Icu Emergency NSG

NCM 118: Nursing Care of Clients with Life Threatening Conditions, Acute Multiorgan Problems, High Acuity &
Emergency Situations, Acute & Chronic

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NCM 118: NURSING CARE OF CLIENTS
WITH LIFE THREATENING
CONDITIONS, ACUTE ILL/MULTI
ORGAN PROBLEMS, HIGH ACUITY AND
EMERGENCY NURSING COURSE
BACKGROUND: This course deals with concepts,
principles, theories and techniques of nursing care of sick
adult clients with life-threatening conditions, acutely
ill/multi-organ problems, high acuity and emergency
situation toward health promotion, disease prevention,
restoration and maintenance, and rehabilitation.
OBJECTIVE: The learned are expected to provide safe
and appropriate and holistic nursing care to groups of
clients with health problems and special needs utilizing the
nursing process
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NCM 118: Nursing Care of Clients with Life Threatening Conditions, Acute Multiorgan Problems, High Acuity & Emergency Situations, Acute & Chronic
Chapter I
INTRODUCTION
CRITICAL CARE NURSING CRITICAL NURSING SHOULD BE:
● Is the specialty within nursing that deals ● Patient-centered
specifically with human responses to ● Safe
life-threatening problems. These problems ● Effective
deal dynamically with human responses to ● Efficient
actual or potential life-threatening illnesses The nursing interventions are expected to be
● Is based on a scientific body of knowledge delivered in a timely and equitable manner
and incorporates the professional
competencies specific to critical care nursing CATEGORIES OF CRITICAL CARE
practice and is focused on restorative, UNIT
curative, rehabilitative, maintainable, or ● The critical care unit can be categorized
palliative care, based on identified patient’s according to patient’s age group or medical
need. specialties
● Professional regulation Commission - Board A. AGE GROUP
of Nursing (PRC-BON) is committed to 1. Neonatal: 0-28 days
provide need-driven, effective and efficient 2. Pediatric: 18 and below
specialty nursing care services of high 3. Adult: 18+
standard and at international level within the B. SPECIALTY
obtainable resources. In the existing environment, the majority of
● The Critical Care Nurses Association of the the critical care units in the Philippines
Philippines, Inc. (CCNAPI) provide service for patients or various
specialties. They are labeled as general ICUs.
PRC-BON WORKING GROUP In certain hospitals, the critical care
DEVELOPING THE NURSING unit/service is dedicated to the ff specific
SPECIALTY FRAMEWORK (1996) groups:
● Take on the task of setting the process-based
1. Medical
framework and guidelines for specialty
2. Surgical
nursing services
3. Cardio-Thoracic
● WORKING GROUP MEMBERS:
4. Cardiac
○ Clinical Nurse Practitioners
5. Respiratory
○ Nurse Educators
6. Neurosurgical
○ Nurse Managers
7. Trauma
GOALS OF CRITICAL CARE

NURSING Levels of care provision
● To promote optimal delivery of safe and ● Guidelines on Critical Care Personnel and
quality care to the critically ill patients and Services published in 2003 by the Critical
their families by providing highly Care Medicine
individualized care so that the physiological ● Stratified by the Philippine Society of
dysfunction as well as the psychological Critical Care Medicine (PSCCM), Society of
stress in the ICU are under control Pediatric Critical Care Medicine (SPCCM),
● To use relevant and up-to-date knowledge, and Critical Care Nurses of the Philippines,
caring attitude and clinical skills, supported Inc. (CCNAPI)
by appropriate technology for the prevention, ● Apply the 3 levels of classification
early detection and treatment of accordingly
complications to facilitate recovery ● Capable of providing immediate
● To provide palliative care to the critically ill resuscitation for the critically-ill and
patients in situations where their health short-term cardio-respiratory support
status is progressing to unavoidable death, because patients are at risk of deterioration
and to help the patients and families go
through their painful sufferings.
2
LEVEL 1 ●
A nurse in-charge and the majority of the
● Has a major role in monitoring and nursing staff have intensive care certification
preventing complications in “at risk” medical and;
and surgical patients ● Nurse patient ratio is at least 1:1 for all
● Must be capable of providing mechanical patients at all times
ventilation and simple invasive ** TOP OF THE LINE (50/50)
cardiovascular monitoring
● Has a formal organization of medical staff
and at least one registered nurse SYSTEM OPERATION OF
● A certain number of nurses including the CRITICAL CARE UNITS
nurse in-charge of the unit should possess
A. OPEN SYSTEM
post-registration qualification in critical care
● The admitting and other attending
or in related clinical specialties and;
doctors dictate management, change
● Nurse patient ratio is 1:1 for all critically ill
management, or perform procedures
patients
without consultation or
** LESS CRITICAL
communication with a critical care
** SWAN-GANZ (?)
specialist
● A critical care specialist may be
LEVEL 2 available for advice or be consulted
● Should be capable of providing a high
to provide interventional skills
standard of general critical care for patients
(optional)
who are stepping down from higher levels of
● No designated person who assumes
care or requiring single organ
the “gatekeeper” role.
support/support postoperatively
B. CLOSED SYSTEM
● Capable of providing sustainable support for
● Management is coordinated by a
mechanical ventilation, renal replacement
qualified critical care specialist
therapy, invasive hemodynamic monitoring
and equipment for critically ill patients of ● The critical/intensive care specialist
various specialties such as medicine, surgery, has clinical and administrative
trauma, neurosurgery, and vascular surgery responsibility
● Has a designated medical director with ● There is a multidisciplinary team of
appropriate intensive care qualification and a specially trained critical care staff.
duty specialist available exclusively to the ● The “intensivist” is the final
unit at all times common pathway for all medical
● The nurse in-charge and a significant number decision-making including decision
of nursing staff in the unit have critical care to admit or discharge patients
certification and; irrespective of the ICU “system”
operations, i.e, open system or close
● Nurse patient ratio is 1:1 for all critically ill
system, or a mixture of the two,
patients
** ADVANCED MEDICAL CONDITIONS ● There should be a designated group
of registered nurses under unique
management to provide highly
LEVEL 3
● A tertiary referral unit, capable of managing specialized care to the critically ill
all aspects of critical care medicine (this does patients. The nurses in-charge and
not only include the management of patients the majority of nursing staff in each
requiring advanced respiratory support but unit should have the relevant
also patients with multi-organ failure qualification in the specialty of the
● Has a medical director with specialist respective unit.
critical/intensive care qualifications and a
duty specialist available exclusively to the
unit and medical staff with an appropriate
experience present in the unit at all times
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SCOPE OF CRITICAL CARE LEGAL AND ETHICAL ISSUES IN
NURSING CRITICAL CARE NURSING
● Is defined by the dynamic interaction of the ETHICAL PRINCIPLES
critically ill patient/family,the critical care
● Autonomy
nurse and the critical care environment to
● Beneficence
bring about optical patient outcomes through
● Non-maleficence
nursing proficient in an environment
● Justice
conducive to the provision of the highly
● Veracity
specialized care.
● Fidelity
DYNAMIC INTERACTIONS LEGAL AND ETHICAL ISSUES IN

IT REQUIRES: INFORMED CONSENT
● CONSTANT INTENSIVE ASSESSMENT
● Based on the principle of autonomy
● TIMELY CRITICAL CARE INTERVENTION
● CONTINUOUS EVALUATION OF MANAGER
● Connotes voluntary agreement, permission
TROUGH MULTIDISCIPLINARY EFFORTS or compliance
● PALLIATIVE CARE SHOULD BE ● Permission of the pt to perform an act to
INSTITUTED his/her body for purposes of diagnostic
treatment
- Neurologic assessment (Glasgow Coma ● Issues arise due to the presence of acute
Scale) illness or life-threatening conditions that
- V/S Monitoring alter capabilities to make medical decisions.
- Suctioning, cleaning, monitoring, wound
FOUR ELEMENTS OF CONSENT
care, ngt feeding
● Voluntariness
● Capacity
CRITICAL CARE NURSES ● Knowledge
● Registered nurses, trained and qualified to ● Decision-making
practice critical care nursing.
TYPES OF CONSENT
● Possess the standard critical care nursing
● Implied Consent: the agreement given by a
competencies in assuming specialized and
person’s action (even just a gesture) or
expanded roles in caring for the critically ill
inaction, or can be inferred from certain
patients and their family.
circumstances by any reasonable person
● Is personally responsible and committed to
● Expressed consent (verbal or written):
continuous learning and updating of his/her
Permission for something that is given
knowledge and skills.
specifically, either verbally or in writing.
● Carry out intervention and collaborates
patient care activities to address
life-threatening situations that will meet the GUIDELINES
patient's biological psychological,cultural ● Given Voluntarily
and spiritual needs. ● If pt is not mentally capable to give consent
it can be obtained from a surrogate or legal
next of kin
CRITICAL CARE ENVIRONMENT ● Given by a person of sound mind and 18
● Constantly supports the interactions between
years and above
the critically ill patients, their family and the
● Requires a disclosure of basic info
critical care nurses to achieve desired patient
considered necessary for decision making
outcomes.
○ Principle of veracity
● It entails readily available and accessible
● Patients should be free from pain and
emergency equipment, sufficient supplies
depression during informed consent
and effective support system to ensure
quality patient care as well as staff safety and INVALIDATION OF CONSENT
productivity. ● Consent from minor
● Under fear, fraud or misrepresentation
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● Patient is not fit to consent CARDIOPULMONARY
● Language barrier RESUSCITATION DECISIONS
● Under intoxication, sedation, or ● CPR: used to reverse the clinical signs of
semi-conscious death
● Inadequate information on possible risks or ● AHA 2000 - Healthcare providers may stop
treatment CPR when 30 mins (Adult/Child) or 15 mins
(Newborn) of attempt has not restored any
MEDICO-LEGAL CASE signs of life
● Presence of “Do not Resuscitate” order
● Any case where in the discipline of medicine
● Advanced directives
comes to help the legal fraternity in its
● Financial Status is the deciding factor
● Autonomy of patient is a weak concept
CASES CONSIDERED AS
MEDICO-LEGAL CASES
● Injuries WITHHOLDING OR WITHDRAWAL
● Burn OF LIFE SUPPORT
● Withholding is to never initiating a
● Assault
treatment
● Intoxication or poisoning
● Withdrawal is stopping a treatment that has
● Cases Referred from court
been started
● Suspected or evident abortion
● Ending treatment due to sound moral reason
● Not natural caused comatose
does not violate professional obligations
● Dead on Arrival or Unexpected Death
● Needs careful decisions between health care
● Self-inflicted injuries or attempted suicinde
professionals and the patient/family
It is important to notify the police, preservation and
● Clarify technical terms, weigh treatment
collection of samples and dying declaration if there
options, consider the values and wishes,
is any.
context of prognosis and treatment
● Final decision should reflect the patient’s
MEDICO-LEGAL DOCUMENTATION wishes.
● A legal necessity
● Should be correct, clear, chronological and
contemporaneous
CONSIDERATIONS
● Patient’s glasgow coma scale of 5 and below,
● Consent before procedure is mandatory, legal
absence of pupil and motor response for 3
and moral requirement (3YRS)
days after arrest
● 72 hours. Procedure of record upon legal
● Communication
request
● Provide consistent and honest information
● All medical information and documentation
● Discuss properly the pros and cons, burden
should be very specific.
vs benefits
RESTRAINTS ● Recognize family anticipatory grieving and
● Chemical or Physical provide support.
● Any interventions that limits a person to
move
● Can cause trauma, depress, muscular
Organ donation
● Potential donor may agree to donate an organ
atrophy, nosocomial infection, anger,
by signing a donor card but a final consent
contractures, continence if limps,
for donation by the patient or legal surrogate
constipation, increase agitation and decline
should be signed before the organ
functional and cognitive state because it
transplantation team harvest the organ
limits autonomy
● Everyone has the right to donate an organ
● Used only when all managing the problem
● Ethical principles involved are respect for
method has failed and employed with caution
person, autonomy, beneficence,
and least restrictive method as possible.
non-maleficence, justice, and fidelity
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● Nurses acts as advocate to donors and
recipients and must be a skilled assessor for
possible organ donors
● Cost vs outcome
FIVE MOST CONCERNED ETHICAL

ISSUES
● Protection of patients rights and human
dignity
● Risk provision of care (aids, hepa b etc)
● Respecting informed consent to treatment
● Staffing patterns (limit nursing care)
● Use or nin-use of restraints
WAYS TO RESOLVE ETHICAL

