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NSG 4100
Theory Topics
Detailed Content Outline
Complex Perfusion Problems (Part I) o Hemodynamic Monitoring Continuous assessment of the cardiovascular system to diagnose & manage complex medical conditions Use by direct pressure monitoring systems Types Central Venous Pressure- measurement of the vena cava or right atrium and reflects the filling pressure of the right ventricle (preload). Normal CVP is 2-6 mm Hg. CVP > 6 mm Hg indicates an elevated right ventricular preload. CVP < 2 mm Hg indicates reduced right ventricular preload. CVP catheter can also be used for infusing IVF, administering IV medications, and drawing blood specimens. Pulmonary Artery Pressure- used to assess the left ventricular function, diagnosing the etiology of shock, and evaluating the patient’s response to medical interventions. Can measure right atrial, pulmonary artery systolic/diastolic, and pulmonary artery wedge pressures. Intra-arterial blood pressure monitoring- used to obtain direct and continuous BP measurements in critically ill patients who have severe hypertension or hypotension. They also can be used for frequent ABG measurements and blood samples. Nursing Interventions and Assessment Hand hygiene Dressing Change Catheter site- assess regularly-visually when changing the dressing or by palpation through an intact dressing. Remove dressing for a thorough assessment if the patient has: Tenderness at the insertion site Fever Other signs of local or bloodstream infections. Keep all components of the pressure monitoring system sterile. Replace transducers, tubing, continuous-flush device, and flush solution every 96 hours or per policy Do not infuse dextrose through the monitoring system. Bathing Do not submerge the catheter site in water Showering is permitted if the catheter and related tubing are placed in an impermeable cover. Patient education- ask patient to report any new discomforts from the catheter site. Nursing Diagnosis Risk for Infection Cardiac Dysrhythmias Cardiac rhythm abnormality affecting impulse generation or conduction. Indicate an underlying pathophysiologic disorder and can impair normal cardiac output Sinus Tachycardia
- Incorporate leadership skills required to provide and continuously improve the delivery of safe, patient- centered quality healthcare to patients experiencing complex, perfusion health problems. (CSLO 3)
- Integrate best practices and current evidence when using clinical reasoning to care for patients experiencing complex, perfusion health problems. (CSLO 4)
- Integrate how information systems and technology can be used to communicate, manage knowledge, mitigate error, and support decision making to care for patients experiencing complex, perfusion health problems. (CSLO 5) 6. Evaluate how effective communication and collaboration skills to improve patient satisfaction and health outcomes when caring for patients experiencing complex, perfusion health problems. (CSLO 6)
NSG 4100 P Wave: Normal and Consistent Shape, always in front of QRS PR Interval: 0.12-0.20 seconds Medical Depends on Cause Emergency Transcutaneous Pacing Medications Adrenergic Receptor (Epinephrine) Anticholinergic (Atropine) Diagnosis EKG Nursing Diagnosis Risk for complications of decreased cardiac output Atrial Fibrillation Pathophysiology/Pathogenesis Atrial depolarizations are blocked at the AV Node, with a few reaching the ventricles and initiating ventricular contractions. Causes the atria to quiver rather than contract forcefully. Completely disorganized and irregular atrial rhythm accompanied by an irregular ventricular rhythm of variable rate. Etiology Age Hypertension Diabetes Obesity Heart Failure Clinical Manifestations Risk for formation of Thrombi Cerebrovascular Stroke Heart Failure- increasing cardiac workload. Nursing Treatment/Interventions History and Physical Stroke Risk Assessment Monitor Lab (Coags and H/H) Keep INR 2.0 and 3. Electrical Cardioversion- Anticipate TEE performed to evaluate for atrial thrombi before cardioversion. Interpretation/Characteristics Rate: Atrial rate is 300 to 600 bpm, Ventricular Rate is 120 to 200 bpm Rhythm: Irregular QRS Shape: Usually normal, but may be abnormal P Wave: No discernible P waves, irregular, and shape are referred as fibrillatory waves PR Interval: Cannot measure Sign and Symptoms Some patients are asymptomatic Palpitations Heart Failure Shortness of Breath Hypotension Dyspnea on Exertion Fatigue Medical Treatment Prevent Emboli events
