Cardio Nursing

CARDIOLOGY NURSING

THE CARDIOVASCULAR SYSTEM

HEART’S NORMAL ANATOMY

• The heart is located in the LEFT side of the mediastinum

• Consists of Three layers - epicardium, myocardium and endocardium


• The epicardium covers the outer surface of the heart

• The myocardium is the middle muscular layer of the heart

• The endocardium lines the chambers and the valves


• The layer that covers the heart is the PERICARDIUM

• There are two parts - parietal and visceral pericardium

• The space between the two pericardial layers is the pericardial space


• The heart also has four chambers - two atria and two ventricles

• The Left atrium and the right atrium

• The left ventricle and the right ventricle

The Cardiovascular System

The heart chambers are guarded by valves

• The atrio-ventricular valves - tricuspid and bicuspid

• The semi-lunar valves - pulmonic and aortic valves


The Blood supply of the heart comes from the Coronary arteries

1. Right coronary artery supplies the RIGHT atrium and RIGHT ventricle, inferior portion of the LEFT ventricle, the POSTERIOR septal wall and the two nodes - AV (90%) and SA node (55%)


2. Left coronary artery- branches into the LAD and the circumflex branch

• The LAD supplies blood to the anterior wall of the LEFT ventricle, the anterior septum and the Apex of the left ventricle

• The CIRCUMFLEX branch supplies the left atrium and the posterior LEFT ventricle


The CONDUCTING SYSTEM OF THE HEART

Consists of the• 1. SA node- the pacemaker• 2. AV node- slowest conduction• 3. Bundle of His – branches into the Right

and the Left bundle branch• 4. Purkinje fibers- fastest conduction


The Heart sounds

• 1. S1- due to closure of the AV valves

• 2. S2- due to the closure of the semi-lunar valves

• 3. S3- due to increased ventricular filling

• 4. S4- due to forceful atrial contraction


Heart rate

• Normal range is 60-100 beats per minute

• Tachycardia is greater than 100 bpm

• Bradycardia is less than 60 bpm

• Sympathetic system INCREASES HR

• Parasympathetic system (Vagus) DECREASES HR


Blood pressure• Cardiac output X peripheral resistance• Control is neural (central and

peripheral) and hormonal• Baroreceptors in the carotid and aorta• Hormones- ADH, aldosterone,

epinephrine can increase BP; ANF can decrease BP


• The vascular system consists of the arteries, veins and capillaries

• The arteries are vessels that carry blood away from the heart to the periphery

• The veins are the vessels that carry blood to the heart

• The capillaries are lined with squamos cells, they connect the veins and arteries


• The lymphatic system also is part of the vascular system and the function of this system is to collect the extravasated fluid from the tissues and returns it to the blood


Cardiac Assessment


Laboratory Test Rationale

• 1. To assist in diagnosing MI

• 2. To identify abnormalities

• 3. To assess inflammation


Laboratory Test Rationale• 4. To determine baseline value• 5. To monitor serum level of

medications• 6. To assess the effects of

medications

The Cardiovascular SystemLABORATORY PROCEDURES

CARDIAC Proteins and enzymes

CK- MB ( creatine kinase)Elevates in MI within 4 hours, peaks in 18 hours and then declines till 3 days



CK- MB ( creatine kinase)Normal value is 0-7 U/L



Lactic Dehydrogenase (LDH)Elevates in MI in 24 hours, peaks in 48-72 hours

Normally LDH1 is greater than LDH2



Lactic Dehydrogenase (LDH)MI- LDH2 greater than LDH1 (flipped LDH pattern)

Normal value is 70-200 IU/L



MyoglobinRises within 1-3 hoursPeaks in 4-12 hoursReturns to normal in a day



MyoglobinNot used aloneMuscular and RENAL disease

can have elevated myoglobin


Troponin I and T• Troponin I is usually utilized

for MI• Elevates within 3-4 hours,

peaks in 4-24 hours and persists for 7 days to 3 weeks!

• Normal value for Troponin I is less than 0.6 ng/mL


Troponin I and T• REMEMBER to AVOID IM injections before obtaining blood sample!

• Early and late diagnosis can be made!


SERUM LIPIDS• Lipid profile measures the

serum cholesterol, triglycerides and lipoprotein levels

• Cholesterol= 200 mg/dL• Triglycerides- 40- 150 mg/dL


SERUM LIPIDS

• LDH- 130 mg/dL

• HDL- 30-70- mg/dL

• NPO post midnight (usually 12 hours)


ELECTROCARDIOGRAM (ECG)

• A non-invasive procedure that evaluates the electrical activity of the heart

• Electrodes and wires are attached to the patient

The Cardiovascular SystemLABORATORY PROCEDURESHolter Monitoring• A non-invasive test in which the client wears a Holter monitor and an ECG tracing recorded continuously over a period of 24 hours


Holter Monitoring• Instruct the client to resume normal activities and maintain a diary of activities and any symptoms that may develop


ECHOCARDIOGRAM• Non-invasive test that studies

the structural and functional changes of the heart with the use of ultrasound

• No special preparation is needed


Stress Test• A non-invasive test that

studies the heart during activity and detects and evaluates CAD

• Exercise test, pharmacologic test and emotional test


Stress Test

• Treadmill testing is the most commonly used stress test

• Used to determine CAD, Chest pain causes, drug effects and dysrhythmias in exercise


Stress Test• Pre-test: consent may be required, adequate rest , eat a light meal or fast for 4 hours and avoid smoking, alcohol and caffeine


• Post-test: instruct client to notify the physician if any chest pain, dizziness or shortness of breath . Instruct client to avoid taking a hot shower for 10-12 hours after the test


Pharmacological stress test

• Use of dipyridamole• Maximally dilates coronary artery

• Side-effect: flushing of face


Pharmacological stress test

• Pre-test: 4 hours fasting, avoid alcohol, caffeine

• Post test: report symptoms of chest pain

The Cardiovascular SystemLABORATORY PROCEDURES• CARDIAC catheterization• Insertion of a catheter into

the heart and surrounding vessels

• Determines the structure and performance of the heart valves and surrounding vessels

The Cardiovascular SystemLABORATORY PROCEDURES• CARDIAC catheterization• Used to diagnose CAD, assess coronary atery patency and determine extent of atherosclerosis


• Pretest: Ensure Consent, assess for allergy to seafood and iodine, NPO, document weight and height, baseline VS, blood tests and document the peripheral pulses


• Pretest: Fast for 8-12 hours, teachings, medications to allay anxiety


• Intra-test: inform patient of a fluttery feeling as the catheter passes through the heart; inform the patient that a feeling of warmth and metallic taste may occur when dye is administered


• Post-test: Monitor VS and cardiac rhythm

• Monitor peripheral pulses, color and warmth and sensation of the extremity distal to insertion site

• Maintain sandbag to the insertion site if required to maintain pressure

• Monitor for bleeding and hematoma formation


• Maintain strict bed rest for 6-12 hours

• Client may turn from side to side but bed should not be elevated more than 30 degrees and legs always straight

• Encourage fluid intake to flush out the dye

• Immobilize the arm if the antecubital vein is used

• Monitor for dye allergy


CVP• The CVP is the pressure

within the SVC• Reflects the pressure under

which blood is returned to the SVC and right atrium


CVP• Normal CVP is 0 to 8 mmHg/ 4-10 cm

H2O• Elevated CVP indicates increase in

blood volume, excessive IVF or heart/renal failure

• Low CVP may indicated hypovolemia, hemorrhage and severe vasodilatation


Measuring CVP• 1. Position the client supine with

bed elevated at 45 degrees• 2. Position the zero point of the CVP

line at the level of the right atrium. Usually this is at the MAL, 4th ICS

• 3. Instruct the client to be relaxed and avoid coughing and straining.

