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DMRN 129

9/28/2014

Find my PMI!

Tricuspid

Heart Sounds: S1, S2 (lud-dub)

S3 (Kentucky) and S3 gallop: heart failure
S4 (Tennessee): HTN, stiffness
Murmurs
4

9/28/2014

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence
followed by a Korotkoff sound. What action should the nurse take next?
A. Note the presence of an auscultatory gap
B. Reinflate the cuff to a higher number
C. Reposition the stethoscope over the brachial artery
D. Continue with the blood pressure assessment<
But if the nurse immediately hears a Korotkoff sound: what she needs to do?
And if the patient is elderly and the nurse suspects an auscultatory gap?
During a fecal impaction removal, and elderly male client complains of feeling dizzy and
cold. What intervention should the nurse implement?
A. Insert a gloved finger into the rectum and gently massage the rectal sphincter to
facilitate relaxation
B. Encourage the client to take slow, deep breaths while continuing the procedure
C. Instruct the UAP to apply a warm blanket and massage the clients back
D. Stop the procedure and observe for a reduction in symptoms before continuing<
Before a Foley insertion or giving a bed bath, which condition is the most important to
consider in a patient?
A. Iodine allergy
B. Infected skin wound
C. Orthopnea<
D. Left sided hemiplegia

Understanding right and left heart

PRELOAD

FROTHY SPUTUM

CVP?

CRACKLES

Cor Pulmonale?

PCWP?

AFTERLOAD: BP

Cardiac Output???
6

9/28/2014

RIGHT SIDE HEART FAILURE

LEFT SIDE HEART FAILURE

Dependent edema

Exertion dyspnea, orthopnea, PND

Hepatomegaly and H-J reflux

Pulmonary edema, crackles

Ascitis, bloating

Cough (nocturnal)

NVD (at 45)

Frothy, blood-tinged sputum

Weight gain

Fatigue, confusion

Fatigue, confusion

S3 gallop: 1,2,3
Decreased renal function

Lab: elevated B natriuretic peptide (BNP)

Elevated CVP (5-10 cm H2O) and PCWP (6-12 mmHg)
Treatment:

Raise HOB, dangle legs

Diuretic, ACE inhibitors, low doses Beta blockers, digoxin
Morphine and nitrate in pulmonary edema: cardiac work
Low Na, high K diet
Daily weight: 1 Kg = 1 L

SWAN-GANZ CATHETER

9/28/2014

A.
B.
C.
D.

A client's family asks why their mother with heart failure

needs a pulmonary artery (PA) catheter now that she is
in the intensive care unit (ICU). What information should
the nurse include in the explanation to the family?
A central monitoring system reduces the risk of
complications undetected by observation.
A pulmonary artery catheter measures central pressures like
PCWP for monitoring fluid replacement. <
Pulmonary artery catheters allow for early detection of lung
problems.
The healthcare provider should explain the many reasons for
its use.

How is PCWP in pulmonary embolism? In

hypovolemia? In left heart failure?

Acyanotic heart defects:

Cyanotic hear defects:

Atrial septal defect

Ventricular septal defect
Persistent ductus arteriosus

Tetralogy of Fallot

Obstructive heart defect:

Coarctation of aorta

10

9/28/2014

Right to Left shunt

Infants have acute episodes of
cyanosis (hypercyanotic spells)
Children present with squatting,
clubbing of fingers, poor growth
Polycythemia
Clubbing
Prostaglandins to keep ductus
open until surgery

Squatting / Knee-Chest
Why?

What to do?

11

Crying Cyanotic Spell Knee-Chest position Oxygen

12

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Hypertension in upper
extremities.
Absent pulses in lower
extremities
Ankle/brachial index < 0.9
Difference UE/LE BP > 20
mmHg
Complication: Heart failure

The nurse is caring for a toddler who has a medical diagnosis of coarctation of
the aorta. Which assessment finding should the nurse report to the healthcare
provider immediately?
A. Pulse oximeter reading of 94%
B. Crackles at the end of inspiration<
C. Weak femoral pulses
D. Blood pressure higher in upper extremities

14

9/28/2014

Acute systemic inflammatory

disease of unknown cause

Cardiac involvement most serious

post-acute complication
Fever; red throat; rash, cracking lips,
swollen hands & feet; enlargement of
lymph node; desquamation of skin of;
fingers
Strawberry tongue!
Thrombocytosis
Acetylsalicylic acid (aspirin) and IVIG

Autoimmune, post strep-throat

Polyarthritis, carditis, chorea, nodules and

erythema marginatum.

ASO +
Rest, ASA.
Prophylactic antibiotics for R.F.
Life long prophylactic antibiotics for
bacterial endocarditis

15

Infection of endocardium and valves

Previous valvular damage (rheumatic
fever): importance of prophylaxis
IV drug users (Staphylococcus aureus)

Valvular vegetations
Septic Embolus to circulation

Meningitis and brain abscess and stroke

Kidney, liver, retina, fingers septic emboli

Symptoms:
Fever, new onset murmurs,
sepsis, embolizations, ESR
Diagnostic: echocardiogram, blood
cultures
Treatment: antibiotics for 6 weeks.
Prophylaxis of endocarditis

16

9/28/2014

The nurse is assessing a client with bacterial meningitis. Which assessment finding
indicates the client may have developed septic emboli?
A. Cyanosis of the fingertips.<
B. Bradycardia and bradypnea.
C. Presence of S3 and S4 heart sounds.
D. 3+ pitting edema of the lower extremities.

