Understanding Congestive Heart Failure
Understanding Heart Disease (Basics)
Actual Heart Surgery
Stable Angina
Coronary Artery Bypass Graft
Percutaneous Transluminal Coronary Angioplasty(PTCA)
Wednesday, January 28, 2009
Cardiovascular videos - PTCA,Heart Basics,Actual heart Surgery,Stable Angina,CABG
More videos...for nursing lectures.
Cardiovascular Videos
Videos from youtube user medflux
Percutaneous Coronary Intervention(STENT)
Myocardial Infarction
Cardiac Arrhythmia
Coronary Angioplasty
CardioMyopathy
Altered Neurological Function
ALTERED NEUROLOGICAL FUNCTION
OUTLINE for this nursing lecture
- To determine if client will be able to do his ADLs
- Test for cerebral function
- LOC – most important single indication of cerebral function
- Level I: Conscious – normal awareness (oriented)
- Level II: Lethargy, Somnolence, or Obstundation – responds with confusion; falls asleep when left alone; responds briskly to painful stimuli
- Level III: Stupor – minimal physical & mental activity; reacts by reflex &/or making unintelligible sounds
- Level IV: Semi-coma – no spontaneous movement withdrawal from painful stimuli; verbal response is limited to groaning; cough & swallowing reflex may occur; incontinence
- Level V: Coma – no spontaneous movement; reflexes are very minimal to absent
- Assessment tool designed to note trends in response to stimuli
- Score Eye opening Verbal Response Motor
- 6 x x Obeys command
- 5 x oriented & converses Localizes pain
- 4 simultaneously opens confused, converses Withdraws fr. pain
- 3 verbal command Inappropriate Decorticate
- 2 Pain Incomprehensible Decerebrate
- 1 NO RESPONSE (GCS = 3)
- Scores: >11 = 86% chance of moderate disability or recovery
- 9+ = conscious
- 8 = 50/50condition
- 7↓ = lethargic
- <7>
- 3-4 = 85% chance of dying or vegetative state
- O lfactory (S) = test smell using odorous substances
- Hyperosmia – acute sense of smell
- Parosmia – abnormal sense of smell
- Anosmia – loss of sense of smell anosmia
- O ptic (S) = Snellen’s (3-6y/o =20/20vision)
- O cculomotor (M) eye movements = 6 gaze directions ( √ diplopia &
- T rochlear (M) strabismus, nystagmus)
- T rigeminal (B) (S) = facial sensations using pins/cottons
- A bducens (M) (M) = chewing & corneal reflex using cotton (+) blinking
- F acial (B) -> (S) = anterior tongue; (M) = facial expressions ( √ for Bell’s Palsy)
- A coustic (S) = hearing (tinnitus & vertigo) & balance -> Romberg’s test (+) means ataxia is present;
- G lossopharyngeal (B) -> (S) = posterior tongue; (M) = swallowing: √gag reflex
- V agus (B) -> √ gag reflex
- S pinal accessory (M) = head & shoulder movement
- H ypoglossal (M) = tongue movement
- Muscle strength
- Akinesia, hemiplegia, hemiparesis, paraplegia, quadriplegia
- 5-point Scale
- 5/5 = normal (full strength & ROM against gravity & applied resistance/pressure)
- 4/5 = full ROM but weakness upon against pressure
- 3/5 = move actively against gravity alone
- 2/5 = able to move with support
- 1/5 = contraction is palpable & visible; trace/flicker movements occur
- 0/5 = undetectable contraction & movement
- Muscle tone:
- Hypotonicity – soft, flabby, flaccid
- Hypertonicity – rigid, spastic
- Muscle coordination – Finger-to-nose test, heel Down Opposite Shin
- Babinski– normal for infants til 2y/o
- Brudzinski’s sign- flexion of hips & knees upon forward flexion of the neck
- Kernig’s sign – resistance or pain upon straightening the knees as the legs, hips, & knees are flexed
- Grading: 0 = absent
- +1= diminished
- +2 = normal
- +3 = brisker than ave.