CARDIAC ASSESSMENT

ASSESSMENT1. Health History• Obtain description of present

illness and the chief complaint

• Chest pain, SOB, Edema, etc.• Assess risk factors

CARDIAC ASSESSMENT

2. Physical examination • Vital signs- BP, PP, MAP• Inspection of the skin• Inspection of the thorax• Palpation of the PMI, pulses• Auscultation of the heart sounds

CARDIAC ASSESSMENT

• 3. Laboratory and diagnostic studies• CBC • cardiac catheterization• Lipid profile • arteriography• Cardiac enzymes and proteins• CXR • CVP• EEG• Holter monitoring• Exercise ECG

CARDIAC IMPLEMENTATION

1. Assess the cardio-pulmonary status

VS, BP, Cardiac assessment

2. Enhance cardiac output

– Establish IV line to administer fluids


3. Promote gas exchange

–Administer O2

–Position client in SEMI-Fowler’s

–Encourage coughing and deep breathing exercises


4. Increase client activity tolerance–Balance rest and activity periods–Assist in daily activities

5. Promote client comfort–Assess the client’s description of

pain and chest discomfort–Administer medication as

prescribed


6. Promote adequate sleep7. Prevent infection

–Monitor skin integrity of lower extremities

–Assess skin site for edema, redness and warmth

–Monitor for fever–Change position frequently


8. Minimize patient anxiety–Encourage verbalization of feelings, fears and concerns

–Answer client questions. Provide information about procedures and medications

CARDIAC DISEASES

• Coronary Artery Disease• Myocardial Infarction• Congestive Heart Failure• Infective Endocarditis• Cardiac Tamponade• Cardiogenic Shock

VASCULAR DISEASES

• Hypertension• Buerger’s disease• Varicose veins• Deep vein thrombosis• Aneurysm

CAD

• CAD results from the focal narrowing of the large and medium-sized coronary arteries due to deposition of atheromatous plaque in the vessel wall

CADRISK FACTORS• 1. Age above 45/55 and Sex- Males and

post-menopausal females• 2. Family History• 3. Hypertension• 4. DM• 5. Smoking• 6. Obesity• 7. Sedentary lifestyle• 8. Hyperlipedimia

CADRISK FACTORS

Most important MODIFIABLE factors:

• Smoking

• Hypertension

• Diabetes

• Cholesterol abnormalities

CAD

Pathophysiology• Fatty streak formation in the

vascular intima T-cells and monocytes ingest lipids in the area of deposition atheroma narrowing of the arterial lumen reduced coronary blood flow myocardial ischemia

CAD

Pathophysiology• There is decreased perfusion of

myocardial tissue and inadequate myocardial oxygen supply

• If 50% of the left coronary arterial lumen is reduced or 75% of the other coronary artery, this becomes significant

• Potential for Thrombosis and embolism

Angina Pectoris

•Chest pain resulting from coronary atherosclerosis or myocardial ischemia

Angina Pectoris: Clinical Syndromes

Three Common Types of ANGINA

1. STABLE ANGINA–The typical angina that occurs during exertion, relieved by rest and drugs and the severity does not change



2. Unstable angina–Occurs unpredictably during exertion and emotion, severity increases with time and pain may not be relieved by rest and drug



3. Variant angina–Prinzmetal angina, results from coronary artery VASOSPASMS, may occur at rest

Angina Pectoris

ASSESSMENT FINDINGS1. Chest pain- ANGINA• The most characteristic symptom• PAIN is described as mild to

severe retrosternal pain, squeezing, tightness or burning sensation

• Radiates to the jaw and left arm

Angina Pectoris

ASSESSMENT FINDINGS

1. Chest pain- ANGINA• Precipitated by Exercise, Eating

heavy meals, Emotions like excitement and anxiety and Extremes of temperature

• Relieved by REST and Nitroglycerin

Angina Pectoris

ASSESSMENT FINDINGS• 2. Diaphoresis• 3. Nausea and vomiting• 4. Cold clammy skin• 5. Sense of apprehension and

doom• 6. Dizziness and syncope

Angina Pectoris

LABORATORY FINDINGS1. ECG may show normal tracing if patient

is pain-free. Ischemic changes may show ST depression and T wave inversion

2. Cardiac catheterization–Provides the MOST DEFINITIVE source

of diagnosis by showing the presence of the atherosclerotic lesions

Angina Pectoris

NURSING MANAGEMENT1. Administer prescribed medications• Nitrates- to dilate the coronary arteries• Aspirin- to prevent thrombus formation• Beta-blockers- to reduce BP and HR• Calcium-channel blockers- to dilate

coronary artery and reduce vasospasm

2. Teach the patient management of anginal attacks

• Advise patient to stop all activities • Put one nitroglycerin tablet under the tongue• Wait for 5 minutes• If not relieved, take another tablet and wait for 5

minutes• Another tablet can be taken (third tablet)• If unrelieved after THREE tablets seek medical

attention

Angina Pectoris

3. Obtain a 12-lead ECG4. Promote myocardial perfusion• Instruct patient to maintain bed rest• Administer O2 @ 3 lpm• Advise to avoid valsalva maneuvers• Provide laxatives or high fiber diet

to lessen constipation• Encourage to avoid increased

physical activities

Angina Pectoris

5. Assist in possible treatment modalities• PTCA- percutaneous transluminal

coronary angioplasty–To compress the plaque against the

vessel wall, increasing the arterial lumen

• CABG- coronary artery bypass graft–To improve the blood flow to the

myocardial tissue

Angina Pectoris

6. Provide information to family members to minimize anxiety and promote family cooperation

7. Assist client to identify risk factors that can be modified

8. Refer patient to proper agencies

Myocardial infarction

• Death of myocardial tissue in regions of the heart with abrupt interruption of coronary blood supply


ETIOLOGY and Risk factors• 1. CAD• 2. Coronary vasospasm• 3. Coronary artery occlusion by

embolus and thrombus• 4. Conditions that decrease

perfusion- hemorrhage, shock


Risk factors• 1. Hypercholesterolemia• 2. Smoking• 3. Hypertension• 4. Obesity• 5. Stress• 6. Sedentary lifestyle


PATHOPHYSIOLOGY• Interrupted coronary blood flow

myocardial ischemia anaerobic myocardial metabolism for several hours myocardial death depressed cardiac function triggers autonomic nervous system response further imbalance of myocardial O2 demand and supply


ASSESSMENT findings1. CHEST PAIN• Chest pain is described as

severe, persistent, crushing substernal discomfort

• Radiates to the neck, arm, jaw and back


ASSESSMENT findings1. CHEST PAIN• Occurs without cause, primarily

early morning• NOT relieved by rest or

nitroglycerin• Lasts 30 minutes or longer


Assessment findings• 2. Dyspnea• 3. Diaphoresis• 4. cold clammy skin• 5. N/V• 6. restlessness, sense of doom• 7. tachycardia or bradycardia• 8. hypotension• 9. S3 and dysrhythmias


Laboratory findings• 1. ECG- the ST segment is ELEVATED.