ISSUES
● Gather relevant fact and identify the decision
maker and stakeholder
● Identify ethical problems using ethical
standards, guidance and resources
● Analyze problems using ethical standards,
guidance and resources
● Guided deliberation and justification of
choice/s
● Evaluation and Reflection.
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Chapter II
ALTERED VENTILATORY FUNCTION
● A sputum test, using a sample of sputums
PNEUMONIA (spit) or mucus from cough, may be used to
INTRODUCTION: find out what germs are causing your
● Inflammation of the lung parenchyma pneumonia.
● Caused by microorganisms which enter the Signs/symptoms:
lower respiratory system and cause infection ● Shortness of breath
○ Bacteria ● Increase breathing rate
○ Mycobacteria ● Heavy sputum
○ Mycoplasma ● Fever and chills
○ Fungi ● Chest pain that is worse when you breathe or
○ Parasites cough
○ Viruses ● Fatigue and muscle aches
● Infection or inflammation that develops after ● Nausea, vomiting or diarrhea
someone inhales airborne pathogens or ● Cough, particularly cough productive of
aspirates pathogens in secretions from the sputum
upper respiratory or gastrointestinal tract
● It can cause breathing problems and other
PATHOPHYSIOLOGY
● Pneumonia arises from flora present in
symptoms. In community acquired
patients whose resistance has been altered or
pneumonia can get infected in a community
from aspiration of flora present in the
setting. It doesn't happen in a
oropharynx
○ Hospital
● An inflammatory reaction may occur in the
○ Nursing home
alveoli, producing exudates that interfere
○ Health center
COMMUNITY ACQUIRED PNEUMONIA
with the diffusion of oxygen and carbon
Pneumonia is an acute infection of the dioxide.
pulmonary parenchyma with an intense infiltration of ● White blood cells also migrate into the
neutrophils in and around the alveoli and the terminal alveoli and fill normally air filled spaces.
bronchioles. The affected bronchopulmonary ● Due to secretions and mucosal edema, there
segment or the entire lobe may be consolidated by are areas of the lung that are not adequately
the resulting inflammation. ventilated and cause partial occlusion of the
VENTILATOR ACQUIRED alveoli, with a resultant decrease in alveolar
RESPI-PANDEMIC oxygen tension.
VAP is pneumonia that develops 48 hours or ● Hypoventilation may follow causing
longer after mechanical ventilation is given by means ventilation perfusion mismatch.
of an endotracheal tube or tracheostomy. Intubation ● Venous blood entering the pulmonary
compromises the integrity of the oropharynx and circulation passes through the under
trachea and allows oral gastric secretions to enter the ventilated areas, and travels to the left side of
lower airways. the heart poorly oxygenated
● The mixing of oxygenated and poorly
Diagnostics:
oxygenated blood can result in arterial
● Physical examination may reveal dullness to
hypoxemia.
percussion of the chest. crackles or rales on
Auscultation, Bronchial breath sounds, TREATMENT AND MANAGEMENT
Tactile Fremitus, EgophonyAuscultation, ● The treatment may vary based on symptoms
Bronchial breath sounds Tactile Fremitus and type of pneumonia. If the patient has
Egophony. severe pneumonia, they will need to stay in
● A chest x-ray looks for inflammation in your the hospital for some time.
lungs. A chest x-ray is often used to diagnose ● Antibiotics are the key to treatment for
pneumonia. bacterial CAP. The health provider will
● Blood test such as a complete blood count likely start patient on this medicine even
( CBC) see whether your immune system is before identifying the type of bacteria
fighting an infection.
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● Bacteria pneumonia: Patients with mild ●
Exposure to fumes from burning fuel
pneumonia who are otherwise healthy are ●
Genetics
treated with oral macrolide antibiotics. ●
Occupational exposure to dusts and
chemicals
MANAGEMENT DIAGNOSTIC CRITERIA: Cough of 3 months for 2
● Dont smoke consecutive years
● Practice good hygine Emphysema
● Stay rested and fit ●
Complex lung disease characterized by
● Wearing surgical masks by the sick may also destruction of the alveoli, enlargement of
prevent illness distal airspaces, and a breakdown of alveolar
● Appropriate treating underlying illnesses walls. There is a slowly progressive
● Get a pneumonia vaccination deterioration of lung function for many years
before the development of illness.
NURSING RESPONSIBILITIES Types of Emphysema :
● Assess the rate, rhythm, and depth of
● Panlobular Emphysema: destruction of
respiration, chest movement, and use of
accessory, chest movement, and use of respiratory bronchiole, alveolar duct and
accessory muscles. alveolus.
Tachypnea, shallow respirations and ○ All air spaces within the lobule are
asymmetric chest movement are frequently essentially enlarged, but there is little
present because of the discomfort of moving inflammatory disease
the chest wall and fluid in the lung due to a ○ Hyperinflated chest, marked
compensatory response to airway
dyspnea on exertion, and weight
obstruction.
● Assess cough effectiveness and productivity loss occurs
coughing is the most effective way to ○ Expiration becomes active and
remove secretions. Pneumonia may cause requires muscular effort
thick and tenacious secretions in patients. ● Centrilobular (Centroacinar) Emphysema:
● Auscultate lung fields, noting areas of pathologic changes take place mainly in the
decreased airflow and adventitious breath center of the secondary lobule, preserving
sounds; crackles, wheezes.
Decreased airflow occurs in areas with the peripheral portions of the acinus
consolidated fluid. ○ There is a derangement of V/Q
● Observe the sputum color, viscosity, and ratios, producing chronic
odor. Report changes. hypoxemia, hypercapnia,
Changes in sputum characteristics may polycythemia, and episodes of
indicate infection. Sputum that is right-sided HF
discolored,tenacious, or has an odor may
○ Leads to central cyanosis and
increase airway resistance and warrant
further intervention. respiratory failure
● Assess the patient's hydration status. ○ Peripheral edema also manifests
● Airway clearance is hindered by inadequate S/sx of emphysema:
hydration and the thickening of secretions. ● Dyspnea, decreased exercise tolerance
● Minimal cough, except with respiratory
CHRONIC OBSTRUCTIVE infection
PULMONARY DISEASE ● Sputum expectoration
Introduction: ● Barrel chest
● Airflow limitation that is not fully reversible,
progressive and is normally associated with CHRONIC BRONCHITIS
an inflammatory response of the lungs due to Chronic inflammation of the lower respiratory tract
irritants. characterized by excessive mucous secretion,
● One of the major causes of chronic morbidity cough, and dyspnea on exertion associated with
and mortality worldwide recurring infections of the lower respiratory tract.
Risk Factors S/Sx of Chronic Bronchitis:
● Tobacco Smoking: most common ● Usually insidious, developing over a period
● Asthma of years
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● Presence of a productive cough lasting at diaphragmatic breathing with activities such
least 3 mos a year for 2 successive years as walking, bathing, bending, or climbing
● Production of thick, gelatinous sputum; stairs
● Provide small frequent meals and offer liquid
greater amounts produced during
nutritional
superimposed infections ● Administer low flow of oxygen (1-2L/min)
● Wheezing ● Administer bronchodilator as prescribed
● Dyspnea ● Adequately hydrate the patient
GOLD SYSTEM FOR GRADING COPD ● Instruct the patient to avoid bronchial
● Allows the doctors to better match pts with irritants
right treatments ● If indicated, perform CPT in the morning
and at night as prescribed
● Encourage alternating activity with rest
1. Symptom Grades periods
- CAT (COPD Assessment Test) ● Teach relaxation technique or provide a
- mMRC (Modified Medical relaxation tape for patient
Research) ● Enroll patient in pulmonary rehabilitation
2. Spirometry Grades program where available
- GOLD 1: Mild ● Assessing the patient
- GOLD 2: Moderate
ACUTE EXACERBATION OF COPD
- GOLD 3: Severe
●
Acute changes worsening in the pts
- GOLD 4: Very Severy respiratory symptoms beyond the normal
3. Exacerbation risk day-to-day variations.
- Time when COPD symptoms get so ● Cause: tracheobronchial infection and air
much worse that it need to make a pollution
change in medication which is Signs and symptoms:
termed as FLARE ● Dyspnea
- Flare ups are more likely if the ● Confusion
● Lethargy
spirometry result is Gold 3 and Gold
● Respiratory muscle fatigue
4 ● Persistent worsening hypoxemia
4. Other health problems ● Paradoxical chest wall movement
● Peripheral edema
DIAGNOSTIC PROCEDURE ● Worsening or new onset of central cyanosis
● Worse coughing
● ABG Levels
● Fever
● CXR: painless, non-invasive test; most
commonly preferred dx examination to
Management:
● Roflumilast (Daliresp)
produce images of heart, lungs, airways, ● Tx of an exacerbations require identification
blood vessels, etc. of primary cause and administering the
● Alpha-antitrypsin test: used to detect a specific treatment
deficiency of the AAT protein ● Bronchodilator: first line therapy
○ Normal range 100-200 mg/dL ● Corticosteroids, antibiotic agents, O2 therapy,
and intensive respiratory interventions
Management and Treatment: ● When a pt arrives in ED, the first line
● Smoke cessation treatments are:
● Bronchodilators ○ Supplemental O2
● Inhaled and systemic Corticosteroids ○ Short-acting inhaled bronchodilator
● Alpha 1 antitrypsin augmentation therapy ○ Oral or IV corticosteroids (in
addition to bronchodilators
● Antibiotics
○ Antibiotics
● Mucolytics ● Bullectomy
● Antitussive ● Lung Volume Reduction Surgery
● Vasodilators ● Lung transplantation
Nursing interventions: ● Pulmonary Rehabilitation
● O2 Therapy
● Pulmonary rehabilitation
● Pursed-lip breathing Nursing interventions
● Assessing the pt
● Instruct the patient to coordinate
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● Achieving Airway Clearance pressure
● Improving Breathing Patterns ● Assessing risk factor, skin care and
● Improving activity Intolerance protection
● Monitoring and Managing Potential ● Providing correct and appropriate nutrition
Complications therapy
ACUTE RESPIRATORY DISTRESS PNEUMOTHORAX

