["MED-SURG BROUGHT TO YOU BY \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 101","KIDNEY OVERVIEW med-surg renal\/ urinary FUNCTIONS fun fact: ANATOMY of the kidneys The right of the kidney \\\"A WET BED\\\" kidney sits lower than the Minor calyx a Acid-base balance left due to the location of Major calyx the liver w water balance Renal vein Renal pelvis e Electrolyte balance Renal Pyramid hilum Renal nerve Papilla t toxin removal Renal column Renal artery Renal cortex b blood pressure control Renal medulla e erythropoietin Ureter dvitamin metabolism TERMS TO KNOW Capsule Dysuria ................. Pain while urinating Enuresis............... Involuntary voiding during sleep Nocturia.............. Excessive urination at night Proteinuria ......... Abnormal amounts of protein in the urine Hematuria ............ Bloody urine Oliguria ............... Urine output: <400 mL\/day Frequency........... Voiding more than every 3 hours Anuria .................. Urine output: <50 mL\/day Urgency ............... Strong desire to void Micturition ......... Voiding Incontinence...... Involuntary voiding URINE FORMATION 1 2 3 4 GLOMERULAR TUBULAR TUBULAR URINE FILTRATION REABSORPTION SECRETION EXCRETION Blood \ufb02ows into the kidneys: Fluid moves from renal Fluid moves from Adults should void 120 mL\/min tubules into the capillaries. the capillaries into 1-2 L\/day They reabsorb \ufb02uid into the the renal tubules to get Filters water, electrolytes, & small eliminated\/excreted. No less than 30mL\/hr molecules into the glomerulus venous circulation. (Large molecules stay in the bloodstream) \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 102","LAB VALUES RELATED TO THE KIDNEYS med-surg renal\/ urinary DESCRIPTION EXPECTED RANGE \u2193 \u2191 GLOMERULAR Rate of blood 90 - 120 mL\/min possible causes: - FILTRATION flow through Kidney dysfunction RATE (GFR) glomthereulusthe kidneys (such as chronic kidney disease) CREATININE End product of muscle 0.6 - 1.2 mg\/dL \u2022 Muscle mass is low \u2022 Acute or chronic metabolism; solely \u2022 Hyperthyroidism kidney disease Creatinine is filtered from the Rhyme: Creatinine over \u2022 Starvation a better indicator 1.3 = think bad kidney \u2022 Liver disease \u2022 Congestive tdheeacngryfertaisrmeaeste of kidney function blood via glomerulus heart failure than BUN \u2022 Dehydration \u2022 Certain drugs BLOOD UREA Normal waste product 7 - 20 mg\/dL \u2022 Liver damage Can be due to NITROGEN resulting from the \u2022 Malabsorption PRErenal failure, Think hamburger BUNs... \u2022 Poor diet POSTrenal failure, (BUN) breakdown of proteins. Hamburgers can cost \u2022 Low nitrogen diet or INTRArenal failure \u2191 levels can indicate anywhere from $7 - $20 a kidney problem See \u201cACUTE KIDNEY & be toxic in the body INJURY (AKI)\u201d page URINE Measures the 1.010 - 1.030 \u2022 Too much \u2022 Dehydration SPECIFIC kidney's ability fluid intake \u2022 Syndrome of GRAVITY to excrete or Urine output: conserve water AT LEAST 30 mL\/hr \u2022 Diabetes Insipidus inappropriate URINE The amount of urine antidiuretic hormone OUTPUT a person excretes Average adult: secretion (SIADH) from their bladder 1500 mL\/day via the urethra diluted concentrated urine makes Urine makes the #'s go the #'s go up down \u2022 Shock \u2022 Diabetes mellitus \u2022 Hypotension \u2022 Diabetes insipidus \u2022 Trauma \u2022 Too much diuretics \u2022 Infection \u2022 Chronic kidney injury NORMAL Free from glucose, ketones, blood, protein, bilirubin, nitrates FINDINGS or leukocyte esterase in the urine \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 103","med-surg renal\/ ACUTE GLOMERULONEPHRITIS (POSTSTREPTOCOCCAL) urinary PATHOLOGY 1 Untreated strep 2 Immune system response by creating antigen-antibody complexes (14 days after infection) 3 These antibodies get \\\"lodged\\\" in the glomeruli 4 Inflammation & scarring 5 \u2193 GFR erulus It's not the strep that causes the in\ufb02ammation of the kidneys. Inflammation of the glom It's the antigen-antibody complexes that form due to the strep that causes the in\ufb02ammation & damage to the glomeruli SIGNS & SYMPTOMS \u2022 Hematuria Blood in the urine waste in the blood \u2022 Azotemia Tea colored urine (cola \u2022 Malaise Excessive nitrogenous color) \u2022 Edema \u2022 Swelling in the face\/eyes \u2022 Headache \u2022 \u2191 Blood pressure \u2022 Proteinuria (mild) \u2022 Retaining sodium \u2022 Hypoalbuminemia \u2022 \u2191 Urine specific gravity \u2022 \u2193 GFR = Oliguria \u2022 \u2191 BUN & creatinine Main cause: \u2022 (+) ASO (Antistreptolysin) Titer Recent group A beta-hemolytic streptococcal infection INTERVENTIONS \u2022 Fix the cause! (strep) \u2022 Monitor ooffr1Ae1tk,wa0gei0niig0eshdetmqfgLuluaaiildnto \u2022 Diet modifications \u2022 Daily intake & output \u2022 Daily weight \u2022 Fluid restriction \u2022 Sodium restriction \u2022 Bed rest \u2022 \u2193 Protein \u2022 Monitor blood pressure \u2022 Provide a lot of carbohydrates \u2022 Antihypertensives Carbohydrates \u2022 Diuretics provide energy & stop the breakdown of protein \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 104","ACUTE KIDNEY INJURY (AKI) med-surg WHAT IS IT? renal\/ urinary Sudden renal damage! Causes a build-up of waste, \ufb02uid, and electrolyte imbalance. It can be reversible. Formerly called Acute Renal Failure. PRERDaEmNagAe LbeFfoArIeLURE INTRAREDaNmaAgeLinFAILURE the kidneys the kidneys \u2193 volume\/perfusion to the kidneys\u00a0 Prolonged Ischemia \u2022 Cardiac damage \u2022 Myoglobinuria \u2022 \u2193 or impaired cardiac output \u2022 Hemoglobinuria \u2022 Example: MI \u2022 Rhabdomyolysis \u2022 Nephrotoxic drugs \u2022 Vasodilation \u2022 Hemorrhage (hypovolemia) \u2022 Examples: NSAIDs, antibiotics \u2022 Burns (aminoglycosides), chemo drugs, \u2022 GI losses (vomiting\/diarrhea) contrast dyes POSTRDaEmNagAe LaftFeArILURE \u2022 Infections \u2022 Examples: Glomerulonephritis the kidneys Obstruction\/blockage in the urinary tract\u00a0 \u2022 Renal calculi (stones) \u2022 Blood clots \u2022 Benign prostatic hyperplasia (BPH) \u2022 Tumors \u2022 Neuro damage (stroke) \\\"OH OH DARN RENAL\\\" OH DARN RENAL OH OLIGURIA DIURETIC RECOVERY ONSET\/INITIATION Cause of AKI \u2191 in kidney function is corrected May take up to PHASES Triggering event \u2193 Urine output Gradual \u2191 in 6 - 12 months < 400 mL\/24 hrs urinary output (Prerenal, intrarenal Glomerulus decreases the ability to or postrenal failure) \ufb01lter blood (\u2193 GFR) TREATMENT Correct & identify DIET modifications: Large amount of Some patients the underlying \u2022 Low protein diet diluted urine with may never cause to prevent \u2022 Limit \ufb02uid intake \u2022 Strict I&O + daily weights electrolytes recover and may long term damage Monitor develop chronic to nephrons! Monitor EKG & labs kidney disease (CKD) \u2022 Watch for HYPERkalemia > 5.0 the patient for \u2022 \u2191 BUN & creatinine dehydration & \u2022 Dialysis may be needed hypokalemia until kidney function returns \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 105","NEPHROTIC SYNDROME med-surg renal\/ urinary PATHOLOGY Causes synthesis Hyperlipidemia of cholesterol Generalized edema In\ufb02ammatory response & triglycerides Possible blood clots in the glomerulus (thrombosis) Fluid shift Risk for infection Damage to membrane Albumin is a protein Loss of protein (albumin) which prevents Albumin regulates oncotic pressure clot formation Hypoalbuminemia Can lose protein that helps Low albumin levels \ufb01ght infections Protein leaking (immunoglobulins) Protein in urine Urine collected for test CAUSES SIGNS & SYMPTOMS \u2022 Bacteria or viral infection \u2022 Hypoalbuminemia \u2022 Cancer \u2022 Genetic predispositions \u2022 Edema \u2022 Systemic disease (lupus or diabetes) \u2022 Fatigue & loss of appetite \u2022 NSAIDs \u2022 Hyperlipidemia \u2022 Proteinuria (> 3 g\/day) \u2022 Large amounts of protein in the urine INTERVENTIONS \u2022 Medications \u2022 Monitor fluid status \u2022 Diuretics \u2022 Statins (lipid-lowering drugs) \u2022 Daily weights & I&O's \u2022 Prednisone to \u2193 in\ufb02ammation \u2022 Swelling & abdominal girth \u2022 Antineoplastic agent \u2022 Immunosuppressant \u2022 Diet modifications \u2022 Monitor signs of... \u2022 \u2193 Cholesterol & saturated fats \u2022 \u2193 Na+ intake \u2022 Infection \u2022 Moderate protein intake \u2022 Blood clots \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 106","CHRONIC KIDNEY DISEASE (CKD) med-surg renal\/ urinary PATHOLOGY SIGNS & SYMPTOMS \u2219 Progressive & irreversible loss In the end stages of CKD, of kidney function almost every body system is negativity affected \u2219 Occurs over a long period of time \u2219 \u2193 Urinary output (UOP) CAUSES \u2022 Oliguria = <400 mL\/day \u2022 Anuria = <100 mL\/day \u2219 Untreated acute kidney injury (AKI) \u2219 Diabetes mellitus \u2219 Proteinuria & hematuria \u2219 Hypertension \u2219 Family history \u2219 Lethargy \u2219 Recurrent infections \u2219 Altered LOC\/confusion \u2219 Autoimmune disorders \u2219 Seizures \u2219 Hypertension \u2219 Fluid volume excess (hypervolemia) \u2219 Heart failure STAGES \u2219 Anorexia \u2219 Nausea\/vomiting Stages are based on the GFR rate \u2219 Uremic fetor (ammonia breath) As CKD worsens... GFR decreases \u2193 \u2219 Metallic taste Stage gfr \u2219 Impaired immune > 90 & in\ufb02ammatory response 1 Stage \u2219 Anemia (\u2193 erythropoietin [EPO]) \u2219 \u2191 Risk for bleeding 2 60 - 89 \u2219 Prolonged bleeding time 3Stage a: 45 - 59 \u2219 Amenorrhea B: 30 - 44 \u2219 Erectile dysfunction \u2219 \u2193 Libido Stage 4 15 - 29 Stage \u2219 Uremic frost \u2219 Pruritus 5 < 15 end stage renal disease TREATMENT LABS \u2219 \u2191 Magnesium \u2219 \u2191 BUN \u2219 \u2193 Calcium \u2219 Dialysis \u2219 \u2191 Creatinine \u2219 \u2191 Phosphate \u2219 \u2191 K+ \u2219 Kidney transplant \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 107","TYPES OF DIALYSIS: HEMODIALYSIS med-surg renal\/ urinary Dialysis is a way to remove waste products from the blood in those with kidney dysfunction. In a healthy body, the kidneys are able to \ufb01lter waste products. But if the kidneys are not functioning properly and are injured, they need help removing excess waste from the blood. Otherwise, waste