T wave inversion, presence of Q wave• 2. Myocardial enzymes- elevated CK-

MB, LDH and Troponin levels• 3. CBC- may show elevated WBC count • 4. Test after the acute stage- Exercise

tolerance test, thallium scans, cardiac catheterization

Myocardial infarctionNursing Interventions

1. Provide Oxygen at 2 lpm, Semi-fowler’s2. Administer medications

–Morphine to relieve pain– nitrates, thrombolytics, aspirin and

anticoagulants–Stool softener and hypolipidemics

3. Minimize patient anxiety–Provide information as to procedures and

drug therapy


4. Provide adequate rest periods

5. Minimize metabolic demands

–Provide soft diet

–Provide a low-sodium, low cholesterol and low fat diet

6. Minimize anxiety

–Reassure client and provide information as needed


7. Assist in treatment modalities such as PTCA and CABG

8. Monitor for complications of MI- especially dysrhythmias, since ventricular tachycardia can happen in the first few hours after MI

9. Provide client teaching

MI

• Medical Management

• 1. ANALGESIC–The choice is MORPHINE

–It reduces pain and anxiety

–Relaxes bronchioles to enhance oxygenation

MI


• 2. ACE–Prevents formation of

angiotensin II

–Limits the area of infarction

MI


• 3. Thrombolytics–Streptokinase, Alteplase

–Dissolve clots in the coronary artery allowing blood to flow


NURSING INTERVENTIONS AFTER ACUTE EPISODE

• 1. Maintain bed rest for the first 3 days

• 2. Provide passive ROM exercises

• 3. Progress with dangling of the feet at side of bed



• 4. Proceed with sitting out of bed, on the chair for 30 minutes TID

• 5. Proceed with ambulation in the room toilet hallway TID



Cardiac rehabilitation• To extend and improve quality of

life• Physical conditioning• Patients who are able to walk 3-4

mph are usually ready to resume sexual activities

CARDIOMYOPATHIES

• Heart muscle disease associated with cardiac dysfunction

CARDIOMYOPATHIES

• 1. Dilated Cardiomyopathy• 2. Hypertrophic

Cardiomyopathy• 3. Restrictive cardiomyopathy

DILATED CARDIOMYOPATHY

ASSOCIATED FACTORS

• 1. Heavy alcohol intake

• 2. Pregnancy

• 3. Viral infection

• 4. Idiopathic

DILATED CARDIOMYOPATHY

PATHOPHYSIOLOGY• Diminished contractile

proteins poor contraction decreased blood ejection increased blood remaining in the ventricle ventricular stretching and dilatation.

• SYSTOLIC DYSFUNCTION

HYPERTROPHIC CARDIOMYOPATHY

• Associated factors:

• 1. Genetic

• 2. Idiopathic

HYPERTROPHIC CARDIOMYOPATHY

• Pathophysiology

• Increased size of myocardium reduced ventricular volume increased resistance to ventricular filling diastolic dysfunction

RESTRICTIVE CARDIOMYOPATHY

• Associated factors• 1. Infiltrative diseases like

AMYLOIDOSIS• 2. Idiopathic

RESTRICTIVE CARDIOMYOPATHY

• Pathophysiology• Rigid ventricular wall

impaired stretch and diastolic filling decreased output

• Diastolic dysfunction

CARDIOMYOPATHIES

Assessment findings

• 1. PND

• 2. Orthopnea

• 3. Edema

• 4. Chest pain

• 5. Palpitations

• 6. dizziness

• 7. Syncope with exertion

CARDIOMYOPATHIES

• Laboratory Findings• 1. CXR- may reveal

cardiomegaly• 2. ECHOCARDIOGRAM• 3. ECG• 4. Myocardial Biopsy

CARDIOMYOPATHIES


• 1. Surgery

• 2. pacemaker insertion

• 3. Pharmacological drugs for symptom relief

CARDIOMYOPATHIES

• Nursing Management

1.Improve cardiac output

• Adequate rest

• Oxygen therapy

• Low sodium diet

CARDIOMYOPATHIES

• Nursing Management

2. Increase patient tolerance

• Schedule activities with rest periods in between

CARDIOMYOPATHIES

• Nursing Management3. Reduce patient anxiety• Support• Offer information about

transplantations• Support family in anticipatory

grieving

Infective endocarditis

• Infection of the heart valves and the endothelial surface of the heart

• Can be acute or chronic


• Etiologic factors• 1. Bacteria- Organism

depends on several factors• 2. Fungi


Risk factors• 1. Prosthetic valves• 2. Congenital malformation• 3. Cardiomyopathy• 4. IV drug users• 5. Valvular dysfunctions


Pathophysiology• Direct invasion of microbes

microbes adhere to damaged valve surface and proliferate damage attracts platelets causing clot formation erosion of valvular leaflets and vegetation can embolize


Assessment findings• 1. Intermittent HIGH fever• 2. anorexia, weight loss• 3. cough, back pain and joint

pain• 4. splinter hemorrhages

under nails


• Assessment findings• 5. Osler’s nodes- painful

nodules on fingerpads• 6. Roth’s spots- pale

hemorrhages in the retina


• Assessment findings• 7. Heart murmurs• 8. Heart failure


• Prevention• Antibiotic prophylaxis if

patient is undergoing procedures like dental extractions, bronchoscopy, surgery, etc.


• LABORATORY EXAM• Blood Cultures to

determine the exact organism


Nursing management• 1. regular monitoring of

temperature, heart sounds • 2. manage infection• 3. long-term antibiotic

therapy


Medical management• 1. Pharmacotherapy• IV antibiotic for 2-6 weeks• Antifungal agents are

given – amphotericin B


Medical management• 2. Surgery• Valvular replacement

CHF

• A syndrome of congestion of both pulmonary and systemic circulation caused by inadequate cardiac function and inadequate cardiac output to meet the metabolic demands of tissues

CHF

• Inability of the heart to pump sufficiently

• The heart is unable to maintain adequate circulation to meet the metabolic needs of the body

• Classified according to the major ventricular dysfunction- Left or Right

CHFEtiology of CHF

• 1. CAD• 2. Valvular heart diseases• 3. Hypertension• 4. MI• 5. Cardiomyopathy• 6. Lung diseases• 7. Post-partum• 8. Pericarditis and cardiac tamponade

New York Heart Association

Class 1• Ordinary physical activity does

NOT cause chest pain and fatigue

• No pulmonary congestion• Asymptomatic• NO limitation of ADLs


Class 2• SLIGHT limitation of ADLs• NO symptom at rest• Symptom with INCREASED

activity• Basilar crackles and S3


Class 3

• Markedly limitation on ADLs

• Comfortable at rest BUT symptoms present in LESS than ordinary activity


Class 4

• SYMPTOMS are present at rest

CHF

PATHOPHYSIOLOGY• LEFT Ventricular pump

failure back up of blood into the pulmonary veins increased pulmonary capillary pressure pulmonary congestion

CHF

PATHOPHYSIOLOGY• LEFT ventricular failure

decreased cardiac output decreased perfusion to the brain, kidney and other tissues oliguria, dizziness

CHF

PATHOPHYSIOLOGY• RIGHT ventricular failure

blood pooling in the venous circulation increased hydrostatic pressure peripheral edema

CHF

PATHOPHYSIOLOGY• RIGHT ventricular failure blood pooling venous congestion in the kidney, liver and GIT

LEFT SIDED CHFASSESSMENT FINDINGS

• 1. Dyspnea on exertion• 2. PND• 3. Orthopnea• 4. Pulmonary crackles/rales• 5. cough with Pinkish, frothy

sputum• 6. Tachycardia

LEFT SIDED CHFASSESSMENT FINDINGS

• 7. Cool extremities• 8. Cyanosis• 9. decreased peripheral pulses• 10. Fatigue• 11. Oliguria• 12. signs of cerebral anoxia

