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CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION
(PART 2)
Mr. Jayesh Patidar
DIAGNOSTIC TESTS
CK-MB (CREATININE KINASE, MYOCARDIAL MUSCLE)
An elevation in value indicates myocardial damage
An elevation occurs within 4 to 6 hours and peaks 18 to 24 hours following an acute ischemic attack
Normal value is 0% to 5% of total; total CK is 26 to 174 units/L
LACTATE DEHYDROGENASE (LDH) Elevations in LDH levels occur 24 hours
following myocardial infarction and peak in 48 to 72 hours
Normally, LDH1 is lower than LDH2; when the serum concentration of LDH1 is higher than LDH2, the pattern is indicated as “flipped”, signifying myocardial necrosis
140 to 280 IU/L
TROPONIN Is composed of troponin C, cardiac
troponin I, and cardiac troponin T
Has a high affinity for myocardial injury; it rises within 3 hours and persists for up to 7 days
Troponin I – lower than 0.6ng/mL Troponin T – 0 to 0.2ng/mL
COMPLETE BLOOD COUNT RBC decreases in rheumatic heart
disease and infective endocarditis and increases in conditions characterized by inadequate tissue oxygenation
The WBC increases in infectious and inflammatory diseases of the heart and after MI to dispose necrotic tissue resulting from infarction
Elevated hematocrit level can result from vascular volume depletion
Decreases in hematocrit and hemoglobin levels can indicate pneumonia
SERUM LIPIDS The lipid profile measures serum
cholesterol, triglyceride, and lipoprotein levels
Is used to assess the risk of developing coronary artery disease
Serum cholesterol – lower than 200mg/dL
LDL – lower than 130mg/dL HDL – 30 to 70 mg/dL
B-TYPE NATRIURETIC PEPTIDE (BNP) Is released in response to atrial and
ventricular stretch; it serves as a marker for congestive heart failure
Should be lower than 100pg/mL
The higher the level, the more severe the congestive heart failure
ELECTROCARDIOGRAPHY Noninvasive test that records the
electrical activity of the heart and is useful for detecting cardiac dysrhythmias, location and extent of MI, and cardiac hypertrophy and for evaluation of the effectiveness of medications
INTERVENTIONS
Determine the client’s ability to lie still; advise the client to lie still, breathe normally, and refrain from talking during the test
Reassure the client that an electrical shock will not occur
Document any cardiac medications the client is taking
ECHOCARDIOGRAPHY
Noninvasive procedure based on the principles of ultrasound and evaluates structural and functional changes in the heart
Heart chamber size is measured, ejection fraction is calculated, and flow gradient across the valve is determined
EXERCISE TESTING (STRESS TEST) Noninvasive test that studies the heart
during activity and detects and evaluates coronary artery disease
Treadmill testing is the most commonly used mode of stress testing
INTERVENTIONS
Obtain an informed consent if required
Provide adequate rest the night before the procedure
Instruct the client to eat a light meal 1 to 2 hours before the procedure
Instruct the client to avoid smoking, alcohol and caffeine before the procedure
Instruct client to wear nonconstrictive, comfortable clothing and supportive rubber-soled shoes for the exercise stress test
Instruct the client to notify the physician if any chest pain, dizziness, or shortness of breath occurs during the procedure
Instruct client to avoid taking a hot bath or shower for at least 1 to 2 hours after the procedure
DIGITAL SUBTRACTION ANGIOGRAPHY
This test combines x-ray techniques and a computerized subtraction technique with fluoroscopy for visualization of the cardiovascular system
A contrast media (dye) is injected
INTERVENTIONS
Assess for allergies to seafood, iodine, or radiopaque dyes. Premedicate client with antihistamines or corticosteroids to prevent a reaction
Obtain informed consent
Monitor vital signs
Assess injection site for bleeding or discomfort
MAGNETIC RESONANCE IMAGING Noninvasive diagnostic test that
produces an image of the heart or great vessels through interaction of magnetic fields, radio waves, and atomic nuclei
Provides information on chamber size and thickness, valve and ventricular function, and blood flow through the great vessels and coronary arteries
INTERVENTIONS
Evaluate client for the presence of pacemaker or other implanted items that present a contraindication to the test
Ensure client has removed all metallic objects such as watch, jewelry, clothing with metal fasteners, and metal hair fasteners
Inform client that she or he may experience claustrophobia while in scanner
SICKLE CELL ANEMIA
Constitutes a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S
Caused by inheritance of a gene for a structurally abnormal portion of the hemoglobin chain
Hemoglobin S is sensitive to changes in the oxygen content of the RBC
Insufficient oxygen causes the cells to assume a sickle cell shape and the cells become rigid and clumped together, obstructing capillary blood flow
Situations that precipitate sickling include fever and emotional or physical stress; any condition that increases the need for oxygen or alters the transport of oxygen can result in sickle cell crisis
At risk are those having parents heterozygous for hemoglobin S or being of African American descent
Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency ; these include vaso-occlusive crisis, splenic sequestration, and aplastic crisis
VASO-OCCLUSIVE CRISIS
Caused by stasis of blood with lumping of the cells in the microcirculation, ischemia, and infarction
Fever, painful swelling of the hands, feet, and joints, and abdominal pain
SPLENIC SEQUESTRATION
Caused by the pooling and clumping of blood in the spleen (hypersplenism).