NSG 4100 Electrolytes Low Potassium Low Calcium Low Magnesium Congenital Diagnosis EKG Signs & Symptoms Rhythm likely to cause the patient to deteriorate and become pulseless Interpretation/Characteristics Polymorphic VT Medical Interventions Correcting electrolyte imbalances Medications Magnesium Sulfate Nursing Interventions Assessment Evaluating Labs Rhythm Interpretation Administer Medications Ventricular Fibrillation Pathophysiology/Pathogenesis Rapid, uncoordinated cardiac rhythm that results in ventricular quivering and lack effective contraction. Etiology Same as Ventricular Tachycardia Premature heart beats Accelerating V-Tach Coronary Artery Disease Acute MI Cardiomyopathy Acid-Base Imbalances Electrical Shock Clinical Manifestations Decreased cardiac output resulting in decrease blood supply to other tissue. Diagnosis EKG Physical Exam Signs and Symptoms Pulseless Loss of Consciousness Apnea Interpretations/Characteristics Rate: Ventricular rate is greater than 300 bpm Rhythm: Extremely irregular, without a pattern QRS Shape: Irregular with changing amplitudes. No recognizable QRS complexes. Medical Management Medications Potassium Channel Blocker (Amiodarone) Adrenergic agonist (Epinephrine)
NSG 4100 Pacemaker Implantation Used when a patient has a permanent or temporary slower than normal impulse Paces the atrium and then ventricle when activity is not sensed for a period of time. Types: depends on dysrhythmia, underlying cardiac function, and age On-Demand pacing Fixed pacing Transcutaneous Pacing Complications Dislodgement of pacing electrode Pacemaker malfunction Medications Anticholinergic (Atropine) Nursing Interventions Physical Assessment Cardiac Monitoring If patient does not have symptoms; no treatment or decreasing the cause (i.e. withhold medication or treatment) Premature Ventricular Contractions Pathophysiology/Pathogenesis The ventricles do not activate the atria while the normal sinus rhythm is buried in the bizarre-looking QRS complex from the premature ventricular beat. The interval between the sinus beat preceding the premature beat and the sinus beat following the premature beat is twice the regular interval. Etiology Coronary Artery Disease Drug Overdose Electrolyte Disturbance- Hypokalemia, Hypomagnesemia Caffeine, Nicotine, Alcohol Heart Failure Tachycardia Digitalis Toxicity Hypoxia Acidosis Diagnosis EKG Signs and Symptoms may be asymptomatic or may feel heart “skipped a beat” Interpretation/ Characteristics Rate: Depends on underlying rhythm Rhythm: Irregular due to early QRS QRS Shape: 0.12 seconds or longer, shape is bizarre and abnormal P Wave: May be absent or hidden, depends on timing of QRS PR Interval: If P Wave is in front of the QRS, the interval is less than 0.12 seconds Unifocal vs Multifocal Medical Management Medications Potassium Channel Blocker (Amiodarone) Nursing Management Monitoring patient for frequent PVCs
NSG 4100 Complications Hypovolemia Hemorrhage Cardiac Tamponade Fluid Overload Hypothermia Hypertension Cardiac Failure MI Stroke Acute Kidney Injury Electrolyte Imbalances Hepatic Failure Infection Nursing Management Preoperative Medication Administration Beta Blockers Aspirin Statins Assessment See Preoperative Interventions Postoperative Communication between team members Care of NGT to decompress stomach Care of Endotracheal tube Care of Central Venous Access, Swan Ganz, SVO Cardiac Monitoring Assess Pulses Neuro Assessment Assess Skin Epicardial Pacing Mediastinal and pleural chest tubes Care of Arterial Line Foley Cath care Nursing Diagnosis Decreased cardiac output Impaired gas exchange Risk for acute confusion Acute pain Anxiety Fear Geriatric Considerations May not present with pain Dyspnea Weakness Give Medications cautiously Nursing Diagnosis (ACS) Acute Pain Risk for Decreased Cardiac Tissue Perfusion Ineffective Peripheral Tissue Perfusion
NSG 4100 PVCs
UNIT 6
Theory Content from syllabus Clinical Learning Lab Content from syllabus
Complex Perfusion Problems (Part II) Cardiac Tamponade Pulmonary Edema Cardiogenic Cardiomyopathy Heart Transplant Abdominal Aortic Aneurysm (AAA) Aneurysms of Central and Peripheral Arteries Coagulation Disorders DIC ITP HIT Complex Perfusion Problems (Part II) CPE A (Central Line/PICC Dressing Change) Demonstration and practice