RIGHT SIDED CHFASSESSMENT FINDINGS

• 1. Peripheral dependent, pitting edema

• 2. Weight gain• 3. Distended neck vein• 4. hepatomegaly• 5. Ascites

RIGHT SIDED CHFASSESSMENT FINDINGS

• 6. Body weakness

• 7. Anorexia, nausea

• 8. Pulsus alternans

CHF

LABORATORY FINDINGS• 1. CXR may reveal

cardiomegaly• 2. ECG may identify Cardiac

hypertrophy• 3. Echocardiogram may

show hypokinetic heart

CHF

LABORATORY FINDINGS• 4. ABG and Pulse oximetry may

show decreased O2 saturation• 5. PCWP is increased in LEFT

sided CHF and CVP is increased in RIGHT sided CHF

CHF

NURSING INTERVENTIONS• 1. Assess patient's cardio-

pulmonary status• 2. Assess VS, CVP and

PCWP. Weigh patient daily to monitor fluid retention

CHF

NURSING INTERVENTIONS

• 3. Administer medications- usually cardiac glycosides are given- DIGOXIN or DIGITOXIN, Diuretics, vasodilators and hypolipidemics are prescribed

CHF

NURSING INTERVENTIONS• 4. Provide a LOW sodium

diet. Limit fluid intake as necessary

• 5. Provide adequate rest periods to prevent fatigue

CHF

NURSING INTERVENTIONS• 6. Position on semi-fowler’s

to fowler’s for adequate chest expansion

• 7. Prevent complications of immobility

CHF

NURSING INTERVENTION AFTER THE ACUTE STAGE

• 1. Provide opportunities for verbalization of feelings

• 2. Instruct the patient about the medication regimen- digitalis, vasodilators and diuretics

• 3. Instruct to avoid OTC drugs, Stimulants, smoking and alcohol

CHF


• 4. Provide a LOW fat and LOW sodium diet

• 5. Provide potassium supplements

• 6. Instruct about fluid restriction

CHF


• 7. Provide adequate rest periods and schedule activities

• 8. Monitor daily weight and report signs of fluid retention

CARDIOGENIC SHOCK

• Heart fails to pump adequately resulting to a decreased cardiac output and decreased tissue perfusion

ETIOLOGY• 1. Massive MI• 2. Severe CHF• 3. Cardiomyopathy• 4. Cardiac trauma• 5. Cardiac tamponade

CARDIOGENIC SHOCK

ASSESSMENT FINDINGS• 1. HYPOTENSION• 2. oliguria (less than 30 ml/hour)• 3. tachycardia• 4. narrow pulse pressure• 5. weak peripheral pulses• 6. cold clammy skin• 7. changes in sensorium/LOC• 8. pulmonary congestion

CARDIOGENIC SHOCK

• LABORATORY FINDINGS

• Increased CVP–Normal is 4-10 cmH2O

CARDIOGENIC SHOCK

NURSING INTERVENTIONS• 1. Place patient in a modified

Trendelenburg (shock ) position• 2. Administer IVF, vasopressors and

inotropics such as DOPAMINE and DOBUTAMINE

• 3. Administer O2• 4. Morphine is administered to decreased

pulmonary congestion and to relieve pain

CARDIOGENIC SHOCK

• 5. Assist in intubation, mechanical ventilation, PTCA, CABG, insertion of Swan-Ganz cath and IABP

• 6. Monitor urinary output, BP and pulses

• 7. cautiously administer diuretics and nitrates

CARDIAC TAMPONADE

• A condition where the heart is unable to pump blood due to accumulation of fluid in the pericardial sac (pericardial effusion)

CARDIAC TAMPONADE

• This condition restricts ventricular filling resulting to decreased cardiac output

• Acute tamponade may happen when there is a sudden accumulation of more than 50 ml fluid in the pericardial sac

CARDIAC TAMPONADE

Causative factors

• 1. Cardiac trauma

• 2. Complication of Myocardial infarction

• 3. Pericarditis

• 4. Cancer metastasis

CARDIAC TAMPONADE

ASSESSMENT FINDINGS

• 1. BECK’s Triad- Jugular vein distention, hypotension and distant/muffled heart sound

• 2. Pulsus paradoxus

• 3. Increased CVP

• 4. decreased cardiac output

CARDIAC TAMPONADE

• ASSESSMENT FINDINGS

• 5. Syncope

• 6. anxiety

• 7. dyspnea

• 8. Percussion- Flatness across the anterior chest

CARDIAC TAMPONADE

• Laboratory FINDINGS• 1. Echocardiogram• 2. Chest X-ray

CARDIAC TAMPONADE

NURSING INTERVENTIONS• 1. Assist in PERICARDIOCENTESIS• 2. Administer IVF• 3. Monitor ECG, urine output and BP• 4. Monitor for recurrence of

tamponade

Pericardiocentesis

• Patient is monitored by ECG • Maintain emergency equipments• Elevate head of bed 45-60 degrees• Monitor for complications-

coronary artery rupture, dysrhythmias, pleural laceration and myocardial trauma

HYPERTENSION

• A systolic BP greater than 140 mmHg and a diastolic pressure greater than 90 mmHg over a sustained period, based on two or more BP measurements.

HYPERTENSION

Types of Hypertension

1. Primary or ESSENTIAL–Most common type

2. Secondary –Due to other conditions like

Pheochromocytoma, renovascular hypertension, Cushing’s, Conn’s , SIADH

HYPERTENSION

• CLASSIFICATION OF HYPERTENSION by JNC-VII

HYPERTENSION

PATHOPHYSIOLOGY

• Multi-factorial etiology

• BP= CO (SV X HR) x TPR

• Any increase in the above parameters will increase BP

• 1. Increased sympathetic activity

• 2. Increased absorption of Sodium, and water in the kidney

HYPERTENSION

PATHOPHYSIOLOGY

• Multifactorial etiology

• BP= CO (SV X HR) x TPR

• Any increase in the above parameters will increase BP

• 3. Increased activity of the RAAS

• 4. Increased vasoconstriction of the peripheral vessels

• 5. insulin resistance

HYPERTENSION


• 1. Headache

• 2. Visual changes

• 3. chest pain

• 4. dizziness

• 5. N/V

HYPERTENSION

• Risk factors for Cardiovascular Problems in Hypertensive patients

Major Risk factors• 1. Smoking• 2. Hyperlipidemia• 3. DM• 4. Age older than 60 • 5. Gender- Male and post menopausal W• 6. Family History

HYPERTENSION

• DIAGNOSTIC STUDIES

• 1. Health history and PE

• 2. Routine laboratory- urinalysis, ECG, lipid profile, BUN, serum creatinine , FBS

• 3. Other lab- CXR, creatinine clearance, 24-huour urine protein

HYPERTENSION

• MEDICAL MANAGEMENT• 1. Lifestyle modification• 2. Drug therapy• 3. Diet therapy

HYPERTENSION

MEDICAL MANAGEMENTDrug therapy

• Diuretics• Beta blockers• Calcium channel blockers• ACE inhibitors• A2 Receptor blockers• Vasodilators

HYPERTENSION

• NURSING INTERVENTIONS• 1. Provide health teaching to

patient• Teach about the disease

process• Elaborate on lifestyle changes• Assist in meal planning to lose

weight

HYPERTENSION

• NURSING INTERVENTIONS• 1. Provide health teaching to the

patient• Provide list of LOW fat , LOW

sodium diet of less than 2-3 grams of Na/day

• Limit alcohol intake to 30 ml/day• Regular aerobic exercise• Advise to completely Stop smoking