Profound anemia, hypovolemia, and shock
APLASTIC CRISIS
Caused by the diminished production and increased destruction of RBC, triggered by viral infection or the depletion of folic acid
Profound anemia and pallor
INTERVENTIONS
Maintain adequate hydration and blood flow with IV administered NSS and with oral fluids
Administer oxygen and blood products as prescribed
Administer analgesics as prescribed(ATC)
Administration of meperidine (Demerol) is avoided
Assist the child to assume a comfortable position so that the child keeps the extremities extended to promote venous return
Elevate the bed of the head 30 degrees, avoid putting strain on painful joints, and do not raise the knee gatch of the bed
Encourage consumption of high-calorie, high protein diet, with folic acid supplementation
Administer antibiotics as prescribed to prevent infection
Monitor for signs of complications, including increasing anemia, decreased perfusion, and shock
Instruct the child and parents about the early signs and symptoms of crisis and the measures to prevent crisis
IRON DEFICIENCY ANEMIA
Iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in RBC
Commonly results from blood loss, increased metabolic demands, syndromes of GI malabsorption and dietary inadequacy
SIGNS AND SYMPTOMS
Pallor
Weakness and fatigue
Irritability
INTERVENTIONS
Increase the oral intake of iron
Instruct the child and parents in food choices that are high in iron
Administer iron supplements as prescribed
Give iron supplements between meals for maximum absorption
Give iron supplements with a multivitamin or fruit juice because vitamin C increases absorption
Do not give iron supplements with milk or antacids because these items decrease absorption
Teach the child and parents that a liquid iron preparation stains the teeth and should be taken through a straw
Inform parents/client on side effects (constipation, black stools, foul aftertaste)
HEMOPHILIA
Refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins
Factor VIII deficiency (hemophilia A or classic hemophilia)
Factor IX deficiency (hemophilia B or Christmas disease)
Result as an X-linked recessive disorder
Most frequently transmitted by the union of an unaffected male with a trait-carrier female; however, it can result from the union between an affected male and a normal or carrier female
SIGNS AND SYMPTOMS
Abnormal bleeding in response to trauma or surgery (usually detected after circumcision)
Epistaxis
Joint bleeding causing pain, tenderness, swelling and limited ROM
Tendency to bruise easily
Platelet test is normal; clotting factor function may be abnormal
INTERVENTIONS
Monitor for bleeding and maintain bleeding precautions
Prepare to administer replacement factors as prescribed
Monitor for joint pain; immobilize the affected extremity if joint pain occurs
Assess neurological status (child is at risk for intracranial hemorrhage)
Control joint bleeding by immobilization, elevation, and the application of ice; in addition, apply pressure (15 minutes) for superficial bleeding
Instruct parents how to control bleeding
Instruct the parents on activities to be avoided by the child, emphasizing avoidance of contact sports and the need for protective devices while learning to walk
Instruct the child to wear protective devices such as helmets and knees and elbow pads when participating in sports such as bicycling and skating
KAWASAKI DISEASE
Is known as mucocutaneous lymph node syndrome and is an acute systemic inflammatory illness
The cause is unknown but may be associated with an infection from an organism or toxin
Cardiac involvement is the most serious complication; aneurysms can develop
SIGNS AND SYMPTOMS
Fever
Conjunctival hyperemia
Red throat acute stage
Swollen hands, rash, and enlargement of the cervical lymph nodes
Crackling lips and fissures
Desquamation of the skin on the tips of the fingers and toes subacute
stage Joint pain
Cardiac manifestations
Thrombocytosis
Convalescent stage
appears normal but signs of inflammation may be present