accumulates and becomes toxic\/harmful to the body. mcemodtmoihasmoltyodsniosf HEMODIALYSIS uses a dialyzer (an artificial kidney) arti\ufb01cial kidney to remove excess fluids and toxins. blood back to body THE PROCESS \ufb01stula tohuetsbioddey The dialyzer blood (Artificial kidney) to COMPLICATIONS \u2193 dialyzer \u2022 Hypotension Brings blood to the dialyzer \u2022 Disequilibrium syndrome \u2022 Hemorrhage \u2193 \u2022 Air embolus \u2022 Electrolyte imbalances Filters out toxins\/waste products PATIENT EDUCATION \u2193 On the arm that has Brings clean blood back to the body vascular access, you need to avoid: 3X a week \u2718 Compression (3 - 5 hours per treatment) \u2718 Blood draws Typically done in the hospital \u2718 Blood pressure readings \u2718 Tight clothing or in a dialysis clinic \u2718 Carrying bags \u2718 Sleeping on that arm ACCESS sruerbqgouetirrhye VASCULAR ACCESS Fistula Joining an artery to a vein syrnistkdhinIeufsnoteecircrrtteionmioaftsneahetceedtiroianl graft Inserting synthetic graft material between an artery and a vein EVALUATION OF PATENCY: \u2714 Feel the thrill (palpating the fistula) \u2714 Hear the bruit (heard during auscultation) \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 108","med-surg renal\/ TYPES OF DIALYSIS: PERITONEAL DIALYSIS urinary Dialysis is a way to remove waste products from the blood in those with kidney dysfunction. In a healthy body, the kidneys are able to \ufb01lter waste products. But if the kidneys are not functioning properly and are injured, they need help removing excess waste from the blood. Otherwise, waste accumulates and becomes toxic\/harmful to the body. PERITONEAL DIALYSIS Uses a peritoneum to remove excess fluids and toxins THE PROCESS Dialysate solution tihnesibdoedy Warm the solution! \u2193 Drain Dialysate is infused into the Diffuses waste peritoneal cavity by gravity COMPLICATIONS \u2193 Close the clamp on the infusion line This procedure is commonly done at home and has an increased risk \u2193 for infection in the peritoneum. Dialysate dwells for a set amount of time (dwell time) PERITONITIS (INFECTION) \u2022 Cloudy or bloody drainage \u2193 \u2022 Fever The drainage tube is unclamped \u2022 Abdominal pain \u2022 Malaise \u2193 Fluid drains from the peritoneal cavity by gravity \u2193 A new container of dialysate is infused as soon as drainage is complete \u2193 REPEAT! 7X a week (multiple exchanges per day) Typically done at home Catheter cap ACCESS PATIENT EDUCATION Catheter PERITONEAL How to avoid infections: Peritoneum CATHETER \u2714 Good hand hygiene performed at the before and after dialysis bedside or in the \u2714 Clean site of catheter daily operating room \u2714 Keep supplies in a clean, dry place \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 109","URINARY TRACT INFECTION med-surg renal\/ urinary PATHO UTIs typically start Infection within the urinary system in the lower tract caused by either a bacteria, upper & move upwards viral, or fungus. specISiCfBTiOcAHaMClETlMyMEOERON.ISACToli urinary tract making it to CAUSES the upper tract \u2219 Most common in women Pyelonephritis (shorter urethra & urethra is close infection of the kidneys to the rectum) Ureteritis infection of the ureter \u2219 Overuse of antibiotics lower Cystitis \u2219 Indwelling catheters urinary tract infection of the bladder \u2219 Hormone changes (pregnancy changes) \u2219 Diabetes Urethritis \u2219 Lifestyle infection of the urethra \u2022 Baths, scented tampons, perfumes, etc. EDUCATION SIGNS & SYMPTOMS \u2219 Take entire antibiotics course \u2219 Smelly urine \u2219 Wipe from front to back \u2219 Void after intercourse \u2219 Chills & fever \u2219 Avoid caffeine & ETOH \u2219 Void frequently \u2219 Costovertebral angle (CVA) tenderness \u2219 Avoid bubble baths, perfumes, \u2219 Nausea & vomiting or sprays! \u2219 Wear non-tight cotton underwear \u2219 Headache\/malaise \u2219 Painful urination (dysuria) \u2219 Burning on urination 12th rib \u2219 Frequency & urgency NURSING CONSIDERATIONS \u2219 Nocturia \u2219 Maintain \ufb02uid status \u201c\ufb02ushing\u201d out the \u2219 Incontinence \u2022 2 - 3 L per day urinary \u2022 Remove the catheter ASAP \u2219 Hematuria tract (per HCP order) BE\ufb01uarFrnsiOnttiebdRTiaoEcoksutgeeilctiuvsoirfneg \u2219 Fever \u2219 Medications \u2219 WBCs in the urine costovertebral \u2022 Antibiotics angle \u2022 Analgesia (control pain) \u2022 Phenazopyridine (Pyridium) MayAtoonrtau\u2193anrlgnpgeaeusinricine Elderly patients may show atypical symptoms: \u2219 Confusion \u2219 Lethargy \u2219 New incontinence \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 110","RENAL CALCULI med-surg renal\/ urinary PATHO TREATMENT\u2219 tphceaososmswtMoomnnon!oesinttw'lsyi,ll Medications to control the *PAIN* Stones (calculi) found in the urinary tract & kidney! \u2219 NSAIDs \u2193 Pain & in\ufb02ammation Nephrolithiasis: \u2219 Opioid analgesics stones in the kidneys (makes the stone easier to pass) Ureterolithiasis: stones \u2219 Strain the urine stones in the ureter \u2219 Stones can be very large \u2219 keep any stones or very small & send them to the lab to evaluate the type of stone \u2219 They can be found inside the kidneys, ureters, or the bladder \u2219 Get them moving or DfooerfPcwiurneasfrahedscset&tisooornniueskt! frequently turning them! \u2219 \u2191 Fluids! SIGNS & DIAGNOSIS \u2219 Diet: SYMPTOMS \u2219 KUB: X-ray of kidneys, \u2219 Limit protein, Na+ foods, & calcium \u2219 Pain! ureters, bladder \u2219 Procedures: \u2219 Discomfort \u2219 IVP: intravenous \u2219 Hematuria \u2192 (RBCs) pyelogram Noninvasive Extracorporeal Shock Wave Lithotripsy (ESWL) \u2219 Pyuria \u2192 (WBCs) Sends shock waves to break up the stone! \u2219 Nausea & vomiting \u2219 Ultrasound or CT scan \u2219 Urine test Invasive! Percutaneous Nephrolithotomy Stone removed by an incision made on the back where the kidneys are located. What is Uric acid is a waste products Uric Acid? of the breakdown of purines MOST calcium uric acid struvite Cystine COMMON! stone type Too much uric acid Persistent alkaline Rare, genetic, Forms due to \u2191 amounts in the urine environment that is inherited disorder of calcium & oxalate (acidic urine) ammonia-rich urine that affects renal in the urine Due to a bacteria absorption of cystine causes \u2022 Hypercalcemia \u2022 Gout \u2022 Chronic urinary \u2022 Hypercalciuria \u2022 Foods high tract infections \u2022 Hyperparathyroidism (UTIs) \u2022 \u2191 intake of Na+ in purine or \u2022 Dehydration animal proteins \u2022 Foreign bodies \u2022 GI disorders \u2022 Dehydration \u2022 Neurogenic \u2022 \u2191 intake of calcium \u2022 Metabolic issues (diabetes) bladder supplements with vitamin D \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 111","CARDIAC OVERVIEW med-surg cardiac LAYERS OF THE HEART PERICARDIUM There are three layers of the heart: Thin sac that encases the heart. epicardium, Myocardium, and endocardium Composed of two layers: epicardium the Parietal pericardium Exterior layer & the Visceral pericardium. Epi means Parietal pericardium \\\"upon\\\" endocardium Myocardium Thin inner layer Middle layer Lines the inside of the Responsible for heart & valves pumping action Endo means \\\"within\\\" Myo means \\\"muscle\\\" Visceral Fluid pericardium lubricates the surface of Adheres to the heart & reduces friction the epicardium CARDIAC TERMS CARDIAC OUTPUT FORMULA NORMAL: 4 - 8 L\/min Total volume of blood HR x SV = CO ejected (pumped) by INTERPRETATION the heart per minute. Heart Stroke Cardiac \u2193 CO = Less volume It's the amount of blood Rate Volume Output reaching the tissues. (\u2193 perfusion to the vital organs) HR= The # of times the heart contracts each minute (normal 60 - 100 bpm) \u2191 CO = More volume SV= Amount of blood ejected from the (could be due to hypervolemia, etc.) left ventricle with each heartbeat STROKE VOLUME PRELOAD AFTERLOAD Amount of blood pumped Amount of blood Pressure that the left out of the ventricle with returned to the right side ventricle has to pump each beat or contraction against (the resistance of the heart at the end it must overcome to CONTRACTILITY of diastole circulate blood) Force \/ strength of contraction Clinically measured by of the heart muscle systolic blood pressure! EJECTION FRACTION (EF) opthfuIfewmtthhlhpEeaeeifXtnt\u2019EsAhgvFMeeinoaniPsusrtiLttrd5Eiic5e5s:l5%eo%f, 112 % of blood expelled from the left ventricle with every contraction Normal EF: 50 - 70% \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.","med-surg LAB VALUES RELATED TO THE CARDIAC SYSTEM cardiac EXPECTED RANGE DESCRIPTION \u2193 \u2191 TOTAL < 200 mg\/dL Measurement of the total amount Indicates a Increases the risk CHOLESTEROL of cholesterol in your blood lower risk for for heart disease cardiovascular TRIGLYCERIDES < 150 mg\/dL Most common type of fat in the and stroke body. Takes the food you eat and disease stores it as excess energy LOW DENSITY < 100 mg\/dL lDL CARDIAC LIPOPROTEINS bad lDL think: we want (LDL) low levels \\\"bad fat\\\" HIGH DENSITY F > 40 mg\/dL HDL Increases the risk Indicates a LIPOPROTEINS M > 55 mg\/dL good for heart disease lower risk for HDL think: we want High levels, cardiovascular (HDL) because it's a Happy cholesterol and stroke disease D-DIMER < 0.5 mcg\/mL D-dimers are fragments of Normal\/low Levels BNP fibrin that are in the blood Elevated\/high levels when a clot dissolves or is \u2022 Blood clot is (positive result) ruled out broken down. Possible Causes: Helps to indicate \u2022 Blood clot may be D-dimer helps to determine heart failure is not if a clot is present present in the body present \u2022 Disseminated somewhere in the body intravascular < 100 pg\/mL BNP is a peptide released when coagulation (DIC) the ventricle is filled with too much Congestive fluid and stretches heart failure (HF) Hemodynamic Parameters CARDIAC OUTPUT (CO) 4 - 8 L\/min Total volume pumped per minute CARDIAC INDEX (CI) 2.5 - 4.0 L\/min\/m2 Cardiac output per body surface area CENTRAL VENOUS 2 - 8 mmHg PRESSURE (CVP) CI = CO surface area MEAN ARTERIAL PRESSURE (MAP) Pressure in the superior vena cava. Shows how SYSTEMIC VASCULAR RESISTANCE (SVR) much pressure from the blood is returned to the right atrium from the superior vena cava 70 - 100 At least