*

MCC NURSING Diana Blum MSN

*S3= sounds like *S4= sounds like

heard

kentucky (ventricular) tennesee (atrial)

*Rub= related to

inflammation high pitched sweaky yet muffled like sandpaper from turbulent flow aka bruit

*Gallop=when s3 and 4 *Murmur=vibrations

*
6

* Arteries have 3 layers: tunica intima, tunica

media, and tunica adventitia (figure 32-1)

* Disease process that occurs over time * Starts in infancy * Risk factors: age gender diet sedentary life
smoking

* Atherosclerosis affects medium arteries that

feed heart brain and kidneys as well as aorta

* 2 branches off Aorta: Supplies posterior & inferior

myocardium: * 1. Right (Longest) coronary artery * *occlusion results in inferior MI

* * * * *

(30% of inferior MIs include right ventricle)

*lower mortality than anterior MI *more mild AV node dysrhymias

*
(first & second degree blocks)

SYMPTOMS OF INFERIOR MI: - hypotension from a decrease in preload available to the LV due to d RV emptying

*
8

*
* *

left anterior descending artery(LAD) = supplies anterior and bottom of Left vent and front of the septum * most involved with occlusions * Blockage here results in anterior MI which has higher mortality rate AND more serious dysrhythmias !!!!! * may include 2nd & 3rd degree blocks * diminished ejection fraction & symptoms of heart failure !!!!! * When > 40% of left vent. Is damaged * mortality is extremely high

circumflex= supplies the left atrium & back of left vent

10

11

*
* 1. Stable Angina: * - no or minimal myocardial injury * - collateral circulation develops * - pain begins with exertion or stress * - pain relieved with rest * - pain lasts less than 20 minutes * - relieved by NTG (may take SL up to * 3 times every 5 minutes) If not relieved * after these 3 doses, pt may be infarcting * -ST segment depression with pain then * returns to normal with pain subsides

12

* 2. Unstable Angina: * - pain resolves with NTG * - similar to stable angina BUT angina * occurs more freq with less exertion * - often begins at rest with increasing * severity * - normal cardiac enzymes * - ST depression with prolonged CP

13

* 3. variant (Prinzmetal) angina: * - rare & associated with angina at rest * - tend to be younger women (smokers) * & pain occurs in early am & with menstrual * - ST elevation (reversible) but cardiac enzymes
norm * - CAUSE: coronary artery spasm occurs * at stenosed area * Treat: responds to NTG * long-term: calcium channel blockers

14

* A. reflux or peptic ulcer disease * B. chest wall pain (pain reproduced on palpation and
localized) * - occurs from bruised/ fx ribs * C. esophageal problems * - achalasia, esophageal spasm * D. pericarditis (will be sed rate, low-grade * fever, viral cause (coxsackievirus) * E. pneumonia * F. Aortic dissection (CV EMERGENCY) watch * for severe pain radiating to back

*
15

* Goal in treatment of Angina:

dilate vessels, O2 availability, O2 demand

* HOW?

* Angina without MI} often relieved with rest and NTG * Angina with MI } may be relieved with rest, NTG, 02, MS,
rescue angioplasty, etc. * Think MONA

* Morphine * Oxygen * Nitroglycerin * Aspirin

*
http://www.youtube.com/watch?v=4GlQmTlP2jE&feature=related

http://www.doctorsecrets.com/yourmedicine/heart-attack-cause-symptomstreatment.html

18

*
* - actual necrosis of myocardial tissue * - most cases, atherosclerotic heart disease
present

* other cases is from artery spasm

*-

IDENTIFICATION OF MI IS MOST IMPORTANT AS WITHIN 6 hours there is irreversible damage!!!!

19

20

*
* Common patterns: * Ant/lat * inf/post * ant/septal * 25% of MI are silent : presents without * chest pain (esp in diabetics with neuropathy) * Patient presents with heart failure, shock,
confusion, delirium (esp in elderly)

21

*
22

*
23

24

* Depends on which vessel involved & region of the

heart muscle * Ischemia of condux system, causes arrythmias * If lg enough area, CHF develops * Occlusion of Left descending artery: left heart failure * Occlusion of Right descending artery: Rt heart failure * Infarct of vent wall can result in rupture, heart hemorrhage into pericardial sac leads to tamponade can be quickly fatal

*
25

* Symptoms * * ECG within 10 minutes * * ST elevated * * ASA, Troponin, CPK-MB, Morphine, Heparin * * Thrombolytic with 30 minutes if PCI not avail * * PCI in24 hours if avail, within 90 min. * * stent angioplasty *
26

*
* Procedure done at the time of cardiac cath. * Balloon angioplasty is accomplished to widen or
open specific coronary vessel-stent is inserted to maintain patency of the vessel.