- +4 = hyperactive
- Orientation
- Language / communication
- Aphasia – defect in using & interpreting symbols of language
- Receptive / sensory
- Motor / expressive
- Dysarthria / anarthria – imperfect articulation causing difficulty in speaking due to crani al nerve dysfunction
- Attention span – serial 3s / 7s
- Memory
- Immediate recall - 5-8digits then reverse 4-6digits
- Recent memory
- Remote memory
- ability to keep its body temperature within certain boundaries, even when temperature surrounding is very different
- Thermo-regulatory center = hypothalamus
- Physiologic adaptation:
- Vasodilatation and sweating are the primary modes to lose excess body
- Skin - assists in homeostasis by reacting differently to hot and cold conditions so that the inner body temperature remains more or less constant
- Heat loss
- Sweating is the only physiological way to lose heat - heat loss by evaporation
- Vasodilatation occurs, this is the process of relaxation of smooth muscle in arteriole walls allowing increased blood flow through the artery. This redirects blood into the superficial capillaries in the skin increasing heat loss by radiation and conduction
- Heat production
- Piloerection - lifting the hair follicle upright; makes our hairs stand on end which acts as an insulating layer, trapping heat
- Vasoconstriction - blood is rerouted away from the skin and tow ards the warmer core of the body; this prevents blood from loosing heat to the surroundings and also prevents the core temperature dropping further
- Seizures & Epilepsy nursinglectures.blogspot.com
- Paroxysmal uncontrolled abnormal discharge of electrical activity in the brain
- Malfunction of hypersensitive neurons in cerebral cortex & limbic centers
- A symptom rather disease in itself
- Classification according to etiology
- Primary / Unknown – assessment finding does not reveal a definite cause
- Secondary / Symptomatic – causes
- Hyperpyrexia
- CNS infection
- Cerebral hypoxia &/or trauma
- Toxic agents / poison; metabolic intoxication
- Brain defects
- Degenerative diseases
- anaphylaxis
- Generalized – usually begins bilaterally without local onset, EEG abnormalities
- Grand Mal / Generalized Tonic-Clonic Seizure
- Precede by an aura (strange feeling of sensation)
- Loss of consciousness
- Tonic phase – entire body stiffens in rigid contractions, fixed jaw, clenched fists, temporary interruption of respiration (30-60s duration)
- Clonic phase – rhythmic jerky contraction & relaxation of muscles (esp. extremities), may bite lip 7 tongue, may be followed by fatigue, confusion, depression, amnesia
- Petit Mal / Absence seizure
- No actual convulsive movement
- Vacant stare
- Childhood or early adolescence
- No recall of attack
- Partial / Focal Seizure – most common; depends on brain part involved
- Jacksonian / Simple Partial Motor Seizure
- Tonic-clonic convulsive movement in a localized body region opposite of lesion
- Usually without loss of consciousness
- nursinglectures.blogspot.com
- nursinglectures.blogspot.com Hypothermia, hypoglycemia, hypoxia, toxic substances Firing of neurons in increasing frequency & amplitude Threshold of intensity of electrical discharges Firing spreads to adjacent neurons Brain stem Cortex & basal ganglia Muscle contraction & loss of consciousness Slowing of neuronal firing Intermittent contraction-relaxation phase seizures
- Priorities: airway & safety
- Provide privacy
- Ensure patent airway
- Side-lying position
- Padded tongue depressor
- Prevent injury
- Raise padded side rails
- Do not leave client alone (stay with client until fully conscious)
- D not attempt to restrain
- Protect the head (slip a small pillow under; place on lap)
- Reorient client to surroundings upon waking
- Note position of eyeball & head at the beginning of attack
- Note duration of unconsciousness
- Observe for fecal or urinary involvement
- A brain disorder accompanied by periodic convulsions and loss of consciousness
- Causes:
- Head trauma – most common cause (closed head injuries)
- Brain tumors
- Risk factors:
- CVA
- CNS infections
- Toxic substances interfering with brain metabolism (O 2 & glucose supply) – lead, alcohol & substance abuse