Average pressure in the systemic circulation mmHg 60 mmHg is (your body) through the cardiac cycle required to adequately perfuse the vital organs 800 - 1200 dynes\/sec\/cm The resistance it takes to push blood through the circulatory system to create blood \ufb02ow \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 113","med-surg FLOW OF BLOOD THROUGH THE HEART cardiac 1 12 RIGHT LEFT Oxygenated Blood 6 Deoxygenated Blood 7 Pulmonary Vein* 7 1 Superior Vena Cava 8 Left Atrium \/ Inferior Vena Cava 9 Bicuspid\/Mitral Valve 2 8 10 Left Ventricle 3 2 Right Atrium (RA) 1 10 9 3 Tricuspid Valve (TV) 11 Aortic Valve 11 4 Right Ventricle (RV) 12 Aorta 4 5 5 Pulmonary Valve (PV) 6 Pulmonary Artery* carries OXYGENATED carries DEOXYGENATED blood to the blood to the LUNGS TISSUES\/BODY OVERVIEW OF BLOOD VESSELS ARTERIES VEINS Carry oxygenated Carry deoxygenated AV Node blood to tissues blood back to the heart METMRIOCRKY Arteries think Away from the heart * EXCEPTIONS Bundle of His The only exception to this is the Left bundle pulmonary artery and pulmonary vein branch \u2193\u2193 brings deoxygenated blood carries oxygenated blood from the heart to the lungs from the lungs to the heart SA Node Electrical Conduction of the Heart Right bundle Purkinje branch fibers Cardiac MNEMONIC Steps in the heart\u2019s conduction system Conduction System: Send SA node (SinoAtrial node) Primary pacemaker of the heart. ThhiseaNisrotatrnaeotr:emal A AV node (AtrioVentricular) Creates electrical impulses of Generates & transmits Big bundle of His 60 - 100 bpm Bounding bundle branches (right & left) electrical Pulse purkinje fibers Secondary pacemaker of the heart \u201cbackup pacemaker.\u201d If the SA node impulses malfunctions, the AV node takes over at a rate of 40 - 60 bpm which stimulates contractions of If the SA & the AV nodes fail, the atria and then the Purkinje \ufb01bers can \ufb01re at the ventricles. a rate of 30 - 40 bpm \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 114","AUSCULTATING HEART SOUNDS med-surg cardiac 5 areas All People Enjoy Time Magazine for Listening Aortic Right 2nd intercostal space to the Heart Pulmonic Left 2nd intercostal Space ERB\u2019s Point (S1, S2) Left 3rd intercostal space Tricuspid Lower left sternal border 4th intercostal Mitral Left 5th intercostal, medial to midclavicular line Think M for Midclavicular NORMAL S1 Tricuspid & mitral valve closure Closing of the valves \u2193LUB Valve opening does not normally S2 Aortic & pulmonic valve closure produce a sound DUB S3 Early Diastole in rapid ventricle filling Abnormal \u2193 ventricular ABNORMAL filling S4 Late Diastole & high atrial pressure qExtra sounds (forcing blood into a stiff ventricle) SYSTOLIC Ventricle pump \/ ejection = LUB (S1) contracted LUB (S1) DUB (S2) \u201cCOZY RED\u201d DIASTOLIC CO (contract) ZY (systole) RE (relax) D (diastole) Ventricle relax \/ filling = DUB (S2) relaxed \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 115","EKG WAVEFORMS med-surg cardiac QRS Complex P wave ............. Atrial contraction (depolarization) PR segment ..... Movement of electrical activity R from atria to ventricles pr st tp QRS Complex... Ventricle contraction (depolarization) interval segment interval St segment ..... Time between ventricular P T P depolarization & repolarization Q T wave ............. Ventricle relaxing (repolarization) S TP Interval ..... Ventricle relaxing & filling pr QT interval Heart Rhythm MEMORY DEpolarization think... segment Measurements TRICK DEcompressing basic rhythms PR Interval MEMORY repolarization think... 0.12 - 0.20 TRICK relaxing normal sinus 60 - 100 bpm repolarizing sinus tachycardia > 100 bpm QRS Complex refilling with blood sinus bradycardia < 60 bpm 0.06 - 0.12 QT Interval < 0.40 seconds PR INTERVAL ST SEGMENT QT INTERVAL Movement of electrical Time between ventricular de- activity from atria to ventricles polarization and repolarization Time it takes for (ventricular contraction) ventricles to depolarize and repolarize (to contract and relax) 5-LEAD PLACEMENT WHITE ON RIGHT RA SMOKE OVER... CHOCOLATE v IN MY HEART la rl GREEN GOES LAST ll FIRE \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 116","6 STEPS TO INTERPRETING EKGs med-surg cardiac #1 P-WAVE BASIC RHYTHMS Identify & examine the P-waves SINUS TACHYCARDIA > 100 bpm \u2022 Should be present & upright NORMAL SINUS 60 - 100 bpm \u2022 Comes before QRS complex \u2022 One P-wave for every QRS complex SINUS BRADYCARDIA < 60 bpm #2 PR INTERVAL Normal PR interval: 1 sec. 0.12 - 0.20 seconds Measure PR interval 0.04 sec. #3 QRS COMPLEX Normal QRS complex: 0.20 sec. Is every P-wave 0.06 - 0.12 seconds 1 large box = 0.20 seconds followed by a 5 large boxes = 1 second QRS complex? 1 small box = 0.04 seconds \u2022 Should not be widened or shortened Widened \u2013 this may indicate a problem! dismreEubelgeiansctlatioonrnxfoctPilceeyVinsttCey&s!, #4 R-R Are the R-R intervals consistent? \u2022 Regular or irregular? #5 DETERMINE THE HEART RATE Count 6 SECOND oMfERT\u2019sHiOnDbetweenBtheeCsosuturreniptatinshde6cbsheoecxcoeknstdhsa!t BIG BOX METHOD the number 300 divided by the number the 6 second strips & multiply by 10 of big boxes between 2 R\u2019s 12 34 56 123 4 5 6 R\u2019s X 10 = 60 beats per minutes 300 \/ 5 = 60 BPM #6 IDENTIFY THE EKG FINDING! 117 \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.","EKGs med-surg cardiac R NORMAL SINUS RHYTHM RATE 60 - 100 bpm PT RHYTHM Regular QS P-WAVE PR INTERVAL Upright & uniform before each QRS QRS COMPLEX Normal Normal SINUS BRADY KEY The sinus node creates an impulse RATE < 60 bpm at a slower-than-normal rate RHYTHM Regular P-WAVE Upright & uniform before each QRS PR INTERVAL Normal QRS COMPLEX Normal CAUSES This is normal: TREATMENT Athletes have a low q Lower metabolic needs RESTING heart rate. q Correct the underlying cause! q Sleep This is because the heart q Athletic training is strong and pumps q \u2191 the heart rate to normal q Hypothyroidism more ef\ufb01ciently with q Vagal stimulation each heartbeat q Medications q Calcium channel blockers, beta blockers, Amiodarone SINUS TACHY KEY The sinus node creates an impulse RATE > 100 bpm at a faster-than-normal rate RHYTHM Regular P WAVE Upright & uniform before each QRS PR INTERVAL Normal QRS COMPLEX Normal CAUSES TREATMENT q Physiologic or psychological stress q Heart failure q Identify the underlying cause! q Blood loss, fever, exercise, dehydration, infection, sepsis q Cardiac tamponade q \u2193 the heart rate to normal q Hyperthyroidism q Certain medications q Stimulants: caffeine, nicotine q Illicit drugs: cocaine, amphetamines q Stimulate sympathetic response: epinephrine q Beta-2 agonists \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 118","EKGs med-surg cardiac VENTRICULAR TACHYCARDIA (VT) RATE 100 - 250 bpm RHYTHM Regular P-WAVE Not visible PR INTERVAL None QRS COMPLEX Wide (like tombstones) > 0.12 seconds looks like Irregular, coarse waveforms of different tombstones shapes. The ventricles are quivering and there is no contraction or cardiac output which may be fatal! CAUSES MANIFESTATIONS q Myocardial ischemia \/ infarction q Patient is usually awake (unlike V-\ufb01b) q Electrolyte imbalances q Digoxin toxicity q Chest pain q Stimulants: caffeine & methamphetamine q Lethargy No Cardiac Output q Anxiety q Syncope = q Palpitations Low Oxygen TREATMENT UNSTABLE CLIENTS WITHOUT A PULSE STABLE CLIENT WITH A PULSE Also called PULSELESS V-TACH q Oxygen q CPR q Antiarrhythmics q Follow ACLS protocol for de\ufb01brillation SHOCK! (ex. Amiodarone...stabilizes the rhythm) q Possible intubation q Synchronized Cardioversion q Drug therapy \u2022 Synchronized administration of shock q Epinephrine, vasopressin, amiodarone (delivery in sync with the QRS wave). \u2022 Cardioversion is NOT defibrillation! (defibrillation is only given with deadly rhythms!) UNTREATED VT can lead to VENTRICULAR FIBRILLATION DEATH \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 119","EKGs med-surg cardiac VENTRICULAR FIBRILLATION (V-FIB) Rapid, disorganized pattern of electrical activity RATE Unknown in the ventricle in which electrical impulses RHYTHM Chaotic & irregular arise from many different foci! P-WAVE Not visible PR INTERVAL Not visible QRS COMPLEX Not visible CAUSES MANIFESTATIONS No Cardiac Output q Cardiac injury q Loss of consciousness q Medication toxicity q May not have a pulse or blood pressure = q Electrolyte imbalances q Respirations may stop No btoloothdeorboodxyygen q Untreated ventricular tachycardia q Cardiac arrest TREATMENT q CPR q Drug Therapy q Oxygen q Epinephrine (causes vasoconstriction) q Defib \u201cDefib the Vfib\u201d q Antiarrhythmics: Amiodarone, lidocaine q Possibly magnesium (follow ACLS protocol for defibrillation) q Possible intubation CARDIOVERSION VS. DEFIBRILLATION CARDIOVERSION VS DEFIBRILLATION \u2022 Synchronized shock Ssbwyenitctcuhhrronmenudizsetr \u2022 Asynchronous Synced shock delivered only on! Done with an automated external de\ufb01brillator (AED) during the R wave of the QRS complex \u2022 higher amount of joules (energy) used If the shock is accidentally delivered during \u2022 Resume CPR after shock the T-wave, it can cause R-on-T phenomenon \u2022 Unstable patients \u2022 Lower amount of joules (energy) used EXAMPLE: \u2022 Not done with CPR \u2022 Pulseless ventricular tachycardia (VT) \u2022 Stable patients or (must have a QRS complex) \u2022 Ventricular \ufb01brillation (VF) EXAMPLE: \u2022 A-\ufb01b Patients are sedated for this outpatient procedure. It does not require a hospital stay. Think: Cardioversions are Carefully planned \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 120","EKGs med-surg cardiac ATRIAL FIBRILLATION (A-FIB) irregular r-r intervals RATE Usually over 100 bpm RHYTHM Irregular \u2193\u2193 \u2193 \u2193 \u2193 P-WAVE None. They are irregular (\ufb01brillary waves) PR INTERVAL Visible Uncoordinated electrical activity in the atria QRS COMPLEX Narrow & irregularly irregular that causes rapid & disorganized \u201c\ufb01bbing\u201d qThueivaetrriniagi!s of the muscles in the atrium. MANIFESTATIONS CAUSES q Most commonly asymptomatic q Open heart surgery q Heart failure q Fatigue q COPD q Hypertension q Malaise q Ischemic heart disease q Dizziness All due q Shortness of breath to Low O2 