SYNDROME ● Defined as a collection of air outside the lung
iNTRODUCTION but within the pleural cavity
● Severe inflammatory process which causes ● Occurs when air accumulates between the
diffuse alveolar damage that results in parietal and visceral pleura inside the chest.
sudden and progressive pulmonary edema, The air accumulation can apply pressure on
increasing bilateral infiltrates on CXR, the lung and make it collapse
hypoxemia unresponsive to O2
● Air can enter the pleural space by two
supplementation regardless of the amount of
PEEP, and the absence of an elevated left mechanisms: trauma causing a
atrial pressure. communication through the chest wall; or
● Fluid build-up inside the tiny air sacs of the from the lung by rupture of visceral pleura.
lungs Types of pneumothorax:
● Life-threatening condition
● Traumatic Pneumothorax: can be the result
● Alveoli collapse d/t inflammatory infiltrate,
blood, fluid, and surfactant dysfunction of blunt, penetrating chest or abdominal
● Small airways are narrowed d/t interstitial trauma, or diaphragmatic tear.
fluid and bronchial obstruction. ○ Occurs when air escapes from a
● ↓ Lung compliance → ↓ fxnal residual laceration in the lung itself and
capacity and severe hypoxemia enters the pleural space or from a
● The blood returning to the lung for gas
wound in the chest wall.
exchange is pumped through the non
ventilated, non fxning areas of the lung, ○ May occur during invasive thoracic
causing shunting. procedures
○ Blood is interfacing with non ○ A traumatic pneumothorax resulting
functioning alveoli and gas exchange from major injury to the chest is
is markedly impaired, resulting in often accompanied by hemothorax.
severe, refractory hypoxemia. ○ Open Pneumothorax: one form of
DiagnosticS traumatic pneumothorax
● Blood test ■ Occurs when wound in the
● CXR
● Sputum Analysis chest wall is large enough to
● Heart test allow air to pass freely in
signs/symptoms and out of the thoracic
● SOB cavity with each attempted
● Low blood O2 respiration
● Crackles ■ Sucking sounds are
Management/tx produced because of the rush
Medical Management of air through the wound in
● Supplemental O2 the chest wall. (Sucking
● Mechanical Ventilator chest wounds)
● Sedation
■ Mediastinal flutter: shifting
● Prone positioning
● Sedation of structures/organs to the
● Paralysis uninjured side with each
● Nutritional support inspiration and in the
Medication opposite direction with
● Heparin expiration.
● Lasix ● Simple Pneumothorax: (spontaneous
● Antibiotics
Nursing intervention pneumothorax) occurs when air enters the
● Provide adequate oxygenation pleural space through a breach of either the
● Setting appropriate positive end-expiratory parietal or visceral pleura.
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○ Occurs as air enters the pleural space ○ Endobronchial obstruction
through the rupture of an air-filled ○ Trapped lung
bleb, blister, or a bronchopleural ○ Malpositioned chest tube
fistula. ● Re-expansion pulmonary edema: occurs
○ May be associated with diffuse when a chest tube is connected to (-) pressure
interstitial lung disease and severe after the lung has been collapsed for > 2
emphysema days.
● Tension Pneumothorax: occurs when air is Diagnostics:
drawn into the pleural space from a lacerated ● Physical exam
lung or through a small opening or wound in ● CXR
the chest wall. ● ABG
○ Can be a complication of other ● CT scan
pneumothorax. ● Electrocardiogram
○ Air that enters the chest cavity is
signs and symptoms
trapped and cannot be expelled.
“COLLAPSED”
○ With each breath, tension increases
● Chest pain (sharp and sudden and worst on
which causes the lung to collapse
inspiration); Cyanosis
and the heart, the great vessels, and
● Overt tachycardia and tachypnea
the trachea to shift toward the
● Low BP
unaffected side of the chest
● Low SpO2
(mediastinal shift).
● Absent lung sounds on affected side
○ Respiration and circulation are
● Pushing of trachea to unaffected side
compromised
(tension pneumothorax); mediastinal shift
● Atraumatic Pneumothorax: can happen if a
● Subcutaneous Emphysema (escaping CO2
pt has a lung disease (COPD), but can also
collecting in the skin… Crunchy bulges on
happen for no apparent reason
the skin), Sucking sound with open
○ Primary spontaneous pneumothorax
pneumothorax
(PSP): (spontaneous pneumothorax);
● Expansion of chest side and fall unequal
idiopathic
● Dyspnea
○ Secondary spontaneous
pneumothorax (SSP): Treatment/management
(non-spontaneous pneumothorax or ● Observation: if pneumothorax is minor, the
complicated pneumothorax) result of provider may watch for Signs of heart or
an underlying lung pathology breathing problems.
(COPD, Asthma, TB, CF, or ● Supplemental O2
Whooping Cough) ● Needle aspiration: use of syringe to remove
Diseases related to Pneumothorax some of the air in the pleural space
● Asthma ● Chest tube drainage:
● CF ● Chemical pleurodesis: prevent lungs from
● COPD collapsing
● Pneumocystis jiroveci pneumonia (PCP) Nursing responsibilities
Risk factors: ● Monitor breath sounds
● Men > Women ● Assess rise and fall of the chest, V/S
● 20-40 y/o usually tall & underweight ● Administer O2 as ordered
● Smoking ● Position the client in High Fowlers
● Recreational drug use or abuse ● Assist client with splinting painful are when
● Genetics
coughing, or during deep breathing
● Previous pneumothorax
● Monitor for subcutaneous emphysema
Complication ● Maintain chest tube drainage system if
● Air leaks
placed by physician
● Failure of the lungs to re-expand usually due
● Assess for air leaks in the system; keep it
to one of the ff:
secure
○ Persistent air leak
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● Troubleshoot if the drain comes out or the that compounds the V/Q imbalance
system breaks.
PULMONARY EMBOLISM signs and symptoms
- Sudden occlusion of the pulmonary artery ● Dyspnea: most frequent symptom
by a thrombus that originates in the ● Tachypnea
venous system (deep vein of the legs and ● Chest pain: pleuritic in origin
pelvic vein) or in the right side of the heart ● Tachycardia
(right atrium) ● Apprehension
- Obstruction of the pulmonary artery by a ● Cough
thrombus ● Anxiety
**DVT: thrombus formation in the deep veins, ● Fever
usually in the calf or thigh, but sometimes in the arm, ● Diaphoresis: Excessive Sweating
especially in pts with peripherally inserted central ● Hemoptysis
catheters. ● Syncope
- 95% of PE originates from DVT
Diagnostics
Common cause: Blood clot or thrombus other types ● Chest X-ray - show infiltrates, atelectasis,
of emboli: elevation of the diaphragm or pleural
● Air effusion.
● Fat ● ECG - shows sinus tachycardia,PR interval
● Amniotic fluid depression, and nonspecific T-wave changes
● Septic (from bacterial invasion of the ● ABGAnalysis - show hypoxemia and
thrombus hypocapnia (from tachypnea)
Associated with trauma, surgical, pregnancy, heart ● Ventilation-perfusion scan (V/Q scan) -
failure, age older than 50, and prolonged immobility. The perfusion portion may indicate areas of
diminished or absent blood flow. A
Risk factors ventilation scan may show whether there is a
Venous stasis ventilation abnormality present. If ventilation
● Prolonged immobilization perfusion mismatch, the probability of PE is
● A prolonged period of sitting /traveling high.
● Varicose vein ● Pulmonary Angiography - considered the
● Spinal cord injury gold standard for diagnosis of PE.
Venous Endothelial Disease ● D-dimer Assay - A blood test for the
● Thrombophlebitis clot-dissolving substance D dimer.
● Vascular Disease Treatment/management
● Foreign bodies PHARMACOLOGY
Hypercoagulability Anticoagulation: Prevention of clot formation
● Injury ● Heparin
● Tumor ● Warfarin sodium
● Increase platelet count Thrombolytics: dissolves clot
Certain Disease state ● Urokinase
● Heart Disease ● Streptokinase
● Trauma ● Alteplase
● DM ● Anistreplase
● COPD ● Reteplase
Other predisposing conditions SURGICAL
● Advanced age ● Percutaneous thrombectomy
● Pregnancy ● Pulmonary Embolectomy
● Obesity ● Transverse Catheter Embolectomy
● Constrictive clothing EMERGENCY MANAGEMENT
Pathophysiology ● Nasal oxygen is given immediately to relieve
When a thrombus completely or partially obstructs a hypoxemia respiratory distress and central
pulmonary artery or its branches, the alveolar dead cyanosis; severe hypoxemia may necessitate
space is increased. The area, although continuing to emergency endotracheal and mechanical
be ventilated, receives little or no blood flow. ventilatory support.
Therefore, gas exchange is impaired or absent the ● IV infusion lines are inserted to establish
clot and surrounding area that cause regional blood routes for medication of fluids that will be
vessels and bronchioles to constrict. The results in an needed.
increase in pulmonary vascular resistance a reaction ● For hypotension that does not resolve that
12
does not resolve with IV fluids, prompt Relieving Anxiety
initiation of vasopressor therapy is ● Encourages the stabilized pt to talk about any
recommended, with agents that may include fears or concerns related to this frightening
dopamine or norepinephrine.
episode, answers the patient’s and family’s
● Hemodynamic measurements and evaluation
for hypoxemia (pulse oximetry or arterial questions concisely and accurately, explains
blood gas or performed. If available, the therapy, and describes how to recognize
MDCTA will be performed. untoward effects early.
● The ECG is monitored continuously for Postoperative Care
dysrhythmia and right ventricular failure, ● Measure the pt’s pulmonary arterial pressure
which may occur suddenly . and urinary output and assess the insertion
● Blood is drawn for serum electrolytes.
site of the arterial catheter for hematoma
● If the patient has suffered massive embolism
and is hypotensive, an indwelling urinary formation
catheter is inserted to monitor urinary output. ● Maintaining the blood pressure at a level that
● Small doses of IV morphine or sedatives are supports perfusion of vital organs is crucial.
given to relieve patient anxiety, to alleviate
chest discomfort, to improve tolerance of the PULMONARY HYPERTENSION
endotracheal tube, and to ease adaptation to
the mechanical ventilation if necessary.
Introduction
~ characterized by elevated pulmonary arterial
MANAGEMENT pressure and secondary right ventricular failure. It
Oxygen therapy may be suspected in a patient with dyspnea with
● Correct the hypoxemia exertion without other clinical manifestation. Unlike
● Relieve the pulmonary vascular systemic blood pressure, pulmonary pressures cannot
vasoconstriction be measured indirectly. In the absence of these
● Reduce the PH measurements, clinical recognition becomes the only
Elastic Compression Stockings indicator of PH. However, PH is a condition that is
● Reduces venous stasis. often not clinically evident until late in its
Elevating the leg progression. Patients are classified by the world
● Increases venous flow. health organization ( WHO) into five groups based
upon the mechanism of PH.
NURSING RESPONSIBILITIES
Minimizing r the risk of PE ● Group 1: Pulmonary Arterial Hypertension
● Encourage ambulation and active and (PAH)
passive leg exercises to prevent venous stasis ● Group 2: PH due to left heart disease
in patient prescribed ● Group 3: PH due to chronic lung disease
● Instructs the patient to move the legs in a and/or hypoxemia
pumping exercise. ● Group 4: Chronic thromboembolic
● Advises the patient not to sit or lie in bed for pulmonary hypertension
prolonged periods, not to cross the legs and ● Group 5: PH with unclear multifactorial
not to wear constrictive cloth. mechanism
Preventing thrombus formation
● Conduct a careful assessment of the patient Pathophysiology
health history , family history and ● Conditions such as a collagen vascular
medication record. disease, congenital heart disease,
● Assess for the pain or discomfort in the anorexigens (Specific appetite depressant),
extremities and evaluate for warmth, redness chronic use of stimulants, portal
and inflammation. hypertension, and HIV infection increase the
Assessing the Potential PE risk of PH in susceptible patients.
● Assess pt’s signs every 2 hours during ● Vascular injury occurs with endothelial
thrombolytic infusion, while the patient dysfunction and vascular smooth muscle
remains on bed rest. dysfunction, which leads to disease
Managing Pain progression.
● Provide a semi-fowler’s position to pt ● Normally the pulmonary vascular bed can
● Continue to turn patients frequently and handle the blood volume delivered by the
reposition them to improve the V/Q in the right ventricle. It has a lot of resistance to
lungs blood flow and compensates for increased
● Administer opioid analgesic agents as blood volume by dilation of vessels in the
prescribed for severe pain pulmonary circulation.
● However if the pulmonary vascular bed is
13
destroyed or obstructed, as in PH, the ability ●
Oxygen therapy – this involves inhaling air
to handle whenever flow or volume of blood that contains a higher concentration of
is received is impaired and the increased oxygen than normal
blood flow then increases the pulmonary ● digoxin – this can improve your symptoms
artery pressure. by strengthening your heart muscle
● As pulmonary arterial pressure increases the contractions and slowing down your heart
pulmonary vascular resistance also increases. rate
● Both pulmonary artery constriction and SURGERY
reduction of the pulmonary vascular bed Some people with pulmonary hypertension may need
result in increased pulmonary vascular surgery. The 3 types of surgery currently used are:
resistance and pressure. This increased ● Pulmonary Endarterectomy – an operation
workload affects the right ventricular to remove old blood clots from the
function. pulmonary arteries in the lungs in people
● The myocardium ultimately can not meet the with chronic thromboembolic pulmonary
increasing demands imposed on it leading to hypertension
right ventricular hypertrophy and ● balloon pulmonary angioplasty – a new
failure.Passive hepatic congestion may also procedure where a tiny balloon is guided into
develop the arteries and inflated for a few seconds to
push the blockage aside and restore blood
Diagnostic flow to the lung; it may be considered if
Clinical Assessment pulmonary endarterectomy is not suitable,
● History and examination and has been shown to lower blood pressure
● Functional class in the lung arteries, improve breathing, and
Physiological assessment increase the ability to exercise
● Exercise testing ● atrial septostomy – a small hole is made in
● Pulmonary function the wall between the left and right atria of
● Right heart catheterization the heart using a cardiac catheter, a thin,
Functional Imaging Assessment flexible tube inserted into the heart's
● Echocardiography chambers or blood vessels; it reduces the
● Cardiac magnetic resonance pressure in the right side of the heart, so the
Static Imaging heart can pump more efficiently and the
● Pulmonary angiography blood flow to the lungs can be improved
● Ventilation- per-fusion scan ● transplant – in severe cases, a lung
● Ct and x-ray transplant or heart lung transplant may be
● Ultrasound needed; this type of surgery is rarely used
because effective medicine is available
Signs/Symptoms
● Shortness of breath Nursing Responsibilities
● Tiredness ● The major nursing goal is to identify patients
● Chest pain (angina) at high risk for PH, such as those with
● A racing heartbeat (palpation) COPD, PE, congenital heart disease, and
● Swelling (oedama) in the legs, ankles, feet or mitral valve disease so that early treatment
tummy (abdomen) can commence.
● The nurse must be alert for signs and
Treatment and management symptoms, administer oxygen therapy
Different classes of medications used to treat PH.
appropriately, instruct the patient and family
This includes calcium channel blockers, prostanoids,
about the use of home oxygen therapy.
endothelin antagonists and phosphodiesterase
● In patients treated with prostanoids, the need
inhibitors. The choice of therapeutic agent is based
for central venous access, subcutaneous
on many facets, including the classification group
infection proper administration and dosing of
status of the patient with PH
the medication, pain at the injection site and
There are many treatments for pulmonary arterial
potential severe side-effects is extremely
hypertension (PAH). Which treatment or
important.
combination of treatments you'll be offered will
● Emotional and psychosocial aspects of this
depend on a number of factors, including what's
disease must be addressed.
causing PAH and the severity of your symptoms.
● Formal and informal support groups for
Treatments include:
patients and families are extremely valuable.
PHARMACOLOGIC
● Anticoagulant medicines– such as warfarin
to help prevent blood clot
● diuretics (water tablets) – to remove excess
fluid from the body caused by heart failure
14
Chapter IV
ALTERED TISSUE PERFUSION
ACUTE ISCHEMIC HEART
SIGNS AND SYMPTOMS
DISEASE ● Chest pain (angina) or discomfort,
Acute coronary syndrome (ACS, formerly often described as aching, pressure,
called ischemic heart disease) tightness or burning
- Large spectrum of clinical conditions ● Pain spreading from chest to the
including unstable angina, shoulders, arms, upper abdomen,
back, neck, or jaw
myocardial injury, and MI.
● Nausea or vomiting
- Caused by a sudden onset of cardiac ● Indigestion
tissue ischemia secondary to impaired ● SOB (dyspnea)
blood flow. ● Diaphoresis
- Precipitating event: blockage in the ● Lightheadedness, dizziness or
coronary arteries or a mismatch syncope
between the demand and supply of ● Unusual or unexplained fatigue
● Feeling restless or apprehensive
blood to cardiac tissue.
- The resulting tissue ischemia can TREATMENT & MANAGEMENT
● GOAL: Improve blood flow to the
cause symptoms such as substernal
heart muscle.
chest pressure, radiation of pain to ● Aspirin: blood thinner
the left arm, shoulder, or jaw; and ○ Reduce risk of blood clots,
changes in the ECG. prevent blockage of coronary
DIAGNOSIS arteries.
● Nitrates: widen arteries, improving
ECG: electrodes attached to skin record the
blood flow to and from the heart.
electrical activity of the heart. Certain
Better blood flow means the heart
changes in the heart’s electrical activity may
doesn’t have to work as hard.
be a sign of heart damage.
● Beta blockers: help relax heart
Stress Test: heart rhythm, blood pressure,
muscle, slow heartbeat and decrease
and breathing are monitored while the client
blood pressure so blood can flow to
walks on a treadmill or rides a stationary
the heart more easily.
bike. Exercise makes the heart pump harder
● Angiotensin-converting enzyme
and faster than usual, so a stress test can
(ACE) inhibitors: helps relax blood
detect heart problems that might not be
vessels and lower blood pressure.
noticeable otherwise.
○ Recommended if the pt have
Echocardiogram: help identify whether an
area of the heart has been damaged and isn’t high BP or DM in addition to
pumping. MI.
Stress echocardiogram: similar to a regular ○ Used if the pt has heart failure
echocardiogram, except the test is done after or if the heart doesn’t pump
the client exercises in the doctor’s office on a blood effectively
treadmill or stationary bike. ● Ranolazine (Ranexa): helps relax
Nuclear Stress test: small amounts of
coronary arteries to ease angina.
radioactive material are injected into the
bloodstream. While the client exercises, the ○ Prescribed with other angina
doctor can watch as it flows through the medications, such as calcium
heart and lungs - allowing blood-flow
problems to be identified.
15
channel blockers, beta blockers experienced.