A client at 32-weeks gestation comes to the prenatal clinic with complaints of

pedal edema, dyspnea, fatigue, and a moist cough. Which question is most
important for the nurse to ask this client?
A. Which symptom did you experience first?
B. Are you eating large amounts of salty foods?
C. Have you visited a foreign country recently?
D. Do you have a history of rheumatic fever? <

Aspirin

is prescribed for a 9-year-old child with rheumatic fever to control the

inflammatory process, promote comfort, and reduce fever. What intervention is most
important for the nurse to implement?
A. Instruct the parents to hold the aspirin until the child has first had a tepid
sponge bath.
B. Administer the aspirin with at least two ounces of water or juice.
C. Notify the healthcare provider if the child complains of ringing in the ears.<
D. Advise the parents to question the child about seeing yellow halos around
objects.
17

A child presenting fever and joint pain is diagnosed with rheumatic fever.
What is the primary goal of nursing care?
A. Maintain fluid and electrolyte balance
B. Maintain joint mobility and function
C. Reduce fever
D. Prevent cardiac damage<

18

9/28/2014

Inflammation of pericardium:

Etiology: Viral, trauma, uremia, post MI, autoimmune

Chest pain radiated to neck, improve sitting forward
Fever
Pericardial rub
Muffled sounds if pericardial effusion

Cardiac Tamponade

Pericardial effusion under pressure

Assessment
Pulsus paradoxus
Severe jugular vein distention
Clear lungs
Distant, muffled heart sounds
Decreased cardiac output: hypotension and tachycardia
Interventions
Administer IV fluids as prescribed: fluids???
Keep upright position
Prepare client for pericardiocentesis as prescribed
19

Pericardiocentesis

AUSCULTATION:

PERICARDIAL RUB
PERICARDIAL EFUSION: MUFFLED HEART SOUNDS
PERICARDIAL EFUSION UNDER TENSION: CARDIAC TAMPONADE

20

10

9/28/2014

SHOCK

PATHOLOGY

EXAMPLES

TREATMENT

HYPOVOLEMIC

Low blood volume

(Hypovolemia)
SVR (renin)

Hemorrhage
Dehydration

Fluids: NS, LR
Blood

CARDIOGENIC

Pump failure
(Left ventricle fails)

MI, myocarditis

Oxygen
Nitroprusside
Dobutamine

DISTRIBUTIVE

Sympathetic tone.
Vasodilation

Neurogenic:
spinal shock

SVR
Cardiac output

Vasogenic:
Anaphylaxis
Sepsis (SIRS)

Vasopressors:
Epinephrine
Dopamine
Fluids
Plasma, albumin
Antibiotics

Blood flow
obstruction

P. Embolism
C. Tamponade
T. Pneumothorax

Thrombolysis
Pericardiocentesis
Chest tube

Microcirculation
Cell hypoxia
Lactic acidosis
Oliguria

(Pooling and fluid leak)

(hyperdynamic)

OBSTRUCTIVE

21

The ER is alerted that a child is arriving with a history of flu like symptoms for
the past week. The vital signs are T 102 oF, HR 168 bpm, RR 16 bpm, and BP
90/60 mmHg. The child is lethargic with a capillary refill of 4 seconds. What
equipment should be ready?
A. Automated defibrillator
B. Mechanical ventilator
C. IV infusion pump<
D. Cooling blanket
A patient is admitted with vomits and diarrhea. BP 60/0 mmHg, HR 140 x, RR:
28 rpm Urinary output 10 ml/hr, Specific gravity 1.043, Capillary refill 4
seconds. The nurse anticipates an order of:
A. NS (0.45%) IV at a rate of 150 ml/hr
B. LR at a rate of 25 ml/hr
C. NS at a rate of 130 ml/hr<
D. Sodium Nitroprusside IV at 3 mcg/Kg/min

22

11

9/28/2014

Macrophages ingest LDL-C Foam Cells Fatty Streaks

Smooth muscle migration Atheroma plaque Fibroblasts
Fibrous capsule Calcification Inflammation and rupture
Thrombosis (clot formation)

23

24

12

9/28/2014

Contractility
Inotropism?

Heart rate

Chronotropism?

Afterload, Oxygen consume

HR, Diastole time
HR, Coronary perfusion time
HR, need O2, perfusion time

-blocker and CCB O2 consume

Nitrates O2 consume
Happy heart

25

ANGINA: Chest pain: myocardial ischemia

Patterns of angina

Stable: Constant, predictable trigger.

Medical (drugs) treatment.
Unstable: Increases in frequency and severity.
Hospitalization and surgical treatment
Variant: Prinzmetal angina: Vasospasm. CCB.

Diagnostic studies

ECG: negative T wave, ST depression, reversible

Stress test causes chest pain or changes in ECG

Fasting of at least 4 hours

Cardiac enzyme levels normal

Cardiac catheterization: definitive

Treatment:

Nitrates: NTG, isosorbide.

Tolerance phenomenon

Viagra interaction

Storage of nitrates

Normal EKG

Beta blockers: metoprolol

CCB: diltiazem
ASA, clopidogrel (Plavix)
Statins

ST depression26

ECG: ST depression

13

9/28/2014

Pain without precipitant (at rest)

Atypical symptoms in women (NSTEMI)
Diagnostic studies

Enzymes: CK-MB, Troponin I

ECG: ST segment elevation, Q wave
Thallium scan
Cardiac catheterization

Treatment:

MONA: morphine, oxygen, nitrates, aspirin

Rest. Bed side commode, stool softener
Fibrinolytic therapy (rTPA) and heparin

Reperfusion arrhythmia
Risk for hemorrhages

ASA/Clopidogrel
Beta blockers or CCB
ACE inhibitors
Surgical:

MI

PTCA
Stent
CABG

Complications:

Heart failure
Rupture of papillary muscle
Pericarditis
Ventricular dysrhythmias: PVC VT VF
Cardiac Arrest
27