HYPERTENSION

• Nursing Interventions• 2. Provide information about anti-

hypertensive drugs• Instruct proper compliance and not abrupt

cessation of drugs even if pt becomes asymptomatic/ improved condition

• Instruct to avoid over-the-counter drugs that may interfere with the current medication

HYPERTENSION

• Nursing Intervention• 3. Promote Home care management• Instruct regular monitoring of BP• Involve family members in care• Instruct regular follow-up• 4. Manage hypertensive emergency

and urgency properly

Vascular Diseases

ANEURYSM

• Dilation involving an artery formed at a weak point in the vessel wall

ANEURYSM

• Saccular= when one side of the vessel is affected

• Fusiform= when the entire segment becomes dilated

ANEURYSM

• RISK FACTORS

1. Atherosclerosis

2. Infection= syphilis

3. Connective tissue disorder

4. Genetic disorder= Marfan’s Syndrome

ANEURYSM

• PATHOPHYSIOLOGY

Damage to the intima and media weakness outpouching

Dissecting aneurysm tear in the intima and media with dissection of blood through the layers

ANEURYSM

• ASSESSMENT

1. Asymptomatic

2. Pulsatile sensation on the abdomen

3. Palpable bruit

ANEURYSM

LABORATORY:

• CT scan

• Ultrasound

• X-ray

• Aortography

ANEURYSM

Medical Management:

• Anti-hypertensives

• Synthetic graft

ANEURYSM

Nursing Management:

• Administer medications

• Emphasize the need to avoid increased abdominal pressure

• No deep abdominal palpation

• Remind patient the need for serial ultrasound to detect diameter changes

PERIPHERAL ARTERIAL OCCLUSIVE DISEASE

• Refers to arterial insufficiency of the extremities usually secondary to peripheral atherosclerosis.

• Usually found in males age 50 and above

• The legs are most often affected


• Risk factors for Peripheral Arterial occlusive disease

• Non-Modifiable

• 1. Age

• 2. gender

• 3. family predisposition


• Risk factors for Peripheral Arterial occlusive disease

Modifiable• 1. Smoking • 2. HPN• 3. Obesity• 4. Sedentary lifestyle• 5. DM• 6. Stress


ASSESSMENT FINDINGS• 1. INTERMITTENT CLAUDICATION-

the hallmark of PAOD• This is PAIN described as aching,

cramping or fatiguing discomfort consistently reproduced with the same degree of exercise or activity


• ASSESSMENT FINDINGS• 1. INTERMITTENT

CLAUDICATION- the hallmark of PAOD

• This pain is RELIEVED by REST• This commonly affects the

muscle group below the arterial occlusion


• Assessment Findings• 2. Progressive pain on the

extremity as the disease advances

• 3. Sensation of cold and numbness of the extremities


• Assessment Findings• 4. Skin is pale when elevated

and cyanotic/ruddy when placed on a dependent position

• 5. Muscle atrophy, leg ulceration and gangrene


• Diagnostic Findings

• 1. Unequal pulses between the extremities

• 2. Duplex ultrasonography

• 3. Doppler flow studies

PAOD


1. Drug therapy• Pentoxyfylline (Trental) reduces blood

viscosity and improves supply of O2 blood to muscles

• Cilostazol (Pletaal) inhibits platelet aggregation and increases vasodilatation

• 2. Surgery- Bypass graft and anastomoses


• Nursing Interventions

1. Maintain Circulation to the extremity• Evaluate regularly peripheral pulses,

temperature, sensation, motor function and capillary refill time

• Administer post-operative care to patient who underwent surgery


• Nursing Interventions2. Monitor and manage complications• Note for bleeding, hematoma,

decreased urine output• Elevate the legs to diminish edema• Encourage exercise of the extremity

while on bed• Teach patient to avoid leg-crossing



3. Promote Home management

• Encourage lifestyle changes

• Instruct to AVOID smoking

• Instruct to avoid leg crossing

BUERGER’S DISEASE

• Thromboangiitis obliterans

• A disease characterized by recurring inflammation of the medium and small arteries and veins of the lower extremities

• Occurs in MEN ages 20-35

• RISK FACTOR: SMOKING!

BUERGER’S DISEASE

PATHOPHYSIOLOGY

• Cause is UNKNOWN

• Probably an Autoimmune disease

• Inflammation of the arteries thrombus formation occlusion of the vessels

BUERGER’S DISEASE


1. Leg PAIN• Foot cramps in the arch (instep

claudication) after exercise• Relieved by rest• Aggravated by smoking, emotional

disturbance and cold chilling

2. Digital rest pain not changed by activity or rest

BUERGER’S DISEASE


• 3. Intense RUBOR (reddish-blue discoloration), progresses to CYANOSIS as disease advances

• 4. Paresthesia

BUERGER’S DISEASE

• Diagnostic Studies• 1. Duplex ultrasonography• 2. Contrast angiography

BUERGER’S DISEASE


1. Assist in the medical and surgical management

• Bypass graft• amputation

2. Strongly advise to AVOID smoking

3. Manage complications appropriately


1. Drug therapy• Pentoxyfylline (Trental) reduces blood

viscosity and improves supply of O2 blood to muscles

• Cilostazol (Pletaal) inhibits platelet aggregation and increases vasodilatation

• 2. Surgery- Bypass graft and anastomoses

BUERGER’S DISEASE

• Nursing InterventionsPost-operative care: after amputation• Elevate stump for the FIRST 24 HOURS to

minimize edema and promote venous return

• Place patient on PRONE position after 24 hours

• Assess skin for bleeding and hematoma• Wrap the extremity with elastic bandage

RAYNAUD’S DISEASE

• A form of intermittent arteriolar VASOCONSTRICTION that results in coldness, pain and pallor of the fingertips or toes

• Cause : UNKNOWN• Most commonly affects WOMEN,

16- 40 years old

RAYNAUD’S DISEASE

• ASSESSMENT FINDINGS1. Raynaud’s phenomenon• A localized episode of

vasoconstriction of the small arteries of the hands and feet that causes color and temperature changes

RAYNAUD’S DISEASE

• W-B-R• Pallor- due to vasoconstriction,

then• Blue- due to pooling of

Deoxygenated blood• Red- due to exaggerated

reflow/hyperemia

RAYNAUD’S DISEASE

• ASSESSMENT FINDINGS2. tingling sensation

3. Burning pain on the hands and feet

RAYNAUD’S DISEASE

• Medical management• Drug therapy with the use of

CALCIUM channel blockers–To prevent vasospasms

RAYNAUD’S DISEASE

• Nursing Interventions• 1. instruct patient to avoid situations

that may be stressful• 2. instruct to avoid exposure to cold

and remain indoors when the climate is cold

• 3. instruct to avoid all kinds of nicotine• 4. instruct about safety. Careful

handling of sharp objects

Venous diseases

VARICOSE VEINS

• THESE are dilated veins usually in the lower extremities

VARICOSE VEINS

• Predisposing Factors–Pregnancy–Prolonged standing or sitting

–Constipation (for hemorrhoids)

–Incompetent venous valves

VARICOSE VEINS

• Pathophysiology–Factors venous stasis increased hydrostatic pressure edema

VARICOSE VEINS

• Assessment findings–Tortuous superficial veins on the legs

–Leg pain and Heaviness–Dependent edema

VARICOSE VEINS

• Laboratory findings–Venography–Duplex scan pletysmography

VARICOSE VEINS

• Medical management–Pharmacological therapy–Leg vein stripping–Anti-embolic stockings

