Saturday, March 5, 2011

System Review Intro and CardioVascular disorders - VicNotes

Based on the NCLEX-RN Review MIE I am doing an entire system review this week. Nursing and Medicine are a constantly changing science and reading all the journals and news sometimes makes me less sharp on the basics - okay I forget. I will start with Vickie's version of Cliff Notes of Nursing Basics using my forementioned book as my guide. it is not my intention to plagerize I read, then write what I have understood so I can acess this with out carrying my books to work and family gatherings.

This is my study method - read, write, remember.

  1. AAA - asymptomatic until it is ready to rupture. Prior to rupture c/o back pain and pulsations in the abdomen as common. If it ruptures s/s of hypovolemic shock to know are: anxiety, restlessness, cool, moist, clammy skin, severe back pain, rapid, thready pulse, decreased pressure. Test - chest x-ray. The treatment would be surgical repair a AAA Resection.
  2. Angina - chest pain that usually last 3-5 minutes is described as crushing and substernal but may radiate to the jaw, back and/or arms. Usually triggered by some sort of exertional exercise, emotional extremes or cold exposure. Women tend to have atypical s/s and c/o indigestion, back pain less severe chest discomfort. After assessing, administer meds as ordered, hold nitrates if SBP <90, hold beta-adrenergic blockers for AR <60 abd notify the MD. Tests would be 12 lead EKG looking for ST segment depression and T wave inversion during pain. Treatment PTCA or stent placement.
  3. Arrhythmia's - Afib - rapid P-Wave, irregular pulse, Tx - amiodarone, digoxin, diltiazem, procainamide, verapamil;  Asystole - no pulse and flat line, Tx CPR, intubation, transcutaneous pacing ACLS meds - atropine, epinephrine; V Fib - wavy line no pulse or B/P,  Tx -  CPR,defibrillate, intubation, ACLS meds - amiodarone, epinephrine, lidocaine, magnesium sulfate, procainamide, vasopressin; V Tach -  large wide complex may have weak pulse or no pulse, can be awake, Tx Cardioversion, if pulseless, CPR , defibrillation, intubate, ALCS meds, amiodarone, epinephrine, lidocaine, magnesium sulfate, procainamide. Things to assess- mental status, vital signs, cardiac monitor
  4. Cardiac Tamponade - JVD, Narrow Pulse Pressure, Muffled heart sounds, restlessness, leaning forward posture, pulsus paradoxus. tests - chest x ray - shows widened mediastinum and cardiomegaly, Echo Cardiogram  reveals pericardial diffusion with signs of right ventricular and atrial compression, EKG used to r/o other disorders. TX pericardiocentesis, or thoracotomy to drain fluid epinephrine, dopamine. Things to have on hand, assess, remember -maintain a EKG machine, crash cart, pericardial aspiration needle attached to a 50 ml syringe by a 3-way stopcock connect the precordial EKG lead to the hub of the aspiration needle via alligator clamp and connecting wire this will show either an STsegment elevation or PVCs when the needle touches the myocardium, maintain  HOB 45-60 degrees, monitor vital signs, hypertension could be sign of punctured cardiac chamber. complications  - v fib, vasogagal response, punctured coronary artery or cardiac chamber.
  5. Cardiogenic Shock - cold and clammy, hypotension, narrow pulse pressure, less than30 cc urine output per hour, tachycardia; tests - EKG enlarged Q waves and elevated ST - MI; TX intra-aortic balloon pump, epi, dig, dopamine, dobutamine, inamrinon, milrinone, lasix, bumex, zaroxolyn, ntroprusside, nitro, norepinephrine; Interventions/Assessments - v/s, heart sounds, hemodynamics, cap refill, skin temp, peripheral pulses, breath sounds, ABGs, administer O2, IVs, meds as ordered.
  6. Cardiomyopathy -S3 and S4, murmur; tests EKG shows left Ventricular hypertrophy and non-specific changes. Tx - dual chambers pacing, Beta-Adrenergic blockers - Inderal, Corgard, Lopressor, Calcium Channel Blockers - Cardizem, Calan, Diuretics, Lasix, Bumex, metolazone, Inotropics - dobutamine, milrinone, dig, Anticoagulant - Coumadin. Intervention/Assessments - EKG, VS, Hemodynamics, administer O2 and med as ordered.
  7. CAD (Coronary Artery Disease) - S/S - angina pain, tests - lipids show low high density and high low density lipoproteins, ST segment depression and Twave inversion during angina pain, TX weight loss, increase activity, exercise, change eating habits, low-fat high fiber diet, low dose ASA, antilipemic meds - cholestyramine, lovastatin, simvastatin, nicotinic acid, gemfibrozil, colestipol. Interventions/Assessments - monitor labs, I & O,follow angina protocal with angina pain.