14

9/28/2014

ST Elevation: Acute MI
Pathologic Q wave: Old MI
NSTE MI: Enzymes
29

Rehabilitation:
Stop if SBP drops more 10 mmHg
Stop if heart rate increases more 20 bpm

Coronary perfusion occurs during diastole

When HR , diastole time and coronary perfusion

Stop if extreme fatigue and complaint of severe dyspnea

Avoid isometric exercises, but walk 5 times/week
Sex after MI:

Consult physician
Usually authorized when able to climb 2 flights of stairs without symptoms
Can take nitro prophylactically before sex

Nitroglycerin:

Keep in opaque glass container

Avoid exposition to warm temperatures
Expect sublingual tingling and headaches.
A sip of water before sublingual application is OK
Call ambulance if pain doesnt disappear
Monitor blood pressure
Patches off 12 hours

30

15

9/28/2014

Written consent
Assess history of allergies
NPO (sip of water for meds is OK)
Explain

Flushing sensation with dye

Post procedure diuresis (dye excretion)

Post procedure interventions:

Monitor every 15 minutes:
Distal pulses, capillary refill
Signs of bleeding
Chest pain

Pressure dressing, sand bags

Rest extremity flat for 4-6 hours
Elevate HOB no more than 30
Encourage fluid intake

Arterial Closure Devices (ACD)

Reduce rest time to 2 hours and

eliminate need of external compression
(sand bags)

31

CABG :Saphenous Vein

Mammary Artery

32

16

9/28/2014

A client with an acute myocardial infarction (MI) is given a thrombolytic

medication, aspirin, and IV heparin in the emergency department. Which finding
indicates the client is having a satisfactory response?
A. Guaiac test of the stools is positive
B. S3 heart sounds are present with auscultation
C. Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex
D. Activated partial thromboplastin time (aPTT) is 2 times the control value<

33

34

17

9/28/2014

EKG?

What means?
PR > O.20 sec

18

9/28/2014

3 large boxes between R waves = rate of 100 bpm

5 large boxes between R waves = rate of 60 bpm
Count R waves between first and third mark
300 divided by number of big boxes between two R
waves

37

Rate:
120 bpm

Interventions: treatment of the cause. Adenosine (Adenocard)

Rate:
58 bpm

Interventions: none if asymptomatic. Atropine if symptomatic

19

9/28/2014

This image cannot currently be display ed.

Interventions:

Anticoagulant
Diltiazem, beta-blocker, digoxin if frequency is too high
Synchronized cardioversion

39

ATRIAL FIBRILLATION

ATRIAL FLUTTER

20

9/28/2014

Interventions: monitorization, lidocaine, amiodarone

PVC: high risk in MI

R on T phenomenon

Ventricular Repolarization (T wave): susceptible period for V-Fib

V. Tach. Torsade de Pointes associated with low Mg++

(Treatment: magnesium sulfate IV)
42

21

9/28/2014

Interventions: Hemodynamic stable: Lidocaine, Amiodarone

No pulse: CPR and defibrillation (most frequent)

Intervention: CPR. Defibrillation

22

9/28/2014

A-V Block first degree

A-V Block second degree:
Mobitz I
Mobitz II
Ventricle slow
A-V Third degree
saving rhythm

Interventions: atropine, isoproterenol, pacemaker

B-blockers, CCB, lidocaine, amiodarone: CACA
46

23

9/28/2014

Sensing:

patients QRS

If failure to sense: report and

expect increase in sensitivity
Teach pulse assessment

Capture:

Compare to normal

spike produces QRS

If failure to capture: report and

expect increase in mA of output

Other complications P.M.

Perforation and cardiac tamponade

Persistent hiccups
Endocarditis

Compare to normal PM function:

48

24

9/28/2014

Check response. If choking: check for voice

Call for help (911, RRT, Code Blue)
Check pulse: where is carotid pulse? Brachial for infants
CAB (excluding newborn)
Circulation:
A compression rate of at least 100/min
Compression depth:
2 inches (5 cm) in adults and children
1.5 inches (4 cm) in infants
Allow complete chest recoil
Compression-to-ventilation ratio of 30:2
Rapid defibrillation with AED

Airway

Use head tiltchin lift; if suspected neck injury present, use jaw thrust

ACLS:

Defibrillation starting with 200 jouls

Drug administration

Pregnancy:

Heimlich maneuver: chest compression

CPR: place patient angled to the left side using pillows or a wedge
49

50

25

9/28/2014

51

Arrhythmia Dance
52

26

9/28/2014

Immediately after the nurse delivers and unsynchronized shock for a pulseless
chaotic rhythm, the clients cardiac monitor shows an organized electrical
rhythm. Which intervention should the nurse implement first?
A. Palpate for a carotid pulse
B. Administer an antiarrhythmic
C. Assess for a blood pressure
D. Perform CPR for two minutes<
The nurse is reviewing a clients electrocardiogram and determines that the PR
interval is prolonged. What does this finding indicate?
A. Increased conduction time from the SA node to the AV junction<
B. Inability of the SA node to initiate an impulse at the normal rate
C. Initiation of the impulse from a location outside the SA node
D. Interference with the conduction through on or both ventricles

53

The cardiac monitor of a 50-year-old client admitted for cocaine

ingestion shows ventricular tachycardia (VT) converting to
ventricular fibrillation (VF). What is the priority nursing action to
implement?
A. Prepare for intubation.
B. Defibrillate at 200 joules.<
C. Insert intravenous catheter.
D. Obtain arterial blood gases.
Which drug of choice is indicated for acute ventricular dysrhythmias
associated with myocardial infarction?
A. Diltiazem.
B. Bretylium.
C. Amiodarone. <
D. Adenosine.