- Genetic pre-disposition (cerebral dysrhythmia, monozygotic twins)
- Detailed Hx
- Neurologic assessment
- Mental status exam
- EEG (electroencephalogram) – determines existence & type of epilepsy
- Hair shampoo (Prior & after the test)
- Hold meds (sedatives, tranquilizers, stimulants) & foods with caffeine 2-3days prior
- Skull x-rays – reveals skull configuration
- Remove metallic objects
- Computerized Tomography (CT) scan – visualization of brain & its structures in successive layers; IV contrast medium may be used
- Secure consent
- NPO at least 4hrs prior
- √ for seafood allergy
- C/I: pregnant, obese, claustrophobic, unstable v/s , a llergy to the dye
- MRI
- Positron-emission Tomography (PET) – visualization of physiologic functions; client is given doses of strong radioactive tracers
- Secure consent
- NPO 4hrs prior
- If diabetic client, CBG <>
- Agitated clients may require sedation
- Pharmacologic management - to control or minimize seizure
- IV
- Phenobarbital (Sodium luminal)
- Phenytoin (Dilantin)– slow cardiac arrhythmias & prevent seizures
- Diazepam (Valium) – muscle relaxant
- Oral – maintenance dose
- Carbamazepine (Tegretol)- anti-convulsant
- Dilantin
- Nursing – refer to seizure management
- Help client identify precipitating factors (stress, lack of sleep, alcohol use)
- No alcoholic beverages
- Take meds religiously
- Caution in swimming, horse-back riding, & driving
- Provide support to clients to accept condition & live a life as normal as possible
- Psychosocial counseling
- Carry IDs stating client is epileptic
- Surgery – last resort; client does not respond to meds
- Cortical resection of anterior temporal lobe – safest & most effective
- Criteria: failure of medical approach & localization of a focus of abnormal electrical discharge
- Client must be awake the whole time
- Brain tumor surgery
- Status epilepticus – continuous seizures or rapid succession lasting for at least 30mins
- A medical emergency
- Client may remain comatose & have repetitive seizure for hours
- Precipitating factor: abrupt withdrawal of anti-convulsant meds
- Lorazepam (Ativan) slow IV – med of choice given until seizures stop (Valium or Dilantin may be used instead)
- Ventilation equipment must be ready
- General anesthesia may be used or Vecuronium bromide (Norcuron –neuromuscular blocker)
- Client must be on continuous EEG monitoring
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Tuesday, January 27, 2009
Introduction to Operating Room Nursing
- Many surgical procedures that were once performed in an inpatient setting now take place in an Ambulatory or Outpatient setting.
- Approximately 60% of elective surgeries are now performed in an ambulatory or outpatient setting.
- Pre -operative Phase – begins when decision to proceed with surgical intervention is made and ends with the transfer into the operating table
- Intra -operative Phase – starts from the transfer of patient to the operating table and ends with the admission of the patient to the PACU (post-anesthesia care unit)
- Post -operative Phase – begins with admission to the PACU and ends with follow-up evaluation in the clinical setting or home
- Diagnostic – Eg. Biopsy or explorative laparotomy
- Curative – Eg. Excision of a tumor or inflamed appendix
- Reparative – Eg. Multiple Wound Repair
- Reconstructive / Cosmetic – Eg. Mammoplasty or facelift
- Palliative – Eg. To relieve pain, a PEG tube is inserted to compensate for dysphagia
- Voluntary and written INFORMED consent from the patient is necessary before nonemergent surgery can be performed.
- Consent must be signed before administration of ANY PSYCHOactive medications .
- Voluntary Consent – given FREELY
- Incompetent Patient – (those who are mentally ill, and comatose CANNOT give consent)
- Informed Subject – should be in WRITING. Includes explanation of risks, procedure. Description of benefits & alternatives
- An EMANCIPATED Minor may sign his consent form
- nursinglectures.blogspot.com Brunner & Suddarth’s Textbook
- The signed consent form is placed in a prominent place on the patient’s chart and accompanies the patient to the operating room.
