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Med surg 2 exam 2 - Professor Martinez, Management of Patients with Structural, Infectious, and Primary Concepts Of Adult Nursing II (Nova Southeastern University)

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Med-Surg II

Exam 2 Study Guide

DG, SP, ER, & LV

MRASS & MSARD Mitral Regurgitation Aortic Stenosis (Systolic) - MRASS Mitral Stenosis Aortic Regurgitation (Diastolic) - MSARD Mitral Stenosis -

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Mitral stenosis (Most common Valvular dysfunction)  Obstruction of blood flowing from the left atrium into the left ventricle.  Normally, the mitral valve has the diameter of three fingers. o In cases of marked stenosis, the opening narrows to the width of a pencil.  L atrium has difficulty moving the blood into the ventricle  poor ventricular filling and reduced CO.  Increased blood volume L atrium causes it to dilate and hypertrophy.  Blood backflows from L atrium to the lungs  pulmonary congestion What are the things that can permit it or cause it infection wise?  Most often caused by RHEUMATIC ENDOCARDITIS (treat quickly) o Progressively thickens the mitral valve leaflets and chordae tendineae. o Leaflets often fuse together. o Eventually, the mitral valve orifice narrows and progressively obstructs blood flow into the ventricle.  Rheumatic endocarditis o Acute rheumatic fever, which occurs most often in school-age children o May develop after an episode of group A betahemolytic streptococcal pharyngitis. o Patients with rheumatic fever may develop rheumatic heart disease as evidenced by a new heart murmur, cardiomegaly, pericarditis, and heart failure.  Rheumatic endocarditis from PP: o Occurs most often in school-age children, after group A beta-hemolytic streptococcal pharyngitis o Injury to heart tissue is caused by inflammatory or sensitivity reaction to the streptococci. o Myocardial and pericardial tissue is also affected, but endocarditis results in permanent changes in the valves. o Need to promptly recognize and treat “strep” throat to prevent rheumatic fever  Clinical manifestations: o Dyspnea on exertion is often the first symptom (s/s when valve opening reduced by 1/3 to ½) o Progressive fatigue due to decreased CO o Dry cough or hemoptysis (coughing up blood) o Wheezing o Palpitations & Dysrhythmia o Orthopnea o Paroxysmal nocturnal dyspnea (PND) o Repeated respiratory infections o Enlarged left atrium o PND- paroxysmal nocturnal dyspnea  Assessment and diagnostic findings: o Weak and irregular pulse due to atrial fibrillation o Low pitched, rumbling, diastolic murmur is heard at the apex o Atrial hypertrophies o Atrial dysrhythmias o Doppler echocardiography is used to diagnose o Electrocardiography (ECG) and cardiac cath with angiography may be used to determine the severity of mitral stenosis

Med-Surg II 

Exam 2 Study Guide

DG, SP, ER, & LV

Medical management: o Anticoagulant therapy to decrease the risk to develop atrial thrombus o May also require treatment for anemia o Avoid strenuous activity and/or competitive sports since it increases HR. o Percutaneous transluminal valvuloplasty or mitral valve replacement may be performed.

Valvular Disorders -

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The valves of the heart control the flow of blood through the heart into the pulmonary artery and aorta by opening and closing in response to the blood pressure changes as the heart contracts and relaxes through the cardiac cycle. Whether it is stenosis or regurgitation… we are really concerned with Cardiac Output When any of the heart valves do not close or open properly, blood flow is affected. Regurgitation: when valves do not close completely  backflow of blood through valve. Stenosis: when valves do not open completely  reduced flow of blood through valve. Disorders of the mitral valve Mitral valve prolapse (stretching of the valve leaflet into the atrium during systole) Mitral regurgitation (blood flowing back from the left ventricle into the right atrium during systole)

Disorders of the aortic valve Aortic regurgitation (flow of blood back into the left ventricle from the aorta during diastole) Aortic stenosis (narrowing of the orifice between the left ventricle and the aorta) of ten a result of degenerative calcifications

Mitral stenosis (obstruction of blood flowing from the left atrium into the left ventricle) Nursing Priorities, education wise when it comes to post-heart valve surgery -

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Balloon Valvuloplasty  Monitor for HF and emboli  Auscultate and assess heart sounds Q4hrs  Same care provided as post-cardiac catheterization  Pt. usually stays in hospital for 24-48 hrs Surgical Valvuloplasty or Valve Replacements  Focus is hemodynamic stability and recovery from anesthesia  check vitals frequently  Frequent assessments o Neurologic o Respiratory o Cardiovascular  Hemodynamic stabilization  Augmentation of preload  Reducing afterload  Enhancing contractility  Complications: o Thromboembolism o Infection o Arrhythmias o Hemolysis Patient education post-heart valve surgery  Wound care  Diet, activity, medications, self-care