* pre-procedure Plavix given with follow up Plavix

http://preop.medselfed.com/asp/center. asp?centerId=heart&partnerId=preop&id= &cachedate=&emailId=&affId=&campId=& hideNav=

27

28

*
* No ST elevation * * Draw Troponin I * * If elevated * * Cardiac cath vs * *

Medical Management Echo, Stress test

29

*
* Continuous cardiac monitoring * Oxygen * IV line * Hemodynamic monitoring (discuss in a bit) * Bed rest * Emotional support * Need passive & active ROM to reduce risk of * thromboembolism (immobility)

30

*
* For low cardiac output: * - dobutamine +inotropic * -milrinone +inotropic * For hypotension: * - dopamine ( or at low doses used to * improve renal perfusion) * May need Intraaortic balloon pump

31

*http://people.brunel
.ac.uk/~emstawk/IAB P.htm

32

* Aortic or ventricular aneurysms * Ventricular septal defects * Aortic regurgitation

*
33

* Begins as soon as MI stop * Scar tissue dev. at necrotic area (takes 6-8 wks * May see stages of grief in pt with MI * - - we need to identify depression as mortality at 1
to 5 years with associated depression !!!!

* MUCH TEACHING NEEDED; * - MODIFY RISK FACTORS, LIFESTYLE

CHANGES, WORK WITH BOTH FAMILY/PT

*
34

*
* Papillary muscle rupture * Ventricular aneurysm * Ventricular rupture

35

* Precautions with Nitrates and Viagra use: * - reports of sudden death, dramatic * drop in blood pressure, and further * compromising restricted coronary * arterial perfusion

*
36

*
* Vasodilators to reduce preload/afterload * - nitroglycern or nitroprusside * ACE inhibitors: * - reduce afterload * Beta blockers: * - reduce myocardial oxygen consumption * - decrease heart rate and BP * Statins: * - restrict development of artherosclerosis * & also have anti-inflammatory effects * Platelet inhibitors: * - ASA
37

Platelet activation = treat with GP IIb/IIIa inhibitors examples: Abciximab (ReoPro): 0.25mg/kg IV bolus followed by 0.125ug/kg/min for 12 hours (others: Integrilin, Aggrastat)

* What precaution should we

take with beta blockers ???
* Heart has Beta 1:
so Beta Blockers lower BP * slowing heart rate * Lung has Beta 2: so Beta blockers constrict * bronchioles, making it harder to * breathe * Propranolol blocks both types of beta receptors so SHOULD NOT BE USED IN ASTHMATICS * Metopolol CAN be used since it is specific for Beta 1 and DOES NOT CONSTRICT BRONIOLES SO SAFE WITH ASTHMATICS.

40

* Streptokinase: depletes fibrinogen to predisposed to

systemic bleeding & allergic reaction possible with second time use

* Alteplase (tPA, Activase): used most often * Reteplase (rPA, Retavase) a synthetic, 2nd generation
that works more quickly & lower bleeding

*
41

*
* Minimal arterial or venous sticks * Use finger oximetry * Avoid automated blood pressure cuffs (bruising * Assess for signs of bleeding(hypotension, tachycardia,
reduced level of consciousness) * Reperfusion arrhythmias common * - bradycardia and V-tach most common * IF BLEEDING COMPLICATIONS: * -stop fibrinolytic agent, FFP &/or cryoprecipitate to replenish fibrin & clotting factors, Aminocaproic acid (Amicar)

42

*
* Hx of intracranial hemorrhage * Known structural cerebrovascular lesion * Known intracranial tumor * Ischemic stroke <3 months * Severe uncontrolled hypertension * Acute pancreatis * Aortic dissection * Hx of hemorrhagic stroke * pregnancy

43

* EKG: rate, rhythm, ischemia (T-inverted), injury

(ST segment elevation), arrhythmias, strain, infarction (q wave) * Echocardiogram: (TEE) sound wave test detects size of chambers, valve integrity, flow, wall motion, Cardiac Output