- The overall goal in the pre-operative period is for the patient to have as many positive health factors as possible…
- o besity, u ndernutrition, w eight loss,
- m alnutrition, d eficiencies in specific nutrients, m etabolic a bnormalities,
- the e ffects of medications on nutrition, and s pecial p roblems of the hospitalized patient (Quinn, 1999)
- m easurement of b ody m ass i ndex and
- w aist c ircumference (National Institutes of Health, 2000)
- Protein
- Calories
- Water
- Vitamin C
- Thiamin, Niacin, Riboflavin, Folic Acid, Vit. B12
- Vitamin A
- Vitamin K
- Iron
- Zinc
- People who abuse drugs attempt to HIDE and DENY it
- Acutely intoxicated persons are susceptible to injury
- Alcohol withdrawal delirium ( delirium tremens ) may be anticipated up to 72 hours after alcohol withdrawal.
- Goal : Optimal Respiratory Function
- B reathing E xercises
- Use of I ncentive S pirometry
- Surgery is USUALLY postponed if patient have a R espiratory I NFECTION
- SMOKING urged to STOP 2 Months before surgery (Counseling has a positive effect 24 hours before operation)
- i ncreased a irway r eactivity
- d ecreased m ucociliary c learance,
- p hysiologic c hanges in the c ardiovascular and i mmune systems
- GOAL : to ensure a well functioning cardiovascular system to meet the oxygen, fluid, and nutritional needs of the perioperative period.
- GOAL : optimal function of the liver and urinary systems so that medications, anesthetic agents, body wastes, and toxins are adequately processed and removed from the body.
- Hypoglycemia and Hyperglycemia
- Acidosis
- Glucosuria
- GOAL : Maintain the blood glucose level at less than 200 mg/dl
- Adrenal insufficiency – for those who have received corticosteroids
- Thyrotoxicosis (hyperthyroid disorders)
- Respiratory failure (hypothyroid disorders)
- Existence of Allergies
- Latex Allergy
- Immunosuppression
- The mildest symptoms or slightest temperature elevation must be investigated.
- Great care is taken to ensure strict asepsis
- OTC Meds – Aspirin, HPN meds, Insulin
- Herbal Meds –
- echinacea,
- ephedra,
- garlic ( Allium sativum),
- ginkgo, ginseng
- kava kava ( Piper methysticum),
- St. John’s wort ( Hypericum perforatum)
- licorice (Glycyhiza glabra)
- valerian ( Valeriana officinalis)
- Emotional Reaction
- Psychological Distress
- Anxiety – Anticipatory response
- Different responses of persons to FEAR:
- 1. Repeatedly asking questions
- 2. Withdrawal, avoiding communication
- 3. Some talk about it
- *** NURSE Must be an EMPHATETIC listener
- Cortico steroids – Prednisone(Delta sone )
- Diuretics – Hydrochlorothiazide(Hydro DIURIL )
- Pheno Thiazines – Chlorpromazine (Thor azine )
- Tranquil izers – Diazepam (Val ium )
- Insulin
- Anti biotics – Erythro mycin (Ery-tab)
- Anti coagulants – Warfa rin (Coumadin)
- Anti seizure – Pheny toin (Dilantin)
- MAO Inhibitors – Phenelzine sulfate (Nardil)
- Less physiologic Reserve
- Sensory limitations – vision, hearing and reduced tactile sensitivity
- Arthritis – may affect mobility
- Dental assessment – impt to Anesthesiologist
- Ability to perspire – fragile skin (dry)
- Fatty Tissues – susceptible to infection
- Technical & Mechanical Problems
- Wound dehiscence(separation) and wound infections are more common.
- For Every 30 lbs excess weight, additional 25 miles of blood vessels needed, thus increasing workload of the heart.