or nitrates.
CORONARY HEART
Procedures to improve DISEASE/cardiogenic
blood flow arterial disease
● Angioplasty and stenting: A catheter
INTRODUCTION
is inserted into the narrowed part of ● Usually caused by atherosclerosis,
the artery. A wire with a tiny balloon which occurs when fatty material and
is threaded into the narrowed area and a substance called plaque (or
inflated to widen the artery. A small atheroma) build-up on the walls of the
wire mesh coil (stent) is usually arteries which causes them to narrow.
inserted to keep the artery open. ● Narrowing of coronary arteries →
slow or stopped blood flow to the
● Coronary Artery Bypass surgery:
heart → chest pain (stable angina),
surgeon uses a vessel from another SOB, heart attack, et. al.
part of the body to create a graft that ● Because of the reduced blood flow
allows blood to flow around the and the rough edges of the plaque, a
blocked or narrowed coronary artery. blood clot sometimes forms. This can
○ Usually used only for people block the artery. Or the plaque may
rupture, which also causes the blood
who have several narrowed
to clot. This is called
coronary arteries. atherothrombosis.
● Enhanced external counterpulsation: ● Atherothrombosis stops an area of the
this noninvasive outpatient treatment heart muscle receiving blood and O2,
might be recommended if other leading to permanent damage. This is
treatments haven’t worked. Cuffs that called MYOCARDIAL INFARCTION
have been wrapped around the legs or heart attack. If a lot of the heart
muscle is damaged, the heart may
are gently inflated with air then
stop beating regularly or stop beating
deflated. The resulting pressure on the at all.
blood vessels can improve blood flow
DIAGNOSTIC FINDINGS
to the heart. ● ECG: evaluate ventricular fxn. It may
INTERVENTIONS be used to assist in diagnosing and MI
● Monitor blood pressure, apical heart ● Exercise stress test: determines
rate, and respirations every 5 minutes presence of CAD.
during an angina attack. ○ Terminated when the target
● Maintain continuous ECG monitoring heart rate is achieved or if the
or obtain a 12-lead ECG, as directed, pt experiences signs of
monitor for arrhythmias and ST Myocardial ischemia
elevation ○ Instruct pt not to eat or drink
● Place patient in comfortable position anything for at least 3 hours
and administer O2, if prescribed, to before the test
enhance myocardial O2 supply ○ Advise the pt to refrain from
● Identify specific activities patients eating any liquids or food that
may engage in that are below the contain chocolate or caffeine
level at which anginal pain occurs. for 24 hours.
● Reinforce the importance of notifying
nsg staff whenever angina pain is
16
● Electron-beam computed afterwards. The stent

tomography (EBCT): look for Ca in +
sometimes releases a drug that
the lining of the arteries. The more helps to keep the blood vessel
Ca+ the higher the chance for CHD. open.
● Magnetic resonance angiography ● Coronary artery bypass graft (CABG):
(MRA): noninvasive, painless the surgeon takes a piece of blood
technique that is used to examine both vessel from the leg or chest and uses
the physiologic and anatomic it to bypass the narrowed coronary
properties of the heart. arteries. The bypass provides the heart
● Coronary angiography/ with more blood. This is open heart
arteriography : an invasive procedure surgery.
designed to evaluate the heart arteries NURSING INTERVENTION
under X-ray. ● Patient is directed to stop all activities
After a heart attack, or if the patient develop and sit in bed in a Semi-Fowler’s
angina, the doctor will prescribe medicines position to reduce the O2 requirements
to help stop the heart disease from getting of the ischemic myocardium.
worse or to present further heart attacks. ● Assess the patient’s angina, asking
● Nitroglycerin: potent vasodilator that questions to determine whether the
improves blood flow to the heart angina is the same as the pt typically
muscle and relieves pain. experiences.
● Aspirin: reduces risk of having a heart ● Continue to assess the pt, measure
attack V/S and observe for signs of
● Statins: lower the cholesterol levels respiratory distress. If the pt is in the
and slow down the process of hospital, a 12-lead ECG is usually
atherosclerosis. obtained and assessed for ST-segment
● Beta-blockers: slow the heart rate and and T-wave change.
reduce the pumping power of the ● Nitroglycerin is given sublingually,
heart. This reduces the heart’s demand and the pt’s response is assessed
for O2. (relief of chest pain and effect on
○ Widen blood vessels helping to blood pressure and heart rate)
lower BP. ● Administers O2 therapy if the pt’s
● ACE inhibitors: lower BP respiratory rate is increased or if the
● O2 Administration: O2 sat level is decreased.
Surgery ● If the pain is significant and continues
● Angioplasty: (aka percutaneous after these interventions, the pt is
coronary intervention or PCI), further evaluated for acute MI and
○ A collapsed balloon is threaded may be transferred to a higher-acuity
through the blood vessels until nursing unit.
it reaches the arteries of the
heart. The balloon is inflated to
widen the narrowed coronary
artery. A stent (flexible mesh
tube) is sometimes inserted to
help keep the artery open
17
CONGESTIVE HEART HISTORY & RISK FACTORS

FAILURE ● Hx of HF, CAD, myocardial
INTRODUCTION infarction (MI), hypertension,
● Is a broad term referring to the hypercholesterolemia, obstructive
inability of the heart to eject an sleep apnea, DM, arrhythmias, and
adequate cardiac output to meet the recent viral illness
O2 and metabolic requirements of the ● Familial hx of CAD and MI
body. ● Age older than 65 years
● Effective pumping of the heart is ● Obesity
determined by the components of CO: ● Hx of HF symptoms including
preload, afterload and contractility of fatigue, weight gain, decreased
the myocardium. Myocardial exercise tolerance, dyspnea, or
contractility depends heavily on the peripheral edema
delivery of O2 and nutrients to ● In pts with previously diagnosed HF,
nutrients to the heart. compliance with low-sodium diet,
● The term heart failure is preferred weight monitoring, fluid restriction,
over the older term, “congestive heart medications, and exercise
failure,” because not all patients have recommendations.
pulmonary or systemic congestion. ETIOLOGIES
● Organs and tissue will suffer from the ● CAD
decreased blood flow, pressure in the ● Previous heart attack
heart increases which over works the ● HTN
ventricles, body can become ● Cardiomyopathy
congested with fluids (enter into ● Valvular heart disease
congestive heart failure) that can ● Other less common causes of HF
cause life-threatening complications. include anemia, hyperthyroidism,
● It is recognized as a clinical syndrome dysrhythmias, and myocarditis.
characterized by signs and symptoms
of fluid overload or of inadequate
TYPES OF HEART FAILURES
● Left-sided heart failure: the left side
tissue perfusion.
PATHOPHYSIOLOGY of the heart cannot pump blood out of
● HF results from a variety of cardiovascular the heart efficiently so blood starts to
conditions, including chronic HTN, CAD,
back-up in the lungs
and valvular disease.
● As HF develops, the body activates ○ Most common type of heart
neurohormonal compensatory mechanisms failure
● Systolic HF results in decreased blood
volume being ejected from the ventricle
○ Left-sided HF is likely to lead
● The sympathetic nervous system is then to right-sided HF
stimulated to release epinephrine and ○ HF can be either SYSTOLIC
norepinephrine.
● Decrease in renal perfusion causes renin or DIASTOLIC
release, and then promotes the formation of DYSFUNCTION.
angiotensin I is converted to angiotensin II ■ Systolic: Ventricular
by ACE which constricts the blood vessels
and stimulates aldosterone release that systolic dysfunction”;
causes Na+ and fluid retention. “PUMPING
● There is a reduction in the contractility of the PROBLEM”
muscle fibers of the heart as the workload
increases ■ Diastolic: “left
● Compensation. The heart compensates for ventricular diastolic
the increased workload by increasing the
thickness of the heart muscle.
dysfunction”;
“FILLING PROBLEM”
18
● Right-Sided Heart Failure: The right palpitations, dyspnea, or anginal pain.

side of the heart cannot pump the ● Class II: Patients with cardiac disease
“used” blood it received from the resulting in slight limitations of
physical activity. They are
body efficiently so it can’t get the
comfortable at rest. Ordinary physical
blood back to the lungs to get activity results in fatigue, palpitations,
replenished with O2. This causes the dyspnea, or anginal pain.
blood to back up peripherally (legs, ● Class III: Patients with cardiac disease
hands, feet, abdomen). resulting in marked limitation of
○ Right-sided heart failure causes physical activity. They are
congestion of blood in the comfortable at rest. Less than
ordinary physical activity causes
heart and this increases the
fatigue, palpitations, dyspnea, or
pressure in the IVC anginal pain.
○ Other causes: Pulmonary heart ● Class IV: Patient with cardiac disease
disease “cor pulmonale” as a resulting in an inability to carry on
complication from pulmonary any physical activity without
HTN or COPD discomfort. Symptoms of cardiac
○ Right-sided heart failure is insufficiency or of anginal syndrome
may be present even at rest. If any
usually caused from left-sided
physical activity is undertaken,
failure discomfort is increased.
LVF + RVF = CHF
SIGNS AND SYMPTOMS
- Usually RVF is d/t LVF occurring ● Dyspnea (esp with exertion,
first. commonly severe in acute setting)
CLASSIFICATIONS OF CVD ● Paroxysmal nocturnal dyspnea
● Pulmonary edema (pronounced
AHA/ACC Stages of HF
crackles)
● Stage A: Patients at high risk for HF ● Chest discomfort or tightness
d/t the presence of conditions strongly ● Peripheral edema
associated with the dev’t of HF. ● Cool, pale, cyanotic skin
Asymptomatic. ● Oliguria
● Stage B: Patients with structural ● Reported weight gain
disease, such as previous MI, but have ● Fatigue
never shown S/Sx of HF HEART FAILURE ASSESSMENT
● Stage C: Patients with structural heart Left-sided HF Pulmonary Edema and
disease who have current or prior congestion
symptoms of HF ● Decreased exercise tolerance
● Stage D: Patients with advanced ● Fatigue
● Weakness
structural heart disease and marked
● Anxiety
symptoms at rest in spite of optimal ● Dyspnea
medical therapy and who require ○ At rest
specialized interventions. ○ On Exertion
New York Heart Association Functional ○ Paroxysmal Nocturnal dyspnea
Classification ● Cough (possibly moist with frothy
● Class I: patients with cardiac disease sputum)
but without resulting limitations of ● Diaphoresis
physical activity. Ordinary physical ● Palpitations
activity does not cause undue fatigue, ● Rales (most often diminished lung
19
sounds, in lung base) creatinine level

● Atrial fibrillation or other atrial RADIOLOGIC TEST
arrhythmias secondary to atrial ● CXR
distension ● Cardiac magnetic resonance imaging
● Pulsus alternans (every other beat (MRI)
diminished) ● Cardiac computed tomography (CT
● Cough Scan)
● Hyperventilation ● Transthoracic echocardiogram
● Cardiac pressures (cardiac utz)
○ Increased LV and LA pressure ● Transesophageal echocardiogram
○ Increased pulmonary artery ● Single photon emission computed
pressures tomography (SPECT)
● Heart Sounds INVASIVE CARDIOLOGY
○ S3 gallop (occasionally) S4 ● Coronary angiography/Cardiac
○ Pansystolic murmur at apex Catheterization
secondary to mitral NURSING INTERVENTION:
regurgitation ASSESSING:
Right-sided HF cor pulmonale and systemic
● Assess pt for worsening symptoms
congestion
(RHF: peripheral swelling vs LHF:
● Decreased exercise tolerance pulmonary edema)
● Fatigue ● Patient responsiveness to medication
● Peripheral edema (legs, hands, treatment
abdomen, sacrum) ○ Watch heart rate (Digoxin)
● Weight gain ○ Respiratory status)
● Abdominal tenderness ○ Blood pressure (vasodilators
● Nausea, vomiting, constipation, and cause hypotension)
anorexia ○ Diuretics (strict intake and
● JVD output, daily weights, monitor
● Liver enlargement and tenderness electrolyte levels, especially
● Positive hepatojugular reflux K+)
(pressure on the liver increases JVD) MONITORING
● Ascites ● Fluid status (may be ordered a foley
● Decreased appetite catheter, if on diuretics)
● Cardiac pressure ● Cardiac diet (low salt and fat)
○ Increased RV pressure ● Fluid restriction (no more than 2L per
○ Increased RA pressure day)
● Heart sounds ● Lab values: Watch BNP, kidney fxn
○ S3 (early sign) BUN & creatinine, troponins level,
○ S4 (may also present) electrolytes (especially K+ if on Lasix:
○ Wide split S2 waste K+ and low potassium increase
○ Pansystolic murmur to lower the risk of digoxin toxicity)
left sternal border secondary to ● Edema in the leg: Keep legs elevated
stretching of the tricuspid ring. and patient in high Fowler’s to help
DIAGNOSTIC TEST: with breathing
BLOOD STUDIES ● Safety (at risk for falls d/t fluid status
● Complete blood count changes, swelling in legs and feet, and
● Electrolytes orthostatic hypotension).
● B-type (BNP) and natriuretic pre-INP
peptide
● Arterial Blood Gas (ABG) analysis EDUCATING:
● Blood urea nitrogen (BUN) and
20
● Early S/Sx HF exacerbation ejection, and promote