  8. Endocarditis - S/S - fever, chills, fatique, loud murmur Tests - EKG, Echo, serial blood cultures, Tx - fluids, antibiotics, asa, Intervention/Assessment - monitor for embolisms, BUN, Creatine, I&O, s/s heart failure ie. dyspnea, edema, JVD, weight gain, crackles, tachycardia, prophylactic antibiotics before, during, and after dental work, childbirth, GU, GI or GYN procedures.
  9. Heart Failure - Left sided - crackles, dyspnea, gallop rhythm S3, S4; Right sided - dependent edema, JVD, Weight gain; Tests - (left sided) BNP elevation, Chest xray results show increased pulmonary congestion and left ventricular hypertrophy; (right sided) BNP elevation, chest xray shows pulmonary congestion, cardiomegaly and pleural effusions, ABG hyppoxemis, and hypercapnia. Tx - human BPN Natrecor, ACE inhibitors - capipril, enalapril, lisinopril, diuretics, dig, inoropic agents, nitrates, vasodilators. Interventions/Assessments - v/s, hemodynamics, O2 Sats Respiratory status, maintain semi fowlers position, daily weights.
  10. Hypertention - can be asymtomatic, headache, visual disterbances. Tests - Bp sustained readings higher than 140/90. Tx - weight reduction, exercise, dietary changes - low sodium, limiting alcohol, ACE inhibitors, antihypertensive meds - methyldop, hydralazine, prazosin, doxazosin, diuretics Interventions/Assess - take the average of 2 or more readings.
  11. Hypovolemic Shock - cold and clammy, decreased sensorium, hypotensive, narrow pulse pressure, less than 25 cc/hr urine output, tachycardia. Tests - labs - high potassium, serum lactate and BUN, urine specific gravity 1.020, urine osmolarity increased, decreased blood pH, ppaO2, increased ppaCO2, possible H & H. Tx - blood and fluid replacement, control bleeding. Interventions/assessment - v/s, assess peripheral pulsed, respiratory status, O2 Sat, telemetry, if sbp less than 80 low cardiac out put may reslut aeb -  inadequate coronary artery blood flow, cardiac ischemia, arrhythmias, increase oxygen and notify MD STAT. large bore IV - NS, LR, blood. Hemodynamic montitoring, Foley for hourly outputs (30cc/hr) manitol.
  12. MI - anginal type pain that last longer and is not releived by nitro or rest, may not be painful in women just fatique or other atypical pain symptoms. Test - EKG - enlarged Q wave, elevated or depessed St segment, and T wave invertion. Tx-anticoagulants, thrombolitic therapy, oxygen, nitrate, pain management, morphine. Interventions/assessments - VS, telemetry, medication as ordered, assess cardiovascular and respiratory status.
  13. Myocarditis - arrythmias, dyspnea, fatique, fever Tests - EKG - diffuse St segment and t wave abnormality, conduction defects, arrhythmias, endomyocardial biopsy confirms dx may get false negative. Tx - bedrest, antibiotics, antiarrhythmics, diuretic, dig. interventions/assessments - assess cardiovascular status, assist wtih bathing, stress bedrest, reassure patient,
  14. Pericarditis - (Acute) - pericardial friction rub, sharp and sudden pain starts over the sternum and radiates to the neck, shoulders, back, and arms, increases with deep inspiration, decresases when sits upright, leaning forward; (Chronic) friction rub, fluid retention, ascites, hepatomegaly. Tests - Echo - shows an echo-free space between the ventricular wall and the pericadium (in cases of pleual effusion)EKG - shows (acute) ST segments in the standad limb leads and most precordial leads w/o significant changes in QRS that occur in MIs. Tx- bedrest, surgery - pericardectomy for recurent pericarditis, total pericadectomy or constrictive pericarditis, antibiotics, Intervention/Assessments - bedrest, assess pain maintain upright position, medicate for pain, O2, reassurance is temporary and treatable.
  15. Peripheral Artery Disease - (Femoral, popliteal, or innominate ateries) mottling of extremity, pallor, paralysis and paresthesia in affected limb, pulselessness distal to the occlusion, sudden and localized pain in affected limb, temperature change distal to occlusion. (Internal and External Carotid arteries) TIAs, s/s minocular blindness, dysarthria, hemiparesis, aphasia, confusion, decreased mentation, headache. (Subclavian artery) subclavian steel syndrome - this characacterized by the backflow of blood from the brain through the vertebral artery on the same side as the occlusion into the suclavian artery distal to the occlsion; clinical effects of the vertebrobasilar occlusion and exercise-indused arm claudicaiton. (Vertebral and basilar arteries) TIAs, s/s  binocular vision, vertigo, dysarthria, falling without LOC. Tests - arteriography, doppler US, Tx - Surgery, atherectomy, balloon angioplasty, bypass graft, embolectomy, lser angioplasty, patch grafting, stent placement, thromboendartectomy or amputaion; Thrombolytic agents - Activase, Streptase. Interventions/assessment: (during acute episode) - Pre-op- PVA, pain management, IV heparin, I & O, monitor lytes. Post-op - VS, PVA, monitor drsg, watch for s/s hemorrhage. Carotid, innominate, vertebral, or Subclavian artery occulsion, neuro assessment, in mesenteric occulsion, NG to low intermittent suction. I & O. Abd assessment, Saddle block occlusion - ck distal pulses, s/s renal failure, severe abd pain (mesenteric occulsion) and cardiac arrhythmias. IIliac artery occlusion - output, meticulous catherter care, Fem/Pop occlusions - PVA, early ambulation, discourage prolonged sitting.