- IDEAL timing – Pre-admission visit not ON the DAY of SURGERY
- GOAL – Promote OPTIMAL Lung Expansion after ANESTHESIA
- USE of Incentive SPIROMETER
- Splinting of Incision line if possible
- GOAL – Coughing, mobilizes secretions
- Deep Breathing
- Promote Mobility POST-OP
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- Identification of ACUTE and CHRONIC Pain
- PAIN Scale
- Patient Controlled Analgesia ( PCA )
- Epidural Catheter (Bolus/Infusion)
- P.Controlled Epidural Analgesia ( PCEA )
- Oral Meds for Home Meds
- Cognitive Coping Strategies – Imagery , Distraction , Optimistic Self-recitation
- Watch out! UNNECESSARY LONG FASTINGS
- Warn Patients they might feel thirsty and teach strategies(as permitted): b rushing teeth, r insing the mouth, and c hewing gum
- 8 hours fasting after eating fatty foods
- 4 hours after ingesting milk products
- 2 hours for clear liquids in an elective procedure
- G own left U ntied, O PEN in the B ACK
- M outh Inspected, D entures removed
- Jewelries not WORN , If patient refuse , some allow ring to be taped in finger
- All Patients should VOID immediately(except those with UROLOGIC D/O) to promote continence and make abdominal organs more accessible
- nursinglectures.blogspot.com
- Anxiety related to the surgical experience (anesthesia, pain) and the outcome of surgery
- Fear related to perceived threat of the surgical procedure and separation from support system
- Knowledge deficit of preoperative procedures and protocols and postoperative expectations
- 1. During the preoperative assessment of a man scheduled for hand surgery in an ambulatory setting, you think that the patient’s responses indicate that he does not understand the procedure and that he has not made plans for postoperative care. What further assessment and teaching is indicated? What nursing interventions are warranted?
- 2.A patient with a long history of the use of several herbal supplements is scheduled for major surgery. What effect would this information have on your preoperative care of this patient?
- 3. Two patients are admitted to the same-day surgery unit for bilateral knee replacements. One patient is a 30-year-old who ambulates with crutches and the other is a 75-year-old who lives alone. How would your assessments, preoperative teaching , and preparation differ for these two patients?
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Post Operative Nursing
- AKA post anesthesia recovery room
- Located adjacent to Operating Rooms
- Has soft pleasing colors, soundproof ceiling, equipments that control noise(rubber)
- Well ventilated (decrease anxiety and promote comfort)
- Phase I PACU – immediate recovery phase, Intensive nursing care is provided
- Phase II PACU – patients who require less frequent observation and nursing care ,also referred as STEP-down , Sit-up , or progressive Care units
- TO provide Nursing care until the patient has recovered from the effects of ANESTHESIA .
- nursinglectures.blogspot.com
- Signs
- Choking
- Noisy and Irregular respirations
- O2 Saturation Scores
- Cyanosis
- nursinglectures.blogspot.com
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- Pallor
- Cool, moist skin
- Rapid breathing
- Cyanosis of the lips, gums, and tongue
- Rapid, weak, thready pulse
- pulse pressure
- blood pressure and concentrated urine
- Primary – VOLUME REPLACEMENT
- Infusion of lactated Ringer’s Solution
- Position Patient flat on bed with legs elevated at 20° and knees straight
- Special considerations for JEHOVAH’s witness or those who decline blood transfusions
- Turn patient to the one side to promote mouth drainage & prevent aspiration of vomitus ( can cause asphyxiation and death )
- Anti-emetics:
- Ondansetron ( Zofran )
- Droperidol ( Inapsine )
- Metoclopromide ( Reglan )
- Promethazine ( Phenergan )
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- PR , BP and RR –every 15 mins( 1 st hour )
- PR , BP and RR –every 30 mins( next 2 hours )
- Less frequently = more stable VS
- Temperature – every 4 hours ( 1 st 24 hours )
- nursinglectures.blogspot.com
- Atelectasis (alveolar collapse)
- Pneumonia
- Hypostatic pulmonary congestion
- Subacute hypoxemia
- Episodic hypoxemia
- Turn frequently and deep breathing every 2 hours
- Encourage coughing (contraindicated in head and eye injuries)
- Encourage YAWNING (lung expansion) or take sustained maximal inspirations
- Use of Incentive spirometer (10 deep breaths every hour while awake)
- Encourage early ambulation (increases metabolism and pulmonary aeration) the day of surgery or no later than the 1 st post-op day – prevents pulmonary complications in elderly
- PREVENTIVE approach favored over “PRN” approach
- Hypothalamic stress response = platelet aggregation and blood viscosity (can cause phlebothrombosis and pulmonary embolism
- Patient Controlled Anesthesia (PCA) – 2 reqmts: understanding of the need to self-dose and the physical ability to self-dose.