VARICOSE VEINS

• Nursing management• 1. Advise patient to elevate

the legs• 2. Caution patient to avoid

prolonged standing or sitting

VARICOSE VEINS

• Nursing management• 3. Provide high-fiber foods

to prevent constipation• 4. Teach simple exercise to

promote venous return

VARICOSE VEINS

• Nursing management

• 5. Caution patient to avoid knee-length stockings and constrictive clothings

VARICOSE VEINS

• Nursing management• 6. Apply anti-embolic stockings as directed

• 7. Avoid massage on the affected area

DVT- Deep Vein Thrombosis

• Inflammation of the deep veins of the lower extremities and the pelvic veins

• The inflammation results to formation of blood clots in the area


• Predisposing factors–Prolonged immobility

–Varicosities

–Traumatic procedures


•Complication

–PULMONARY thromboembolism


• Assessment findings

• Leg tenderness

• Leg pain and edema

• Positive HOMAN’s SIGN


• Laboratory findings

• Venography

• Duplex scan


• Medical management–Antiplatelets–Anticoagulants–Vein stripping and grafting–Anti-embolic stockings


• Nursing management

• 1. Provide measures to avoid prolonged immobility

–Repositioning Q2

–Provide passive ROM

–Early ambulation


• Nursing management• 2. Provide skin care to

prevent the complication of leg ulcers

• 3. Provide anti-embolic stockings


• Nursing management• 4. Administer

anticoagulants as prescribed

• 5. Monitor for signs of pulmonary embolism

Blood disordersBlood disorders

AnemiaAnemiaNutritional anemiaNutritional anemiaHemolytic anemiaHemolytic anemiaAplastic anemiaAplastic anemiaSickle cell anemiaSickle cell anemia

ANEMIAANEMIA

A condition in A condition in which the which the hemoglobin hemoglobin concentration is concentration is lower than normallower than normal

ANEMIAANEMIA

Three broad categoriesThree broad categories1. Loss of RBC- occurs with 1. Loss of RBC- occurs with

bleedingbleeding2. Decreased RBC 2. Decreased RBC

productionproduction3. Increased RBC 3. Increased RBC

destructiondestruction

Hypoproliferative AnemiaHypoproliferative Anemia

Iron Deficiency AnemiaIron Deficiency Anemia–Results when the Results when the dietary intake of iron dietary intake of iron is inadequate to is inadequate to produce hemoglobinproduce hemoglobin


Iron Deficiency AnemiaIron Deficiency Anemia–Etiologic FactorsEtiologic Factors–1. Bleeding- the most 1. Bleeding- the most common causecommon cause

–2. Mal-absorption2. Mal-absorption–3. Malnutrition3. Malnutrition–4. Alcoholism4. Alcoholism


Iron Deficiency Iron Deficiency AnemiaAnemia

PathophysiologyPathophysiology–The body stores of iron The body stores of iron decrease, leading to decrease, leading to depletion of depletion of hemoglobin synthesishemoglobin synthesis


Iron Deficiency AnemiaIron Deficiency AnemiaPathophysiologyPathophysiology

–The oxygen carrying The oxygen carrying capacity of hemoglobin is capacity of hemoglobin is reducedreduced tissue hypoxia tissue hypoxia


Iron Deficiency AnemiaIron Deficiency AnemiaAssessment FindingsAssessment Findings1. Pallor of the skin and 1. Pallor of the skin and mucous membranemucous membrane

2. Weakness and fatigue2. Weakness and fatigue3. General malaise3. General malaise4. Pica4. Pica


Iron Deficiency AnemiaIron Deficiency AnemiaAssessment FindingsAssessment Findings5. Brittle nails5. Brittle nails6. Smooth and sore 6. Smooth and sore tonguetongue

7. Angular cheilosis7. Angular cheilosis


Iron Deficiency AnemiaIron Deficiency AnemiaLaboratory findingsLaboratory findings1. CBC- Low levels of Hct, 1. CBC- Low levels of Hct, Hgb and RBC countHgb and RBC count

2. low serum iron, low 2. low serum iron, low ferritinferritin

3. Bone marrow aspiration- 3. Bone marrow aspiration- MOST definitiveMOST definitive


Iron Deficiency AnemiaIron Deficiency AnemiaMedical managementMedical management1. Hematinics1. Hematinics2. Blood transfusion2. Blood transfusion


Iron Deficiency AnemiaIron Deficiency AnemiaNursing ManagementNursing Management1. Provide iron rich-foods1. Provide iron rich-foods

–Organ meats (liver)Organ meats (liver)–BeansBeans–Leafy green vegetablesLeafy green vegetables–Raisins and molassesRaisins and molasses


Nursing ManagementNursing Management2. Administer iron 2. Administer iron Oral preparations tablets- Fe Oral preparations tablets- Fe

fumarate, sulfate and gluconatefumarate, sulfate and gluconate Advise to take iron ONE hour Advise to take iron ONE hour

before mealsbefore meals Take it with vitamin CTake it with vitamin C Continue taking it for several Continue taking it for several

monthsmonths

Hypoproliferative AnemiaHypoproliferative AnemiaNursing ManagementNursing Management2. Administer iron 2. Administer iron Oral preparations- liquidOral preparations- liquid It stains teethIt stains teeth Drink it with a strawDrink it with a straw Stool may turn blackish- dark Stool may turn blackish- dark

in colorin color Advise to eat high-fiber diet to Advise to eat high-fiber diet to

counteract constipationcounteract constipation

Hypoproliferative AnemiaHypoproliferative AnemiaNursing ManagementNursing Management2. Administer iron 2. Administer iron IM preparationIM preparation Administer DEEP IM using the Administer DEEP IM using the

Z-track methodZ-track method Avoid vigorous rubbingAvoid vigorous rubbing Can cause local pain and Can cause local pain and

stainingstaining

APLASTIC ANEMIAAPLASTIC ANEMIA

A condition A condition characterized by characterized by decreased number decreased number of RBC as well as of RBC as well as WBC and plateletsWBC and platelets


CAUSATIVE FACTORSCAUSATIVE FACTORS1. Environmental toxins- 1. Environmental toxins-

pesticides, benzenepesticides, benzene2. Certain drugs- 2. Certain drugs-

Chemotherapeutic agents, Chemotherapeutic agents, chloramphenicol, chloramphenicol, phenothiazines, Sulfonamidesphenothiazines, Sulfonamides

3. Heavy metals3. Heavy metals4. Radiation4. Radiation


PathophysiologyPathophysiologyToxins cause a direct bone Toxins cause a direct bone marrow depressionmarrow depression acellualr bone marrowacellualr bone marrow decreased production of decreased production of blood elementsblood elements


ASSESSMENT FINDINGSASSESSMENT FINDINGS1. fatigue1. fatigue2. pallor2. pallor3. dyspnea3. dyspnea4. bruising4. bruising5. splenomegaly5. splenomegaly6. retinal hemorrhages6. retinal hemorrhages


LABORATORY FINDINGSLABORATORY FINDINGS1. CBC- decreased blood 1. CBC- decreased blood cell numberscell numbers

2. Bone marrow 2. Bone marrow aspiration confirms the aspiration confirms the anemia- hypoplastic or anemia- hypoplastic or acellular marrow acellular marrow replaced by fatsreplaced by fats


Medical ManagementMedical Management1. Bone marrow 1. Bone marrow transplantationtransplantation

2. Immunosupressant 2. Immunosupressant drugsdrugs

3. Rarely, steroids3. Rarely, steroids4. Blood transfusion4. Blood transfusion


Nursing managementNursing management1. Assess for signs of 1. Assess for signs of bleeding and bleeding and infectioninfection