Med-Surg II 

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Exam 2 Study Guide

Anticoagulation therapy o Need for frequent follow-up appointments and blood lab studies o Those pts tx w/annuloplasty ring or tissue valve replacement require therapy for only 3 months Prevention of infective endocarditis Antibiotic prophylaxis is necessary before dental procedures and w/any other invasive procedure Follow-up Doppler echo performed 3-4 weeks after discharge from hospital o Provides baseline for further comparison if cardiac complications develop

Differences between arterial and venous insufficiency

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DG, SP, ER, & LV

Nursing Process – Care of Pt. w/Peripheral Arterial Insufficiency (Assessment)  Health hx o Most important is pain hx  What precipitates pain?  Pain characteristics  Area of pain  Worse at night  ABI, skin changes, brittle nails, cyanosis (V/rubor (A)  Medications  Risk factors  S&S of Arterial insufficiency  Claudication and rest pain  Color changes  Weak or absent pulses Nursing Diagnosis  Altered peripheral tissue perfusion  Chronic pain  Risk for impaired skin integrity from decreased blood flow o At risk for ulcers  Knowledge deficit  lifestyle changes Major goals:  Increased arterial blood supply  Promotion of vasodilatation  Protecting skin from breakdown

Med-Surg II    

Exam 2 Study Guide

DG, SP, ER, & LV

Prevention of vascular compression Relief of pain Attainment or maintenance of tissue integrity Adherence to self-care program

DVTs -

Deep Vein Thrombosis Venous Thromboembolism (VTE) is made up of DVT and pulmonary embolism (PE) DVT/VTE can be prevented Measures include application of graduated compression stockings, use of intermittent pneumatic compression devices, and encouragement of early mobilization and leg exercises.  Additional method in surgical pts includes SQ low molecular weight heparin (LMWH)

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Virchow’s Triad  Factors that play important role in development of DVTs o Stasis of blood (venous stasis) o Vessel wall injury o Altered blood coagulation

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S&S of DVT  Unilateral edema  Pain  Warm skin and elevated temperature  If inferior vena cava (IVC) is involved, will have bilateral LE edema

Med-Surg II

Exam 2 Study Guide

DG, SP, ER, & LV

If superior vena cava (SVC) is involved, will have bilateral UE edema, and neck, back and face may be edematous and cyanotic  If calf is involved, will have positive Homan’s sign S&S of SVT  Palpable, firm, subcutaneous, cord-like vein  Surrounding area warm, red, and tender to touch  Edema may or may not be present  Most common cause in arms is IV therapy; in legs is due to varicose veins 

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Antidotes for Bleeding -

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Principal complication of Anticoagulant therapy is spontaneous bleeding Early signs of bleeding:  Kidney bleed – blood in urine o Often first sign of excessive dosage  Bruises  Nosebleeds  Bleeding gums Protamine sulfate  Antidote for Heparin and LMWH  Less effective with LMWH than with unfractionated Heparin Vitamin K/Fresh Frozen Plasma (FFP)/Prothrombin Concentrate  Antidote for Warfarin  Is more difficult Recombinant factor VIIa  Reverses anticoagulant effects of direct thrombin inhibitors  Tx of thrombocytopenia w/Heparin therapy

Raynaud’s Disease -

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Localized, intermittent episodes of vasoconstriction of small arteries of hands, and less commonly feet  color and temp changes Etiology/Pathophysiology  Vasospastic attacks tend to be bilateral and manifestations usually begin at tips of digits o Causes pallor, numbness, and sensation of cold  Attacks are triggered by exposure to cold, emotional stress, caffeine ingestion, and tobacco use Assessment  Symptoms usually appear in hands after exposure to cold or stress o Bilateral and symmetrical  Classic triphasic color changes in hands w/reduction in skin temp o Pallor, cyanosis, and rubor  Intensity of pain increases as disease progresses  Skin of fingertips may thicken and nails may become brittle Interventions  Educate pt. to avoid situations that may be stressful or unsafe  Minimize exposure to cold and areas where fall or winter may be cold. o Pt. should wear layers of clothing when outside

Med-Surg II     

Exam 2 Study Guide

DG, SP, ER, & LV

Pts should warm car before getting into vehicle to avoid touching steering wheel or door handle, which can elicit an attack During summer, a sweater should be available when entering AC rooms Avoid all forms of nicotine Caution when handling sharp objects to avoid injuring their fingers Educate about postural hTN that can result from medications o I.e. calcium channel blockers to tx Raynaud’s phenomenon

Risk Factors Predisposing People to Venous Disorders Modifiable Nicotine Diet HTN Diabetes Obesity Stress Sedentary Lifestyle CRP Hyperhomocysteinemia

Non-Modifiable Age Gender Familial predisposition Genetics

Aneurysm (Select all that applies) -

What is an Aneurysm  Localized sac or dilation formed at a weak point in the wall of the artery  Most common forms are sacular and fusiform o Sacular aneurysm projects from only one side of the vessel o Fusiform aneurysm develops if an entire arterial segment becomes dilated o Myotic aneurysms: very small aneurysms due to localized infection  Aneurysms are serious because they can rupture and lead to hemorrhage and death!!!!