54

27

9/28/2014

Peripheral Vascular
Disease:

Venous Disease

Arterial Disease

History:

Varicose veins,
DVT

Intermittent Claudication,
DM, Tobacco

Pain relief with legs:

Elevation

Hanging down

Capillary Refill:

< 3 seconds

> 3 seconds

ABI: ankle/brachial index

(systolic BP)

Normal: >1

Abnormal: < 1

Skin:

Pigmented (hemosiderin),
Normal pulses,
Varicose veins and edema

Pale, cool, shiny, thin skin

Loss of hair
pedal, post. tibial pulses

Ulcer Localization:

Above malleolus, on
medial malleolus

Distal and over bony

prominences

Ulcer Aspect:

Irregular borders, beefy

granulation, wet exudate

Punched with sharp

borders, dry and pale bed

55

Buergers Disease?

56

28

9/28/2014

Post-Op: assess for hemorrhage and obstruction

Which pulses does the nurse monitor?

58

29

9/28/2014

Etiology:

Idiopathic
Chronic trauma
Connective tissue disease (SE)

Vasospasm triggered by cold and stress

Triphasic color changes:

Treatment:

Pallor Cyanosis Rubor

Avoidance of cold, stress, tobacco, caffeine

Avoid injury
CCB: nifedipine (Procardia)
Sympathectomy

59

Abnormal dilation of arterial wall

Risk factors: older male, HTN, tobacco
Assessment

Pulsatile mass in abdomen: DO NOT PALPATE

Bruit
Decreased pulses in LE

Dissection: Tearing pain extending to lower

back.
Bruises in scrotum, flanks (Turners)
Syncope; dyspnea; abnormal pulses, death
Hypovolemic shock: surgical emergency
Interventions to prevent rupture:
Antihypertensives to maintain BP within
normal limits
Surgery:
Monitor LE distal pulses
Monitor renal function

60

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9/28/2014

Immediate postoperative nursing care for a client who has had a surgical repair of an
abdominal aortic aneurysm should include which interventions?
a. Assessing pedal pulses frequently and monitoring the nasogastric drainage.<
b. Maintaining strict bed rest for 72 hours and assessing radial pulses.
c. Monitoring an infusion of IV heparin and checking the PTT level daily.
d. Assessing the right flank dressing and monitoring the suprapubic Foley catheter.
What is the most important intervention in peripheral artery disease management?
a. Elevate the legs at night while in bed
b. Rest to avoid intermittent claudication pain
c. Quit smoking<
d. Take a daily dose of pediatric aspirin
Client with diagnosis of AAA complains of back pain radiated to left inguinal area.
Which assessment is a priority?
a. Arterial blood gases and urinalysis
b. Palpation of abdomen for pulsating masses
c. Blood pressure and hematocrit<
d. Abdominal auscultation for bruits

61

31

9/28/2014

From: An Effective Approach to High Blood Pressure Control: A Science Advisory From the American Heart
Association, the American College of Cardiology, and the Centers for Disease Control and Prevention
J Am Coll Cardiol. 2014;63(12):1230-1238. doi:10.1016/j.jacc.2013.11.007

Figure Legend:
Appendix

Date of download:
8/22/2014

Copyright The American College of Cardiology.

All rights reserved.

Angiotensin Converting Enzyme (ACE) Inhibitors : lisinopril

Angiotensin II Receptor Blockers (ARB): losartan, valsartan

Beta-Adrenergic Blockers (beta 1, beta 2)

Used to treat
Hypertension
Heart failure
Diabetic nephropathy
Side effects
Persistent dry cough
Orthostatic hypotension: avoid hot showers
Hyperkalemia
Teratogenic

Metoprolol, atenolol, propranolol, nadolol, labetalol, carvedilol

Used: HTN, arrhythmia, CAD, hyperthyroidism, migraines
Decrease the myocardial oxygen demands
Rebound HTN and angina: taper when D/C
Decrease heart rate and contractility (negative chronotropic/inotropic)
May mask symptoms of hypoglycemia
Bronchospasm: Beta 2 block (metoprolol cardio-selective)
Impotence and vivid dreams or nightmares

Calcium channel blockers: diltiazem, verapamil, nifedipine, amlodipine

Used in HTN, CAD, vasospasm, anti arrhythmic
Negative chronotropic and inotropic effect
Ankle edema. Constipation

64

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9/28/2014

Heparin sodium

Activated partial thromboplastin time (aPTT) prolonged 1.5 to 2.5 times

control (usually 60 to 80 seconds)
Antidote: protamine sulfate
LMW heparin: Enoxaparin (Lovenox): no aPTT
HIT: CBC
Observe for hematuria, melena, petechiae

Warfarin sodium (Coumadin)

Lab: PT and INR (2-3)

Overlap with heparin
Antidote is vitamin K [AquaMEPHYTON]: Green vegetables, oils, egg yokl, liver

Cardiac Glycosides: digoxin

Toxic effects

Gastrointestinal (GI) disturbances (anorexia, nausea, vomiting)

Visual disturbances
Bradycardia or tachycardia (cardiac dysrhythmias): report HR <60 and >100

Interventions

Monitor for toxicity; digoxin level above 2 ng/mL

Monitor potassium level for hypokalemia
Monitor apical pulse; if less than 60/min, hold medication, notify physician
Antidote: Digibind

65

Diuretics

Thiazides: HCTZ
Loop diuretics: furosemide, butenamide
Potassium sparing diuretics:
Spironolactone (Aldactone), Triamterene, Amiloride

Antidysrhythmic Medications

Class I: sodium channel blockers

Quinidine, procainamide, lidocaine
Prolong QT: Torsade de Points
Class II: beta blockers
Class III: potassium channel blockers: Amiodarone
Class IV: calcium channel blockers
Other: adenosine

Antilipemic Medications (Statins, fibrate, cholestiramine, ezetimibe)

