HIGH RISK ADULT

HEART FAILURE Heart Failure – (RSHF)

Is inability of the heart to maintain adequate circulation to meet the metabolic needs of the body . Assessment :

Types Anorexia, nausea, weight gain

Left sided heart failure Pitting edema, bounding pulse, hepatomegaly, cool extremities, oliguria

Right sided heart failure Elevated CVP, decreased p02,increased SGPT

High output failure Diagnostics:

Types CXR

Left sided heart failure 2-D-ECHO

MI
HEART FAILURE[HF]
Hypertension
Ischemic heart disease Medical Management

Aortic valve disease Determination & elimination/control of underlying cause.

Mitral stenosis Drug therapy: digitalis, diuretics, vasodilators

Sodium restricted diet to decrease fluid retention

Heart Failure ( LSHF)
Nursing intervention:
Assessment :
Monitor respiratory status and provide adequate ventilation
Dyspnea, orthopnea, PND, tiredness, muscle weakness, cough
Provide physical & emotional rest
Tachycardia, wheezing, rales, cyanosis, pallor
Increase cardiac output
Decreased p02, increased pC02
Reduce/eliminate edema
Diagnostics:
Provide client teaching discharge
CXR

2-D-ECHO
DYSRHYTHMIAS
HEART FAILURE[RSHF] DYSRHYTHMIAS- Sinus node dysrhythmias
Right sided heart failure Sinus tachycardia
Left sided heart failure
Heart rate >100 bpm originating in the SA node
RV infarction
Cause:
Atherosclerotic heart disease
Fever, apprehension, physical activity anemia, hyperthyroidism
COPD
Drugs ( epinephrine, theophylline)
Pulmonic stenosis
Myocardial Ischemia , caffeine
Pulmonary embolism
TX: correction of underlying cause, elimination of stimulant, sedatives, propranolol
High output failure
Hyperthyroidism Sinus Bradycardia

Anemia Slowed heart rate initiated by SA node

AV fistula HR <60 bpm

pregnancy Cause:
Excessive vagal or decreased sympathetic tone
MI , meningitis , myxedema, well-trained athletes
 usually not needed Hypertensive heart disease , CHD
Cardiac output inadequate : Atropine, isoproterenol TX: digitalis, propranolol,direct current cardioversion
Drugs not effective : Pacemaker Ventricular dysrhythmias
DYSRHYTHMIAS Premature ventricular Complex ( PVC)
DISORDER IN THE FORMATION OR CONDUCTION OF ELECTRICAL IMPULSES WITHIN THE HEART. Ventricular Tachycardia
Disruption in the normal events of the cardiac cycle
Ventricular Fibrillation
TYPES:
Ventricular dysrhythmias
Sinus node dysrhythmias
Premature ventricular Complex ( PVC)
Atrial dysrhythmias
Firing of an irritable pacemaker in the ventricles before the next normal sinus impulse
Junctional dysrhythmias reaches the AV node.
Ventricular dysrhythmias >6/min with normal beat – bigeminy
Conduction abnormalities In pairs after every third beat – trigeminy
Atrial dysrhythmias TX:
Premature atrial complex IV push of Lidocaine ( 50-100mg) followed by IV drip of lidocaine at rate 1-4mg/min
Atrial flutter Procainamide, quinidine
Atrial fibrillation Treatment of underlying cause
Atrial dysrhythmias Ventricular Tachycardia
Premature atrial complex 3 or more PVC’s in a row