*
44

Biomarkers: * Troponin I will show elevation IN 3-48hrs of MI period and normalizes after 1-2 weeks <0..06 is negative 0.10-0.60 is intermediate and may indicate injury >0.60 is positive evidence of MI Myoglobin normal is 17-106ng/mL * CPK-MB will show increase 2-12 hrs after MI and normalizes 12-18hr after infarct BNP can be elevated 48 hrs after MI which indicates heart failure

*
45

*
* CBC: anemia * CMP: screening K+, etc * PT, INR * PTT * Lipid profile: looks at total cholesterol (good and
bad)

46

47

*
* ABG: assess acid/base levels * Pulse Oximetry: generally >92% * Holter monitoring: 24+ hr of EKG + events * Stress test: treadmill or pharmacological * Cardiac Catheterization: invasive, NPO 6-8h, consent.
Visualizes chambers, valves, arteries, pressures, CO * Heart-CT scan: assesses CAD * Nuclear scans: assess heart muscle viability * EPS: NPO, consent, IV, assess electrical activity

48

* Low fat low cholesterol diet * Prescribed exercise program 5-7 days a week * Knows correct use of NTG for angina * Management of DM, HTN * Stop smoking * Medications to reduce work load or dilate

50

* 5-7 X week is goal to include stretches with * Strengthens heart muscle, reduces BP, BS,
weight, stress, tension, appetite, LDLs. improves immune system

warm-up, progressive walking program, light weights, stretches with cool down.

* Increases HDLs, energy and self esteem and

51

* Decreased cardiac output r/t Dysrhythmias * Pain r/t lack of 02 to myocardium * Anxiety r/t to feeling of doom, lack of
understanding of medical diagnosis

*
52

* You are asked to evaluate a 55-year old Caucasian woman who presents to the

Emergency Department with the chief complaint of chest pain for several hours. * She awoke with the discomfort at 4:00AM today, and it has been a "ten out of ten" since then. The pain is substernal, radiates to her back, and is associated with moderate-to-severe shortness of breath and nausea. * No previous such episodes are reported, but the patient states there is a strong family history of cardiac disease, and that she has smoked one-half pack of cigarettes daily for the past thirty-five years. * Other than that, she denies past medical or surgical conditions, takes only hormone replacement therapy, and has no known drug allergies. * Social history reveals that the patient is married, has three children, and works as an accountant. * On physical exam, the patient appears to be in mild discomfort due to chest pain, but otherwise appears normal. * Temperature is 97.7F, pulse is 110, blood pressure is 150/100, and respirations are 20. * Head and neck, lung, heart, and abdominal exams are normal. * An EKG is performed, which shows nonspecific T-wave changes in the lateral leads. * Other tests, including troponin-I, cardiac enzymes, and chest x-ray have been performed, but results are still pending.

* What are risk factors? * What are you concerned with? * What to do?

54

* Coronary artery bypass graft- done after

confirmation with cardiac catheterization. * Re-route blood vessels using mammary or saphenous v from aorta around block in coronary artery.

* Valve replacement or repair * Septal repair and other congenital repairs * CCU post op, chest tubes * Pre-op teaching with post op expectations

55

*
* 1. damage to blood (platelets, RBCs WBCs &
plasma proteins)

* 2. Incorporation of abnormal substances into

blood (bubbles, fibrin, platelet aggregates)

* 3. a systemic inflammatory response * 4. increase in systemic vascular resistance * 5. increase catecholamines

56

* 1. fluid status (fluid leaks from vessels) * 2. O2 sats (indicates excess capillary leaking) * 3. postop bleeding from anticoagulation for

procedure * 4. hemodynamic monitoring * 5. pain relief * 6. dysrhythmia control * 7. warming pt may need vasopressors to maintain BP initially (undesirable to let pt shiver as oxygen demands) (use warmed blankets, warmed blood to infuse, warmed inspired gases)

*
57

*
* 8. bleeding not to exceed 300 mL/hour in first
couple hours then 150-200 ml/hour but average blood loss is 1 L. * Notify physician if excessive. * Autotransfusion of medialstinal blood is filtered & infused * 9. aggressive suctioning then enc coughing * 10. monitor electrolytes to prevent dysrhthmias

58

* 11. dysrhythmias treated pharmacologically * 12. pacing wires placed on right atrium and
ventricle before surgical closure.