2. Instruct to avoid 2. Instruct to avoid exposure to offending exposure to offending agentsagents

Megaloblastic AnemiasMegaloblastic Anemias

Anemias characterized Anemias characterized by abnormally large RBC by abnormally large RBC secondary to impaired secondary to impaired DNA synthesis due to DNA synthesis due to deficiency of Folic acid deficiency of Folic acid and/or vitamin B12 and/or vitamin B12


Folic Acid deficiencyFolic Acid deficiencyCausative factorsCausative factors1. Alcoholism1. Alcoholism2. Mal-absorption2. Mal-absorption3. Diet deficient in 3. Diet deficient in uncooked vegetablesuncooked vegetables

Megaloblastic AnemiasMegaloblastic AnemiasPathophysiology of Folic acid Pathophysiology of Folic acid

deficiencydeficiencyDecreased folic acidDecreased folic acid impaired impaired

DNA synthesis in the bone DNA synthesis in the bone marrowmarrow impaired RBC impaired RBC development, impaired nuclear development, impaired nuclear maturation but CYTOplasmic maturation but CYTOplasmic maturation continuesmaturation continues large large sizesize


Vitamin B12 deficiencyVitamin B12 deficiencyCausative factorsCausative factors1. Strict vegetarian diet1. Strict vegetarian diet2. Gastrointestinal 2. Gastrointestinal

malabsorptionmalabsorption3. Crohn's disease3. Crohn's disease4. gastrectomy4. gastrectomy


Vitamin B12 deficiencyVitamin B12 deficiency

Pernicious AnemiaPernicious Anemia Due to the absence of intrinsic Due to the absence of intrinsic

factor secreted by the parietal factor secreted by the parietal cells cells

Intrinsic factor binds with Vit. Intrinsic factor binds with Vit. B12 to promote absorptionB12 to promote absorption


Assessment findingsAssessment findings 1. weakness1. weakness 2. fatigue2. fatigue 3. listless3. listless 4. neurologic manifestations 4. neurologic manifestations

are present only in Vit. B12 are present only in Vit. B12 deficiencydeficiency


Assessment findingsAssessment findings Pernicious AnemiaPernicious Anemia

– Beefy, red, swollen tongueBeefy, red, swollen tongue– Mild diarrheaMild diarrhea– Extreme pallorExtreme pallor– Paresthesias in the extremitiesParesthesias in the extremities


Laboratory findingsLaboratory findings 1. Peripheral blood smear- 1. Peripheral blood smear-

shows giant RBCs, WBCs with shows giant RBCs, WBCs with giant hypersegmented nucleigiant hypersegmented nuclei

2. Very high MCV2. Very high MCV 3. Schilling’s test3. Schilling’s test 4. Intrinsic factor antibody test4. Intrinsic factor antibody test


Medical ManagementMedical Management 1. Vitamin supplementation1. Vitamin supplementation

– Folic acid 1 mg dailyFolic acid 1 mg daily 2. Diet supplementation2. Diet supplementation

– Vegetarians should have vitamin Vegetarians should have vitamin intakeintake

3. Lifetime monthly injection 3. Lifetime monthly injection of IM Vit B12of IM Vit B12


Nursing ManagementNursing Management 1. Monitor patient1. Monitor patient 2. Provide assistance in 2. Provide assistance in

ambulationambulation 3. Oral care for tongue sore3. Oral care for tongue sore 4. Explain the need for 4. Explain the need for

lifetime IM injection of vit B12lifetime IM injection of vit B12

Hemolytic Anemia: Sickle Hemolytic Anemia: Sickle CellCell

A severe chronic A severe chronic incurable hemolytic incurable hemolytic anemia that results anemia that results from heritance of the from heritance of the sickle hemoglobin sickle hemoglobin gene.gene.


Causative factorCausative factor–Genetic inheritance Genetic inheritance of the sickle gene- of the sickle gene- HbS geneHbS gene


PathophysiologyPathophysiologyDecreased O2, Cold, Decreased O2, Cold, Vasoconstriction can Vasoconstriction can precipitate sickling precipitate sickling processprocess

Hemolytic Anemia: Sickle Hemolytic Anemia: Sickle CellCellPathophysiologyPathophysiology

FactorsFactors cause defective cause defective hemoglobin to acquire a hemoglobin to acquire a rigid, crystal-like C-shaped rigid, crystal-like C-shaped configurationconfiguration Sickled Sickled RBCs will adhere to RBCs will adhere to endotheliumendothelium pile up and pile up and plug the vesselsplug the vessels ischemia resultsischemia results pain, pain, swelling and feverswelling and fever


Assessment FindingsAssessment Findings1. jaundice1. jaundice2. enlarged skull and 2. enlarged skull and facial bonesfacial bones

3. tachycardia, 3. tachycardia, murmurs and murmurs and cardiomegalycardiomegaly


Assessment FindingsAssessment FindingsPrimary sites of Primary sites of thrombotic occlusion: thrombotic occlusion: spleen, lungs and CNSspleen, lungs and CNS

Chest pain, dyspneaChest pain, dyspnea


Assessment FindingsAssessment Findings1. Sickle cell crises1. Sickle cell crises

–Results from tissue hypoxia Results from tissue hypoxia and necrosisand necrosis

2. Acute chest syndrome2. Acute chest syndrome–Manifested by a rapidly Manifested by a rapidly falling hemoglobin level, falling hemoglobin level, tachycardia, fever and tachycardia, fever and chest infiltrates in the CXRchest infiltrates in the CXR


Medical ManagementMedical Management1. Bone marrow 1. Bone marrow transplanttransplant

2. Hydroxyurea2. Hydroxyurea–Increases the HbFIncreases the HbF

3. Long term RBC 3. Long term RBC trnasfusiontrnasfusion


Nursing ManagementNursing Management1. manage the pain1. manage the pain

–Support and elevate Support and elevate acutely inflamed jointacutely inflamed joint

–Relaxation techniquesRelaxation techniques–analgesicsanalgesics


Nursing ManagementNursing Management2. Prevent and manage 2. Prevent and manage infectioninfection–Monitor status of Monitor status of patientpatient

–Initiate prompt Initiate prompt antibiotic therapyantibiotic therapy


Nursing ManagementNursing Management3. Promote coping skills3. Promote coping skills

–Provide accurate Provide accurate informationinformation

–Allow patient to verbalize Allow patient to verbalize her concerns about her concerns about medication, prognosis medication, prognosis and future pregnancyand future pregnancy


Nursing ManagementNursing Management4. Monitor and prevent 4. Monitor and prevent potential complicationspotential complications–Provide always adequate Provide always adequate hydrationhydration

–Avoid cold, temperature Avoid cold, temperature that may cause that may cause vasoconstrictionvasoconstriction


Nursing ManagementNursing Management4. Monitor and 4. Monitor and prevent potential prevent potential complicationscomplications–Leg ulcerLeg ulcer

Aseptic techniqueAseptic technique


Nursing ManagementNursing Management4. Monitor and prevent 4. Monitor and prevent potential complicationspotential complications–PriapismPriapism

Sudden painful erectionSudden painful erectionInstruct patient to empty Instruct patient to empty bladder, then take a bladder, then take a warm bathwarm bath

PolycythemiaPolycythemia

Refers to an INCREASE Refers to an INCREASE volume of RBCsvolume of RBCs

The hematocrit is The hematocrit is ELEVATED to more than ELEVATED to more than 55%55%