“skipped beats or missed beats” Atrial: 60-100bpm / ventricular 110-250 bpm

Occur when an electrical impulse starts in the atrium prior to the next normal impulse Maybe unresponsive or pulseless
of the sinus node Cause:
Cause Acute MI, CAD , digitalis intoxication, hypokalemia
Nicotine , alcohol , anxiety, low K+ level, hypovolemia, myocardial ischemia TX:
Atrial dysrhythmias IV push of lidocaine ( 1 mg/kg for dose of 50-100 mg) then IV drip of lidocaine 1-
4mg/min
Atrial flutter Procainamide via IV infusion of 2-6 mg/min
Atrial rate 250-400 bpm, ventricular rate 75-150 bpm Direct current cardioversion
“saw-toothed pattern/shape ( F waves ) Propranolol (inderal)
usually indicates the presence of organic heart disease Ventricular Fibrillation
Cause: Life threatening
Valvular disease, hypertension, cardiomyopathy, hyperthyroidism ,
moderate to heavy alcohol consumption. Disorganize ventricular rhythm

TX: correction of underlying problem, betablockers, calcium channel blocker, Absence of audible heartbeat , palpable pulse & respiration
amniodarone,digitalis
Cause:
Atrial fibrillation
Idiopathic sudden death, electrical shock
Rapid disorganized and uncoordinated twitching of atrial musculature
TX: counter-shock - DEFIBRILLATION
Different rates radial & apical
Conduction abnormalities
Rhythm: atrial & ventricular – regularly irregular
First degree atrioventricular(AV) Block
Cause:
Second degree AV Block type I
Rheumatic – mitral stenosis
Second degree AV Block type II
Thyrotoxicosis, cardiomyopathy
 Third degree AV block Severe brain injury
Conduction abnormalities Dysfunction of the chest wall

First degree atrioventricular(AV) Block Musculoskeletal disorder

Muscular dystrophy
All atrial impulses are conducted into the AV node at a slower rate than normal
Polymyositis
Myastenia gravis
Second degree AV Block type I
Spinal cord disorder
All but one of a series of atrial impulses are conducted through the AV node.

CAUSES:
Conduction abnormalities
Dysfunction of the lung parenchyma
Second degree AV Block type II
Pleural effusion
Only some atrial impulses conducted to the AV node
Hemothorax
Pneumothorax
Third degree AV block Pneumonia
No atrial impulse is conducted to the AV node Status asthmaticus
Lobar atelectasis
RESPIRATORY FAILURE Pulmonary edema
Sudden and life threatening deterioration of the gas exchange function of the lungs

2 types : RESPIRATORY FAILURE

Acute respiratory failure ( ARF) CRF

Chronic respiratory failure ( CRF) Causes

ARF – COPD
decrease in arterial 02 tension <50 mmHg (hypoxemia) NEUROMUSCULAR DISEASE
Increase PaC02 > 50 mm Hg ( hypercapnia) s/sx
pH < 7.35 Early sign :
CRF – restlessness, fatigue, headache, dyspnea, air hunger, tachycardia & inc. BP
Deterioration in the gas exchange function of the lung that has developed insidiously after Late sign:
episode of ARF
confusion, lethargy, tachycardia, tacypnea, central cyanosis, diaphoresis & respiratory
ARF – arrest
Ventilation Or Perfusion Mechanism In The Lung Are Impaired.

CAUSES: RESPIRATORY FAILURE-ARF

Decrease Respiratory drive PE :
Dysfunction of the chest wall Decrease Breath sound
Dysfunction of the lung parenchyma
Medical Mgt:
RESPIRATORY FAILURE-ARF
Correct underlying cause
CAUSES:
Restore adequate gas exchange in the lung
Decrease Respiratory drive
Mechanical ventilation (MV) & oxygenation
Severe hypothyroidism
Sedative medication Nursing Mgt:
 Assist with intubation

Maintain MV RENAL FAILURE

Care @ ICU ( turning sched, mouth care, skin care, range of motion exercise) Acute renal failure