HMG-CoA reductase inhibitors = statins
Side effects
Hepatotoxicity: Elevated serum liver enzyme
Myopathy: Muscle pain and elevated CK
Gemfibrozil potentiates adverse effects of statins

66

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34

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35

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71

36

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37

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75

PRACTICE MONITOR TRACES

https://www.youtube.com/watch?v=BeNbXtsod3M&list=PL3881040FC6DBB1BA

38

9/28/2014

Aortic stenosis characteristics SAD:

Syncope

Angina

Dyspnea

MI: therapeutic treatment ROAMBAL:

Reassure

Oxygen

Aspirin

MI: basic management BOOMAR:

Bed rest

Oxygen
Opiate
Monitor
Anticoagulate

Reduce clot size

Collagen vascular disease

Aortic aneurysm
Radiation

Drugs (such as hydralazine)

Infections
Acute renal failure
Cardiac infarction
Rheumatic fever
Injury
Neoplasms

Dressler's syndrome

Decreased arterial pressure

Lidocaine

Arrhythmia/ Anemia
Ischemia/ Infarction/ Infection

Lifestyle: taken too much salt

Upregulation of CO: pregnancy, hyperthyroidism
Renal failure
Embolism: pulmonary

Myocardial infarctions: treatment INFARCTIONS:

Beck's triad (cardiac tamponade) 3 D's:

Distant heart sounds

Distended jugular veins

Beta blocker
Angioplasty

CHF: causes of exacerbation FAILURE:

Forgot medication

Pericarditis: causes CARDIAC RIND:

Morphine

IV access
Narcotic analgesics (eg morphine, pethidine)
Facilities for defibrillation (DF)
Aspirin/ Anticoagulant (heparin)
Rest

Converting enzyme inhibitor

Thrombolysis
IV beta blocker
Oxygen 60%
Nitrates
Stool Softeners

77

Heart Failure Cartoons for

Weak Memories

78

39

9/28/2014

DMRN 129

40

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41

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42

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Normal breath sounds: Comparative

Bronchovesicular: over great bronchi (1-2 ice). I = E.

Vesicular : peripheral fields, I > E

Adventitious sounds
Crackle or rale: Mainly at end of inspiration, not cleared by
coughing: pneumonia (unilateral) or pulmonary edema (bilateral)
Wheeze: Musical, sibilant, predominate in expiration
Rhonchi: Low pitched, gargling, clear with cough or suction
Pleural friction rub: Grating quality, stop if apnea. Pleuritic pain
Stridor: High pitched, lauder in neck than in chest

Vocal sounds: Vocal fremitus to palpation and auscultation:

increased in pneumonia (pectoriloquy = clear vocalization),
decreased in other pathologies

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9/28/2014

Epiglottitis

Tripod positioning, drooling, stridor, absence of cough

Nasal flaring, suprasternal and intercostal retractions

Interventions

Dont visualize pharynx, nor throat culture, or take oral temperature

Do not force child to lie down.
Cool mist oxygen
Intubation/tracheostomy available
Prevention: Haemophilus influenzae type b (Hib) vaccine

Laryngotracheobronchitis (LTB)

Viral form of croup

Seal bark, hoarse voice , brassy cough
Inspiratory stridor and suprasternal retractions

Interventions:

Cool mist or steamy shower.

Nebulized bronchodilators and epinephrine
Intubation equipment available
87

The mother of a 3 year old child with laryngotracheitis is encouraged to stay

with her son during hospitalization. What is the rationale behind this
recommendation?

A. Separation anxiety is the predominant psychological need at this age

B. The mother could provide a continuous surveillance of the childs respiration
status
C. The presence of the mother calm down the child decreasing the respiratory
effort<
D. Teaching of prevention of recurrence is more effective if the mother participates
in the child care

A client develop skin rash, shortness of breath and wheezes after receiving a
dose of ceftriazone (Rocephin). The nurse needs to be prepared to administer
the ordered:
A. Diphenhydramine (Benadryl) 25 mg PO
B. Hydrocortisone 100 mg IV stat
C. Albuterol 2.5 mg via nebulization
D. Epinephrine 1:10000: 0.1 mg IV every 3-5 minutes<

88

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Postoperative interventions

Position child prone or side-lying;

facilitates drainage
Monitor for signs of bleeding:
frequent swallowing and changes
of vital signs
Discourage nose blowing,
coughing
Ice collar
Have suction equipment available,
but dont suction unless airway
obstruction occurs
Avoid red liquids
Avoid milk, pudding, ice cream
(coating)

Tonsillectomy Scab

89

Inflammation + bronchoconstriction
Increased eosinophil count
Decreased FEV1 and peak expiratory flow
Status asthmaticus
Pulsus paradoxus
abolition of wheezes

Medications
Rescue: Short-acting 2 agonists: albuterol & metaproterenol (Alupent)
Side effects: Tachycardia, palpitations, tremor and hyperglycemia
Long term management:
Corticosteroids: fluticasone (Flovent), budesonide (Pulmicort)
Thrush. Growth retardation. Immunsupression .

Long-acting 2 agonists: salmeterol (Serevent, Advair), formoterol (Foradil)

Leukotriene modifiers: monteleukast (Singulair)
Chromoglycate (Intal)
Anticholinergics: ipratropium (Atrovent), tiotropium (Spiriva)
Methyl-xantines (theophylline) : toxicity. Blood levels (10-20 mcg/dL)

MDI technique

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Peak flow interpretation

Green >80%, Yellow 50-80%, Red: < 50%

91

During lung auscultation of a client mechanically ventilated, the nurse hears

coarse, snoring sounds over the upper anterior chest with clear vesicular
sounds over the other lung fields. What intervention should the nurse
implement at this time?