Postop BRADYCARDIA most common indication for need of pacer.

59

* Hemorrhage, cardiac tamponade, MI, ventricular

dysfunction, dysrhythmias, death

* Cardiac tamponade: * - watch for pts that have bleeding in chest

tube (significant) then suddenly STOPS bleeding & becomes hypotensive

- reopen & immed return to OR

60

*
61

* CAD, advancing age * HTN is a major factor > CHF x 3 * DM, Smoking, Obesity * Valvular incompetency, alcohol or other
chemicals, idiopathic,(unknown)

*
62

63

64

* Inability of either ventricles to pump

effectively

* Both rt and lt failure * Symptoms are a combo of both

* Mediated thru Sympathetic Nervous System: as

CO drops, baroreceptors alert brain>>>signals adrenal glands to release catecholamines{norepinephrine and epinephrine}

* This causes stimulation Beta 1=>>HR * Stimulation Beta 2= bronchodilation * Activate Alpha receptors
peripherally=constriction=>>bp

*
66

* CO drops initiating renin-angiotensin

mechanism

* Results in powerful vasoconstrictor angiotensin

II,>> aldosterone (hormone) which causes kidneys to retain Na and H20 which increases blood volume

*
67

* The heart enlarges which results in strain * The increase in volume causes the ventricles
to dilate

* Eventually remodeling will occur

*
68

*
* H&P * Chest x-ray: see size of heart and fluid in lungs * EKG: strain, MI * Echocardiogram: size of heart and CO * CBC: anemia * CMP: screening * Thyroid function * ABGs * BNP=B type natriuretic peptide= hormone released in

response to Ventricular stretch ( CHF peptide) * Nuclear studies to determine heart function, EF, tissue viability * Cardiac Cath to determine exact nature of heart function

69

* Directed at: Improving LV function

(Contractility) by decreasing intravascular volume and decreasing vascular resistance

* Decreasing venous return (Preload) * Decreasing BP (Afterload) * Improving gas exchange and 02 * Increasing the CO and reducing anxiety

70

71

*
* I & O q shift * Daily am weights before breakfast and after voiding.
2-3# weight gain in 1-4 days call MD * Sodium restricted diet * Medications: to decrease intravascular volume thus reducing venous return, dilate and reduce BP and improve contractility * surgery * http://chfsolutions.com/zip_how_aquapheresis_work s.html#

72

Ultrafiltration Compared to Loop Diuretics

Ultrafiltrate is isotonic with plasma, whereas the diuresis of loop diuretics is virtually always hypotonic to plasma Ultrafiltration removes more sodium than diuretic

therapy
No electrolyte disturbances Ultrafiltration decreases ECF volume more than a comparable volume of diuretic-induced fluid loss

Schrier. J Am Coll Cardiol. 2006;47:1-8.

*
* ACE inhibitors ( proven to mortality in CHF * Beta blockers (proved to mortality) * - begin once pt diuresis occurs) * Diuretics (loop and K+ sparing) * Spironolactone (proven to mortality in class IV
CHF) * Digoxin may be used (doesnt improve mortality in CHF BUT improves symptoms, hosptialization

74

75

* Food decreases absorption * Give on an empty stomach * Postural hypotension (monitor) * Watch for hyperkalemia, angioedema,
PERSISTENT DRY COUGH

* NOT TO BE USED WITH PREGNANT WOMEN

AS IT IS FETOTOXIC !!!!
76

*
* Prototype: LOSARTAN * Similar actions to ACE inhibitor * These meds are a substitute for pts who cannot tolerate

ACE inhibitors (those with severe cough or angioedema) * - lowers BP * - reduces morbidity & mortality assoc. with * hypertension * Only need once a day dosing * Adverse effects similar to ACE inhibitors but without the cough * Contraindicated with pregnancy

77

78

*
* ABSOLUTE improved systolic functioning &
reverses cardiac remodeling

* Initially may have exacerbation of symptoms * Decreases heart rate & inhibits release of renin * Two drugs approved for heart failure: * 1. Carvedilol (nonselective B-adrenoreceptor
antagonist that also blocks adrenoreceptors

2. Metoprolol (selective B1 selective antagonist)

79

80

*
* By dilating venous blood vessels, leads to decrease in
cardiac preload

* By dilating arterial vessels, leads to reduction of

systemic arteriolar resistance & decrease afterload

* NITRATES

81

Diuretics
The use of loop diuretics in ADHF patients with dyspnea and shortness of breath is standard therapy
In patients with ADHF, diuretics

May induce a natriuresis

Decrease extracellular fluid (ECF) volume Provide symptomatic relief

Schrier. J Am Coll Cardiol. 2006;47:1-8.