D. Fusiform aneurysm E. Sacular aneurysm

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Thoracic area is most common site for a dissecting aneurysm Approx. 85% of all cases of thoracic aortic aneurysms are caused by atherosclerosis Occur most frequently in males 40-70 y/o About 1/3 of pts w/thoracic aneurysm die of rupture of aneurysm Clinical manifestations:

Thoracic

Med-Surg II

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Exam 2 Study Guide

DG, SP, ER, & LV

o Pain – most prominent symptom (may occur when patient is supine o Dyspnea – result of pressure of aneurysm sac against the trachea, a main bronchus, or the lung) o Cough – frequently paroxysmal and w/a brassy quality o Hoarseness, stridor, or weakness, or complete loss of voice (aphonia) o Dysphagia  Assessment and Dx Findings o When large veins in chest are compressed by the aneurysm:  Superficial veins of the chest, neck, or arms become dilated  Edematous areas of the chest wall and cyanosis are often evident  Unequal pupils  Diagnosed by CXR, CTA, and transesophageal echo (TEE)  Medical Management o Tx based on whether aneurysm is symptomatic, expanding in size, is caused by iatrogenic injury, contains a dissection, or involves branch vessels o Control BP, especially in pt w/dissecting aneurysms o Pre-op, SBP is maintained between 100-120 w/a beta-blocker such as esmolol or metoprolol. Nipride may be used to emergently lower the BP o Surgery is used to repair the aneurysm and restore vascular continuity w/vascular graft o Morbidity and mortality is lower when repair of thoracic aneurysms is done using endovascular grafts placed percutaneously in an interventional suite (such as cath lab) compared to traditional surgical techniques Abdominal Aortic Aneurysm  Most common cause is Atherosclerosis!  More common among Caucasians  Affects men 4x more than women  More prevalent in geriatric pts  Mostly occur below renal arteries (infrarenal aneurysms)  Risk factors: o Genetic predisposition o Tobacco use o HTN  Clinical Manifestations o Some pts complain they can feel their heart beating in abdomen when lying down o They may say they feel an abdominal mass or abdominal throbbing o Small cholesterol, platelet, or fibrin emboli may lodge in interosseous or digital arteries, causing cyanosis and mottling of the toes  Assessment and Dx Findings o MOST IMPORTANT DIAGNOSTIC INDICATION IS PULSATILE MASS IN MIDDLE AND UPPER ABDOMEN  About 80% of this aneurysm can be palpated o Systolic bruit may be heard over the mass o Duplex US or CTA is used to determine size, length, and location of the aneurysm o When aneurysm is small, US is conducted Q6 months until it reaches a size so that surgery to prevent rupture is of more benefit than the possible complications of a surgical procedure  Gerontologic Considerations o Most abdominal aortic aneurysms occur in pts between 60-90 y/o o Rupture is more likely in HTN pts and w/aneurysms more than 6 cm wide Dissecting Aneurysms  Present w/sudden, severe, and persistent pain described as tearing or ripping in the anterior chest or back  Pain may extend to shoulder, epigastric area, or abdomen

Med-Surg II

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Exam 2 Study Guide

DG, SP, ER, & LV

 Pallor, sweating, and tachycardia will be evidenced  Initially pt may have elevated BP that may be different in one arm from the other!!!!  Possible syncope and paralysis of lower extremities (LE) may be present Nursing Diagnoses  Ineffective tissue perfusion  Pain  Anxiety Surgical Care  Surgical management may be performed on an emergency or elective basis o Surgery not usually performed on aneurysms less than 4-5 cm  Emergency surgery is only intervention for clients w/a rupture  Hematomas in scrotum, perineum, flank, or penis indicate retroperitoneal rupture.  Once aorta ruptures anteriorly into peritoneal cavity, death is almost certain  Surgical technique involves excision of aneurysm w/replacement of excised segment w/synthetic graft  Pre-op, the nurse marks and assesses all peripheral pulses for comparison post-op  Post-op, the nurse assesses for complications, which may include: o Graft occlusion o Hypovolemia o Renal failure o Respiratory distress o Cardiac dysrhythmias o Paralytic ileus o Paraplegia/Paralysis Priorities when Pt has an aneurysm  Anticipate a rupture  Recognize pt may have cardiovascular, cerebral, pulmonary, and renal impairment from atherosclerosis  Assess functional capacity of all organs  Medical therapies designed to stabilize physiologic function should be promptly implemented  Signs of impending rupture includes o Severe back or abdominal pain, which can be persistent or intermittent o Localized pain in middle or lower abdomen to L of midline o Constant, intense back pain o Falling BP o Decreasing hematocrit o Rupture in peritoneal cavity is rapidly fatal o Signs of HF/loud bruit may suggest rupture into vena cava.