A.
B.
C.
D.

Continue to assess the client frequently

Begin manual ventilation with ambu bag
Notify respiratory therapy immediately
Suction the clients endotracheal tube<

A 6 year old who has asthma is showing a prolonged expiratory phase and
wheezing, and has a 35% of personal best peak expiratory flow rate. What
action should the nurse take first?

A.
B.
C.
D.

Determine what triggers precipitated this attack

Encourage the child to cough and deep breathe
Report findings to the healthcare provider
Administer a prescribed bronchodilator<

A.
B.
C.
D.

Instruct the client to breathe into a paper bag

Prepare to administer NS IV fluids
Initiate oxygen administration at 2 L/min per nasal cannula
Institute cough and deep breathing exercises <

A client with pneumonia has arterial blood gases at: pH 7.33, PaCO2 49 mmHg,
HCO3 25 mEq/L, PaO2 95 mmHg. What intervention should the nurse
implement?

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Chronic Bronchitis

Emphysema

Pink puffer, underweight

Smoking or 1anti-trypsin
Alveoli destruction
RV and barrel chest
Expiratory dyspnea
pO2, CO2 elevated late
Polycythemia
Cor Pulmonale
Management:

Smoking cessation
Pursed lip respiration
Low flow O2
Bronchodilators: anticholinergics
Vaccines: pneumococcal, flu
Nutrition:
Low carbohydrates: why?
High calories and proteins

93

Blue bloater, obese, edema

Smoking
Bronchi inflammation
Chronic cough (3 mo/2y),
Production of mucus
Expiratory dyspnea
pO2, CO2
Polycythemia
Cor Pulmonale
Management:
Same treatment
DOC: Anticholinergics
(ipratropium) and steroids
Beta-adrenergics
Theophylline: second line

94

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COPD patients are specially susceptible to respiratory infections

Position: Upright, tripoid. Intolerance of flat position

95

The nurse is assessing a client who smokes cigarettes and has been
diagnosed with emphysema. Which finding should the nurse expect this
client to exhibit?

A. A decreased total lung capacity.

B. Normal arterial blood gases.
C. Normal skin coloring. <
D. An absence of sputum.

A smoker client with a history of 45 pack/year arrives to ER with RR 28 x,

HR: 120 x, wheezes in both lungs, and O2 sat 80%. After bronchodilator
treatment and O2 by nasal cannula at 2 lpm the patient is somnolent and
ABG report pO2 79 mmHg and pCO2 49 mmHg. What immediate order
should the nurse anticipate?

A.
B.
C.
D.

Replace nasal cannula with non-rebreather mask with FiO2 0.80

Administer 120 mg of methylprednisolone (Solumedrol) IV
Prepare equipment for endotraqueal intubation <
Administer a loading dose of antibiotic IV

<

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Thrombi. Risk Factors:

DVT: surgery, obesity, trauma, malignancy, pregnancy, OC, prolonged sitting\

Right atrium thrombosis (A. fib), right heart valvulopathy
Air embolism: central catheters
Fat embolism: long bones fractures: petechiae
Amniotic fluid embolism: pregnancy

Symptoms

Sudden collapse (1st to 2nd week post-surgery, long travels, after childbirth)
Hypotension
Hypoxemia and SOB
Neck vein distension, increased CVP and PCWP
Chest pain: lateral chest, increase with respiratory movements
Hemoptysis: rare

Spiral CT angio-scan
V/Q scan
Arteriography
D-dimer

Diagnostic

Treatment:

Thrombolytic therapy
Anticoagulants
Vena Cava Filter
97

V-Q SCAN

VENA CAVA FILTER

Two days postoperative, a male client reports aching pain in his left leg.
The nurse assesses redness and warmth on the lower left calf. What
intervention should be most helpful to this client?
A. Apply sequential compression devices (SCDs) bilaterally.
B. Assess for a positive Homan's sign in each leg.
C. Pad all bony prominences on the affected leg.
D. Advise the client to remain in bed and compare legs circumferences<

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Secondary to sepsis, trauma, shock

Severe dyspnea, crackles, cyanosis.
Hypoxemia refractory to 100% O2

Chest X ray: bilateral infiltrates:

Non cardiogenic pulmonary edema

pO2 < 60 mmHg, pCO2 > 50 mmHg

ground glass

PCWP < 18 mmHg (cardiogenic >18 mmHg)

Increased permeability A-C membrane
Decreased pulmonary compliance

Management:

Fluid restriction
Oxygen
Artificial ventilation and PEEP
Prone position

99

Oops! Wrong slide

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Figure 2: Computed tomography scan of the lungs showing acute respiratory distress
syndrome when the patient is lying supine (left) and prone (right).

Gattinoni L , and Protti A CMAJ 2008;178:1174-1176

Autosomal recessive disorder

Sweat chloride determination (salty child)

Cl >60 mEq/L: diagnostic (pilocarpine test)

Meconium ileus: earliest presentation

Respiratory system: Stagnation of mucus in airways
Bronchiectasis

Pancreatic insufficiency: malabsorption, steatorrhea,

hypovitaminosis ADEK
Reproductive system: Sterility of males
Pancreatic enzymes PO; high-calorie, high-protein diet;
Supplementation of vitamins A, D, E, K

Chest percussion and postural drainage (no after meals)

Why in the specially in mornings?

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104

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NO SUPINE: ASPIRATION
105

Etiology: bacterial, viral, fungi

Most common is Streptococcus pneumoniae or pneumococcus

Mouth anaerobic bacteria: aspiration pneumonia, pulmonary abscess
Pneumocystis jirovenci: AIDS
Legionnaire disease: Contaminated water. High mortality

Community-acquired versus nosocomial pneumonia: Gram (-)

Droplets precautions
Prophylaxis:

Influenza and pneumococcal vaccines

Prevention aspiration and mouth care
Prevention atelectasis: IE, deep breath and cough, early ambulation.