Elevated Neurohormones Cause Diuretic Resistance

Glomerulus Norepinephrine (and endothelin) decreases renal blood flow and GFR

Proximal Tubule Ang II increases sodium reabsorption

Collecting Duct Aldosterone increases sodium reabsorption

Krmer et al. Am J Med. 1999;106:90.

* Decrease plasma vol. * * which will decrease venous return (preload) * * which decreases cardiac workload & Oxygen
demand

* * Which decreases afterload by reducing plasma

volume thus decreasing blood pressure

*
84

* Since metabolized by the liver before excreted

in feces, the pt with hepatic disease may require decreased dosing.
DIGOXIN TOXICITY. dig?

* HYPOKALEMIA PREDISPOSES THIS PATIENT TO

* What can be used to detoxify the body from

*
DIGOXIN IMMUNE FAB (THIS BINDS AND INACTIVATES THE DRUG)

*
85

* ADVERSE EFFECTS: * Cardiac: progressively more severe dysrhythmias,

eventually to complete heart block

* That is why is is so important to make sure K+ is

normal !!

* GI: anorexia, n/v * CNS: headache, fatigue, confusion, blurred vision,

alterations of color perception, HALOS

*
86

* Hypokalemia leads to serious arrhythmias * - will see this most in pts on thiazide or loop
diuretics (prevented by using a potassium-sparing diuretic OR supplement with potassium chloride )

* ALSO note that: * Hypercalcemia AND hypomagnesemia ALSO

predispose to dig toxicity !!!!

*
87

* Education re: heart failure

* Explanation of heart failure * Expected S/S and when to call MD * Self monitoring of daily weights * Know medications and need to take them * 2000mg sodium restricted diet * Importance of low level daily exercise program
(energy conservation) * Prognosis / advanced directives

*
88

*
89

* Diagnosis: CBC, Chest X-ray, C reactive

protein, EKG, Heart Cath, blood cultures

* Interventions: PREVENTION is key, PCN like * Educate pt and family about prophylactic
Antibx treatment

antibx, NSAIDS for joint pain, Cardiac meds, Bedrest

90

*
*Inflammation of pericardial sac *3 causes: *Infectious *Coxsackie Virus B *Respiratory diseases *Noninfectious *Uremia *AMI *Surgery *Autoimmune *Rhuematoid *Drug Reactions *Connective Tissue Disorders

91

92

* Uncommon * Frequently associated with pericarditis * Usually viral in nature * S/S: fatigue, malaise, achy joints, GI upset, flu like
symptoms

* Dx: WBC, chest x-ray, heart cath, echo, cardio

enzymes, etc

* Tx: immune therapy, antimicrobials, ACE, * Scarring causes permanent damage

93

Antidysrhythmics, anticoagulants, antianxiety

* Infective endocarditis caused by gram+cocci * A deformed or damaged valve is usual focus of

infection

* Dental procedures can cause bacteremia * Diagnosis: cultures, transesophageal

echocardiography

*
94

* Fever- (99-105) * Chills and night sweats may accompany * Malaise, fatigue and weight loss * Appearance of petechiae in the mouth, conjunctiva
and legs

* Chest and abdominal pain indicating embolization

*
95

* H&P and Lab tests

*
CBC with diff with leukocytosis, > sed rate, blood cultures

* May have heart murmur

vegetation

* Echocardiogram to visualize valves and

* Chest x-ray: CHF * Long term antibiotics, rest, limited activity,

prophylactic anticoagulants, valve replacement after inflammation treated

96

* Clients with known valvular disease need to be

treated with prophylactic antibiotics prior to any invasive procedure including dental. Immunosuppression and any source of contamination places clients at risk

97

98

* (Also referred to as regurgitation) * The inability of the valves to close completely. * Allows the blood to backflow. * i.e., After the L A has contracted some of the
blood will flow back into the L A