q Tachycardia q Anxiety q Palpitations TREATMENT STABLE PT. UNSTABLE PT. q Oxygen q Oxygen q Drug therapy! q Cardioversion q Beta blockers q Synchronized administration of shock q Calcium channel blockers (delivery in sync with the QRS wave). q Digoxin q Cardioversion is NOT de\ufb01brillation! q Amiodarone defibrillation q Anticoagulant therapy Defibrillation is only given to prevent clots with deadly rhythms! risk for clots The atria quiver causes pooling of blood in the heart which increases the risk for clots = increased risk for MI, PE, CVA, & DVTs! \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 121","EKGs med-surg cardiac PREMATURE VENTRICULAR CONTRACTIONS (PVCs) PVC RATE Depends on the underlying rhythm RHYTHM Regular but interrupted due to early P-waves Early or premature conduction of a QRS complex P-WAVE Visible but depends on timing of PVC CAUSES \u2022 Exercise (may be hidden) \u2022 Fever PR INTERVAL Slower than normal but still 0.12 - 0.20 seconds q Heart failure \u2022 Hypervolemia QRS COMPLEX Sharp, bizarre, and abnormal during the PVC q Cardiomyopathy \u2022 Heart failure q Electrolyte imbalance \u2022 Tachycardia BIGEMINY: every other beat q Myocardial ischemia \/ infarction TRIGEMINY: every 3rd beat q Drug toxicity QUADRIGEMINY: every 4th beat q Caffeine, tobacco, alcohol q Stress or pain R-ON-T PHENOMENON: PVC arises q \u2191 workload on the heart spontaneously from the repolarization gradient (T-wave) may precipitate V-\ufb01b TREATMENT MANIFESTATIONS chest pain *Treatment based on underlying cause* q May be asymptomatic Notify the healthcare q May not be harmful if the client has a healthy heart provider if the client q Oxygen q Feels like your heart... complains of chest pain, q \u2193 caffeine intake q skipped a beat if the PVCs increase in q Correct the electrolyte imbalances q is pounding frequency or if the PVCs q D\/C or adjust the drug causing toxicity occur on the T-wave q \u2193 stress or pain q Chest pain (R-on-T phenomenon). ASYSTOLE RATE flatline RHYTHM P WAVE PR INTERVAL QRS COMPLEX CAUSES TREATMENT \u2022 Heel of hand on center of the chest \u2022 Arms straight q Myocardial ischemia\/infarction HIGH QUALITY CPR \u2022 Shoulders aligned over hands q Heart failure \u2022 Compress at 2-2.4 inches q Electrolyte imbalances sternum at a rate of 100-120\/min (common: hypo\/hyperkalemia) center of chest \u2022 30 compressions to 2 rescue breaths \u2022 Minimal interruptions q Severe acidosis (between nipples) q Cardiac tamponade 122 q Cocaine overdose \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.","EKGs med-surg cardiac ATRIAL FLUTTER RATE 75-150 bpm RHYTHM Usually regular Sawtooth P-WAVE \u201cSawtooth\u201d P-wave con\ufb01guration Similar to A-\ufb01b, but the heart\u2019s electrical shaped \ufb02utter waves signals spread through the atria. The heart\u2019s PR INTERVAL Unable to measure QRS COMPLEX Usually normal & upright upper chambers (atria) beat too quickly but at a regular rhythm. MANIFESTATIONS CAUSES q May be asymptomatic q Fatigue \/ syncope q Coronary artery disease (CAD) q Chest pain q Hypertension q Shortness of breath q Heart failure q Low blood pressure q Valvular disease q Palpitations q Hyperthyroidism q Dizziness q Chronic lung disease q Pulmonary embolism UNSTABLE PT. q Cardiomyopathy q Cardioversion TREATMENT q Synchronized administration of shock (delivery in sync with the QRS wave). STABLE PT. q Cardioversion is NOT de\ufb01brillation! q Drug therapy! defibrillation q Calcium channel blockers q Antiarrhythmics Defibrillation is only given q Anticoagulants with deadly rhythms! risk for clots Atrial flutter causes pooling of blood in the atria = risk for clots \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 123","HEART FAILURE med-surg cardiac Can also be referred to as congestive heart failure PATHOLOGY DIAGNOSTIC Cardiac disorder that impairs the ability \u2219 \u2191 B-type natriuretic peptides (BNP) of the ventricles to \ufb01ll or eject properly. \u2219 Chest x-ray The heart muscle can't pump enough blood to meet the body's needs. (enlarged heart & pulmonary in\ufb01ltrate) \u2219 Echocardiogram (measures ejection fraction) RISK FACTORS \u2219 Cardiac stress test \u2219 Uncontrolled hypertension BNP is a peptide released when the ventricle \u2219 Congenital heart defect is filled with too much fluid and stretches. \u2219 Arrhythmias It's a marker for congestive heart failure (hf). \u2219 Coronary artery disease \u2219 Faulty heart valves BNP <100 pg\/mL Expected Range \u2219 Damage or in\ufb02ammation BNP 100 - 300 pg\/mL HF is suspected of the heart muscle BNP > 300 pg\/mL Mild HF PATIENT EDUCATION BNP > 600 pg\/mL Moderate HF BNP > 900 pg\/mL Severe HF \u2219 report S&S of \ufb02uid retention (edema, weight gain) NURSING CONSIDERATIONS \u2219 Elevate HOB monitor: Daily weights (Semi or High-Fowler's position) \u2219 I&Os are the best way \u2219 Daily weights \u2219 Balance periods of activity & rest \u2219 For edema & to monitor HF diet modifications: othnSetoophudra\u2193etaraddytdhuc+irar\ufb02issnnutugdidcyks pulmonary edema Monitor for weight gain over \u2219 Fluid restrictions \u2219 \u2193 Sodium a short period \u2219 \u2193 Fat of time (2-3 lbs) \u2219 \u2193 Cholesterol MEDICATIONS Potassium sparing Diuresis the body (Spironolactone) \u2219 Diuretics Diuretics = Diuresis = Dry inside \u2219 Ace inhibitors Potassium wasting \u2219 Beta blockers (Loop & thiazide) \u2219 Digoxin \u2219 monitor potassium levels NORMAL K+: 3.5 - 5.0 mEq\/L \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 124","HEART FAILURE CONTINUED med-surg cardiac MOST A patient can right-sided have both! Left-sidedCOMMON Heart Failure Heart Failure Also called right ventricular (RV) heart failure Also called left ventricular (LV) heart failure Typically occurs as a result of Description Ejection fraction left-sided HF Systolic HF Weakened Ejection fraction reduced When the left ventricle fails, heart muscle Also called heart failure pressure from \ufb02uid builds up The ventricle with reduced ejection and causes a back \ufb02ow of \ufb02uids does not EJECT fraction (HFrEF) into the right side of the heart (squeeze) properly This causes damage to the Diastolic HF Stiff & non-compliant Normal ejection fraction right side of the heart heart muscle Also called heart failure with preserved ejection This is not an issue with the fraction (HFpEF) ejection fraction (the heart ejects properly). The issue is that the ventricles do not FILL properly Fluid is backing up into the Fluid is backing up into lungs = pulmonary symptoms the venous system left side think lungs Right = the Rest of the body signs & symptoms d Dyspnea Chronic HF s Swelling of the legs & hands r Rales (crackles) w Weight gain o Orthopnea may show both e Edema (pitting) w Weakness\/fatigue of these signs & symptoms l Large neck veins (JVD) n Nocturnal paroxysmal dyspnea l Lethargy\/fatigue i Increased HR i Irregular heart rate n Nagging cough (frothy, blood tinged sputum) n Nocturia g Gaining weight (2-3 lbs a day) HOSy3Tp\u2191GoHtUaEelOnlRosPpSio&nS g Girth (ascites) SHpOeAlpeTnnaoHotroEmemxReieagSga&alylSy \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 125","CORONARY ARTERY DISEASE (CAD) med-surg cardiac PATHOLOGY Damage in the coronary arteries due to atherosclerosis. MCOARSTTDYIDCOPOIVSEMEAOASMFCSOEUNLAR Atherosclerosis is plaque build-up Accumulation that causes narrowing of the vessels of fatty plaque and limits blood supply to the heart. ovbtehlroattoimhdaevpeopsnesentlshe The plaque may rupture causing thrombi (clot) and may obstruct walls blood \ufb02ow, leading to an acute MI. RISK FACTORS DIAGNOSTIC non-modifiable modifiable \u2219 Blood tests: \u2219 Age \u2219 Diabetes LDL, HDL, total cholesterol, triglycerides \u2219 Gender \u2219 Hypertension \u2219 Race \u2219 Smoking \u2219 EKG: assess for changes in ST segments \u2219 Family history \u2219 Obesity \u2219 Stress test \u2219 Physical inactivity \u2219 Cardiac catheterization \u2219 High cholesterol \u2219 Metabolic syndrome normal low O2 no O2 SIGNS & SYMPTOMS Cholesterol Usually asymptomatic LDL Want LOW levels \u2219 Chest pain Low Density (<100 mg\/dL) (stable angina which goes away with rest) BAD cholesterol Lipoprotein \u2219 Shortness of breath \u2219 Epigastric distress (heartburn) HDL Want HIGH levels \u2219 Pain radiating to the jaw or left arm High Density (>60 mg\/dL) MEDICATIONS HAPPY cholesterol Lipoprotein \u2219 Antiplatelets \u2219 Medications to normalize cholesterol levels PATIENT EDUCATION (statins, bile acid sequestrants, \ufb01bric acids) heart healthy diet: TREATMENT \u2219 \u2193 in saturated fats \u2219 \u2191 in \ufb01ber \u2219 Percutaneous coronary intervention (PCI) preventative measures \u2219 Check cholesterol levels \u2219 Manage hypertension \u2219 Control diabetes \u2219 Smoking cessation \u2219 Increase physical activity \u2219 Weight loss if needed \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 126","ANGINA PECTORIS med-surg cardiac Angina is chest pain associated with ischemia. It\u2019s due to narrowing of at least one major coronary artery. TYPES OF ANGINA \u201cPredictable\u201d Occurs with exertion STABLE EXAMPLE Exercise or strenuous activity UNSTABLE \u201cPreinfarction\u201d Occurs at rest & more frequently PRINZMETAL'S\/ \u201cCoronary artery vasospasm\u201d Pain at rest with VARIANT reversible st-elevation SIGNS & SYMPTOMS INTERVENTIONS Goal: \u2193 oxygen \u2022 Chest pain (heavy sensation) \u2022 Reperfusion procedures demand may radiate to neck, jaw, or shoulders CABG PCI \u2022 Unusual fatigue Coronary Artery Percutaneous \u2022 Weakness Coronary \u2022 Shortness of breath Bypass Graft \u2022 Pallor Interventions \u2022 Diaphoresis DRUG THERAPY nitrates Calcium Channel beta blockers Antiplatelet \/ Blockers Anticoagulant \u2193 myocardial oxygen Vasodilators Relaxes blood vessels consumption Prevents platelet \u2193 ischemia = \u2193 pain \u2191 oxygen supply aggregation & Usually administered to the heart thrombosis sublingual \u2193workload of heart patient Sublingual NTG or Spray Keep in original container teaching (dark, glass bottle) \u2219 1 tab\/spray sublingual every 5 minutes, in a dry, cool place. Do not swallow or up to 3 doses. chew these tablets \u2219 If angina is not relieved or is