Unit Student Learning Outcomes
- Prioritize holistic, culturally competent care for patients experiencing complex, perfusion health problems. (CSLO 1)
- Evaluate professional values and behaviors when delivering standards-based nursing care to patients experiencing complex, perfusion health problems. (CSLO 2)
- Incorporate leadership skills required to provide and continuously improve the delivery of safe, patient- centered quality healthcare to patients experiencing complex, perfusion health problems. (CSLO 3)
- Integrate best practices and current evidence when using clinical reasoning to care for patients experiencing complex, perfusion health problems. (CSLO 4)
- Integrate how information systems and technology can be used to communicate, manage knowledge, mitigate error, and support decision making to care for patients experiencing complex, perfusion health problems. (CSLO 5)
- Evaluate how effective communication and collaboration skills to improve patient satisfaction and health outcomes when caring for patients experiencing complex, perfusion health problems. (CSLO 6)
Theory Topics
Detailed Content Outline
Complex Perfusion Problems (Part II) Cardiac Tamponade Pathophysiology/Pathogenesis/Etiology o Accumulation of pericardial fluid without clinical significance except as indicator of underlying disease o Tamponade is the compression of heart chambers impairing filling. Clinical Manifestations o Sudden chest pain, tachypnea, and dyspnea Signs and Symptoms o heart rate o distended neck veins o Pulsus paradoxus- Rising filling pressures in heart chambers o Muffled heart sounds o Dull chest pain o Diminished electrocardiographic amplitude Diagnosis
NSG 4100 Signs and symptoms of impending rupture Severe back pain or abdominal pain Often localized in the middle or lower abdomen Indications of a rupturing aneurysm Constant, intense back pain Falling blood pressure Decreasing hematocrit Diagnosis Palpable pulsatile mass in the middle and upper abdomen A systolic bruit may be heard over the mass. Duplex ultrasonography or CTA is used to determine the size, length, and location of the aneurysm. Rupture is likely with coexisting hypertension and aneurysms more than 6 cm wide. Gerontological considerations Older patient that is at risk for complications related to surgery or anesthesia then the aneurysm is not repaired until 5.5 cm wide. Medical management Medication Antihypertensives Diuretics (Hydrochlorothiazide) Beta blockers (Atenolol) ACE inhibitors (Captopril) Angiotensin II Receptor Blockers (ARB) (Losartan) Calcium channel blockers (Amlodipine) Endovascular and surgical management Standard treatment has been open surgical repair of aneurysm by resecting the vessel and sewing a bypass graft in place. Prior to endovascular repair or surgery, nursing care must be guided by the anticipation of a rupture or by recognizing the patient may have cardiovascular, cerebral, pulmonary, and renal impairment due to atherosclerosis. Functional capacity of all organs should be assessed. Medical therapy is designed to stabilize the physiologic function. Hemorrhage that leads to shock is a serious consequence that must be treated. The endovascular aortic repair has become the treatment of choice for treating an infrarenal abdominal aortic aneurysm. Involves the transluminal placement and attachment of suture less aortic graft prosthesis across an aneurysm. Procedure done under local or regional anesthesia. Comparable mortality rates with similar 5-year survival rates. Potential complications include: Bleeding Wound infection Hematoma Distal ischemia or embolization Dissection or perforation of aorta Graft thrombosis or infection Break of the attachment system Graft migration Proximal or distal graft leaks Delayed rupture Bowel ischemia Nursing management
