravenous gamma globulin (very expensive) and the
chemotherapy agent vincristine are also effective.
• Another approach involves using anti-D (WinRho) for
patients who are Rh(D) positive.
• Thrombopoiesis-stimulating protein AMG 531 has
been successfully used to treat patients with chronic
ITP.
• Epsilon aminocaproic acid (EACA; Amicar) may be
useful for patients with significant mucosal bleeding
who are refractory to other treatment modalities.
• Platelet infusions are avoided except to stop
catastrophic bleeding.
Nursing Management
• Assess patient’s lifestyle to determine the risk of bleeding
from activity.
• Obtain history of medication use, including over-the
counter medications, herbs, and nutritional supplements;
recent viral illness; or complaints of headache or visual
disturbances (intracranial bleed). Be alert for sulfa-
containing medications and medications that alter
platelet function (eg, aspirin or other nonsteroidal anti-
inflammatory drugs [NSAIDs]). Physical assessment
should include a thorough search for signs of bleeding,
neurologic assessment, and vital sign measurement.
• Teach patient to recognize exacerbations of disease
(petechiae, ecchymoses); how to contact health care
personnel; and the names of medications that induce ITP.

J.A.K.E 57 of 57