○ SOB enhanced myocardial
○ Weight gain contractility. HF patients
○ Orthopnea should have their medication
● Low salt (allowed 2-3 G Na+ per day) regimen reviewed during
and fluid restriction (no more than hospitalization to ensure
2L/day) optimal medical therapy.
● Vaccination to prevent illness, such as Evidenced-based therapy to improve
annual flu and to be up-to-date with morbidity and mortality in systolic
pneumonia vax dysfunction
● Exercise aerobic (as tolerated) ● Beta-adrenergic blocking agents. The
● Daily weights (watch for no more HF clinical guidelines specify the use
than 2-3 lbs per day and 5 lbs per of three beta-blockers that have been
week) shown to improve survival
● Compliance with medications (carvedilol, metoprolol succinate, and
● Smoking cessation bisoprolol).
● Limiting alcohol
COLLABORATIVE MN’T ● ACEIs (benazepril, captopril,
enalapril, fosinopril, lisinopril,
CARE PRIORITIES
perindopril, quinapril, ramipril,
1. Treat the underlying cause and
trandolapril): ACEIs affect the RAAS
precipitating factors
by inhibiting the conversion of
● Initial therapy on stabilizing,
circulating angiotensin I into
the hemodynamic and
angiotensin II. They reduce
respiratory status and searching
remodeling, preload, and afterload to
for reversible causes of HF
decrease the work of the ventricles.
2. Provide O2 therapy and support
● Aldosterone antagonists
ventilation
(spironolactone, eplerenone)
● Supplemental O2 is required to
● Hydralazine and isosorbide dinitrate
optimize the pt’s SpO2
SYMPTOM MANAGEMENT in HF
● Pulse oximetry (SpO2):
● Diuretics: reduce blood volume and
External monitoring of pt’s
decrease preload. Diuretics effectively
hemoglobin saturation. SpO2
manage respiratory distress caused by
does not provide information
pulmonary edema, but have not been
about ventilation and CO2
shown improve survival in HG pts.
retention
Diuretics are the only medications
3. Provide evidence-based
used in HF therapy that can control
pharmacotherapy to help improve
the retention of fluid.
long-term prognosis, relieve
● Digoxin: slows HR, giving the
symptoms, and promote stabilization
ventricles more time to fill, strengthen
during acute episodes.
contractions, and improves CO.
● Medications help reduce
○ Prescribed for pts with LV
intravascular volume, promote
end-systolic dimension who
vasodilation to reduce
remain symptomatic on
resistance to ventricular
21
standard therapy, especially if 5. Initiate a low cholesterol and

they develop atrial fibrillation. low-sodium diet.
Digoxin controls ventricular - Extra salt and water are held in the
response in atrial fibrillation circulatory system, causing increased
without decreasing BP. strain on the heart. Limiting sodium
● Inodilators (milrinone and will reduce the amount of fluid
inamrinone): Phosphodiesterase- retained by the body. In addition,
inhibiting drugs increase myocardial fluids may be limited to 1500 to 2000
contractility and lower systemic mL/day in patients who are
vascular resistance through hyponatremic.
vasodilation. 6. Consider an implanted cardiac device
● Morphine ● Implanted cardioverter defibrillator
● Intravenous nitroglycerin (NTG) (ICD): systolic dysfunction places
4. Manage acute pulmonary edema; patients at increased risk of sudden
include the ff immediate cardiac death. Implantation of an ICD
interventions is indicated for patients with LVEF ≤
○ Monitor for S/Sx of acute 35% and HF symptoms. Patients must
respiratory failure be on optimal medical therapy and at
○ Titrate supplemental O2 to least 40 days post MI before
maintain adequate oxygenation implantation. ICD therapy has been
○ Provide NiPPV for pts with shown to significantly reduce
increased work of breathing mortality in patients with reduced
○ Elevate HOB as needed to LVEF.
promote oxygenation ● Cardiac resynchronization therapy
○ If NiPPV (noninvasive positive (CRT): approximately ⅓ of HF pts
pressure ventilation) is developed a widened QRS complex,
unsuccessful, consider indicating asynchronous ventricular
endotracheal (ET) intubation fxn. Implantation of biventricular
with mechanical ventilation pacing allows coordination of the
○ Diuretic therapy: In severely ill right and left ventricles.
pts, furosemide or bumetanide 7. Initiate advanced HF therapy
may be used as continuous IV ● Inotropic agents: Dopamine,
infusion to assist with constant dobutamine, and milrinone are
fluid removal. Patients with inotropic agents used to treat
renal impairment/failure may advanced HF. Inotropes may be used
require infusions of appropriate acutely in the pt with CS or as a
diuretics bridge to transplant or other advanced
○ In patients refractory to therapy. Inotropic therapy may also be
diuretic therapy, ultrafiltration used as a palliative measure in pts
may be utilized for isotonic with end-stage HF for symptom relief.
fluid removal. ● Left-ventricular Assistive Device
(LVAD) or Mechanical heart pump:
some patients with CS unresponsive
to intra-aortic balloon counter
22
pulsation and IV inotrope therapy symptom mn’t should be continued to

may be referred for mechanical prevent abrupt worsening of clinical
circulatory support. LVADs may be condition.
used as a bridge to cardiac
transplantation or as a destination CARDIOMYOPATHY
therapy for those ineligible for Introduction
transplant. The inflow cannula of an - Cardio: heart
LVAD is connected to the apex of the - Myo: muscle
left ventricle. Blood is pumped by the - Pathy: Disease
device via the outflow cannula to the ● Is a general term that refers to
diseases of the heart muscle
aorta.
● The heart muscle becomes
● Cardiac transplantation: indicated enlarge,thick or tough and cannot
for end-stage GF patients with beat as well as it should
symptoms refractory to ● The heart is less able to pump
guideline-based medical therapy. blood effectively and prone to
Cardiac transplantation has been heart valve failure, heart valve
problems and to arrhythmias,
shown to improve symptoms and
including atrial fibrillation.
quality of life. Patients are not ● There are different of
transplant candidates if they have cardiomyopathy
significant comorbidities including
pulmonary hypertension, active TYPES
infection, significant psychosocial Dilated Cardiomyopathy
issues, or history of medical PATHOPHYSIOLOGY
noncompliance. ● Systole- period when the heart muscle
8. Patient education and psychosocial contracts blood is ejected out
● Diastole-muscle of heart is relaxing
support
and ventricles are filling with blood
● Self-care: HF patients should be Causes:
educated on self-care of their HF. This ● Genetics problems to the problems to
education includes daily weight the proteins in the muscle cells
monitoring, symptom management, ● Inflammation from viral infection
follow-up care, and dietary and known as myocarditis
medication compliance. ● Toxins that affect the heart alcohol
● Advance directives: pts with ● Pregnancy increased risk
● Idiopathic
advanced HF should have a ● Known as systolic failure less blood is
discussion about plan of care, ejected out from the ventricles
including resuscitation status. (ejection fraction)
● Palliative care: care to manage ● 50-70 percent of the blood
physical and psychosocial symptoms ● To compensate for this, the chamber
of HF should be incorporated in dilates the total volume of the
chambers of the ventricular
conjunction with goal-directed
increases>increased filling.
medical therapy. In patients with ● Goal: for adequate amount of blood to
advanced HF who enter palliative or be ejected out from each heart beat
hospice care, evidenced based therapy ● Dilatation progressively worse and
such as beta-blockers, ACEIs, and worse,not only were the ventricular
dilated but also the atria as well
23
because of the the back up of blood the heart muscle

● Gets to the point where the chambers ➢ Sarcoidosis- granulomas are
cannot dilate enough , the signs and deposited
symptoms of heart failure began to 2. The heart muscle is not able to relax
develop unable to fill properly decrease
● Signs and symptoms heart failure volume of blood
could be due to decreased ability to DIAGNOSTIC EXAMINATION
pump the flow forward which cause Ambulatory monitoring- uses devices that
chest pain and fainting there is not
track your heart rhythm.
(enough blood to the brain)
1.Probems of the heart muscles Cardiac CT-uses x- ray to make a video of
a. Genetic abnormality of the blood vessels and hearth
muscle cell properly Cardiac MRI- uses radio waves and magnets
to create images of the heart.
2. Abnormality in protein dont allow the Echocardiogram- use sound waves to create
muscle to contract properly
an image of the blood flow and hearbeart.
3. Decreased contractility compensate by
hypertrophying cells got bigger overtime Electrocardiogram- record the hearth’s
4. Result to 2 major problems: electricity activities.
a. Chambers have become smaller Exercise stress teat- raises that heart rate in
● Decrease ability of the heart to a controlled way to see the hearth will
fill properly decreased outflow respond.
● Diastolic failure Cardiac catheterization - use a catheter to
b. Intermittent outflow obstruction
because of the septum hypertrophy, measure that heart's blood flow and pressure.
there is narrowness of the outflow Myocardial biopsy-- studies a small sample
tract leading to blockers of blood out of the heart muscle tissue to look for cell
to the aorta. changes.
These two problems result to the sign and Signs and sYmptoms
symptoms such as fainting/syncope even ● Fatigue
sudden death ● Heart palpitation
● Edema on the legs calves and ankles
Restrictive ● Shortness of breath
cardiomyopathy ● Syncope fainting
● The lower heart chamber (the
ventricle) grow stiffer and more rigid Treatment and management
Nio cure , only supportive care
as the condition progress making in
Medication:
unable to relax
➢ Heart medications can improve the
● Occurs because abnormal tissue is
blood flow, control symptoms or treat
replacing the regular heart muscle.
underlying conditions. Blood thinners
The abnormal tissue.
such as warfarin (coumadin),beta
● This type of cardiomyopathy is more
blockers such as propranolol (inderal)
common in older people.
or medication to lower cholesterol.
PATHOPHYSIOLOGY Devices to correct arrhythmias:
1. Problem with the heart muscle ➢ Pacemakers or implantable
A. fibrosis /scarring-caused by cardioverter defibrillators (icd), treat
radiation from cancer treatment irregular heart rhythms. These devices
or may be idiopathic monitor heart beat. They send
B. Infiltration- electrical impulses to the heart when
➢ Amyloidosis- proteins are deposit in an arrhythmia starts.
24
Devices to improve blood flow: BUN & creatinine, troponins level,
➢ Cardiac resynchronization therapy electrolytes (especially K+ if on Lasix:
(CRT) devices control the waste K+ and low potassium increase
contractions between the left and right the risk of digoxin toxicity)
sides of the heart. A left ventricular ● Edema in the leg: Keep legs elevated
assist device (LVAD)helps the heart and patient in high Fowler’s to help
pump blood. with breathing
Surgical: ● Safety (at risk for falls d/t fluid status
➢ For severe symptoms or underlying changes, swelling in legs and feet, and
heart conditions, heart surgery is orthostatic hypotension).
recommended.
➢ Providers usually only recommend
open heart surgery or a heart EDUCATING:
transplant when other treatments have
● Early S/Sx HF exacerbation
failed to bring relief.
○ SOB
Nursing management ○ Weight gain
● Maintain cardiac output, increase
activity tolerance and relieve anxiety. ○ Orthopnea
● Monitor for any complication. ● Low salt (allowed 2-3 G Na+ per day)
● Monitor vital signs and symptoms of and fluid restriction (no more than
heart failure. 2L/day)
● Advice to take proper nutrition ● Vaccination to prevent illness, such as
● Provide emotional support annual flu and to be up-to-date with
● Encourage adequate rest
pneumonia vax
● Treat HTN-DASH diet, sodium
restriction beta blockers. ● Exercise aerobic (as tolerated)
What is arrhythmia? ● Daily weights (watch for no more
● Is an irregularity of the heartbeat that than 2-3 lbs per day and 5 lbs per
can cause the heart to beat too week)
fast(tachycardia)>100bp, too slow ● Compliance with medications
(bradycardia)<60bmp, or origin of
● Smoking cessation
conduction.
● The speed and rhythm of the heartbeat ● Limiting alcohol
is controlled by an internal electrical COLLABORATIVE MN’T
system that generates the electrical CARE PRIORITIES
pulse through the heart's conduction
1. Treat the underlying cause and
system, causing the heart to contract
and pump blood. This process repeats precipitating factors
each new heartbeat. ● Initial therapy on stabilizing,
Classification of arrhythmias the hemodynamic and
Heart Rate respiratory status and searching
● Slow for reversible causes of HF
● Fast 2. Provide O2 therapy and support
● Absent
Classification ventilation
● Bradyarrhythmia ● Supplemental O2 is required to
● Tachyarrhythmia optimize the pt’s SpO2
● PulsCardiac diet (low salt and fat) ● Pulse oximetry (SpO2):
● Fluid restriction (no more than 2L per External monitoring of pt’s
day) hemoglobin saturation. SpO2
● Lab values: Watch BNP, kidney fxn
25
does not provide information manage respiratory distress caused by