worse 5 min after the first dose, call 911! \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 127","MYOCARDIAL INFARCTION (MI) med-surg cardiac PATHO Complete blockage in one or more arteries of the heart EMERGENCY! atherosclerosis angina Myocardial Coronary arteries Due to become narrow ischemia Infarction (mI) (low O2) due to plaque \u2193 Plaque rupture build-up \u2193 become a blood clot that blocks arteries of blocked coronary the heart arteries dying muscle SIGNS & SYMPTOMS DIAGNOSIS \u2022 ECG SST-TTw--dealevepevraientsivoseinorsn(ino(onloOw2)O2) Sudden, crushing, radiating chest pain \u2022 that continues despite rest & medications \u2022 \u2022 Women present with \u2022 Shortness of breath different symptoms \u2022 Troponin \u2022 Nausea & vomiting \u2022 Sweating \u2022 Fatigue \u2022 Stress tests \u2022 Pale & dusty skin \u2022 Shoulder blade discomfort \u2022 Shortness of breath \u2022 Chemical & exercise Pain felt in the... Left arm \u2022 Mid back\/shoulder \u2022 Heartburn TREATMENT cath lab or Prevention immediate clot buster -Stue-afp\ufb01slexaeses: & Rest m MORPHINE Medications prevent \/ stabilize clot \u2193workload of the heart \u2022 Thrombolytics \u2022 Heparin IV & \u2193 pain (clot busters) \u2022 Example: Streptokinase Rest the heart with... o OXYGEN \u2191O2 to the heart Surgery \u2022 Nitro \u2022 PCI \u201cPercutaneous \u2022 Beta-blockers n NITROGLYCERIN \u2022 Calcium channel blockers opens up the vessels Coronary Intervention\u201d \u2022 CABG Any time a ASPIRIN \u2022 Endarterectomy wotafhtcyrbhooleumfeobgdroiilvnsyegitg!iacn,s Prevents platelets from sticking together \u2022 Cut out the blockage \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 128","PERIPHERAL VASCULAR DISEASE WORKSHEETNKTONEOSCTWHYELOEATUDIRGNEG!:) med-surg is an umbrella term for... cardiac PERIPHERAL PERIPHERAL VENOUS DISEASE ARTERIAL DISEASE Think \u201cBAD\u201d (PVD) (PAD) Deoxygenated blood ARTERY ARTER Narrow artery (atherosclerosis) where can\u2019t get back to the heart. VEIN VEIN oxygenated blood can\u2019t get to the Pooling of oxygenated blood distal extremities (hands & feet). in the extremities. Ischemia & necrosis of the extremities Y pain ? x x pain ? Pulse ? Pulse ? opfobolloiondg nonboloOo2d Edema ? No blood in the extremities Edema ? Temp ? Temp ? Color ? Color ? Wounds ? Wounds ? Gangrene ? Gangrene ? Positioning ? Positioning ? CAUSES OF BOTH Smoking \u2022 Diabetes \u2022 High cholesterol \u2022 Hypertension DX: TREAMENT TREAMENT Want more worksheets? Check out The Complete Laminated Study Templates! \u2022 Position \u2022 Position \u2022 Medications \u2022 Perform \u2022 Surgery \u2022 Stop \u2022 Avoid \u2022 No \u2022 Medications \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 129","PERIPHERAL VASCULAR DISEASE med-surg cardiac is an umbrella term for... PERIPHERAL PERIPHERAL Think VENOUS DISEASE ARTERIAL DISEASE \u201cBAD\u201d (PVD) (PAD) Deoxygenated blood Narrow artery (atherosclerosis) where can\u2019t get back to the heart. oxygenated blood can\u2019t get to the Pooling of oxygenated blood distal extremities (hands & feet). in the extremities. ARTERY ARTER Ischemia & necrosis VEIN YVEIN of the extremities pain ? Dull, constant, achy pain! x x pain ? Sharp pain: Gets worse at night Pulse ? May not be palpable opfobolloiondg nonboloOo2d \u201crest pain\u201d due to edema Intermittent claudication Pulse ? Very poor or even absent Edema ? BloNodo bisloPoOdOiLnINthGeinextthreemleigties Edema ? No blood in the extremities Temp ? Temp ? Color ? Warm legs Color ? Cool No blood = cool leg Wounds ? (Blood is warm) Wounds ? (blood is warm) Gangrene ? Gangrene ? Positioning ? Stasis dermatitis Positioning ? Pale, hairless, dry, scaly, thin skin (Brown\/yellow) due to lack of nutrients (\u2193 O2 ) Venous STASIS ulcers, Regular in shape, red sores Irregular shaped wounds, shallow round appearance \u201cpunched out\u201d We have too much blood! Gangrene is Tissue death caused by caused by insufficient amounts of blood. a lack of blood supply Elevate Positions that make it worse: dangling, Dangle arteries Veins sitting\/standing for long periods of time CAUSES OF BOTH Smoking \u2022 Diabetes \u2022 High cholesterol \u2022 Hypertension DX: Doppler Ultrasound or Ankle Brachial Index (ABI) TREATMENT KEEP VEIN OPEN! TREATMENT GET BLOOD MOVING! V\u2022 Elevate eins A\u2022 D ngle Arteries (Dependent position) \u2022 Medications - Aspirin or Clopidogrel \u2022 Perform daily skin care with moisturizer \u2022 Stop smoking - Cholesterol lowering drugs \u201cstatin\u201d \u2022 Avoid tight clothing (vasoconstriction) \u2022 No heating pads! \u2022 Surgery \u2022 Medications - Angioplasty - Vasodilators - Bypass (CABG) - Antiplatelets - Endarterectomy \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 130","CARDIAC BIOMARKERS med-surg cardiac EXPECTED RANGE Troponin I Peak Troponin Troponin I < 0.03 ng\/mL 10-24 hours Troponin t < 0.1 ng\/mL 2-6 hours 5-9 days BEST indicator of an acute MI Detected Fall Protein released in the blood stream when the heart muscle is damaged. Troponin t Peak There are 3 isomers of troponin: 10-24 hours Troponin C: 2-6 hours 7-14 days Binds calcium to activate muscle contraction Detected Fall Troponin I & T: Speci\ufb01c for cardiac muscle troponin t think two weeks it can stay elevated myoglobin EXPECTED RANGE Peak 5 - 70 ng\/mL 2-6 hours 12-24 hours Myoglobin is found in cardiac & skeletal muscle 1-2 hours NOT a speci\ufb01c indicator of an acute MI, but a (-) sign is good for ruling out an acute MI Detected Fall Myoglobin think Muscle ck-mb EXPECTED RANGE Peak 0 - 5 ng\/mL Creatine Kinase - MB 12-24 hours Cardiac-specific isoenzyme 3-6 hours 24-48 hours BUT\u00a0less reliable than Troponin Detected Fall An enzyme released in the bloodstream when the heart, muscles or brains are damaged! \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 131","HYPERTENSION (HTN) med-surg cardiac Most accurate diagnosis for HTN HYPER tension = HIGH BP categories Systolic Diastolic congestive heart failure (chf) (Squeeze) (Decompress) Overworking of the heart muscle hypotension < 100 < 60 affected organs (ventricle enlarges) Normal < 120 < 80 stroke Pre-htn 120 - 139 80 - 89 Weak & narrow vessels could lead to rupture of vessels Stage 1 htn 140 - 159 90 - 99 renal failure Stage 2 htn > 160 > 100 Too much blood \ufb02owing to the HTN crisis > 180 > 120 kidneys at a fast rate & high pressure visual changes Damages blood vessels in the retina (blurred vision, can\u2019t focus on objects) RISK FACTORS CHECKING Primary HTN MOST BLOOD PRESSURE COMMON \u2192 Place stethoscope over Also called F Family HX brachial artery essential or idiopathic HTN A advanced age C \u2191 cholesterol \u2192 Patients should not smoke, exercise, etc. \u2022 Cause is unknown T too much caffeine within 30 minutes of having their BP checked \u2022 Not curable, only controllable O obesity (could lead to in\ufb02ated BP) R restricted activity S sleep apnea \u2192 Instruct the client to: q\u2022 Sit in a chair with legs uncrossed R Race (African Americans) \u2022 Arm at level I intake of Na\/ETOH \u2022 Correct size cuff S smoking \u2192 No BPs should be Too small = auscultated in arms with: false high BP K Low k+ & vitamin D levels \u2022 Mastectomy - HX of AV shunt Too large = - Blood clots false low BP secondary HTN - PICC lines\/central lines Has a direct cause \/ preexisting condition ANTIHYPERTENSIVE MEDICATION OVERVIEW \u2022 Chronic kidney disease \u2022 Cushing syndrome \u2022 Diabetes \u2022 Pregnancy \u2022 Hypo\/Hyperthyroidism \u2022 Certain drugs (oral contraceptives) SIGNS & SYMPTOMSUsually asymptomatic! Symptoms (if seen): ace beta calcium diuretics digoxin \u2022 Blurred vision inhibitors blockers channel blockers Commonly called the \u2022 Headache \u201csilent killer\u201d \u2022 Chest pain AbcDD \u2022 Nose bleeds SUFFIXES EDUCATION A ACE inhibitors -pril B BETA Blockers \u2022 Limit sodium intake -olol \u2022 Limit alcohol intake C Calcium Channel Blockers -pine -amil \u2022 Smoking cessation \u2022 Teach how to measure D Diuretics BP & keep a record D Digoxin \u2022 Exercise programs for weight loss if needed \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 132","med-surg ENDOCRINE SYSTEM OVERVIEW endocrine The endocrine system is made up of glands & organs that release FUNCTION OF THE hormones (chemical messengers). These chemical messengers carry ENDOCRINE SYSTEM: information & instructions from one cell to another. HORMONES RELEASED by the endocrine organs\/glands 4 1 THYROID GLAND \u2022 Thyroxine (T4) 5 \u2022 Triiodothyronine (T3) \u2022 Calcitonin 2 PARATHYROID GLAND \u2022 Parathyroid hormone (PTH) 3 3 ADRENAL GLAND 8 1 \u2022 Adrenal cortex \u2022 Aldosterone \u2022 Cortisol \u2022 Adrenal medulla \u2022 Epinephrine \u2022 Norepinephrine 2 4 HYPOTHALAMUS \u2022 Growth hormone-releasing hormone (GHRH) \u2022 Thyrotropin-releasing hormone (TRH) \u2022 Gonadotropin-releasing hormone (GnRH) \u2022 Corticotropin-releasing hormone (CRH) 67 5 PITUITARY GLAND \u2022 Anterior \u2022 Luteinizing hormone (LH) \u2022 Follicle-stimulating hormone (FSH) \u2022 Prolactin \u2022 Thyroid-stimulating hormone (TSH) \u2022 Growth hormone (GH) \u2022 Adrenocorticotropic hormone (ACTH) \u2022 Posterior \u2022 Antidiuretic hormone (ADH) (Vasopressin) \u2022 Oxytocin 6 TESTES 7 OVARIES 8 PANCREAS \u2022 Testosterone \u2022 Estrogen \u2022 Insulin \u2022 Progesterone \u2022 Glucagon \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 133","ENDOCRINE HORMONES med-surg endocrine Thyroxine (T4) These hormones are created and stored in the thyroid. Triiodothyronine (T3) Maintains body metabolism in a steady state. Calcitonin Secreted by the thyroid gland. calcitonin think calcium Regulates calcium in the body. Thyroid-Stimulating Hormone (TSH) TSH stimulates the thyroid, causing T3 & T4 to be released Oxytocin Muscle contractions to help expel the baby Prolactin Stimulates milk production after childbirth Insulin Works to decrease blood glucose levels. Insulin puts sugar & potassium into the cells to be used later as energy Glucagon Works to INCREASE blood glucose levels. Breaks down stored glucose (glycogen) in the liver Epinephrine & Norepinephrine Stress hormones. They are catecholamines that are released when blood pressure