NSG 4100 Dissecting Aorta Pathophysiology Associated with poorly controlled HTN, blunt chest trauma, and cocaine use Dissection is caused by rupture in the intima layer May occur through adventitia or into lumen through the intima As separation progresses the area of aorta sheer and occlude May progress backward in direction of heart or may occur in opposite direction occluding GI tract, kidneys, spinal cord, and legs Clinical Manifestations Onset of symptoms is sudden, severe, and persistent pain. Patient may appear pale, sweating, and tachycardic. Blood pressure may be elevated or different from one arm to the other. Medical Management Medical or surgical treatment is same as those for thoracic aortic aneurysms. Nursing Management Same nursing care Coagulation Disorders Pathophysiology Defects of the normal clotting mechanisms. Etiology Not an actual disease but a sign of an underlying condition. May also contribute to inappropriate activation of the coagulation cascade producing excessive clot formation (DIC) Disseminated Intravascular Coagulation Pathophysiology Represents a paradox of both thrombosis and hemorrhage. Accelerated intravascular clotting in small vessels is initiated by contact with blood that has damaged vascular endothelium, generation or release of procoagulants in the blood, or stagnant blood flow. Coagulation factors are rapidly consumed, the fibrinolytic system is activated to break down clots, and fibrin degradation products or fibrin split products result acting as circulating anticoagulants. Combination of coagulation, anticoagulation, and fibrinolysis ultimately leads to hemorrhage An acquired hemorrhagic syndrome in which both clotting and bleeding occur simultaneously. Etiology Mortality rate can exceed 80% in patients who develop severe DIC with ischemic thrombosis, frank hemorrhage, and multiple organ dysfunction syndrome (MODS). Widespread clotting in small vessels leads to consumption of clotting factors and platelets causing bleeding. Can be both acute or chronic Chronic Seen with cancer patients with malignancies-less severe Acute Occurs secondary to variety of factors including malignancy, sepsis, snake bite, abruptio placentae, trauma, crushing injuries, transfusions of incompatible blood, burns, shock, severe liver disease. Clinical Manifestations Primarily reflected in compromised organ function or failure. Decline in organ function is a result of excessive clot formation with resultant ischemia to all or part of the organ.
NSG 4100 Contusion Flail Chest Pneumothorax/Hemothorax Chest Tubes Malignant Disorders Lung Cancer Laryngeal Cancer
Unit Student Learning Outcomes
- Prioritize holistic, culturally competent care for patients experiencing complex, oxygenation, chest trauma, and malignant health problems. (CSLO 1)
- Evaluate professional values and behaviors when delivering standards-based nursing care to patients experiencing complex, oxygenation, chest trauma, and malignant health problems. (CSLO 2)
- Incorporate leadership skills required to provide and continuously improve the delivery of safe, patient- centered quality healthcare to patients experiencing complex, oxygenation, chest trauma, and malignant health problems. (CSLO 3)
- Integrate best practices and current evidence when using clinical reasoning to care for patients experiencing complex, oxygenation, chest trauma, and malignant health problems. (CSLO 4)
- Integrate how information systems and technology can be used to communicate, manage knowledge, mitigate error, and support decision making to care for patients experiencing complex, oxygenation, chest trauma, and malignant health problems. (CSLO 5)
6. Evaluate how effective communication and collaboration skills to improve patient satisfaction and health
outcomes when caring for patients experiencing complex, oxygenation, chest trauma, and malignant health problems. (CSLO 6) Obstruction of the Airway Bronchiectasis
Theory Topics
Detailed Content Outline
Pathophysiology/Etiology/Pathogenesis o Dilation of the bronchi o Congenital or acquired o Classified according to shape o Characterized by recurrent infections and inflammation. Diagnosis o Based on a history of chronic cough o X-rays o ABG o Pulmonary Function Test o CT Manifestations o Chronic cough o Production of purulent sputum o Hemoptysis o Clubbing of the fingers o History of recurrent pulmonary infections o Nursing Interventions and Assessment o Promote bronchial drainage o Clear secretions o Chest physiotherapy o Patient Education: fatigue, nutrition and energy conservation during dyspnea. o Treatment