Clasified as Primary or Clasified as Primary or SecondarySecondary


POLYCYTHEMIA VERAPOLYCYTHEMIA VERA–Primary PolycythemiaPrimary Polycythemia–A proliferative disorder A proliferative disorder in which the myeloid in which the myeloid stem cells become stem cells become uncontrolled uncontrolled


POLYCYTHEMIA VERAPOLYCYTHEMIA VERACausative factorCausative factor

–unknownunknown

PolycythemiaPolycythemiaPOLYCYTHEMIA VERAPOLYCYTHEMIA VERAPathophysiologyPathophysiology

–The stem cells grow The stem cells grow uncontrollablyuncontrollably

–The bone marrow becomes The bone marrow becomes HYPERcellular and all the blood HYPERcellular and all the blood cells are increased in numbercells are increased in number


–The spleen resumes its function The spleen resumes its function of hematopoiesis and enlargesof hematopoiesis and enlarges

–Blood becomes thick and Blood becomes thick and viscous causing sluggish viscous causing sluggish circulationcirculation


–Overtime, the bone Overtime, the bone marrow becomes fibroticmarrow becomes fibrotic

PolycythemiaPolycythemiaPOLYCYTHEMIA VERAPOLYCYTHEMIA VERAAssessment findingsAssessment findings

–1. Skin is ruddy1. Skin is ruddy–2. Splenomegaly2. Splenomegaly–3. headache3. headache–4. dizziness, blurred vision4. dizziness, blurred vision–5. Angina, dyspnea and 5. Angina, dyspnea and thrombophlebitisthrombophlebitis

PolycythemiaPolycythemiaPOLYCYTHEMIA VERAPOLYCYTHEMIA VERALaboratory findingsLaboratory findings

–1. CBC- shows elevated RBC 1. CBC- shows elevated RBC massmass

–2. Normal oxygen saturation2. Normal oxygen saturation–3 Elevated WBC and 3 Elevated WBC and PlateletsPlatelets

PolycythemiaPolycythemiaPOLYCYTHEMIA VERAPOLYCYTHEMIA VERAComplicationsComplications

–1. Increased risk for 1. Increased risk for thrombophlebitis, CVA and thrombophlebitis, CVA and MIMI

–2. Bleeding due to 2. Bleeding due to dysfunctional blood cellsdysfunctional blood cells

PolycythemiaPolycythemiaPOLYCYTHEMIA VERAPOLYCYTHEMIA VERAMedical ManagementMedical Management

–1. To reduce the high blood cell 1. To reduce the high blood cell mass- PHLEBOTOMYmass- PHLEBOTOMY

–2. Allopurinol2. Allopurinol–3. Dipyridamole3. Dipyridamole–4. Chemotherapy to suppress 4. Chemotherapy to suppress bone marrowbone marrow

PolycythemiaPolycythemia Nursing ManagementNursing Management

– 1. Primary role of the nurse is 1. Primary role of the nurse is EDUCATOREDUCATOR

– 2. Regularly asses for the 2. Regularly asses for the development of complicationsdevelopment of complications

– 3. Assist in weekly phlebotomy3. Assist in weekly phlebotomy– 4. Advise to avoid alcohol and aspirin4. Advise to avoid alcohol and aspirin– 5. Advise tepid sponge bath or cool 5. Advise tepid sponge bath or cool

water to manage prurituswater to manage pruritus

LeukemiaLeukemiaMalignant disorders of blood Malignant disorders of blood

forming cells characterized by forming cells characterized by UNCONTROLLED proliferation UNCONTROLLED proliferation of WHITE BLOOD CELLS in the of WHITE BLOOD CELLS in the bone marrow- replacing bone marrow- replacing marrow elements . The WBC marrow elements . The WBC can also proliferate in the can also proliferate in the liver, spleen and lymph nodes.liver, spleen and lymph nodes.

LeukemiaLeukemia

The leukemias are named The leukemias are named after the specific lines of after the specific lines of blood cells afffected blood cells afffected primarilyprimarily– MyeloidMyeloid– LymphoidLymphoid– MonocyticMonocytic

LeukemiaLeukemia

The leukemias are named also The leukemias are named also according to the maturation of according to the maturation of cellscells

ACUTEACUTE– The cells are primarily immatureThe cells are primarily immature

CHRONICCHRONIC– The cells are primarily mature The cells are primarily mature or diferentiatedor diferentiated

LeukemiaLeukemia

ACUTE myelocytic leukemiaACUTE myelocytic leukemiaACUTE lymphocytic leukemiaACUTE lymphocytic leukemia

CHRONIC myelocytic leukemiaCHRONIC myelocytic leukemiaCHRONIC lymphocytic leukemiaCHRONIC lymphocytic leukemia

LeukemiaLeukemia

ETIOLOGIC FACTORSETIOLOGIC FACTORS– UNKNOWMUNKNOWM– Probably exposure to Probably exposure to radiationradiation

– Chemical agentsChemical agents– Infectious agentsInfectious agents– GeneticGenetic

LeukemiaLeukemia

– PATHOPHYSIOLOGY of PATHOPHYSIOLOGY of ACUTE LeukemiaACUTE Leukemia

Uncontrolled proliferation of Uncontrolled proliferation of immature cellsimmature cells suppresses bone marrow suppresses bone marrow functionfunction severe anemia, severe anemia, thrombocytopenia and thrombocytopenia and granulocytopeniagranulocytopenia

LeukemiaLeukemia

– PATHOPHYSIOLOGY of PATHOPHYSIOLOGY of CHRONIC LeukemiaCHRONIC Leukemia

Uncontrolled proliferation of Uncontrolled proliferation of DIFFERENTIATED cellsDIFFERENTIATED cells slow suppression of bone slow suppression of bone marrow functionmarrow function milder milder symptomssymptoms

LeukemiaLeukemia

ASSESSMENT FINDINGSASSESSMENT FINDINGS ACUTE LEUKEMIAACUTE LEUKEMIA

– PallorPallor– FatigueFatigue– DyspneaDyspnea– HemorrhagesHemorrhages– OrganomegalyOrganomegaly– HeadacheHeadache– vomitingvomiting

LeukemiaLeukemia

ASSESSMENT FINDINGSASSESSMENT FINDINGS CHRONIC LEUKEMIACHRONIC LEUKEMIA

– Less severe symptomsLess severe symptoms– organomegalyorganomegaly

LeukemiaLeukemia

LABORATORY FINDINGSLABORATORY FINDINGS Peripheral WBC count varies Peripheral WBC count varies

widely widely Bone marrow aspiration biopsy Bone marrow aspiration biopsy

reveals a large percentage of reveals a large percentage of immature cells- BLASTSimmature cells- BLASTS

Erythrocytes and platelets are Erythrocytes and platelets are decreaseddecreased

LeukemiaLeukemia

Medical ManagementMedical Management

1.1. ChemotherapyChemotherapy

2.2. Bone marrow transplantationBone marrow transplantation

LeukemiaLeukemia

Nursing ManagementNursing Management 1. Manage AND prevent 1. Manage AND prevent

infectioninfection– Monitor temperatureMonitor temperature– Assess for signs of infectionAssess for signs of infection– Be alert if the neutrophil count Be alert if the neutrophil count

drops below 1,000 cells/mm3drops below 1,000 cells/mm3

LeukemiaLeukemia

Nursing ManagementNursing Management 2. Maintain skin integrity2. Maintain skin integrity

3. Provide pain relief3. Provide pain relief

4. Provide information as to 4. Provide information as to therapy- chemo and bone therapy- chemo and bone marrow transplantationmarrow transplantation

Documents

Cardio Nursing