- Epidural infusions – local opiod + anesthetic
- Intrapleural anesthesia – administration of anesthetic between parietal & visceral pleura
- Subcutaneous pain management – a silicone catheter is attached to a pump that delivers the local anesthetic
- Nonpharmacologic relief measures
- Establish BASELINE Vital Signs
- Report Sys BP 90mmhg and below
- Report if BP drops 5mmhg every 15mins
- Intake and Output (<240ml>
- Promote Early ambulation (prevents DVT and peristalsis)
- Patient may sit at the edge of bed first.
- Wound drains – allow escape of blood and serous fluids that could serve as culture medium for bacteria
- Record output of wound drains
- Mark drainage on dressings with pen. Record date and time to note if it is increasing.
- Portable wound suction provides continues suction and this prevents formation of “dead spaces”
- nursinglectures.blogspot.com
- Inflammatory
- Proliferative
- Maturation
- nursinglectures.blogspot.com
- Wound is usually packed with SALINE moistened sterile dressings and covered with DRY sterile dressing nursinglectures.blogspot.com
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- Keep wound dry and clean
- Apply hypoallergenic tape
- Report signs of infection : (R,W,P,C)
- Swelling is common (Rest, Elevate)
- WOUND DEHISCENCE – disruption of surgical incision or wound EVISCERATION - protrusion of wound contents nursinglectures.blogspot.com
- N & V – common in obese, women, pts. Prone to motion sickness and those with prolonged surgery
- Insert NGT (for persistent Vomiting)
- Hiccups – caused by intermittent spasms of the diaphragm 2 nd to phrenic nerve irritation
- Phenothiazine medication for persistent Hiccups
- Oral intake – stimulates digestive juices, promotes gastric function & peristalsis
- Liquids 1 st
- Water, fruit juices, tea in increasing amounts
- Soft foods (gelatin, custard, milk and creamed soups)
- Solid foods
- Return of peristaltic activity
- Auscultate bowel sounds
- Passage of Flatus
- Paralytic ileus and intestinal obstruction – potential post-operative complications
- Voiding – expected within 8 hours post-op
- Letting water run
- Apply heat to the perineum
- Risk Factors
- Dehydration
- Venous pooling
- Low Cardiac output
- Bed rest
- Dorsiflexion of the foot causes pain in the calf muscle
- Low-dose heparin (SQ) until ambulatory
- Low-molecular weight heparin and low-dose warfarin
- External pneumatic compression
- Thigh-high elastic compression stockings
- nursinglectures.blogspot.com
- 1. Your patient has a history of esophageal cancer and is HIV positive. After undergoing ambulatory surgery to insert a gastric feeding tube, he is to be discharged to home. Indicate which assessment findings would indicate his readiness for discharge. Describe a teaching plan for the patient and his family. How would you modify the plan if the patient lives alone?
- 2. A patient who has undergone abdominal surgery reports severe pain and as a result is unable to cough and deep breathe. When you listen to the patient’s lungs you hear crackles in the bases. Analyze this findings and indicate the interventions you would implement in this situation. How would your care differ if the patient has a musculoskeletal disorder that makes turning and ambulation difficult?
- You are visiting a 72 yr old woman who had emergency surgery for a broken hip 3 weeks ago and has returned to her home, where she is living alone. How would you direct your assessment to identify the factors that might affect her recovery? How would you modify your assessment and nursing care plan because of her age?
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