NSG 4100 o Decreased or absent lung sounds due to little to no air movement o Stridor o Wheezing o Universal distress signal o Apprehension o Treatment o Intubation o Removal of foreign body via abdominal thrusts (Heimlich) Nursing Diagnosis o Ineffective airway clearance o Ineffective breathing pattern Epiglottitis Pathophysiology/Etiology/Pathogenesis o Rapidly progressing cellulitis of epiglottis and surrounding tissues o Primarily causes by H. Influenza Type B (Hib) o Often seen in children 2-4 years old o Can lead to fatal swelling Diagnosis o Direct or fiber optic visualization of epiglottis. o X-Ray o CBC Clinical Manifestations o Drooling o Dysphagia o Rapid onset fever o Inspiratory stridor o Retractions o Sniffing in children Treatment o Intubation o Preventative treatment (Hib vaccination) o Medications o Antibiotics as prescribed Nursing Diagnosis o Impaired Gas Exchange o Ineffective Breathing Pattern Pulmonary Emboli Pathophysiology/Etiology/Pathogenesis o An undissolved detached material that occludes blood vessels of the pulmonary vasculature. Includes Thrombotic and fat emboli. o Risk factors include extended bed rest, postoperative state, immobility, obesity, dehydration, smoking, pregnancy, oral contraceptives, burns and trauma. o Thrombi are dislodged by multiple mechanisms. The undissolved material travels into pulmonary vasculature. Most involve the lower lobes due to the high volume of blood flow. Pulmonary hypertension occurs, which can lead to right sided heart failure. Diagnosis o Chest X-Ray o ECG o D-Dimer o Pulse Oximetry, ABG o V/Q Scan o Computed Tomography o Angiography
NSG 4100 o Assess oxygen saturation o Assess response to medications Nursing Diagnosis o Impaired Gas Exchange o Ineffective Breathing Pattern Lung Transplant Pathophysiology/Etiology/Pathogenesis o Viable and definitive option for treatment of severe COPD or lung cancer in selected patients o Limited by both the shortage of donors but also the cost of the procedure and treatment afterwards. o After surgery, recipients will be on lifelong immunosuppressants r/t the risk of rejection. Chest Trauma Contusion Pathophysiology/etiology/pathogenesis o Abnormal accumulation of fluid in the interstitial and intra-alveolar spaces o Injury to the lung parenchyma capillary network results in leakage of serum protein and plasma, which exerts osmotic pressure that enhances loss of fluid from capillaries Diagnosis o Physical examination o ABG’s o Chest X-ray Clinical Manifestations o Mild, moderate of severe o Tachypnea, o Tachycardia, o Decreased breath sounds o Chest pain o Hypoxemia o Blood tinged secretions o Severe crackles o Frank bleeding o Cyanosis Medical Treatment o Mechanical Ventilation with PEEP o Medication o Opioids (Morphine Sulfate) o Antimicrobial medications as prescribed Nursing Diagnosis o Impaired Gas Exchange Flail Chest Pathophysiology/Etiology/Pathogenesis o Caused by multiple rib fractures associated with trauma to the chest wall. o Each rib is broken at two sites, creating instability and a flail segment. Diagnosis o Serial Blood Gases o Chest X-ray Signs and Symptoms: o Paradoxical chest wall movement o Hypotension o Inadequate tissue perfusion o Metabolic acidosis o Decreased cardiac output o Pain
NSG 4100 Assist with insertion and management of chest tube Chest Tubes Indications Pneumothorax or Hemothorax After thoracic surgery Types of Systems Traditional (Wet suction) Water Seal Dry Suction Patient management Respiratory Assessment Monitor oxygenation Monitor EKG Assessment of dressing Encourage and assist patient with turning, deep breathing and coughing Chest Drainage Management Check connections Clamping of tubes Assess water seal Monitor characteristics of drainage (color, amount and consistency) Specimen collection Note fluctuations in the water seal chamber (tidaling) and for air leaks. Keep the drainage system below the patient’s chest Ensure suction is at prescribed level Emergent care: chest tube pulled out or disconnected Lung Cancer Pathophysiology/Etiology/Pathogenesis Form from a single transformed epithelial cell Classification and staging Primary or secondary Risk factors Smoking (firsthand, Secondhand) Occupational exposure Genetic predisposition Diagnosis Lung Biopsy CT Chest X-Ray Clinical Manifestations Often no symptoms until later in the course Most common sign is cough Signs and Symptoms Dyspnea Change in chronic cough Hemoptysis Pain Recurrent fever Medical Surgical removal Radiation therapy Immune therapy Medications o Chemotherapy Gerontological Consideration