* Mitral valve is the most commonly affected

*
99

* Often accompanies mitral stenosis as a result of

rheumatic fever. * Valve leaflet become rigid and shorten, prevents closure of valve. * Hypertrophy of Left Atrium and Ventricle = L sided heart failure occurs * Murmur heard. F/U with echocardiogram * Edema and shock appear quickly * Afib is common

* TX: vasodilators, same as for stenosis

*
100

*
* Mitral valve leaflets become thickened and
fibrotic. * Rheumatic heart disease is a common cause * Affect women age 20-40 * S/S: dyspnea, afib, dry cough, palpitations, angina, crackles, fatigue, CHF may develop * TX if failure develops: Digoxin, Lasix, beta blockers, and anti arrhythmics, lo Na diet, etc * Will monitor with yearly echocardiogram * Surgery if worsens * Prophylactic antibiotics prior to invasive procedure or dental work

101

Cardiac insufficiency can be caused by many factors by a swelling of the heart muscle (1), an enlargement of the hollow chambers in the heart (2), a heart attack (3) or a blood clot (4).

102

* Occurs when valve cusps become fibrotic and calcify. * Most commonly caused by aging and atherosclerosis. * Occurs most predominantly in men * Untreated will lead to Left sided CHF * S/S: dyspnea is most common, syncope, angina

*
103

*
* Caused primarily by rheumatic fever * May also be caused by chronic HTN * Predominantly in men * Hypertrophy of the Left ventricle and
eventually to left sided CHF

* Blood may eventually back up into the

pulmonary system and lead to Right Ventricle failure sign

* S/S: palpatations, diastolic murmur is classic

104

* Presents with increased ventricular pressures * 3 common presentations of: * 1. dilated (most common) * 2. hypertrophic * 3. constrictive * Prognosis is POOR * NO CURATIVE MEASURES AT THIS TIME

*Cardiomyopathies: heart
muscle disease
105

106

*
* Dilated cardiomyopathy: dilation of cardiac chambers * redux of ventricular contractile funx * Diagnosed: echocardiogram * TREATMENT: * similar to CHF * - inotropic agents * -diuretics * - vasodilators (ACE inhibitors) * -beta blockers * To prevent sudden cardiac death; implant cardioverterdefibrillator * Need intra-aortic balloon to stabilize pt * NEED HEART TRANSPLANT

107

* Inability of heart to relax during diastole * Goal: reduce afterload (beta-blockers, diuretics) * Causes: idiopathic, systemic hypertension, genetic * -atrial & vent arrhythmias seen in of these pts are

responsible for sudden death * S/S: * - dyspnea, angina, arrhythmias cardiac failure, * very forceful apical impulse * sudden death (most common in ages 10 to 35 and occurs during strenuous exertion)

108

* - very noncompliant ventricular muscle * -diminished LV cavity dimensions * - ventricular volumes decreased * CAUSES: * - idiopathic * - interstitial disease * - radiation * - drug toxicity

*
109

*
110

* Monitoring of the blood flow and opressures

within the body

* Purposes:
* Aid in diagnosis * Assist in guiding therapies * Evaluating response to therapies

* Can be invasive or non invasive * Consent is needed especially if invasive unless

in ICU when crashing

111

*
* Obtain IV NS 0.9% and transducer system * Attach the transducer to the IV flush solution and
prime the tubing, removing air bubbles
dead end caps

* Replace all vented caps with non vented sterile * Inflate pressure bag to 300mmHg * Assist the patient into supine position with HOB <or
= to 45 degrees

* Measure and mark phlebostatic axis with marker * Level air fluid interface with that axis * Zero the system * Set alarm limits
112

* Heparin influences the patency of the art lines * Care should be taken so heparin induced
thrombocytopenia is not initiated

* Occurs 4-7 days after heparin exposure * Client at risk for immune response * Thrombosis risk increases

*
113

* Means placing transducer at same level as tip

of cath in the patient

* Use the phlebostatic axis (pg 562 osborn)

* *****important to use same

time is key**** pressure reading pressure reading
fatality

reference each

* Positioning above the transducer lowers the

* Positioning below the transducer increases
* Both can lead to incorrect treatment and

114

115

* First make sure system is intactno air bubbles, no

leaks, and tight connections

* Do Qshift and with each turn * Zeroing calibrates the system to atmospheric
pressure.