Irritability may last up for up to 2 months after the onset of symptoms
Peeling of the hands and feet may occur
Pain in the joints may persist for several weeks
Stiffness in the morning, after naps, and in cold temperatures may occur
INTERVENTIONS
Monitor temperatures frequently (refer if 101F or higher)
Assess heart sounds, rate, and rhythm
Assess extremities for edema, redness, and desquamation
Examine eyes for conjunctivitis
Monitor mucous membranes for inflammation
Monitor strict intake and output
Administer soft foods and liquids that are neither too hot nor too cold
Weigh the child daily
Provide passive range of motion exercises to facilitate joint movement
Administer ASA as prescribed
Administer immune globulin intravenously as prescribed to reduce the duration of the fever and the incidence of coronary artery lesions and aneurysms
CORONARY ARTERY DISEASE
Narrowing or obstruction of one or more coronary arteries as a result of atherosclerosis, which is an accumulation of lipid-containing plaque in the arteries
Causes decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply
Symptoms occur when the coronary artery is occluded to the point that inadequate blood supply to the muscle occurs causing ischemia
Coronary artery narrowing is significant if the lumen diameter of the left main artery is reduced at least 50%, or if any major branch is reduced at least 75%
The goal of treatment is to alter atherosclerotic progression
Cardiac catheterization provides the most definitive source for diagnosis
SIGNS AND SYMPTOMS
Chest pain
Palpitations
Dyspnea
Syncope
Cough or hemoptysis
Excess fatigue
When blood flow is reduced and ischemia occurs, ST segment depression, T wave inversion, or both is noted; ST segment returns to normal when the blood flow returns
With infarction, cell injury results in ST segment elevation, followed by T wave inversion and an abnormal Q wave
Blood lipid levels may be elevated
INTERVENTIONS
Instruct the client regarding the purpose of diagnostic medical and surgical procedures and pre procedure and post procedure expectations
Assist the client to identify risk factors that can be modified
Assist the client to set goals to promote lifestyle changes to reduce the impact of risk factors
Instruct the client regarding a low-calorie, low sodium, low cholesterol, and low fat diet with an increase in dietary fiber
Stress to the client that dietary changes are maintained for life
Provide community resources to the client regarding exercise, smoking cessation, and stress reduction as prescribed
SURGICAL PROCEDURES
PTCA to compress the plaque against the walls of the artery and dilate the vessel
Laser angioplasty to vaporize the plaque
Atherectomy to remove the plaque from artery
Coronary artery bypass grafting to improve blood flow to the myocardial tissue at risk for ischemia or infarction
ANGINA
Chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and oxygen supply
Caused by an imbalance between oxygen supply and demand
Causes include obstruction of coronary blood flow resulting from atherosclerosis, coronary artery spasm, or conditions increasing myocardial oxygen consumption
PATTERNS OF ANGINA
Stable AnginaAlso called exertional angina
Occurs with activities that involve exertion or emotional stress; relieved with rest or nitroglycerin
Usually has a stable pattern of onset, duration, severity and relieving factors
Unstable AnginaAlso called preinfarction angina
Occurs with an unpredictable degree of exertion or emotion and increases in occurrence, duration, and severity over time
Pain may not be relieved with nitroglycerin
Variant AnginaAlso called Prinzmetal’s or vasospastic
angina
Results from coronary artery spasm
May occur at rest
Attacks may be associated with ST segment elevation noted on the ECG
Intractable Angina – is a chronic, incapacitating angina unresponsive to interventions
Preinfarction AnginaAssociated with acute coronary
insufficiency
Lasts longer than 15 minutes