Bronchoscopy -

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What is a bronchoscopy?  Direct inspection and examination of the larynx, trachea, and bronchi through a flexible fiber optic scope Purpose of Diagnostic Bronchoscopy  Examine tissues or collect secretions  Determine location and extent of pathologic process  Obtain a tissue sample for diagnosis  Determine whether a tumor can be resected surgically  Diagnose bleeding sites Purpose of therapeutic procedure  Remove foreign bodies from tracheobronchial tree  Remove secretions obstructing the tracheobronchial tree when pts cannot clear the,

Med-Surg II

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Exam 2 Study Guide

DG, SP, ER, & LV

 Treat post-op atelectasis  Destroy and excise lesions  Also used to place stents to relieve airway obstructions cause by tumors Bronchoscopy Post-Procedure  NPO until cough and gag reflex returns o May occur ice chips once cough and gag reflex occurs  then advance to fluids  Assess for confusion and lethargy in elderly due to high doses of lidocaine administered during procedure  Monitor pt.’s respiratory status  Observe for hypoxia, hTN, tachycardia, dysrhythmias, hemoptysis, and dyspnea

ABG’s Know the normal values (Pg. 298) -

PaO2 = > 70 – 100 mm Hg pH = 7.35 – 7.45 PaCO2 = 35 – 45 mm Hg Bicarb = 19 – 25 mEq/L SaO2 = > 90 – 95%

Know how to identify when it is: (Chapter 14) -

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Respiratory alkalosis  In acute state: o Elevated pH (> 7.45) o Low PaCO2 (< 38 mm Hg) o Normal or decreased Bicarb level Respiratory acidosis  Low pH (< 7.35)  Elevated PaCO2 (> 42 mm Hg)  Normal or increased Bicarb level Metabolic alkalosis  Elevated pH (> 7.45)  Elevated plasma bicarb (> 26 mEq/L)  Elevated or normal PaCO2  May also have hypokalemia (not in ABG) Metabolic acidosis  Low pH (< 7.35)  Low plasma bicarb (< 22 mEq/L)  Decreased or normal PaCO2  May also have hyperkalemia (not in ABG)

Acid-Base Disorders and Compensation (Pg. 297) Disorder Initial Event Respiratory Decreased pH, Increased PaCO2, Increased

Compensation Increased renal acid excretion and increased serum

Med-Surg II

Exam 2 Study Guide

Acidosis or normal Bicarb Respiratory Increased pH, Decrease PaCO2, Decreased Alkalosis or normal Bicarb Metabolic Decreased pH, Decreased Bicarb, Acidosis Decreased or normal PaCO2 Metabolic Increased pH, Increased Bicarb, Increased Alkalosis or normal PaCO2 Actual attaining of the ABG’s (Pg. 616 Chart 24-5) -

DG, SP, ER, & LV bicarb Decreased acid excretion and decreased serum bicarb Hyperventilation w/resulting decreased PaCO2 Hypoventilation w/resulting increased PaCO2

Blood is obtained through an arterial puncture at the radial, brachial, or femoral artery, or through an indwelling arterial catheter Immediately after, hold puncture site for 5 min to prevent arterial bleeding and development of ecchymosis  Should also monitor BP after

Health assessment question: -

Chronic vs Acute Respiratory problem (Pgs. 495-498)  Acute diseases of lungs: o Produce a more severe grade of dyspnea than chronic  Chronic diseases of lungs: o Orthopnea may be found in pts w/chronic diseases o Gradual increase in sputum over time occurs with chronic bronchitis o Clubbing of fingers o Cyanosis o Barrel chest  emphysema

Asthma (3 questions) -

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Aminophylline toxicity  The most constant symptom of toxicity is restlessness  Frequent vomiting is also a symptom  Seizures  death/permanent brain damage  Serum levels higher than 20 mcg/mL cause toxicity  Can lead to Tachycardia  Antidote: activated charcoal Terbutaline toxicity  Can cause: rapid heart rate, dizziness, and chest pain  No antidote  only supportive care How to do the meter dose inhalants properly (Pg. 614, Chart 24-4)  Shake inhaler  Exhale slowly and completely  Place lips around inhaler mouthpiece  Breath in slowly and deeply through the mouth and press down on inhaler once. o Breath in slowly and deeply for as long as possible  Hold breath (and medication...