Assess respiratory status Sudden inability of the kidneys to regulate fluid and electrolyte balance and remove toxic products
from the body.
Monitor level of responsiveness , ABG pulse oximeter & VS
Causes:
Nursing Mgt:
Prerenal
Assess patient understanding of the Mgt strategies that are used
Interfers with perfusion decrease blood flow & GFR
Initiate form of communication to enable patient to express concern & needs health care team Ex: CHF, cardiogenic shock, hemorrhage, burns, sepsis, hypotension.
Provides teaching as appropriate to address disorder. Intrarenal
Cause that damage the nephrons
Acute tubular necrosis, DM,AGN, tumor, blood transfusion reaction
ACUTE RESPIRATORY DISTRESS SYNDROME ( ARDS) Postrenal
Severe form of acute lung injury Mechanical obstruction ( tubules to urethra)

Severe ventilation-perfusion mismatching Calculi , BPH , stricture, blood clots, trauma, anatomic malformation

Assessment : Assessment:

s/sx : sudden & progressive pulmonary edema Oliguric Phase

Rapid onset  severe dyspnea ( 12-48H) Diuretic Phase
Arterial hypoxemia
Recovery or convalescent phase
CXR: increase bilateral infiltrates
Nursing intervention
Causes:
Smoke inhalation- direct Monitor & maintain fluid & electrolyte balance
Pneumonia Promote optimal nutritional status
Drug overdoses
Prevent complication from impaired mobility
Shock – indirect
Prevent fever/ infection
Fluid volume overload
Assessment: Support client/ relieve anxiety

Dyspnea, cough, tachypnea with ICS/suprasternal retraction Provide care for the client receiving dialysis

Changes in orientation, tachycardia, cyanosis Provide client teaching & discharge

Increased pC02 and decreased p02 Chronic Renal failure

hypoxemia Progressive, irreversible destruction of the kidneys that continues until nephrons are replaced by
scar tissue
Cause of death :
Loss of renal function gradually
Multiple-system organ failure + sepsis
RENAL FAILURE-CRF

Mortality rate: 50-60% Assessment:

Management N/V, diarrhea or constipation, decreased Urine output, dyspnea

Promote optimal ventilatory status Early – hypotension ; late : hypertension

Promote rest by spacing activities Lethargy, convulsions , Heart failure

Maintain fluid and electrolyte balance Diagnostics:

Treat cause Urinalysis

 Specific gravity, platelets and calcium decreased Administer enemas, cathartics, intestinal antibiotics and lactulose as ordered to reduce ammonia
levels.
Medical Management:
Protect client from injury
Diet restriction
Avoid administration of drugs detoxified in liver
Multivitamins
Maintain client on bed rest to decrease metabolic demands on liver
Hematinics

Aluminum hydroxide gel

DIABETIC KETOACIDOSIS(DKA)
antihypertensive
Diabetes Mellitus- DKA
Nursing Management:
Acute complication of DM characterized by hyperglycemia and accumulation of ketones in the body.
Prevent neurologic complication
Occurs in insulin-dependent diabetic clients
Promote G.I function
WHAT HAPPEN???
Monitor fluid & electrolyte & balance
Decrease glucose utilization
Assess for hyperphosphatemia
Insulin required for the entrance & utilization of glucose by cell.
Promote maintenance of skin integrity
Increased fat mobilization
Monitor bleeding complication, prevent injury to client
Glucose not available fat stores are consumed leading to KETONE FORMATION
Promote/ maintain maximal cardiovascular function
Increased protein utilization
Provide care for client receiving dialysis
Lack of insulin  protein wasting & higher glucose level