Diagnose:

Cough, sputum (rusty, purulent), fever, dyspnea, chest pain

Auscultation: decreased vesicular sound, crackles, increased vocal fremitus
Sputum: Gram stain, culture and sensitivity
Chest x ray: infiltrates

Treatment

Antibiotics, hydration, oxygen therapy

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Squamous cell and small cell

carcinoma related to tobacco
Symptoms:

Persistent cough, hemoptysis.

Dyspnea, localized wheezes
Recurrent pneumonia
Weight loss
Enlarge neck lymph nodes

Superior vena cava syndrome

Stoke sign

Diagnosis: chest x ray, CT scan,

bronchoscopy and biopsy
Treatment:
Pneumonectomy
Chemotherapy

10
8

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Etiology: Mycobacterium tuberculosis

Airborne precautions in Hospital (no at home: cough etiquette)
Mantoux (PPD) skin test

Positive reaction does not indicate active disease, but exposure or

presence of inactive disease
Area of induration >10 mm in diameter, 72 hours after injection,
indicates exposure to TB
For individuals with HIV infection or immune suppressed, reaction of 5
mm or larger considered positive
When skin test is positive, chest x-ray and sputum culture are necessary
to detect active disease

Symptoms
TB drugs : Quimoprophylaxis Vs. Treatment

Isoniazid (INH)

Adverse reactions: hepatoxicity and neuropathy (B6)

Rifampin

Adverse effects: discoloration of urine, saliva, tears

Hepatotoxicity
Reduced levels of drugs
109

TB. Infection Control:

Airborne precautions

Negative Pressure Isolation room

Do not cohort
All HCW use high particulate mask: N-95
Visitors wear N 95
Patient wears surgical mask going out
Isolation is kept until three consecutive
sputums negative for AFB

DOT (Direct Observation Therapy)

RESPIration
Rifampicin: Hepatotoxic
Ethambutol: Optic neuritis
Streptomycin: Oto-nephrotoxic
Pyrazinamide: Hepatotoxic
Isoniazid: hepatotoxic, neuropathy

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Pneumothorax and tension pneumothorax

Spontaneous (male, thin) or traumatic (rib fractures, punctures)

Dyspnea and pain, decreased vesicular sound, resonance
Tension pneumothorax:
Trachea deviation, hypoxia, tachycardia, widening pulse pressure:

Flail chest

Loose segment of chest wall becomes paradoxical to rest of chest wall

Prepare for ET intubation and mechanical ventilation

Mechanical Ventilation

Causes of alarms
High pressure: Increased secretions; wheezing; bronchospasm; kinks in
tubing; client bites endotracheal tube
Low pressure: Disconnection or leak in ventilator or clients airway cuff;
client stops spontaneous breathing
Complications
Hypotension
Pneumothorax
Stress ulcers
Infections
111

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Description

Collection chamber

Water-seal chamber

Used to remove air and fluids from pleural space

Drainage should not be more than 100 mL/hr
Bright red drainage, should also be reported
Expected water oscillations with clients respirations
No oscillations: obstruction or lung expansion

Expected intermittent bubbling during patients expiration

Continuous bubbling means failing connections and air leaking

Absence of bubbling could be normal or abnormal

Suction control chamber

Water should be gently bubbling continuously

Violent bubbling indicate too high suction pressure
No bubbling if patient ambulating desconected from suction
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Nursing interventions

Maintain drainage system below chest level

Do not milk or strip chest tubes
Avoid clamping
If chest tube disconnects from chest drainage system, insert
chest tube into bottle of sterile water
If chest tube pulled out of chest, apply occlusive dressing
(Vaseline gauze), tape three sides living one side tenting.
Obtain samples from the re-sealable port on the connector tube

Use needle 20 G or smaller

Have client perform Valsalvas maneuver when chest tube

removed

115

116

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The nurse is assessing a client with a chest tube that is

attached to suction and a closed drainage system. Which
finding is most important for the nurse to further assess?
A.
B.
C.
D.

Upper chest subcutaneous emphysema. <

Tidaling (fluctuation) of fluid in the water-seal chamber.
Constant air bubbling in the suction-control chamber.
Pain rated 8 (0-10) at the insertion site.
Subcutaneous emphysema (A) is a complication and indicates air is
leaking beneath the skin. Tidaling in the water-seal chamber and
constant bubbling with suction in the suction-control chamber (B and C)
are expected findings that indicate the closed drainage system is
working. Pain at the insertion site is an expected finding (D) and the
prescribed analgesia should be given to assist the client to breathe
deeply and facilitate lung expansion.

117

Oxygen therapy:

Oxygen sign: Prohibit smoking

Avoid static electricity: wool and
synthetic fabrics (use cotton)
No battery gadgets and frayed cords
No flammables: alcohol, acetone, ether
Ground all electrical equipment

Nasal cannula: 1-6 L/min.

Partial rebreathing mask: 8-12 L/min

Narines and behind ears skin care

FiO2 50-75%
Reservoir bag to be kept semi-inflated in
inspiration
No valves: dead space air is rebreathed

Non-rebreathing mask: 8-12 L/min

FiO2: 80-100%
Same management of reservoir bag
Unidirectional valve in reservoir bag: open in
inspiration, close in expiration
Flaps over lateral ports: open in expiration,
close in inspiration

Venturi mask: exact FiO2 (COPD)

118

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Review suction technique

Cuff:

Inflated when connected to ventilator,

feeding and mouth care (aspiration)

Pressure pilot balloon: < 20

mmHg

Deflated balloon: allows speak

Complications:

Dislodgement:

<72 h: ventilate Ambu bag and call code

72 h: keep open with curve force and
reintroduce tube with obturator in place

Tracheomalacia/stenosis
Tracheal-esophageal fistula:

Air in stomach, food in trachea

A, Dual-lumen cuffed tracheostomy tube with

disposable inner cannula.