drops. Helps in times of ACUTE stress Cortisol Glucocorticoid. Helps regulate metabolism, \u2191 blood glucose levels, and has anti-in\ufb02ammatory properties. Helps in times of CHRONIC stress Antidiuretic Hormone (ADH) Helps regulate the amount of water in your body Aldosterone Mineralocorticoid that helps in \ufb02uid balance Parathyroid Hormone Helps to increase serum calcium in the blood (PTH) Estrogen Helps to regulate the menstrual cycle, uterus growth during pregnancy, Progesterone maintains the pregnancy, and supports the fetus as it grows Helps to regulate the menstrual cycle, stimulates growth progesterone think of maternal tissues and fetal organs during pregnancy pregnancy hormone Testosterone Helps in the development of male sex organs and testosterone reproductive tissue, plays a vital role in sperm think Testes production, promotes secondary sex characteristics (\u2191 bone mass, \u2191 muscle mass, \u2191 growth of body hair) \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 134","med-surg LAB VALUES RELATED TO THE ENDOCRINE SYSTEM endocrine THYROID PANEL EXPECTED RANGE T3 & T4 are always opposite of TSH\u2191 (negative feedback mechanism) T3 80 - 220 ng\/dL (TRIIODOTHYRONINE) Hyperthyroidism: 4 - 12 mcg\/dL T4 \u2191 T3 & T4 \u2193 TSH (THYROXINE) Hypothyroidism: THYROID STIMULATING HORMONE O.5 - 5 mU\/L (TSH) \u2193 T3 & T4 \u2191 TSH Hypothalamus Thyroxine hormone (T4) Thyroid gland Pituitary gland Thyroid Stimulating Triiodothyronine Hormone (TSH) hormone (T3) Calcitonin BLOOD GLUCOSE DESCRIPTION EXPECTED RANGE Any time of the day A finger stick blood (doesn't matter when the last meal was) sugar test is the most Blood glucose goal 70 - 110 mg\/dL common way people with No caloric intake for at least 8 hours diabetes check their Fasting blood sugar < 100 mg\/dL blood glucose levels (FBS) 2-hr oral glucose < 140 mg\/dL Drink a glucose drink tolerance test < 5.7% (75g of glucose dissolved in water) HbA1c Blood test that measures the average blood glucose (sugar) levels for the last 2-3 months \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 135","DIABETES TYPE 1 & 2 med-surg endocrine TYPE 1 TYPE 2 DIABETES MELLITUS (T1DM) DIABETES MELLITUS (T2DM) no insulin production does not produce enough insulin, or produces bad insulin that does not work properly \u2022 Caused by an Type One autoimmune response \u2022 Insulin resistance \u2022 The cells are starved of glucose we have nOne \u2022 Insulin receptors are since there is no insulin to bring worn out & not PATHOLOGY glucose into the cells working properly! Terrible Twos are BAD \u2022 The cells break down protein and fat \u2022 Usually diagnosed in adulthood into energy, causing ketones to build up (due to a poor diet, sedentary lifestyle, = acidosis! and obesity) \u2022 Usually diagnosed in childhood Easy to remember because childhood comes 1st in life and adulthood comes 2nd RISK \u2022 Genetics \u2022 High blood sugar \u2022 Hypertension FACTORS \u2022 Family history \u2022 Obesity \u2022 Inactivity \u2022 High cholesterol \u2022 Family history \u2022 Smoking S&S 3 P'S Onset: ABRUPT 3 P'S Onset: GRADUAL Polyuria: excessive peeing Polyuria: excessive peeing Polydipsia: excessive thirst Polydipsia: excessive thirst Polyphagia: excessive hunger Polyphagia: excessive hunger TREATMENT Only has 1 treatment: Has 2+ treatments: inSULIN 1. Diet & exercise Oral hypoglycemic agents will not work for this pt. 2. Oral hypoglycemic agents Example: Metformin Insulin dependent for life! 3. Possibly Insulin metformin Insulin is not administered routinely in a type 2 diabetic patient. Only in times of stress, surgery, or sickness will insulin need to be administered. DIAGNOSTIC CRITERIA Casual Fasting blood Glucose Tolerance HbA1c Any time of the day sugar (FBS) Test Blood test that measures the (doesn't matter when average blood glucose (sugar) the last meal was) No caloric intake for Drink a glucose drink levels for the last 2-3 months at least 8 hours (75g of glucose dissolved in water) > 200 mg\/dL > 6.5% > 126 mg\/dL > 200 mg\/dL \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 136","med-surg DIABETES TYPE 1 & 2 CONTINUED endocrine DIABETIC FOOT CARE Reduced blood flow \u2219 Wash feet daily Damaged nerves \u2219 Use warm water Ulcers (test temperature beforehand) & mild soap \u2219 Gently pat feet completely dry Callus \u2219 Inspect feet daily with a mirror Bunion (check for any cuts, blisters, or sores) Ingrown \u2219 Avoid over-the-counter products toenail (callus remover, alcohol, etc) \u2219 Cut toe nails straight across Ulcer Corn Dry, cracked skin \u2219 Do not cross legs (hammer toe) \u2219 Report symptoms of infection to the HCP fderieKryt,reie&ctlpaeataivnoon,id! SICK DAY MANAGEMENT monitor report to the hcp if: \u2219 Stay hydrated (avoid dehydration) \u2219 Blood glucose often \u2219 Ketones are present in urine \u2219 Temperature often \u2219 If blood sugar is > 250 mg\/dL \u2219 Urine for ketones \u2219 If temperature is > 101\u00baF Do not skip insulin when you are feeling sick Diabetes can negatively affect almost every organ system This is because high levels of sugar in the blood damages the blood vessel walls and the nerves organ Kidneys Nerves Eyes Heart Brain affected NEPHROPATHY PERIPHERAL Diabetic Cardiovascular stroke complications NEUROPATHY RETINOPATHY disease Kidney damage Excessive blood Excessive blood Damage to the nerves outside Eye damage Damage to the heart & glucose damages glucose can damage of the brain & spinal cord. Excessive major coronary arteries the blood vessels the tiny blood vessels Excessive blood glucose blood glucose and makes them in the \ufb01ltering system can injure the nerves. damages the blood Excessive blood vessels of the retina. glucose damages the stiff. It also can (glomeruli). This causes tingling, numbness, cause a build up and eventually loss of sensation. This causes blindness, blood vessels and of fatty deposits. This causes kidney Nerve damage in the foot can cause cataracts, glaucoma. nerves controlling failure and even serious complications such as major This may cause end-stage kidney the heart. a blood clot that disease. infections in cuts and blisters. This causes coronary travels to the All this sugar in the blood also causes artery disease, brain causing a delayed wound healing = risk for infection hypertension, atherosclerosis. stroke. \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 137","DKA VS. HHNS med-surg endocrine DIABETIC KETOACIDOSIS (DKA) HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNS) Happens mostly in Type 1 Diabetic patients Happens mostly in Type 2 Diabetic patients Not enough insulin NO acidosis present! Simply high amounts PATHOLOGY \u2193 of glucose in the blood Body can't allow blood sugar acidosis ketones into the cells for energy \u2022 Inadequate fluid intake \u2193 \u2022 \u2193 kidney function Blood sugar becomes VERY high \u2022 Infection \u2022 Stress \u2193 \u2022 Older adults Cells break down protein & fat into energy \u2193 bmyepKtraaoebrdteooulnacisetmsof Ketones build up = Acidosis! RISK FACTORS \u2022 Stress (surgery) 4 S's \u2022 Sepsis (infection) \u2022 Skipping insulin \u2022 Stomach (stomach virus: nausea\/vomiting) \u2022 Undiagnosed diabetes Onset: ABRUPT Onset: GRADUAL \u2022 Hyperglycemia (300 - 500 mg\/dL) \u2022 Ketosis & acidosis \u2022 Hyperglycemia (>600 mg\/dL) S&S \u2022 Dehydration Remember: \u2022 3 P's (Polyuria, Polydipsia, Polyphagia) \u2022 Metabolic acidosis cO2 is an acid \u2022 Dehydration (hypovolemia) \u2022 Kussmaul respirations \u2022 Neurovascular changes No (trying to blow off CO2) (confusion, \u2193 LOC, headache) metabolic \u2022 Acid breath \\\"fruity breath\\\" acidosis TREATMENT \u2022 IV insulin with potassium (K+) NOTE FOR BOTH: \u2022 Fluid replacement \u2022 Fluid replacement \u2022 Correction of \u2022 Correction of electrolyte imbalance Regular insulin is the \u2022 Administer bicarbonate for only insulin given IV electrolyte imbalances \u2022 Administer insulin metabolic acidosis regular goes right into the vein \u2022 IV insulin with potassium (K+) insulin causes sugar & K+ to go in \u2022 SubQ insulin the cells, causing hypokalemia unless we administer K+ with IV insulin DKA remember to monitor K levels \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 138","med-surg HYPERGLYCEMIA VS. HYPOGLYCEMIA endocrine HYPERGLYCEMIA HYPOGLYCEMIA \u2191 BLOOD SUGAR BLOOD \u2193 BLOOD SUGAR GLUCOSE GOAL: >200 mg\/dL <70 mg\/dL neneoTdhsgeglluburccaoiosnsee... Gradual (hours to days) 70 - 110 mg\/dL Happens suddenly causes BRAIN DEATH! 3 P'Sscyommmopsmttoonms SIGNS & SYMPTOMS SIGNS & SYMPTOMS \u2219 Polyuria \u2219 Fruity breath \u2219 Cool & clammy skin \u2219 Headache \u2219 Polydipsia \u2219 Deep, rapid breaths \u2219 Sweating (Diaphoresis) \u2219 Shakiness \u2219 Polyphagia \u2219 Palpitations \u2219 Inability to arouse \u2219 Hot & dry skin (air hunger) \u2219 Fatigue & weakness \u2219 Dry mouth \u2219 Numbness & tingling \u2219 Confusion from sleep \u2219 Slow wound healing \u2022 Can lead to coma (dehydration) \u2219 Vision changes Hot & dry = Sugars high Cool & clammy needs some candy CAUSES CAUSES 4 S'S \u2219 Sepsis (infection) \u2219 Exercise \u2219 Stress \u2219 Swimming, cycling, college athlete, etc. \u2219 Steroids \u2219 Skipping insulin or oral diabetic medication \u2219 Alcohol hhyiRgpahopheigadslstyicrntihessekmulfioainr \u2219 Not eating a diabetic diet \u2219 Peak times of insulin DIABETIC DIET TREATMENT Complex carbohydrates Saturated fats CONSCIOUS PATIENTS Fiber-rich foods Trans fats Heart-healthy fish Cholesterol 15 x 15 x 15 \\\"Good fats\\\" Sodium Sugar-free fluids Oral intake of Recheck Give another 15 grams blood glucose 15 grams of carbohydrates in 15 min of carbohydrates if needed Juices, soda, TREATMENT low fat milk. NOT peanut butter or high fat milk \u2219 Administer insulin as needed UNCONSCIOUS PATIENTS \u2219 Test urine for ketones rapid short intermediate long Do not put anything in an unconscious Lispro regular nph client's mouth, they can aspirate! generic Aspart Glargine callEamreaprigdernescpyonse names Glulisine Detemir Administer IV 50% dextrose (D50) or Glucagon (IM, IV, SubQ) Humalog brand Novolog Humulin R Humulin N Lantus names Apidra Novolin R Novolin N Levemir \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 139","THYROID DISORDERS med-surg FUNCTION endocrine \u261e The thyroid gland produces 3 hormone (T3, T4, & Calcitonin) \u2022 You need Iodine to make these hormones \u261e Thyroid gives you ENERGY! HYPERTHYROIDISM HYPOTHYROIDISM PATHOLOGY PATHOLOGY Excessive production of thyroid hormone Low production of thyroid hormone Too much ENERGY! Not enough ENERGY! CMoomsmto\u2219n Hashimoto's disease \u2219 Graves disease \u2219 Anti-thyroid medications \u2219 Too much iodine (helps makes T3 + T4) \u2219 Toxic Nodular Goiter \u2219 Not enough iodine \u2219 Pituitary hormone \u2219 Thyroid replacement medication (Toxicity) \u2219 Thyroidectomy \u2219 Affects women more often then men LAB VALUES LAB VALUES \u2191 T3 & T4 \u2193 TSH \u2193 T3 & T4 \u2191 TSH SIGNS & SYMPTOMS SIGNS & SYMPTOMS \u2219 Hyper-excitable \u2219 Goiter Bulging eyes \u2219 No energy \u2219 Slurred speech \u2219 Nervous\/tremors (enlarged thyroid) due to fluid \u2219 Fatigue \u2219 Dry skin \u2219 Irritable accumulation \u2219 No expressions \u2219 Coarse hair \u2219 \u2193 Attention span \u2219 Hot behind the \u2219 Weight gain \u2219 Decreased: \u2219 Increased appetite \u2219 Cold \u2219 Weight loss \u2219 Exophthalmos eyes \u2219 Amenorrhea \u2219 HR \u2219 Hair loss \u2219 Increased: \u2219 GI function (constipation) \u2219 Blood sugar (Hypoglycemia) \u2219 Blood pressure \u2219 Pulse \u2219 GI function LIFE-THREATENING COMPLICATIONS LIFE-THREATENING COMPLICATIONS thyroid storm! Myxedema Coma! Acute \/ life threatening emergency! TREATMENT TREATMENT \u2219 Anti-Thyroid Medications \u2219 Hormone replacement (replacing levothyroxine) \u2219 Methimazole or PTU \u2219 Synthetic levothyroxine \u2219 Synthroid or Levothroid \u2219 Beta Blockers (\u2193 HR & BP) \u2219 Will be on this medication forever \u2219 Iodine Compounds \u2219 Radioactive Iodine Therapy \u2219 Thyroidectomy *For more information about thyroid medications, see the Pharmacology Bundle \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 140","med-surg PARATHYROID GLAND DISORDERS endocrine FUNCTION As small The parathyroid gland produces and secretes as a grain PTH (parathyroid hormone) which controls of rice the levels of calcium in the blood PTH PTH HYPERPARATHYROIDISM HYPOPARATHYROIDISM \u2191 Calcium \u00a0\u2193 Phosphorus\u00a0 \u2193 Calcium \u00a0\u2191 Phosphorus\u00a0 CAUSES CAUSES Primary cause: \u2219 Can occur due to accidental removal Tumor or hyperplasia of the parathyroid \u2219 Thyroidectomy, parathyroidectomy, of the parathyroid or radical neck dissection secondary cause: Chronic kidney failure \u2219 Genetic predisposition \u2219 Exposure to radiation SIGNS & SYMPTOMS \u2219 Magnesium depletion \u2219 Stones: Kidney stones (\u2191 calcium) SIGNS & SYMPTOMS \u2219 bones: \u2219 Numbness & tingling \u2219 Skeletal pain \u2219 Muscle cramps \u2219 Pathological fractures \u2219 Tetany from bone deformities \u2219 Hypotension \u2219 Anxiety, irritability, & depression \u2219 Abdominal MOANS \u2219 Nausea, vomiting, and abdominal pain \u2219 Weight loss \/ anorexia \u2219 Constipation \u2219 Psychic GROANS Stones, ShaympoecaSl&ceSmofia! POSITIVE TROUSSEAU SIGN: \u2219 Mental irritability Bones, Carpal spasm caused \u2219 Confusion moans, & by in\ufb02ating a blood groans pressure cuff TREATMENT CHVOSTEK\u2019S SIGNS: Contraction of facial \u2219 Parathyroidectomy muscles w\/ light tap \u2219 Removal of more than one gland over the facial nerve \u2219 Administer: Think \u201cC\u201d for Cheesy smile \u2219 Phosphates, calcitonin, & IV or oral bisphosphonates TREATMENT \u2219 DIET: \u2191 fiber & moderate calcium \u2219 IV Calcium \u2219 Phosphorus binding drugs \u2219 DIET: \u2191 Calcium \u2193 Phosphorus \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 141","ADRENAL CORTEX DISORDERS med-surg endocrine RETAINS: Adrenal cortex hormones: Glucocorticoids \u2022 Mineralocorticoids \u2022 Sex hormones LOKS+ES: NA+ The adrenal gland & H2O sits on top of each kidney CUSHING'S ADDISON'S Disorder of the adrenal cortex Disorder of the adrenal cortex Too many steroids Not enough steroids They \\\"have a cushion \\\" We need to \\\"Add\\\" some CAUSES CAUSES \u2219 Females \u2219 Surgical removal of both adrenal glands \u2219 Overuse of cortisol medications \u2219 Infection of the adrenal glands \u2219 Tumor in the adrenal gland that secretes cortisol \u2219 TB, cytomegalovirus, & bacterial infections SIGNS & SYMPTOMS SIGNS & SYMPTOMS \u2219 Muscle wasting \u2219 Fatigue \u2219 Moon face \u2219 Nausea \/ vomiting \/ diarrhea \u2219 Buffalo hump \u2219 Anorexia \u2219 Truncal obesity w\/ thin extremities \u2219 Hypotension & Hypovolemia \u2219 Supraclavicular fat pads \u2219 Confusion \u2219 Weight gain \u2219 \u2193 Blood sugar \u2219 Hirsutism (masculine characteristics) \u2219 \u2193 Na & H20 \u2191 K+ \u2219 \u2191 Glucose \u2191 NA+ \u2219 Hyperpigmentation of the skin \u2219 \u2193 K+ \u2193 CA+ \u2219 Vitiligo: white areas of depigmentation \u2219 Hypertension ADDISONIAN CRISIS TREATMENT Signs & symptoms \u2219 Profound fatigue Think SHOCK! \u2219 Adrenalectomy \u2219 Dehydration \u2022 Hypotension \u2219 Requires lifelong glucocorticoid replacement \u2219 Renal failure \u2022 Weak rapid pulse \u2219 Rapid respiration Treatment: \u2219 Avoid infection \u2219 Hyponatremia Fluid resuscitation \u2219 Adm. chemotherapeutic agents \u2219 Hypokalemia & high-dose \u2219 Cyanosis hydrocortisone if adrenal tumor is present \u2219 Fever \u2219 Nausea\/vomiting TREATMENT \u2219 Adm. glucocorticoid and\/or mineralocorticoid \u2219 Diet: high in protein & carbs \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 142","PITUITARY GLAND DISORDERS med-surg endocrine antidiuretic hormone (adh): iPsGIfTLoAUunNAIdTDDAiHn!RYthe ADH regulates & balances the amount of water in your blood SYNDROME OF INAPPROPRIATE DIABETES INSIPIDUS (DI) ANTIDIURETIC HORMONE (SIADH) sIADH think soaked Inside DI think Dry Inside SIADH is often of non-endocrine origin INCREASED ICP Too much ADH can lead to an Not enough ADH ADH problem retains water loses water CAUSES CAUSES \u2219 Pulmonary disease \u2219 Medications \u2219 Head trauma, brain tumor \u2219 Infections of the central \u2022 TB \u2022 Vincristine nervous system (CNS) \u2022 Severe pneumonia \u2022 Phenothiazines \u2219 Manipulation of the \u2022 Meningitis, encephalitis, \u2022 Antidepressants pituitary \u2219 Disorders of the CNS \u2022 Thiazide diuretics or TB \u2022 Head injury \u2022 Anticonvulsants \u2022 Surgical ablation, \u2022 Brain surgery \u2022 Antidiabetic drugs \u2219 Failure of the renal \u2022 Tumor \u2022 Nicotine craniotomy, sinus surgery, tubules to respond to hypophysectomy ADH \u2219 HIV SIGNS & SYMPTOMS SIGNS & SYMPTOMS \u2219 Excretes large amounts \u2219 Muscle pain & weakness of diluted urine \u2219 Headache \u2219 Low urinary output \u2219 Hypertension \u2219 Postural hypotension of concentrated urine \u2219 Tachycardia \u2219 Polydipsia \u2219 Tachycardia \u2219 Nausea & vomiting \u2219 Low urinary specific \u2219 Fluid volume overload \u2219 Hyponatremia (increased thirst) \u2219 Weight gain without gravity \u2219 Polyuria edema Normal specific gravity: (increased urine output) 1.005 - 1.030 \u2219 Dehydration \u2219 Decreased skin turgor \u2219 Dry mucous membranes TREATMENT TREATMENT \u2219 Implement seizure precautions \u2219 Adequate fluids \u2219 Elevate HOB to promote venous return \u2219 Restrict fluid intake \u2219 IV hypotonic saline \u2219 Adm. loop diuretics \u2219 Adm. vasopressin antagonists \u2219 ADH replacement (replace the missing hormone!) \u2219 Vasopressin or desmopressin \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. \u2219 Monitor \u2219 Intake & output \u2219 Weight 143","ADRENAL MEDULLA DISORDER med-surg endocrine Adrenal medulla hormones: \\\"fight or flight\\\" Epinephrine \u2022 Norepinephrine response PHEOCHROMOCYTOMA RARE tumor on the adrenal gland that secretes excessive amounts of epinephrine & norepinephrine Healthy Adrenal gland chromocytoma Pheo Too much adrenaline is released from adrenal gland Kidney CAUSES \u2219 Family history that makes them prone to developing the tumor SIGNS & SYMPTOMS Avoid TREATMENT H'S \u2219 Hypertension (severe) Stimuli! \u2219 Adrenalectomy (if a tumor is present) \u2219 Tell the client not to smoke, drink caffeine \u2219 Headache It may cause a \u2219 Heat (excessive sweating) hypertensive or change position suddenly \u2219 Hypermetabolism \u2219 Adm. anti-hypertensives \u2219 Hyperglycemia crisis! \u2219 Promote rest & calm environment \u2219 Diet: high in calories, vitamins, & minerals \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 144","AUSCULTATING LUNG SOUNDS med-surg respiratory tips for listening Listen for a Listen directly on the skin with the diaphragm FULL INHALATION TO EXPIRATION Listening inside the Intercostal spaces on each spot Anterior Posterior (IN between the ribs) Listen to the anterior & posterior chest Will hear Will hear Have the client sit upright (high fowler's), upper lobes well lower lobes well arms resting across the lap. Instruct client to take deep breaths Listen from top to bottom (comparing sides) normal sounds Bronchial (Tracheal) Vesicular Bronchovesicular v B B B v B B B description description description v v Bv B v v High, loud & hollow tubular Soft, low pitched, Medium pitched, hollow v v v v breezy \/ rushing sound v Bv Bv v location heard location heard Anteriorly only location heard Heard anterior & posteriorly vv Heard anterior & posteriorly vv (heard over trachea & larynx) vv anterior duration duration duration v Bv Bv v Inspiration < expiration Inspiration > expiration Inspiration = expiration Bv Bv v BBvv BBvv v v v vv v v vv v v posterior Abnormal (adventitious) Sounds Discontinuous Sounds Continuous Sounds Discrete crackling sounds Connected musical sounds Fine Crackles (rales) Wheezes description: High pitched, crackling sounds description: High-pitched musical instrument with (Sound like \ufb01re crackling, or velcro coming part) more than one type of sound quality due to: Previously de\ufb02ated airways that are popping back open (polyphonic) example: Pulmonary edema, asthma, obstructive diseases due to: Air moving through a narrow airway Coarse Crackles (rales) example: Asthma, bronchitis, chronic emphysema description: Low pitched, wet bubbling sound Stridor due to: Inhaled air collides with secretion in the trachea or large bronchi description: High pitched whistling or gasping example: Pulmonary edema, pneumonia, depressed cough re\ufb02ex with harsh sound quality Pleural friction Rub due to: Disturbed air\ufb02ow in larynx or trachea example: Croup, epiglottis, any airway obstruction description: Low pitched, harsh \/ grating sounds due to: Pleura is in\ufb02amed and loses it's lubricant \ufb02uid. REQUIRES MEDICAL ATTENTION It's literally the surfaces rubbing together during respirations example: Pleuritis \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 145","med-surg LAB VALUES RELATED TO THE RESPIRATORY SYSTEM respiratory DEFINITION ABGS INTERPRETATION EXPECTED RANGE PH Measurement of how 7.35 - 7.45 7.35 7.40 7.45 P\u00aaCO2 acidic or alkalotic your blood is 35 - 45 ACIDOSIS ABSOLUTE ALKALOSIS HCO3 22 - 26 NORMAL P\u00aaO2 80 - 100 S\u00aaO2 Measurement of CO2 >45 = Acidosis carbon dioxide 95-100% CO2 <35 = Alkalosis in the blood CO2 think aCid Measurement of Bicarbonate HCO3 >26 = Alkalosis bicarbonate think Base HCO3 <22 = Acidosis in the blood PaO2 <80 = Hypoxemia Measurement of oxygen in the blood (the patient is not getting enough oxygen) Percentage (%) of hemoglobin SaO2 <95 = Hypoxemia that is bound to oxygen (the patient is not getting enough oxygen) COPD pts are expected to have low O2 levels (as low as 88%) OXYGEN LEVELS EXPLAINED DEFINITION EXPECTED RANGE INTERPRETATION FiO2 FiO2 Room air has - P\u00aaO2 21% oxygen Fraction of inspired Oxygen (the air you breathe in) The partial pressure 80 - 100 Hypoxemia of oxygen in the mmHg arterial blood low oxygen in the blood Decreased oxygen in the blood PaO2 = arterial Hypoxemia usually leads to Hypoxia S\u00aaO2 Hemoglobin saturation 95 - 100% Hypoxia percentage of (measured with hemoglobin that low oxygenation a pulse ox) is bound to oxygen Decreased oxygen supply to the tissues Sa02 = Saturation (%) \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 146","UPPER RESPIRATORY TRACT DISORDERS med-surg respiratory Rhinitis PATHOLOGY SIGNS & SYMPTOMS TREATMENT sinusitis tonsillitis In\ufb02ammation of the \u2219 Runny nose \u2219 Saline or steroid nasal sprays mucous membrane \u2219 Nasal congestion \u2219 Antihistamines \u2219 Nasal discharge \u2219 Decongestants in the nose \u2219 Sneezing \u2219 Headache Can be nonallergic or allergic In\ufb02ammation of \u2219 Runny & stuffy nose \u2219 Viral: supportive measure the tissue lining \u2219 Pressure & pain \u2219 Bacterial: antibiotics \u2219 Nasal saline irrigation the sinuses in the face \u2219 Corticosteroids \\\"sinus infection\\\" \u2219 Headache \u2219 Antihistamines \u2219 Post-nasal drip \u2219 Mucus dripping down the throat \u2219 Sore throat In\ufb02ammation \u2219 Sore throat \u2219 Fluids of the tonsils \u2219 Fever \u2219 Salt water gargles \u2219 Snoring \u2219 Rest \u2219 Dif\ufb01culty swallowing \u2219 Humidified air \u2219 Tonsillectomy (surgical removal of the tonsils) laryngitis In\ufb02ammation \u2219 Hoarse voice \u2219 Rest voice in\ufb02amed of the larynx \u2219 Aphonia (loss of voice) \u2219 Avoid smoking & alcohol vocal \u2219 Cough \u2219 Avoid whispering and clearing cords \u2219 Dry sore throat \u2219 Symptoms worsen throat (can irritate vocal cords) (aka the \u201cvoice box\u201d) with cold air or \u2219 Humidified air & cold liquid adequate hydration p haryngiti \u2219 Sore throat s \u2219 Red & swollen \u2219 Viral: supportive measure \u2219 Bacterial: antibiotics In\ufb02ammation pharyngeal membrane \u2219 Rest of the pharynx & tonsils \u2219 Salt water gargles (strep throat) \u2219 Lymph nodes \u2219 White exudate \u2219 Fever \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 147","HEMOTHORAX, PLEURAL EFFUSION, med-surg PNEUMOTHORAX, TENSION PNEUMOTHORAX respiratory URAL EFFUS PATHOLOGY RISK FACTORS TREATMENT h PLE ION x Lung collapse \u2219 Trauma \u2219 Thoracentesis due to collection \u2219 Infection of fluid in the (pneumonia) pleural space emothora Lung collapse due \u2219 A pneumothorax to a collection of is often followed by a hemothorax \u2219 Chest tube blood in the pleural space \\\"Hemo\\\" means blood pn eumothor Lung collapse due \u2219 Trauma \u2219 Chest tube ax to a collection of (blunt or penetrating) air in the \u2219 Medical procedure pleural space (central line placement) \u2219 Gun shot or stab wound pn etuemnostiohnor Medical Signs & symptoms: \u2219 Needle decompression ax Emergency \u2219 Jugular vein distention (aspirate the air) Complications of a (JVD) Pneumothorax. \u2219 Compression on \u2219 Chest tube Occurs when the opening to the pleural the heart (tachycardia, space creates a one- way valve, then air hypotension, chest pain) collects in the lungs and can't escape \u2219 Compression on other (pressure builds up) lung (tachypnea, hypoxia) \u2219 Tracheal shift \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 148","med-surg CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) respiratory PATHOLOGY \u2193 O2 Umfobrreeiltlaheter rm MOST RISK FACTORS & COMMON Progressive pulmonary \u2191 CO2 \u2219 Smoking disease that causes \u2022 Breathing in harmful irritants \u2219 Occupation exposure (APrlpooDhtfeatech1\ufb01te-scailteuhnnneticgtlyrsiyn)opinfsgin chronic air\ufb02ow obstruction. \u2219 Infection COPD causes the alveoli sacs \u2219 Air pollution to lose their elasticity \u2219 Genetic abnormalities (inability to fully exhale) leading to AIR TRAPPING. Emphysema or Chronic Bronchitis \u2219 Asthma \u2219 Severe respiratory infection in childhood DIAGNOSTIC PATIENT EDUCATION \u2219 Arterial blood gases (ABGs) \u2219 Smoking cessation diet modifications: \u2219 Chest X-ray \u2219 \u2191 calories \u2219 Pulmonary function test: Spirometry \u2219 Regular exercise \u2219 Small frequent meals \u2219 Avoid inhaling irritations (Examples: smoke, mold, pollen, dust) \u2219 \u2191 protein \u2219 Stay up to date on vaccines \u2219 Stay hydrated Patients with Obstructive lung disease \u2219 In\ufb02uenza & pneumococcal \u2219 Thins mucous eutChneaseeimOnlroreggPptfDyhoaoytrf(lseoeocestabbmplouroeeafrrc)naiteiathianhsrelegeliyr, FEV1 \/ FVC ratio of vaccine to \u2193 the incidence secretion less than 70% of pneumonia FEV1 FVC \u2219 Teach proper breathing techniques: = = PURSED LIPS Promotes carbon dioxide elimination Forced Forced expiratory vital DIAPHRAGMATIC BREATHING We want to use the DIAPHRAGM rather than the accessory muscles to breathe volume capacity MEDICATIONS NURSING CONSIDERATIONS \u2219 Bronchodilators End in suf\ufb01xes: Monitor oxygen therapy \u2219 Corticosteroids -asone, -inide, -olone respiratory system: \u2219 Lung sounds THOSE Healthy patients are stimulated order of events: \u2219 Sputum production WITHOUT to breath due to \u2191 CO2 \u2219 Oxygen status 1 Bronchodilator: Dilated airways COPD 2 Corticosteroids: Now that airways COPD COPD patients are stimulated are open, the steroids can do its job PATIENTS (ifloysoetuothgbeirveirea\\\"tthdoeroivdmeuuteocthobOr\u2193e2aO.t.h.2teh\\\"e)y Give oxygen with caution EMPHYSEMA ited air flo VS CHRONIC BRONCHITIS \u2193 O2 w Emphysema Lim & Chronic bronchitis \u2191 CO2 \u2022 Abnormal distention of airspaces \u2022 Mucus secretion \u2022 Enlargement & destruction of airspace distal \u2022 Airway obstruction (inflammation) to the terminal bronchiole \u2022 Chronic productive cough & \u2022 Hyperventilation (breathing fast) sputum production for >3 months \u2022 Trying to blow off CO2 (within 2 consecutive years) SIGNS & SYMPTOMS SIGNS & SYMPTOMS \u2022 Hyperin\ufb02ation of the lungs Pink \u2022 Overweight blobaltueers (barrel chest) Puffers \u2022 Cyanotic (blue) - Hypoxemia \u2022 Thin - weight loss bferreBoxoaumcfterhncsteairsnylooCginfrOfigaetshltooet \u2022 Pe\u2022r\u2193ipOhe2r&al \u2191edCeOm2a 149 \u2022 Shortness of breath \u2022 Rhonchi & wheezing \u2022 Severe dyspnea \u2022 Chronic cough 2 \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.","med-surg CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) respiratory NURSING MANAGEMENT & EDUCATION Monitor respiratory system OXYGEN THERAPY \u2739 Lung sounds \u2739 Sputum production \u2022 COPD clients are stimulated to breathe due \u2739 Oxygen status to \u2193 O2 (if you give too much O2...they lose their \\\"drive to breathe\\\") Lifestyle Modifications \u2739 Smoking cessation \u2022 Healthy clients are stimulated to breath due to \u2191 CO2 \u2022 Determine readiness \u2022 Develop a plan or shAodwmin.gOs2igdnusriongf reexspacireartboarytiodnisstress \u2022 Discuss nicotine replacement Adm. oxygen with caution to clients with hypercapnia (elevated PaCO2 levels) chronic 1 - 2 liters max Diet Modifications Clients with COPD (especially emphysema) small, frequent \u2739 Promote nutrition are using a lot of their energy to breathe, meals that are \u2739 Increase calories rich in protein \u2739 Small frequent meals therefore burning a lot of calories \u2739 Stay hydrated \u2022 Thins mucous secretions Teach Proper Breathing Techniques Promotes carbon dioxide elimination \u2739 Pursed lips Allows better expiration by \u2191 airway pressure \u2739 Diaphragmatic breathing that keeps air passages open during exhalation! Surgery We want to use the DIAPHRAGM \u2739 Bullectomy rather than the accessory muscles to breathe! \u2739 LVRS: lung volume reduction surgery \u2739 Lung transplant \u27a5 This strengthens the diaphragm and slows down breathing rate Stay up to date on vaccines \u2739 In\ufb02uenza & pneumococcal vaccine \u2193 the incidence of pneumonia MEDICATIONS Bronchodilators order of events \u2739 Relaxes smooth muscle of lung airways = better air\ufb02ow \u2739 Symbicort (steroid + long-acting bronchodilator) 1 Bronchodilator Dilated airways Corticosteroids SUFFIX: 2 Corticosteroids \u2739 \u2193 in\ufb02ammation (oral, IV, inhaled) Budesonide \\\"-asone\\\" Airways are open; \u2739 Example: Prednisone, Solu-Medrol, \\\"-inide\\\" now the steroids can do their job Bupropion (anti-depressant) \\\"-olone\\\" *For more information about respiratory medications, see the Pharmacology Bundle \u00a9 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 150"]
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