about ventilation and CO2 pulmonary edema, but have not been
retention shown improve survival in HG pts.
3. Provide evidence-based Diuretics are the only medications
pharmacotherapy to help improve used in HF therapy that can control
long-term prognosis, relieve the retention of fluid.
symptoms, and promote stabilization ● Digoxin: slows HR, giving the
during acute episodes. ventricles more time to fill, strengthen
● Medications help reduce contractions, and improves CO.
intravascular volume, promote ○ Prescribed for pts with LV
vasodilation to reduce end-systolic dimension who
resistance to ventricular remain symptomatic on
ejection, and promote standard therapy, especially if
enhanced myocardial they develop atrial fibrillation.
contractility. HF patients Digoxin controls ventricular
should have their medication response in atrial fibrillation
regimen reviewed during without decreasing BP.
hospitalization to ensure ● Inodilators (milrinone and
optimal medical therapy. inamrinone): Phosphodiesterase-
Evidenced-based therapy to improve inhibiting drugs increase myocardial
morbidity and mortality in systolic contractility and lower systemic
dysfunction vascular resistance through
● Beta-adrenergic blocking agents. The vasodilation.
HF clinical guidelines specify the use ● Morphine
of three beta-blockers that have been ● Intravenous nitroglycerin (NTG)
shown to improve survival 4. Manage acute pulmonary edema;
(carvedilol, metoprolol succinate, and include the ff immediate
bisoprolol). interventions
○ Monitor for S/Sx of acute
● ACEIs (benazepril, captopril, respiratory failure
enalapril, fosinopril, lisinopril, ○ Titrate supplemental O2 to
perindopril, quinapril, ramipril, maintain adequate oxygenation
trandolapril): ACEIs affect the RAAS ○ Provide NiPPV for pts with
by inhibiting the conversion of increased work of breathing
circulating angiotensin I into ○ Elevate HOB as needed to
angiotensin II. They reduce promote oxygenation
remodeling, preload, and afterload to ○ If NiPPV (noninvasive positive
decrease the work of the ventricles. pressure ventilation) is
● Aldosterone antagonists unsuccessful, consider
(spironolactone, eplerenone) endotracheal (ET) intubation
● Hydralazine and isosorbide dinitrate with mechanical ventilation
SYMPTOM MANAGEMENT in HF ○ Diuretic therapy: In severely ill
● Diuretics: reduce blood volume and pts, furosemide or bumetanide
decrease preload. Diuretics effectively may be used as continuous IV
26
infusion to assist with constant inotropic agents used to treat

fluid removal. Patients with advanced HF. Inotropes may be used
renal impairment/failure may acutely in the pt with CS or as a
require infusions of appropriate bridge to transplant or other advanced
diuretics therapy. Inotropic therapy may also be
○ In patients refractory to used as a palliative measure in pts
diuretic therapy, ultrafiltration with end-stage HF for symptom relief.
may be utilized for isotonic ● Left-ventricular Assistive Device
fluid removal. (LVAD) or Mechanical heart pump:
some patients with CS unresponsive
to intra-aortic balloon counter
5. Initiate a low cholesterol and pulsation and IV inotropic therapy
low-sodium diet. may be referred for mechanical
- Extra salt and water are held in the circulatory support. LVADs may be
circulatory system, causing increased used as a bridge to cardiac
strain on the heart. Limiting sodium transplantation or as a destination
will reduce the amount of fluid therapy for those ineligible for
retained by the body. In addition, transplant. The inflow cannula of an
fluids may be limited to 1500 to 2000 LVAD is connected to the apex of the
mL/day in patients who are left ventricle. Blood is pumped by the
hyponatremic. device via the outflow cannula to the
6. Consider an implanted cardiac device aorta.
● Implanted cardioverter defibrillator ● Cardiac transplantation: indicated
(ICD): systolic dysfunction places for end-stage GF patients with
patients at increased risk of sudden symptoms refractory to
cardiac death. Implantation of an ICD guideline-based medical therapy.
is indicated for patients with LVEF ≤ Cardiac transplantation has been
35% and HF symptoms. Patients must shown to improve symptoms and
be on optimal medical therapy and at quality of life. Patients are not
least 40 days post MI before transplant candidates if they have
implantation. ICD therapy has been significant comorbidities including
shown to significantly reduce pulmonary hypertension, active
mortality in patients with reduced infection, significant psychosocial
LVEF. issues, or history of medical
● Cardiac resynchronization therapy noncompliance.
(CRT): approximately ⅓ of HF pts 8. Patient education and psychosocial
developed a widened QRS complex, support
indicating asynchronous ventricular ● Self-care: HF patients should be
fxn. Implantation of biventricular educated on self-care of their HF. This
pacing allows coordination of the education includes daily weight
right and left ventricles. monitoring, symptom management,
7. Initiate advanced HF therapy follow-up care, and dietary and
● Inotropic agents: Dopamine, medication compliance.
dobutamine, and milrinone are
27
● Advance directives: pts with

advanced HF should have a Normal Heart Rate
discussion about plan of care,
including resuscitation status.
● Palliative care: care to manage
physical and psychosocial symptoms
of HF should be incorporated in
conjunction with goal-directed
medical therapy. In patients with
advanced HF who enter palliative or
hospice care, evidenced based therapy
such as beta-blockers, ACEIs, and
symptom mn’t should be continued to
prevent abrupt worsening of clinical
condition.eless
Cardiovascular
disease: arrhythmia
What is arrhythmia?
An arrhythmia is an irregularity of the
heartbeat that can cause the heart too beat
too fast (tachycardia) >100bpm, too slow
(bradycardia) <60bmp, or create an abnormal
rate, rhythm, sequence of conduction or
origin of conduction. The speed and rhythm
of the heart beat is controlled by an internal
electrical system that generates the electrical
pulse through the heart’s conduction system,
causing the heart to contract and pump
blood. This process repeats with each new
heartbeat
Classification of Arrhythmias
Heart Rate Classification
Slow Bradyarrhythmia
Fast Tachyarrhythmia
Absent Pulseless
28
DIAGNOSIS
● Loss of consciousness,
unresponsiveness
● Loss of normal breathing: APNEA
● Loss of pulse and BP (apical &
central pulsations [carotid, femoral])
TYPES OF CARDIAC ARREST
● Cardiovascular collapse
● Ventricular fibrillation
● Cardiac standstill
SIGNS AND SYMPTOMS.
● SOB (Women > Men)
● Extreme tiredness (unusual fatigue)
● Back pain
● Flu-like symptoms
● Belly pain, nausea, and vomiting
● Chest pain, mainly angina (Men >
women)
● Repeated dizziness or fainting,
especially while exercising hard,
sitting, or lying on your back
● Heart palpitations, or feelings as if the
heart is racing, fluttering, or skipping
a beat.
It is likely that a person is having a cardiac

arrest if they:
● Collapse suddenly and lose
consciousness (pass out)
● Not breathing or their breathing is
ineffective or they are gasping for air
● No response to shouting or shaking
● No pulse
TREATMENT AND MANAGEMENT
● CPR
● AED
● Call emergency hotline #
EMERGENCY TX
● If you see someone collapse, check to
see whether the person responds to
shouting and tapping on their body.
Check for breathing and a pulse. If the
person is not breathing normally and
CARDIAC ARREST if they do not respond, call for
~ When the heart suddenly stops pumping emergency hotline numbers for help.
blood around the body. ● Start CPR
~ Heart stops pumping blood = brain is ● Locate an AED (automated external
starved of O2 = unconscious and stop defibrillator). Follow the AEDs verbal
breathing instructions to deliver a shock to
29
restart the heart of the affected person.

diabetes mellitus.
● Naloxone should be given as part of
emergency treatment for cardiac What Causes
arrest possibly caused by opioid
overdose. First responders carry
hypertension?
naloxone, If the person is known to be The following lifestyle and medical factors
at risk of opioid overdose and you are may increase the likelihood of hypertension:
trained to give naloxone, you can treat
them before first responders arrive ● having overweight or obesity
● Continue CPR until the first ● eating an unhealthful diet that is high
responders arrive and take over. First in salt
responders will continue CPR and ● not getting very much physical
may use an AED to give more shocks activity
to restore the affected person’s heart ● smoking
rhythm. They may also give ● Having a history of cardiovascular
medicines through an IV line. disease
NURSING ● Having an underlying health
condition, such as diabetes or kidney
RESPONSIBILITIES disease.
● Assess the general condition of the
patient
● Monitor the airway, breathing and tHE FOLLOWING FACTORS
circulation ARE COMMONLY ASSOCIATED
● Administer oxygen
● Closely monitor the ECG changes of the WITH HYPERTENSIVE
patient CRISIS:
● Monitor the oxygen saturation loved
frequently ● not taking, or forgetting to take,
prescribed blood pressure medications
Hypertensive crisis ● taking medications that interact with
Introduction each other in a way that increases
● Uncontrolled hypertension can lead to blood pressure
● using illegal drugs, such as cocaine or
a sudden and severe increase in blood
amphetamines
pressure. This increase is known as ● having a life threatening
hypertensive crisis. cardiovascular condition, such as a
● There are two types of hypertensive stroke or heart attack
crisis: hypertensive urgency and ● experiencing organ failure, such as
hypertensive emergency. heart or kidney failure
● Hypertension is sometimes called “the
silent killer” because people who SIGNS AND SYMPTOMS
have it are often symptoms free. In a ● Some people experiencing
national survey, 32% of people who hypertensive crises may have
had pressures exceeding 140/90 mm symptoms, while others may not have
Hg were unaware of their elevated any symptoms at all.
blood pressure. ● People who are able to check their
own blood pressure may see a reading
● Hypertension often accompanies risk
of 180/120 mm Hg or greater.
factors for atherosclerotic heart
● If no other symptoms are present,
disease, such as dyslipidemia
they recommend waiting 5 minutes
(abnormal blood fat levels) and
and taking another reading.
30
If the blood pressure is high and the person ● Studies show that diets high in fruits,
may experience one or more of following vegetables, and low-fat dairy products
symptoms: can prevent the development of
hypertension and can lower elevated
● severe headache or migraine pressures.
● dizziness
● Confusion
● severe anxiety
PHARMACOLOGIC THERAPY
● nausea or vomiting ● For patients with uncomplicated
● chest pain hypertension and no specific
● changes in vision indications for another medication,
● shortness of breath the recommended initial medications
● nosebleed include diuretics, beta-blockers, or
● fits or seizures both.
● Patients first gave low doses of
ASSESSMENT AND DIAGNOSIS medication. If blood pressure does not
fall to less than 140/90 mm Hg, the
A thorough health history and physical dose is increased gradually, and
examination are necessary. The retinas are additional medications are included as
examined, and laboratory studies are necessary to achieve control.
performed to assess possible target organ
damage. Routine laboratory include:
NURSING INTERVENTION
● Urinalysis
● The objective of nursing care for
● Blood chemistry
hypertensive patients focuses on
● 12- lead electrocardiogram
lowering and controlling the blood
● an ultrasound of the kidneys pressure without adverse effects and
● a chest X-ray of the heart and lungs without undue cost.
● a CT or MRI scan of the brain ● To achieve these goals, the nurse must
support and teach the patient to
MEDICAL MANAGEMENT adhere to the treatment regimen by
implementing necessary lifestyle
● The first-line treatment for
changes, taking medications as
hypertensive crisis will typically be
prescribed, and scheduling regular
intravenous antihypertensive
check-ups to monitor progress or
medications to lower the person’s
identify and treat any complications
blood pressure. Healthcare providers
of disease or therapy.
usually aim to reduce blood pressure
● Increasing Knowledge
by no more than 25% in the first hour,
● The patient needs to understand the
as rapid decreases in blood pressure
disease and how lifestyle changes and
can cause other problems.
medication can control hypertension
● Once a person’s blood pressure is
under control, the healthcare provider
will usually switch to using oral
antihypertensive medications. HYPERTENSIVE CRISIS
● Research findings demonstrate that ● There are two hypertensive crises that
weight loss, reduced alcohol and require nursing intervention:
sodium intake, and regular physical hypertensive emergency and
activity are effective lifestyle hypertensive urgency.
adaptations to reduce high blood ● Hypertensive emergencies and
pressure. urgencies may occur in patients
31
whose hypertension has been poorly proximal to ligament of treitz.

controlled or in those who have ● Melana-refers to black, tarry
abruptly discontinued their stool.
medications. Once hypertensive crisis
has been managed, a complete Causes can include:
evaluation is performed to review the
● Peptic ulcer This is the most
patient’s ongoing treatment plan and
strategies to minimize the occurrence common cause of upper GI
of subsequent hypertensive crises.
● Extremely close hemodynamic bleeding. Peptic ulcers are
monitoring of the patient’s blood
sores that develop on the lining
pressure and cardiovascular status is
required during treatment of of the stomach and upper
hypertensive emergency and urgency.
The exact frequency of monitoring is portion of the small intestine.
a matter of clinical judgment and Stomach acid, either from
varies with the patient’s condition.
● The nurse may think that taking vital bacteria or use of
signs every 5 minutes is appropriate if
the blood pressure is changing rapidly anti-inflammatory drugs,
or may check blood pressure at 15-30 damages the lining, leading to
minute intervals if the situation is
more stable. formation of sores.
aCUTE GASTROINTESTINAL ● Tears in the lining of the

BLEEDING tube that connects your
INTRODUCTION throat to your
Gastrointestinal (GI) bleeding is any type of stomach(esophagus) Known

bleeding that starts in your GI tract, also as Mallory-Weiss tears, they
called your digestive tract. GI bleeding is a
symptom of a disease or condition, rather can cause a lot of bleeding.
than a disease or condition itself. Acute GI
bleeding is sudden and can sometimes be These are most common in
severe. It can occur from any part of the GI people who drink alcohol to
tract that runs from your mouth to your anus.
excess.
TYPES OF BLEEDING ● Abnormal enlarged vein in
1. Upper GI Bleeding Upper GI bleeding the esophagus
arises above the ligament of Treitz, also
called the suspensory ligament of the (esophageal)This condition
duodenum, and it includes bleeding from
the esophagus, stomach, or duodenum. occurs most often in people
with serious liver disease.
Typical presentation includes;
● Esophagitis This
● Hemtemesisvomiting of
blood or altered blood (coffee inflammation of the esophagus
ground). Indicating bleeding
is most commonly caused by
32
gastroesophageal reflux esophagus, stomach, colon or

disease (GERD). rectum can weaken the lining
2. Lower GI Bleeding of the digestive tract and cause
● Lower GI bleeding arises below the bleeding.