* Procedure: * Turn stopcock closest to pt to off position * Remove cap * Hit zeroing on monitor * Wait for display to say zero * Turn stopcock to neutral position

116

* Uses built in flush system (pigtail) * Quickly pull and release * Perform Q8-12 hours, after blood sampling, or
if accuracy is questioned

* Page 563 osborn

*
117

* Indwelling cath inserted by

doctor into artery to monitor BP assess circulation

* Allen test prior to is done to

* Systolic pressure is max left
closure of aortic valve and diastolic is pressure at rest emboli, spasm, infection reasons for, assess site ventricular systolic pressure

* The dicrotic notch represents

* Complications : hemorrhage, * NSG management: explain

118

* Monitors central venous pressure and reflects

preload

* Right atrium * Uses: sepsis, * Obtain consent * Trendelenburg or Supine position for placement * DO NOT USE FOR IV infusion or monitoring until
xray placement confirmation

* Reflects BP in vena cava and rt atrium * 2-6 mmHg is adequate range * Assess site at least Qshift.
119

*
* Multiple lumen * Can measure temp in pulmonary artery * Balloon is inflated up to 1.5ml air * Over inflation can rupture artery and balloon * Hemoptysis is presenting sign * Place pt with affected side down to prevent leaking into
unaffected side and call doctor immediately.

* Once inserted leave uninflated a pressure reading is

needed.

* Assess patient (electrolytes, coag., acid base) * Set up per facility policy or like example earlier * Complications: infection, air emboli, pneumothorax, artery
rupture, pulmonary infarction, arrythmias
120

122

* http://www.accd.edu/SAC/NURSING/math/de
fault.html

* 1. The physician orders dopamine (Intropin) 400 mg

in 250 mg D5W TRA 5 mcg/kg/min. For the client who weighs 110 lbs, how many ml /hr will the pump be set? 9.375 0r 9 cc/hr 1.6 cc/hr 9375 cc/hr

* A. * B. * C. * D.

93.75 cc/hr

*
123

* 9.375 0r 9 cc/hr * 1) Find concentration. 400 / 250 = 1.6 mg/ cc

= 1600 mcg/cc

* 2) Convert lbs to kg. 110 / 2.2 = 50 * 3) Use formula for rate: Dose (5) x kg (50) x 60
/ concentration (1600)

* 5 x 50 x 60 = 15,000 * 15, 000 / 1600 = 9.375

*
124

* 2. Nitroglycerin is infusing at 16 ml/hr. The * A. 5.33 mcg/min * B. 53.3 mcg /min * C. 32 mcg/min * D. 18 mcg/min

bag has 50 mg NTG in 250 ml D5W. How many mcg/min is the client receiving?

125

* 53.3 mcg /min * 1) Find concentration. 50 / 250 = 0.2 mg/cc =

200 mcg/cc

* 2) Use Dose formula: Rate (16) x

Concentration (200) = 3200 / 60 = 53.33

*
126

* 3. Sodium nitroprusside (Nipride) 50 mg / 250

ml of D5W is hanging. The physician orders include titrating the Nipride to keep Mr. Granger's systolic BP <140 mm Hg. The IV is infusing at 20 ml / hr. Mr. Granger weighs 56 kg. What is the dosage (mcg / kg / min the client is receiving?

* A. 3.6 * B. 1.2 * C. 2.4 * D. 0.8

127

* 1.2

*
128

* The Five Rights of Medication

Administration

*Right patient *Right medication *Right dose *Right route *Right time
129

* The Three Checks of Medication

Administration

1.

2.
3.

Read the label of the medication as it is removed from the shelf, unit dose cart, refrigerator, or dispensing system Read the label of the medication when comparing it with the MAR Read the medication label again before administering the medication to the patient

130

Infiltration

*
* 1. end-stage, ischemic, valvular, or congenital
heart disease with maximum med therapy, not amendable to surgery * 2. Class III IV heart failure with max med therapy * 3. prognosis for 1 year survival <75% * 4. age <65 years * 5. psychologically stable, compliant * 6. strong family support system

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* 7. able to adhere to complex med regimen * 8. absence of the following * - systemic disease or infection * - serious, irreversible impariment of hepatic,

renal, pulmonary functions * - recent CVA or neurologic defects * - peptic ulcer disease * - active substance abuse * - pulmonary vascular resistance >6 wood units * - psychological instability * - malignancy * 9. relative contraindications: * - diabetes and advanced periph atherosclerosis
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