Inadequacy of prescribed therapy for DM

HEPATIC Encephalopathy
Precipitating factor:
Terminal complication in liver disease
Undiagnosed diabetes
Diseased liver in unable to covert ammonia to urea neurologic toxic symptoms
Neglect of treatment
Cause:
Infection
Cirrhosis
Cardiovascular disorder
GI hemorrhage
Blood glucose level - >350 mg/dl
Uremia
Elevated ketone levels
Assessment:
fruity” breath odor
Early course : changes in mental functioning, insomnia, slow slurred speech, slight tremor,
Metabolic acidosis
hyperactive reflexes.
HCO3 level less than 10 mEq/L ; CO2 level less than 10 mEq/L
Progressive :asterixis, disorientation,apraxia,tremor
Hyperventilation with possible Kussmaul’s respiration pattern
Late: coma, absent reflexes
Flushed appearance
Diagnostics: Dry skin , thirst , anorexia, vomiting ( hypovolemia)
Increased serum ammonia level Drowsiness
PT prolonged Shock & coma
Mild hyponatremia , extreme hypokalemia
Decreased Hgb & Hct
DKA
Nursing intervention:
Diagnostics:
Neurologic assessment and report deterioration
Serum glucose and ketones elevated
Restrict protein in diet, provide high carbohydrate intake and vitamin K supplements.
BUN/crea , Hct elevated
 sNa decreased , K normal or elevated at first High mortality rate

ABG : metabolic acidosis HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNK)

Nursing intervention:
DKA- Nursing intervention
Same as DKA except treatment for ketosis & metabolic acidosis
Maintain a patent airway
Administer IV therapy as ordered
THYROID Storm
NSS (0.9% NaCl)
Uncontrolled and potentially life threatening hyperthyroidism caused by sudden and excessive release of
When blood sugar drops to 250mg/dl may add 5% dextrose to IV thyroid hormone into the blood stream.

K+ will be added when urine output is adequate Precipitating factors:

Administer insulin as ordered Stress, infection, unprepared thyroid surgery

Regular insulin IV drip ( drip or push) or subcutaneously Assessment finding:

Monitor blood glucose level frequently Apprehension, restlessness

Extremely high temperature, tachycardia, HF, respiratory distress

Check urine output every hour
Delirium, coma
Monitor VS
Maintain patent airway and adequate ventilation
Assist client with self care
Administer 02 as ordered
Provide care for the unconscious client if in a coma
Administer medication as ordered
Discuss with client the reason for ketosis & provide additional diabetic teaching
Antithyroid drugs

Corticosteroids
HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNK)
Sedatives
Complication of diabetes characterized by hyperglycemia and a hyperosmolar state without ketosis.
Cardiac drugs
Occurs in non-insulin-dependent diabetics or nondiabetic persons

HHNK ADRENAL CRISIS

Precipitated by physical stress , infection ADRENAL CRISIS- ADDISONIAN CRISIS
For Non-diabetic due to tube feeding with supplemental water
Too rapid rate of infusion for parenteral nutrition Condition characterized by severe hypotension, shock, vasomotor collapse and coma

Serum glucose 600 to 2,400 mg/dL Life threatening if untreated

Slight drowsiness, insidious stupor, or frequent coma CBR
Polyuria for 2 days to 2 weeks before clinical presentation
Avoid stimuli
Absence of hyperventilation, no breath odor
Extreme volume depletion (dehydration, hypovolemia) High dose of hydrocortisone

Occasional gastrointestinal symptoms Treat shock

ADRENAL CRISIS
Failure of thirst mechanism, leading to inadequate water ingestion
Nursing intervention:
CNS symptoms (disorientation, focal seizures)
Administer IV fluids ( D5NSS) as ordered
HCO3 level greater than 16 mEq/L ; CO2 level normal
Usually normal serum potassium Administere IV glucocorticoid (hydrocortisone-solu-cortef) and vasopressor

Hypernatremia If crisis precipitated by infection, administer antibiotic as ordered

Ketonemia absent Maintain strict bed rest and eliminate all forms of stressful stimuli
Lack of acidosis
Nursing intervention:
 Monitor vs, I&O, daily weights
Protect client from infection
Provide client teaching and discharge planning
Life long replacement therapy- never omit medication
Need to avoid stress & trauma & strenuous exercise
Diet modification- high in protein, carbohydrates and sodium)
Use of salt tablet or ingestion of salty food- increase sweating
Alternate regular exercise with rest period
MULTI-SYSTEM ORGAN FAILURE