● Colon Polyp Small clumps of
ligament of Treitz and includes
cells that form on the lining of
bleeding from the small intestine past
your colon can cause bleeding.
the ligament of Treitz, large
Most are harmless, but some
intestines, rectum, and anus.
might be cancerous or can
Typical presentation includes; become cancerous if not
removed.
● Hematocheziarefers to bright red or
● HemorrhoidsThese are
maroon bleeding, which is a fresh swollen veins in your anus or
blood passing through the anus which lower rectum, similar to
may or may not mixed with stool. varicose veins.
● Anal fissuresThese are small
Causes can include:
tears in the lining of the anus.
● ProctitisInflammation of the
● Diverticular Disease This
lining of the rectum can cause
involves the development of
rectal bleeding.
small, bulging pouches in the
digestive tract (diverticulosis).
RISK FACTOR
If one or more of the pouches
● Chronic vomiting
become inflamed or infected,
● Previous history of GIB
it's called diverticulitis.
● Inflammatory bowel disease ● Medications: NSIAD’s/
(IBD) This includes ulcerative anticoagulants/ antiplatelet
colitis, which causes ● Previous gastrointestinal
inflammation and sores in the surgery

colon and rectum, and Crohn's ● Portal hypertensive
disease, and inflammation of gastropathy
the lining of the digestive tract.
● TumorsNoncanerous (benign) DIAGNOSIS
or cancerous tumors of the ● Your doctor will take a medical
33
history, including a history of recorder you wear on a belt around

previous bleeding, conduct a physical your waist. This enables your doctor
exam and possibly order tests. Tests to see inside your small intestine.
might include: ● Flexible sigmoidoscopy A tube with
● Blood testYou may need a complete a light and camera is placed in your
rectum to look at your rectum and the
blood count, a test to see how fast
last part of the large intestine that
your blood clots, a platelet count and
leads to your rectum (sigmoid colon).
liver function tests.
● Ballon assisted enteroscopy A
● Stool test. Analyzing your stool can
specialized scope inspects parts of
help determine the cause of occult
your small intestine that other tests
bleeding.
using an endoscope can't reach.
● Nasagastric lavageA tube is passed
Sometimes, the source of bleeding
through your nose into your stomach
can be controlled or treated during
to remove your stomach contents.
this test.
This might help determine the source
● Angiography A contrast dye is
of your bleed.
injected into an artery, and a series of
● Upper endoscopyThis procedure
X-rays are taken to look for and treat
uses a tiny camera on the end of a
bleeding vessels or other
long tube, which is passed through
abnormalities.
your mouth to enable your doctor to
● Imaging test A variety of other
examine your upper gastrointestinal
imaging tests, such as an abdominal
tract.
CT scan, might be used to find the
● ColonoscopyThis procedure uses a
source of the bleed.
tiny camera on the end of a long tube,
which is passed through your rectum
SIGNS AND SYMPTOMS
to enable your doctor to examine your
large intestine and rectum. ● Signs and symptoms of GI
● Capsule endoscopy In this bleeding can be either obvious
procedure, you swallow a (overt) or hidden (occult).
vitamin-size capsule with a tiny Signs and symptoms depend
camera inside. The capsule travels
on the location of the bleed,
through your digestive tract taking
which can be anywhere on the
thousands of pictures that are sent to a
GI tract, from where it starts —
34
the mouth — to where it ends to help with low blood

— the anus — and the rate of pressure
bleeding. ● Sedatives, anti-anxiety
● Overtbleeding might show up and pain medications
as: that will help keep your
● Vomiting blood, which might loved one comfortable.
be red or might be dark brown
Treatment that may also be used to treat
and resemble coffee grounds in
gastrointestinal bleeding area:
texture
● Black, tarry stool ● Transjugular Intra-hepatic
● Rectal bleeding, usually in or Portosystemic Shunt (TIPS): a
with stool procedure used to make an opening
With occult bleeding, you might have: between two blood vessels in the
● Lightheadedness liver. This lowers pressure in the liver
● Difficulty breathing and can stop bleeding.
● Fainting ● Blood transfusions
● Chest pain ● Intravenous (IV) fluids to help with
● Abdominal pain blood pressure
● Gastric lavage (a tube passed through
TREATMENT&MANAGEMENT your nose or mouth into your stomach
Medications that may be used to treat to take out your stomach contents)
gastrointestinal bleeding include:
● Endoscopic procedures, such as:
● Laxatives to prepare the
● Vusing an elastic band to tie off
bowel for endoscopy
bleeding veins, known as banding
● Octreotide to help
esophageal varices
control bleeding
● V injecting glue or a medication that
● Pantoloc to help reduce
causes the bleeding blood vessel to
ulcers from forming or
clot
growing
● Balloon tamponade (a tube is inserted
● DDAVP to help control
down the esophagus and into the
bleeding
stomach to decrease bleeding)
● Intravenous medications
35
● Angiographic embolization (a ● Frequent, small feedings may be

procedure done to block the bleeding indicated. Offer snacks; high-protein
blood vessel) • surgery (may be done supplements.
to open the abdomen and stop the
bleeding)
NURSING MANAGEMENT
1. Attaining Normal Fluid Volume
● Maintain NG tube and NPO status to

rest GI tract and evaluate bleeding.
● Monitor intake and output as ordered
to evaluate fluid status.
● Monitor vital signs as ordered.
● Observe for changes indicating
shock, such as tachycardia,
hypotension, increased respirations,
decreased urine output, change in
mental status.
● Administer I.V. fluids and blood
products as ordered to maintain
volume.
2.Attaining Balanced Nutritional Status
● Weigh daily to monitor caloric status.

● Administer I.V. fluids, TPN if ordered
to promote hydration and nutrition
while on oral restrictions.
● Begin liquids when patient is no
longer NPO.
● Advance diet as tolerated. Diet should
be high-calorie, high-protein.
36
Chapter V
ICU/EMERGENCY EQUIPMENT
Nasogastric tube
purposes
Introduction ● To relieve vomiting and digestion
● Nasogastric tube feeding is common
● To feed with fluids when oral intake is
practice and many tubes are inserted
not possible.
daily without incident. However, there
is a small risk that the tube can CONTRAINDICATIONS OF NGT
become misplaced into the lungs ● Head trauma, maxillofacial injury,
during the insertion, or move out of anterior fossa skull fracture
the stomach at e later stages. ● Patient with Hx of esophageal
● Auscultation must not be used to stricture, esophageal varices
check or correct nasogastric tube ● Patient in coma have the potential of
placement as studies have shown this vomiting during an NG insertion
method to be inaccurate.NG tube procedure, thus requiring protection
should be aspirated and the tube of the airway prior to placing NGT.
position confirmed using pH indicator
strips that CE marked and intended NG insertion is most commonly used for
for use on human gastric aspirate. patient who:
● Surgical patients
~ It is a method of introduction a tube ● Ventilated patients
through nose into stomach ● Neuromuscular impairment
● 6-8 french gauge ● Patients who are unable to maintain
● Length of tube is measured in cm adequate oral intake to meet
Types of tubes metabolic/nutrition demands.
Short tubes: passed through the nose into the ● To assess patency of the nares.
stomach equipment
Medium tubes: tubes are passed through the ● Personal protective equipment
nose to the duodenum and jejunum ● NG tube
Long tubes:passed through the nose,through ● Catheter tip irrigation 60 ml syringe
the esophagus and stomach into the intestine. ● Water soluble lubricant preferably 2%
xylocaine jelly
● Adhesive tape
● Low powered suction device OR
drainage bag
● Stethoscope
● Cup of water 9if necessary) ice chips
● Emesis basin
● pH indication ships
Indication of gi Procedure: ng insertion
intubation ● Perform hand hygiene and prepare all
● To decompress the stomach and
remove gas and liquids necessary equipment
● To lavage the stomach and remove ● Identify the pt by closing the door to
ingested toxins the patient's room and/or drawing the
curtain surrounding the patient's bed
● To administer medications and feed
● Introduce yourself for knowledge and
● To collect gastric juice for diagnostic
anxiety regarding insertion of the
NGT
● Explain the procedure and its
37
purpose: answer any question and ● Insert the NG tube tip slowly into the
provide emotional support as needed. patient's nostril in advance steadily.
● Observe standard precaution ● Twist that should slightly, apply
throughout the procedure Assess the downwards pressure, and continue
patient to determine if the patient trying to advance the tube. If
meets the criteria for NGT placement significant resistance is felt, remove
● Check the condition of the NGT for that you've and allow the patient to
defects (e.g..rough edges): use the rest before trying again in the other
catheter to flush water through the nostril.
lumen to verify its impact and Note: if there is difficulty in passing the NG
patients. tube, you may ask the patient to sip water
● Obtaining the patient's verbal consent slowly through a straw unless oral fluids are
prior to beginning the procedure. contraindicated. If oral fluids are not
● Palpitate patient's abdomen for this allowed, ask the patient to try swallowing
tension pain and/or rigidity auscultate while advancing the tube.
for vowel sound. Position patient suctioning
sitting up at 45 to 90 degrees (unless Removal of the secretion from the oral
contraindicated by the patient cavity or nasal cavity and pharynx through
condition), with a pillow under the the suction.
head and shoulders. Suctioning of the upper respiratory airways
● Raised bed to a comfortable working is indicated when the client is:
height. 1. Is unable to expectorate cough
● Agree on signals the patient can use if secretion.
they wish you to pause during the 2. Is unable to swallow.
procedure. 3. Makes flight bubbling or rotting brief
● Place a towel on the patient's chest sounds. Purpose To remove secretion
and provide facial tissue and an that abstract the airway. To facilitate
emesis basin. respiratory ventilation. To prevent
● Provide the patient with drinking infection that may result from
water and straw if the patient is not accumulated secretion
fluid restricted.
● Use your dominant hand to insert the Assessment
tube stand on the patient's right side if ● Assess for restlessness.
you are right handed or on the ● Gurgling sounds during respiration.
patient's left side if you are left ● Adventitious sounds when the chess
handed. is auscultate.
● Measure distance of the tube from the ● Change in mental status, skin color,
tip of the nose to.. rate and pattern of respiratory and
● the earlobe to pulse rate rhythm.
● the xiphoid process PROCEDURE.
● and then mark the tube at his point. a. Explain the procedure to the pt that
● Lubricate NG tube tip for about 6-8 suctioning will receive breathing
inches with lubricant using a paper difficulty and that the procedure is
square or according to your agency painless but may stimulate the cough,
policy. gag, or sneeze reflexes
● Apply clean non sterile gloves. b. Provide semi-fowler’s position to pt
● Curve 10-15 cm off the end of the NG for conscious person who has
tube around your gloves finger, and functional gag reflex with turned to
then release it. one side for oral suctioning or with
● Have the patient drophead forward the neck hyperextended for nasal
and breathe through the mouth. suctioning
38
c. For unconscious client: lateral NASOPHARYNGEAL SUCTION:

position facing the nurse ● Without applying suction, insert the
d. Place the towel or moisture resistance catheter the pre measured or
pad over the pillow or under the chin. recommended distance into either
2. PREPARE THE EQUIPMENT naris and advance it along the floor of
● Set the pressure on the suction gauge the nasal cavity
and turn on the suction: ● Never force the catheter against an
Portable Unit obstruction. If the nostril is
○ Adult: 8-15 mmHg; 100-120 obstructed, try the other.
mmHg Perform suctioning
○ Children: 5-8 mmHg; 50-100 ● Apply your finger to the suction
mmHg control port to start suction, and
○ Infant: 3-5mmHg; 40-60 gently rotate the catheter
mmHg ● Apply intermittent suction for 5-10
Wall Unit seconds; rotate catheter; then remove
○ Adult: 8-15mmHg; 10-15 your finger from the control and
mmHg remove the catheter
○ Children: 5-8 mmHg; 5-10 ● A suction attempt should last for
mmHg 10-15 seconds. During this time, the
○ Infant: 3-5mmHg; 2-5 mmHg catheter is inserted, the suction
● Open the suction package applied and discontinued and catheter
a. Set up the cup or containers, removed.
touching only its outside ●
b. Pour sterile water or saline into
the container -
c. Don the sterile gloves or don 7. Encourage the client to breathe deeply and
non sterile on nondominant to cough between suctions
hand gloves on the non 8. Obtain specimen if required sputum trap
dominant hand and then 9. Promote client comfort
● With the sterile gloved hand pick up 10. Disposed of equipment and ensure
catheter, and attach it to the suction availability for the next suction
unit ● To ensure that equipment is available
● Open lubricant if performing for the next suctioning, change
nasopharyngeal suctioning suction collection bottles and tubing
● daily or more frequently as necessary
3. Make an approximately measure of the 11. Ensure client’s comfort and assess the
depth for the insertion of the catheter and test effectiveness of suctioning.
the equipment ● Auscultate the client breathing sounds
- Measure the distance between the tip to ensure they are clear of secretions
of the client’s nose and the earlobe or ● Observe skin color, dyspnea and level
about 13 cm for an adult of anxiety
- 12. Document relevant data
● Record the procedure: the amount,
– consistency, color, and odor of
sputum, and the clients breathing
4. Lubricate and introduce the catheter status before and after the procedure.
● For nasopharyngeal suction, lubricate INFUSION PUMPS
the catheter tip with sterile water, ● Capable of delivering fluids in large
saline or water-soluble lubricant; for or small amounts, and may be used to
oropharyngeal suction, moisten the tip deliver nutrients or medications - such
with sterile water or saline as insulin or other hormones,
39
antibiotics, chemotherapy drugs, and infusion or the insertion of a