Symptom of worsening cardiac ischemia
Occurs after an MI, when residual ischemia may cause episodes of angina
SIGNS AND SYMPTOMS
Pain
Dyspnea
Pallor
Sweating
Palpitations and tachycardia
Dizziness and faintness
Hypertension
Digestive disturbances
INTERVENTIONS
Assess pain
Provide bed rest
Administer oxygen at 3L/min by nasal cannula as prescribed
Administer nitroglycerin as prescribed
Obtain a 12-lead ECG
Provide a continuous cardiac monitoring
Assist the client in identifying angina-precipitating events
Instruct client to stop activity and rest if chest pain occurs and to take nitroglycerin as prescribed
Instruct client to seek medical attention if pain persists
Assist client to identify risk factors that can be modified
Provide dietary instructions
Provide community resources to the client regarding exercise, smoking cessation, and stress reduction
MYOCARDIAL INFARCTION
Occurs when myocardial tissue is abruptly and severely deprived of oxygen
Ischemia can lead to necrosis of myocardial tissue if blood flow is not restored
Infarction does not occur instantly but evolves over several hours
Obvious physical changes do not occur in the heart until 6 hours after the infarction, when the infarcted areas appears blue and swollen
Not all clients experience the classic symptoms of an MI
Women may experience atypical discomfort , shortness of breath, or fatigue
An older client may experience shortness of breath, pulmonary edema, dizziness, altered mental status, or a dysrhythmia
SIGNS AND SYMPTOMS
Pain
Nausea and vomiting
Diaphoresis
Dyspnea
Dysrhythmias
Feelings of fear and anxiety
Pallor
Cyanosis
Coolness of extremities
INTERVENTIONS
Obtain a description of the chest discomfort
Assess vital signs
Assess cardiovascular status
Place client in a semi-Fowler’s position
Administer oxygen at 2 to 4L/min by nasal cannula as prescribed
Establish an IV access route
Administer nitroglycerin as prescribed
Administer morphine sulphate as prescribed to relieve chest discomfort
Obtain a 12-lead ECG
Monitor thrombolytic therapy, which may be prescribed for the first 6 hours of the coronary event
Administer beta blockers as prescribed
Assess distal peripheral pulses and skin temperature
Monitor intake and output
Assess RR and breath sounds for signs of heart failure
Monitor BP closely
Provide reassurance to the client and family
Maintain bed rest for the first 24 to 36 hours as prescribed
Allow the client to stand to void or use a bed side commode if prescribed
Provide ROM exercises
Encourage client to verbalize feeling regarding the MI
RAYNAUD’S DISEASE
Vasospasms of the arterioles and arteries of the upper and lower extremities
Vasospasms cause constriction of the cutaneous vessels
Attacks are intermittent and occur with exposure to cold or stress
Affects primarily fingers, toes, ears, and cheeks
SIGNS AND SYMPTOMS
Blanching of the extremity, followed by cyanosis during constriction
Reddened tissue when the vasospasm is relieved
Numbness, tingling, swelling, and a cold temperature at the affected body part
INTERVENTIONS
Monitor pulses
Administer vasodilators as prescribed
Assist the client to identify and avoid precipitating factors such as cold and stress
Instruct the client to avoid smoking
Instruct the client to wear warm clothing, socks and gloves in cold weather
Advise client to avoid injuries to fingers and hands
BUERGER’S DISEASE
Thromboangiitis obliterans
An occlusive disease of the median and small arteries and veins
The distal upper and lower limbs are affected most commonly
SIGNS AND SYMPTOMS
Intermittent claudication
Ischemic pain occurring in the digits while at rest
Aching pain that is more severe at night
Cool, numb, or tingling sensation
Diminished distal pulses
Extremities that are cool and red in the dependent position
Development of ulcerations in the extremities
INTERVENTIONS
Instruct the client to stop smoking
Monitor pulses
Instruct the client to avoid injury to the upper and lower extremities
Administer vasodilators as prescribed