Nursing of Adult Patients with Medical

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Nursing of Adult Patients withMedical
Surgical Conditions

• Cardiovascular
• Disorders

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Diagnostic Tests

• Diagnostic Imaging
• Radiographic exam to assess heart size, shape and
  position and outline of shadows.

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Diagnostic Tests

• Computed Axial Tomography (CT/CAT Scan)
• Three dimensional view of the structure

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Diagnostic Tests

• Angiogram
• radiographs are taken after injection of dye into
  an artery
• Aortogram
• visualizes the abdominal aorta and the major leg
  arteries with injection of dye into the femoral
  artery

Iliac Artery
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Diagnostic Tests

• Fluoroscopy
• action-picture

Fluoroscopy Demo
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Diagnostic Tests

• Cardiac Catherterization and Angiography
• Visualizes the hearts chambers, valves, great
  vessels, and coronary arteries
• Catheter is inserted into the heart chambers to
  measure pressure, and blood-volume.
• Contrast dye may be used for better visualization
• Post-procedure
• supine, with sandbag over pressure dressing at
  insertion site

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Cardiac Catheterization
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Cardiac Catheterization Lab
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Cardiac Catheterization with Contrast
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Diagnostic Tests

• Electrocardiogram
• Graphic study of the electrical activities of the
  myocardium

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Review of Cardiac Electrical Activity
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Diagnostic Tests

• Electrocardiogram
• P-wave
• contraction (depolarization) of the atria
• QRS complex
• contraction (depolarization) of the ventricles
• relaxation (repolarization) of the atria is
  covered by the QRS complex
• T-wave
• relaxation (repolarization) of the ventricles

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Relationship of EKG to cardiac muscle activity
(SA Node fires)
Atrial Depolarization
(Impulse to AV node)
(Impulse moves through Bundle of His Perkinje
fibers)
Ventricular Depolarization
Ventricular Repolarization
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Electrocardiogram
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Diagnostic Tests

• Cardiac Monitors
• Continual monitoring of the cardiac electrical
  activity on a video monitor
• Telemetry
• electronic transmission of data to a distant
  location

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Diagnostic Tests

• Thallium Scanning
• Thallium 201 is injected and the patient
  exercises on a treadmill
• Thallium is transported into normal cells, but
  not ischemic or infarcted cells

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Thallium Scanning
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Diagnostic Tests

• Echocardiography
• Ultrasound is used to record size, shape, and
  position of cardiac structures
• Detects
• pericardial effusion
• ventricular function
• cardiac chamber size and contents
• ventricular muscle and septal motion and
  thickness
• cardiac output
• cardiac tumors
• valvular function
• congenital heart disorders.

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Echocardiography
Echocardiogram Demo
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Echocardiography
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Diagnostic Tests

• Positron Emission Tomography (PET)
• Computerized radiographic technique that uses
  radioactive substances to examine the metabolic
  activity of various body structures
• Used to study dementia, stroke, epilepsy, tumors,
  and cardiac tissue

PET Demonstration
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Diagnostic Tests

• Laboratory Exams
• Blood cultures
• Culture and sensitivity
• Compete Blood Count (CBC)
• RBC (erythrocytes) 4-6 million/cu.mm
• Hemoglobin 10-20 gm/100ml
• Hematocrit 40-50 percent
• WBC 5,000-10,000/mm
• Platelets 150,000-400,000/mm
• Coagulation Studies
• Prothrombin Time (PT) 11-12.5 seconds
• Partial thromboplastin time (PTT) 60-70 seconds
• Erythrocyte sedimentation rate (ESR)
• Up to 20mm/minute

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• Serum electrolyte tests
• sodium - maintains fluid balance (135-145mEq/L)
• potassium - relaxes heart muscle (3-5 mEq/L)
• calcium - contraction of cardiac muscle
  (9-11mg/dl)
• magnesium - maintain level of electrical
  excitability in the nerves and muscles (1-2
  mEq/L)
• Serum lipids
• Total Cholesterol (140-200 mg/dl)
• High Density Lipoprotein (HDL) (35-85 mg/dl)
• Low Density Lipoprotein (LDL) (below 100mg/dl)
• Triglycerides (35-135 mg/dl)
• Arterial blood gases
• pH 7.35-7.45
• PaCO2 35-45 mm Hg
• PaO2 80-100 mm Hg
• HCO 21-28 mEq/L
• SaO2 95-100

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Diagnostic Tests

• Cardiac Enzyme Studies
• CPK isoemzyme II (MB)
• enzyme is released when the heart muscle is
  damaged or necrosis occurs
• levels rise in 3-6 hours, peak in 12-18 hours,
  and may remain elevated for 3-4 days
• Normal Value 40-170 U/L
• LDH
• Rises within the first 24-72 hours, peaks in 3-4
  days, and returns to normal in approx 14 days
• Normal Value 100-200 U/L

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Risk Factors forCardiovascular Disorders

• Nonmodifiable Factors
• Family History
• Parent or sibling who has CV disorder before 50
  yrs
• Age
• Normal physiological changes
• Approx 50 of all MI occur after 65 yrs
• Sex (Gender)
• Men are at greater risk than women
• Race
• African Amer. males are at higher risk of
  hypertension

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Risk Factors forCardiovascular Disorders

• Modifiable Factors
• Smoking
• 2-3 times greater risk
• Hyperlipidemia
• Diet high in saturated fat, cholesterol, and
  calories
• Cholesterol levels above 200 mg/dl
• Hypertension
• B/P higher than 140/90

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Risk Factors forCardiovascular Disorders