pain relievers. nasogastric tube)
Syringe Driver: in a syringe pump, fluid is ● The pt does not wish to take regular
held in the reservoir of a syringe, and a medicine by mouth.
moveable piston controls fluid delivery
● Small, portable, battery-operated
device that administers medicines HOW TO OPERATE:
subcutaneously over a selected time Generally, a syringe pump is made of four
period, usually 24 hours. Medicines main components which are the pusher
are drawn up into a syringe that is block which contacts the plunger to initiate
then attached to the driver, which is flow syringe clamps; which allows manual
set to move the plunger of the syringe positioning of the syringe pusher block.
forward at an accurately controlled Control panel that allows one to easily
rate. The tube is inserted using a very program flow rates and volume syringe
thin needle, which is then removed. pump.
● Usually inserted just under the skin on
upper outer arms, thighs, abdomen SYRINGE PUMP OPERATING
(tummy). This is sometimes called INSTRUCTIONS
“continuous subcutaneous infusion.” PROCEDURE FOR INSERTING
● Can be placed into a carry bag or SC CANNULA:
pouch when a pt is mobile or be 1. Wash hands as per hand hygiene
tucked under a pillow if the pt is policy
bed-bound. 2. Explain procedure to pt and gain
MEDICINES IN A SYRINGE consent. Ask pt if they have a
preference for site.
PUMP: 3. Ensure the skin is clean and dry. Wash
● Meds used in syringe pumps are most
with soap and water if visibly soiled.
often used to treat pain, nausea, and
4. Put on gloves
vomiting, agitation, secretions, and
5. Remove needle cover and inspect
seizures. Medicines in a syringe pump
needle and cannula
can be adjusted to suit the pt’s needs.
6. Pinch skin between thumb and
FUNCTION/INDICATION: forefinger to ensure the SC tissue is
● Syringe pumps are used to deliver a identified.
very small amount of meds gradually, 7. When using a soft cannula infusion
mechanically moving the piston of a sets with integrated insertion device:
syringe to send medication into IV Insert cannula at a 90o angle (follow
tubing. instructions for the product you are
● Used to manage symptoms such as using)
pain, nausea and vomiting, seizures, 8. Ensure the built-in adhesive dressing
agitation, and respiratory secretions. is firmly adhered to the skin. If no
● The pt is unable to take meds PO d/t built-in adhesive dressing, then secure
nausea and vomiting, severe oral insertion site with a transparent
lesions (mucosal ulceration, semi-permeable dressing
dysphagia, weakness, sedation, or 9. If unsuccessful, do not re-insert the
coma) cannula. Insert a new cannula
● Poor absorption of oral medicines 10. Write date of insertion of cannula on
● Pain is not able to be controlled using dressing
orally administered medicines or there 11. Document date, time and site of
is a malignant bowel obstruction and cannula insertion on monitoring chart
further surgery is inappropriate 12. Remove the glove
(therefore avoiding the need for an IV 13. Decontaminate hands as per hand
40
hygiene policy. SYRINGE PUMP OPERATING

SETTING UP SYRINGE PUMP: INSTRUCTIONS:
● Forward mov’t of the actuator is
● 2 registered practitioners must be
limited for safety reasons. Thus,
present when setting up the pump
repeated depressions of the FF key
● Always check the battery power
may be required when moving the
before commencing the infusion.
actuator forward. Backwards
Press the INFO key until the battery
movement is not restricted
level option appears on the screen and
● To avoid an inadvertent
then press YES to confirm
administration of a bolus dose, the
● If the battery power has less than 30%
syringe must be attached to the pump
life remaining at the start of an
before being connected to the pt.
infusion then a new battery must be
● The syringe size and brand option will
installed below.
then be displayed.
● The battery should be removed from
● If the syringe size and brand match
the syringe pump when not in use.
the screen message, press the YES
INSERT SYRINGE: key to confirm. If the syringe size
● Lift the barrel clamp arm and seat the and/or brand do not match, scroll with
filled syringe collar/ear and plunger up or down keys until the correct
so the back of the collar/ear sits in the selection appears, then press the YES
central slot (ensure correct key to confirm
placement). The syringe collar/ear
should be vertical with the scale on
the syringe barrel facing forward.
● Click the syringe plunger into the
actuator - this may require some
pressure.
● Lower the barrel clamp arm. The
syringe graphic on the screen ceases
to flash when the syringe is correctly REGULAR CHECKS:
seated at all 3 points. A dedicated syringe driver chart should be
● Ensure the barrel clamp arm is down used to prompt regular checks approximately
on the syringe q4h. This should include:
● Press and hold the ON/OFF key until ● Site condition: does the site need
the “pump identification” screen changing?
appears. The identification screen ● Leakage at the various connections:
briefly shows the pump model and ● Rate setting: Stays the same for the
software version. whole syringe
● The LCD display will indicate ● Volume remaining in ml: is it running
“preloading”and the actuator will start too fast or too slow or not at all?
to move. Wait until it stops moving ● Appearance of contents of the syringe
and the syringe sensor detection and infusion line: is it clear or cloudy
screen (syringe graphic) appears. or can crystals be seen? (precipitation/
● During “Pre-loading” the actuator will crystallization)
return to the start position of the last ● Battery: is the indicator lamp
infusion programmed. If the actuator flashing?
is not in the correct position to
accommodate the syringe, leave the
NURSING CONSIDERATION:
Consideration when using a syringe driver
barrel clamp art down and use the FF
● There is a need to anticipate the pt’s
or BACK keys on the keypad to move
requirements over 24 hours
the actuator.
● An exacerbation of symptoms may
41
necessitate add’l injections to programs. Using medical utz imaging

supplement the infusion allows doctor to diagnose problems
● It should not be seen as the sol’n to all with internal organs and sources of
problems - symptoms still need to be inflammation or pain in the body
assessed regularly and the medication ● Utz imaging is the most common
and does adjusted accordingly testing method used on pregnant
● Some pts may find the syringe driver women to monitor the growth of a
heavy fetus inside the body.
● There is a myth regarded by some that FUNCTION/INDICATION
the syringe driver is a last resort, or a ● To view the uterus and ovaries during
sign of impending death. In fact, some pregnancy and monitor the
pts use a syringe driver for extended developing baby’s health.
periods of time, and may return to ● Diagnose gallbladder disease
oral meds once symptoms are ● Evaluate blood flow
controlled ● Examine a breast lump
● Training of nurses is essential to ● Check the thyroid gland
ensure safe and effective use. ● Find genital and prostate problems
Preparing the pt and family ● Assess joint inflammation (synovitis)
● It is important to recognize that ● Evaluate metabolic bone disease
having a syringe driver can be a
frightening new experience for the pt HOW TO OPERATE?
and their family. Before getting started, set up the B-mode
● Spend time with the pt and family image.
explaining the procedure At the start of every scan, the B-mode image
● Be aware that some people believe a should be optimized to best display the area
syringe driver is a last resort, a sign of of interest.
impending death, or a means of ● Curvilinear probe shows a transverse
euthanasia. These are fears that will scan of the upper abdomen.
need exploring, providing reassurance GAIN:
that these fears are not true ● To make the image clearer, increase
● Invite questions, acknowledge the amplification of the reflected utz
anxieties and reassure where signal in the image so galled gain.
appropriate ● Controlled using a rotary control in
● Remember that the pt with lethargy the middle of the console, similar to a
may not have the energy to follow volume knob.
explanations. ● Increasing gain makes the entire
image brighter
ULTRASOUND DEPTH:
● To best assess the structure of interest,
Introduction displayed as largely as possible and
● A medical device which uses sound centered on the screen, adjust the
waves on a body’s organs for testing, penetration depth of the utz signal to
diagnostic, or therapeutic reasons. the minimum required to still allow
The sound waves travel through the the structures of interest to be
body and are converted into an visualized. It is done using the rotary
ultrasound image showing the control labeled “DEPTH/ZOOM”.
condition and boundaries of fluid and FOCUS:
soft tissue and internal organs in the ● Image resolution can be selectively
body. increased in the area of interest by
● This allows medical staff to diagnose adjusting the focal zone. This is done
problems and decide on treatment using another rotary control
42
DOCUMENTATION FUNCTION line over the B-mode image and

FREEZE FUNCTION: brings up a diagram. This allows us to
● When performing a scan, it can be visualize the movement of the
very helpful to freeze the image at a structures along the cursor line over
specific point in time. You can do this time. Pressing the “M” button again
using the freeze function. The freeze exits the mode.
button is labeled “F-R-Z” and is
located on the lower right of the NSG RESPONSIBILITIES
console. Pressing the button freezes During Labor:
the current image. Once you press ● Assessment and mn’t of the
freeze, most machines allow you to physiologic and psychological
scroll back through the most recent processes of labor
frames to select the best one. You can ● Facilitation of normal physiologic
scroll using the trackball in the center processes such as the women’s desire
of the console, and pressing the freeze for mov’t in labor
button again returns to the real-time ● Provision of physical comfort
image. measures, emotional and
PERFORMING MEASUREMENTS: informational support and advocacy
● Once you’ve frozen the image, you ● Evaluation of fetal well-being during
can also perform measurements. The labor
fxn is activated by pressing the ● Instruction regarding the labor
“CALIPER” button. Next, confirm process
the starting point of your ● Facilitate family participation during
measurements by pressing the “SET” labor and birth.
button. Then use the trackball to
navigate to the end point. Press
“SET” again to confirm and display
the result. Pressing the “NEXT”
button allows you to take another
measurement.
ULTRASOUND MODES:
In addition to B-mode, there are other
scanning modes that provide further
information, the color doppler mode and
M-mode.
COLOR DOPPLER MODE:
● Used to look for the presence of flow,
usually the mov’t of blood in arteries
and veins. The fxn is activated and
deactivated by pressing the “CDI”
button, which stands for “Color
doppler imaging.” Other
manufacturers label this differently,
for example “C” for color or “CF” for
color flow. When color doppler mode
is activated, a box appears on the
screen.
M-MODE:
● Stands for “motion mode” and is
activated on this machine by pressing
the M-button. This projects a cursor
43

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NCM 118: Nursing Care of Clients with Life Threatening Conditions, Acute Multiorgan Problems, High Acuity &

Emergency Situations, Acute & Chronic

GOALS OF CRITICAL CARE

DYNAMIC INTERACTIONS LEGAL AND ETHICAL ISSUES IN

FIVE MOST CONCERNED ETHICAL

WAYS TO RESOLVE ETHICAL

ACUTE RESPIRATORY DISTRESS PNEUMOTHORAX

channel blockers, beta blockers experienced.

● Electron-beam computed afterwards. The stent

CONGESTIVE HEART HISTORY & RISK FACTORS

● Right-Sided Heart Failure: The right palpitations, dyspnea, or anginal pain.

sounds, in lung base) creatinine level

● Early S/Sx HF exacerbation ejection, and promote

standard therapy, especially if 5. Initiate a low cholesterol and

pulsation and IV inotrope therapy symptom mn’t should be continued to

because of the the back up of blood the heart muscle

does not provide information manage respiratory distress caused by

infusion to assist with constant inotropic agents used to treat

● Advance directives: pts with

Heart Rate Classification

It is likely that a person is having a cardiac

restart the heart of the affected person.

whose hypertension has been poorly proximal to ligament of treitz.

aCUTE GASTROINTESTINAL ● Tears in the lining of the

INTRODUCTION throat to your

Gastrointestinal (GI) bleeding is any type of stomach(esophagus) Known

gastroesophageal reflux esophagus, stomach, colon or

2. Lower GI Bleeding of the digestive tract and cause

● Lower GI bleeding arises below the bleeding.

(IBD) This includes ulcerative anticoagulants/ antiplatelet

colitis, which causes ● Previous gastrointestinal

inflammation and sores in the surgery

history, including a history of recorder you wear on a belt around

might include: ● Flexible sigmoidoscopy A tube with

the mouth — to where it ends to help with low blood

● Angiographic embolization (a ● Frequent, small feedings may be

● Maintain NG tube and NPO status to

2.Attaining Balanced Nutritional Status

● Weigh daily to monitor caloric status.

c. For unconscious client: lateral NASOPHARYNGEAL SUCTION:

antibiotics, chemotherapy drugs, and infusion or the insertion of a

hygiene policy. SYRINGE PUMP OPERATING

necessitate add’l injections to programs. Using medical utz imaging

DOCUMENTATION FUNCTION line over the B-mode image and

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