  16. Raynaud's Disease - numbness, and tingling relieved by warmth, blanching of the skin on fingers, cyanotic before turning to red after exposed to cold or stress. Test - arteriography TX activie changes: avoid cold, Smoking cessation, surgery, calcium channel blockers Interventions/Assessments: warn against exposure to the cold
  17. Rheumatic Fever and Rheumatic Heart Disease - carditid, temp greater than 100.4, migratory joint pain or polyarthitis. Tests: elevated WBC, and ESR and slight anemia during inflamation, cardia emzymes elevated in severe carditis, positive C-reactive protein. Tx: Bedrest, Valvular surgery in persistent heart failure, antibiotics - erythromycin and penicillin, NSAIDs - ASA, Indocin. Interventions/Assessments: check for any sensitivity to PCN, instruct on S?S heart failure and have pt report, warn to watch for sign of recurrent infections - sudden sore throat, diffuse throat redness and oropharyngeal exudate, swollen, tender cervical lymph nodes, pain on swallowing, temp of 101 -104, headache, and nausea. Stay away from people with respiratory tract infections.
  18. Thoracic Aortic Aneurysm - Ascending Aneurysm - severe, boring, ripping and extending to hte neck, shoulders, lower back, or abdomen, right carotid and left radial pulses unequal in intesity. Desending Aneurysm - pain is discribed as sharp and tearing, usually starting suddenly between the shoulder blades and radiating to the chest. Transverse Aneurysm - dyspnea, pain is described as sharp and tering and radiating to the shoulders. Test - Aortography  - this shows the lumen of the aneurysm, its size and locatin and the false lumen in a dissecting aneurym, chest xray shows widening of the aorta, CT Scan confirms and locates and my monitor progression. Tx - surgery with Dacron or Teflon graft, replacement of aortic valve, morphine, antihypertensives, Negative inotropic - inderal. Intervientions/Assessment: monitor BP, PAWP, and CVP. assess pain, respirations, carotid, radial and femoral pulses, review labs - CBC with diff, lytes. type and crossmatch, ABG, UA, FC, I and O, IV Nitroprusside. post-op assess LOC, VS, PAP, PAWP, CVP, output, chest tube drainage, heart and lung sounds, medicate as order.
  19. Thrombophlebitis - DVT - cramping calf pain, edema, tender to touch; Superficial vein thrombophlebitis - redness along the vein, warmth, and tender to touch. Test - photoplethysmography shows venous-filling defects, US reveals decreased blood flow. TX - bed rest, elevate affected extremity, anticoagulants, coumadin, heparin, lovenox, antie-inflammatory lmed - ASA, Fragmin, Fibrinolytic med - Streptokinase. Intervention/Assessment - Assess pulmonary status, neurovascular checks, monitor labs, wm moist compressess.
  20. Valvular Heart Disease - Aortic insufficiency - angina, cough, dyspnea, fatique, palpatations. Mitral insufficiency - angina, dyspnea, fatigue, orthopnea, peripheral edema. Mitral stenosis - exertional dyspnea, fatigue, orthopnea, palpitations, peripheral edema, weakness, Mitral Valve Prolapse - may be asymptomatic, palpitations. Tricuspid Insufficiency - dyspnea, fatigue. Test - Aortic Insufficiency - echo and xray checking for left ventricular enlargement and pulmonary vein congestion. Mitral Insufficiency - cardiac cath checking for for mitral insufficiency and elevated atrial pressure and PAWP. Mitral stenosis - cardiac cath checking for diastolic pressure gradient across valve and elevated left atrial and PAWP, echo shows thickened mitral valve leaflets, EKG left atrial hypertrophy. Mitral valve prolapse - EKG shows prolapse of the mitral valve into the left atrium. Tricuspid insufficiency - echo shows systolic prolapses of the tricuspid valve, EKG shows right atrial or right ventricular hypertrophy, x ray shows right atrial dilation and right ventricular enlargement. Tx - surgery - open heart for valve replacement in severe cases, anticoagulant. Intervention/Assessment - watch for s/s heart failur or pulmonary edema and bleeding from anticoagulant, position upright, bedrest, assist with bath and ADLs, monitor VS, heart rhythm, clots, monitor I and O, daily weight, Blood chemistries, chest x-rays, pulmonary artery catheter readings.

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