• Diabetes Mellitus
• Damage to vessels due to high glucose levels
• High cholesterol levels (abnorm. lipid
  metabolism)
• Obesity
• Increases workload of the heart
• Sedentary Lifestyle
• Exercise improves the hearts efficiency, lowers
  glucose cholesterol levels, lowers B/P, reduces
  weight, and reduces stress levels

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Risk Factors forCardiovascular Disorders

• Stress
• Catecholamines are released which cause increased
  heart rate and damage to myocardial cells
• Oral Contraceptives
• Not clearly defined
• Older high dose contraceptives made women at
  higher risk for cardiovascular disorders esp.
  smokers
• Newer low dose contraceptives dont seem to cause
  that risk
• Psychosocial Factors
• Type A personality
• aggressiveness, competitiveness, perfectionism,
  compulsiveness

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Cardiac Dysrhythmias

• Normal Sinus Rhythm
• Originates in the SA node
• Rate 60-100 beats/min
• Rhythm regular

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• Sinus Tachycardia
• Originates in the SA node
• Rate 100-150
• Rhythm regular
• Causes
• exercise, anxiety, fever, shock, medications,
  hypothermia, heart failure, excessive caffeine,
  and tobacco
• Not usually caused by cardiac problems
• Treatment
• Directed at cause

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• Sinus Bradycardia
• Originates SA node
• Rate less than 50-60 beats per min
• Rhythm regular
• Cause
• sleep, vomiting, intracranial tumors, MI, drugs,
  vagal stimulation, endocrine disturbances, and
  hypothermia
• Treatment
• Directed toward cause
• Atropine to increase heart rate
• Temporary or permanent pacemaker

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• Supraventricular Tachycardia (SVT)
• Premature Atrial Contraction (PAC)
• Originates atria
• Rate 150-250 beats/min
• Rhythm regular
• Causes
• drugs, alcohol, mitral valve prolapse, emotional
  stress, smoking, and hormone imbalance
• usually not caused by heart disease
• Treatment
• Eliminate underlying cause
• Decrease heart rate
• carotid sinus pressure, ocular pressure,
  digitalis, calcium channel blockers, propranolol,
  quinidine, and cardioversion

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• Atrial Fibrillation
• Originates atria
• Rate 350-600
• Rhythm irregular may be unable to count
• Causes
• atherosclerosis, mitral valve disease, CHF,
  cardiomyopathy, congenital abnormalities, COPD,
  and thyrotoxicosis
• Treatment
• digitalis, calcium channel blockers (verapamil),
  antidysrhythmics (procainamide), quinidine,
  anticoagulants (heparin, coumadin) and
  cardioversion

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• Atrioventricular Block (1st, 2nd, 3rd degree)
• Originates SA node impulse is slowed at the AV
  junction due to a defect
• Rate
• 1st degree - 60-100 beats/min
• 2nd degree - 30-40 beats/min
• 3rd degree - may be no heart beat
• Cause
• atherosclerotic heart disease, MI, CHF, digitalis
  toxicity, congenital abnormality, drugs, and
  hypokalemia
• Treatment
• directed at cause
• atropine and isoproterenol
• pacemaker for 3rd degree

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• Premature Ventricular Contractions (PVC)
• Originates ventricles
• Rate 60-100 beats/min
• Rhythm
• regular with an occasional extra beat
• may occur as a single event or may occur several
  times in a minute, or in pairs or strings
• Cause
• irritability of the ventricules, exercise,
  stress, electrolyte imbalance, digitalis
  toxicity, hypoxia, and MI
• Treatment
• Treat the cause
• antidysrhythmics (lidocaine, procainamide, or
  bretylium

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• Ventricular Tachycardia
• Originates ventricles 3 or more successive
  PVCs
• Rate 140-240 beats/min
• Rhythm regular to slightly irregular
• Cause
• hypoxemia, drug toxicity, electrolyte imbalance,
  and bradycardia
• Treatment
• IV procainamide (decrease excitability of cardiac
  muscle)
• Lidocaine with MI
• Cardioversion

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• Ventricular Fibrillation
• Originates ventricles
• Rate none
• Rhythm none
• Cause
• untreated ventricular tachycardia, electrolyte
  imbalances, digitalis or quinidine toxicity, and
  hypothermia
• Treatment
• Emergency care
• CPR
• defibrillation (15-20 seconds of the onset)
• medications
• lidocaine, bretylium, or procainamide

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Artificial Cardiac Pacemakers

• Pacemaker
• Battery-operated generators that initiate and
  control the heart rate by delivering an
  electrical impulse to the myocardium
• Temporary
• Used for cardiac support following some MIs or
  open-heart surg.
• Permanent
• Used when other measures have failed to convert
  the dysrhythmia or conduction problem
• 2nd 3rd degree AV block, bradydysrhythmias,
  tachydysrhythmias

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Internal Pacemaker
Catheter-like electrode is placed in the area to
be paced and generator is embedded under the skin
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External Pacemaker
Electrode pad is placed on the chest wall and is
attached to a generator place in a pocket or pouch
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Artificial Cardiac Pacemakers

• Nursing Interventions
• Post-op
• monitor heart rate and heart monitor
• assess vital signs and level of consciousness
• assess insertion site for erythema, edema, and
  tenderness
• bed rest with arm immobilized for first few hours
• Patient Teaching
• continued medical care is very important
• medical-alert ID
• report signs symptoms of pacemaker failure
• weakness, vertigo, chest pain, pulse changes
• avoid electrical equipment
• hairdryers, battery-operated toothbrushes, etc.
• avoid high-output electrical genterators and
  large magnets (MRI)
• teach patient or family member to check pulse
  rate
• notify physician if heart rate drops below 70