B, Single-lumen cannula cuffed tracheostomy tube.

C, Dual-lumen cuffed fenestrated tracheostomy tube.

Erosion innominate artery:

Pulsatile tube, massive hemorrhage

119

120

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9/28/2014

During suctioning, a client with an uncuffed tracheostomy tube begins to cough

violently and dislodges the tracheostomy tube. Which action should the nurse
implement first?
A. Notify the healthcare provider for reinsertion.
B. Attempt to reinsert the tracheostomy tube. <
C. Position the client in a lateral position with the neck extended.
D. Ventilate client's tracheostomy stoma with a manual bag-mask.

The alarm of a clients pulse oxymeter sounds and the nurse notes that the oxygen
saturation rate is indicated at 85%. What action should the nurse take first?
Administer oxygen by face mask. <
Provide 100 % oxygen by nasal cannula
Prepare patient for endotracheal intubation
Repeat the O2 sat measurement in 10 minutes

121

Glaucoma:

Risk: family history, African-American, corticosteroids

Normal pressure < 21 mmHg.
Avoid pupil dilation: Anticholinergics and sympathomimetics
Open angle and angle-closure or narrow-angle glaucoma
Open angle: Gradual loss of peripheral vision, halos around lights
Angle-closure: intense pain, vomits, red eye and acute loss of vision
Treatment:

Miotics: Pilocarpine. Pupil constriction favors aqueous humor drainage

Betablockers: Timolol. Decrease humor production
Prostaglandin analog: Latanoprost (Xalatan). Increase humor outflow
C. anhydrase inhibitors: Dorsolamide (Trusopt) and acetazolamide (Diamox)

Macular degeneration:
Dry (atrophic, age related) or wet (exudative, more severe)
Loss of central vision
Cataracts:
Risk factors: age, DM, steroids, UV light, tobacco, alcohol.
Loss of red reflex (milky white pupil), blurred vision, diplopia
122

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Glaucoma
123

Canal of
Schlemm

124

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125

Retina detachment:

Floaters, flash lights, curtain of blindness

physical and vision rest: bed rest, cover both eyes, no reading or TV,
coughing, etc
Keep detached area dependent

Eye Trauma: evaluate visual acuity

Hyphema

Encourage rest in semi-Fowlers position

Contusions

Place ice or cold compresses on eye

Penetrating objects

Do not remove. Cover both eyes: eye shield without pressure

Client should be seen by physician immediately

Chemical burns

Flush eyes with water for at least 15 to 20 minutes until pH reaches

7.2 to 7.4

Strabismus (corneal light reflex)

Legally blind: 20/200. What means?

Good eye is patched 1-2 hours daily

126

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Sli
de
14
12
7

128

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In reviewing the medical record, the nurse notes that a client's last eye
examination revealed an intraocular pressure (IOP) of 28 mmHg. What
information should the nurse ask the client?
A. Length of time the client has been wearing prescription lenses.
B. Recent experience of seeing light flashes or floaters.
C. Complaints of any blind spots in the client's field of vision.
D. Use of prescribed eye drops since last exam by ophthalmologis<
Before administering timolol maleate (Timoptic) to a client with open-angled
glaucoma, which finding should the nurse report to the healthcare provider?
A. Has a family history of diabetes mellitus, type I.
B. Receives carvedilol (Coreg) for heart failure (HF). <
C. Works outdoors as a construction site supervisor.
D. Drinks a cup of alcoholic beverages daily.
During the admission assessment, the nurse identifies that the client's upper
eyelids are drooping. Which term should the nurse document to describe this
assessment finding?
A. Ptosis. <
B. Bells palsy.
C. Blefaritis.
D. Myasthenia Gravis.
129

Slide 14-130

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131

132

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Hearing loss: Conductive and neurosensorial

Rinne and Weber tests
Presbycusis: loss high-frequency sounds

Normal tone of voice, face audient, longer phrases better than short, care consonants sounds,
dont drop the volume at the end of sentence, pantomime and write

Otitis Media
Position: lateral with affected ear down
Myringotomy
Insertion of tympanostomy tubes
Keeps ear dry: earplugs when showering, diving not allowed
Avoid straws, blowing nose one each time for 7-10 days
Menieres disease
Vertigo + tinnitus + fullness + neurosensorial hearing loss: recurrent
Safety. Change of position
Low sodium diet. Diuretics. Antivert.
Otosclerosis:
Hereditary ossification around stapes, more common white females
Post stapedectomy care: anticipate vertigo, avoid swimming and pressure
changes (cough, sneeze, use of straw)
133

External Otitis:
Risk factors:
Swimming

Topical antibiotics

Motion Sickness:

Scopolamine patch
4 hours before
travel

67

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135

136

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Three types of otitis media are:

Acute otitis media

Chronic otitis media
Serous otitis media

Avoid recurrence in children

138

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Sound doesnt travel

well through air, better
through bone
Frequent causes:
Cerumen impaction
Otitis media serosa

Sound remains clear,

but low volume

AC < BC: Negative

Sound travels OK through

air, but is distorted by
defect of inner ear or VIII
nerve: both air and bone
Common causes:
Noise
Ototoxic drugs
Aging process
Acustic neuromas
Communication
Use low-pitched voice
Stand in front the person
Use visual aids

AC & BC lost in
the same proportion:
AC>BC

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CONDUCTIVE

SENSORINEURAL

WEBER

Lateralization to
bad ear

Lateralization to
good ear

RINNE

Negative,
BC>AC

Positive, AC>BC
(but reduced 3:1)

141

71