Chapter 35 Ignatavicius Medical Surgical Nursing

Some pt. (esp. women) do not experience pain in chest but instead feel discomfort or indigestion when
having an MI
Women present with triad of sx
o 1. Indigestion & feeling of abdominal fullness
o 2. Chronic fatigue despite adequate rest
o 3. Feeling like you cant catch your breath
may also describe sensation as aching, choking, strangling, tingling, squeezing, constricting, or
viselike
those with severe neuropathy may experience few or no tradition sx except SOB, even with major
ischemia
dyspnea (difficulty or labored breathing) that is associated with activity, such as climbing stairs, is
referred to as dyspnea on exertion (DOE).
This is an early sx of HF and may be the only sx experienced by women
Paroxysmal nocturnal dyspnea (PND) develops after pt has been lying down for several hrs.
When lying down, more blood goes to venous system and diseased heart cant handle increased
volume and is ineffectively pumping it out so you get pulmonary congestion.
Pt. wakes up abruptly with feeling of suffocation and panic OR sits upright and dangles legs over
side of bed to relieve dyspnea
o Sensation lasts for 20 min.
Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output and
anaerobic metabolism in skeletal muscle.
Fatigue from CO is worse in evening
may be an early indication of heart disease in women.
Sudden weight increase of 2.2 lbs can result from excess fluid in the interstitial spaces. BEST indicator of
fluid balance is weight.
Extremity pain can be caused by (1) ischemia from atherosclerosis or (2) venous insufficiency of the
peripheral blood vessels
Pts who report a moderate to severe cramping sensation in their legs or buttocks associated with
activity such as walking have intermittent claudication r/t decreased arterial tissue profusion.
o Claudication pain is relieved by resting or LOWERING affected extremity to decrease tissue
demands or to enhance arterial blood flow.
Leg pain from prolonged standing or sitting is r/t venous insufficiency from either incompetent
valves or venous obstruction
o Pain is relieved by ELEVATING extremity
Poor CO and decreased cerebral perfusion may cause confusion, memory loss, and slowed verbal responses
HF pt may also look malnourished and thin
Late signs are ascites, jaundice, and anasarca (generalized edema)
Assessment of skin color:
Decreased perfusion is manifested as cool, pale, and moist skin
Pallor is characteristic of anemia
Blue/gray color is cyanosis and this is early sign of decreased perfusion
Peripheral cyanosis localized in an extremity is usually a result of arterial or venous insufficiency
Rubor (dusky redness) that replaces pallor in a dependent foot is arterial insufficiency
Assessment of edema
Bilateral edema of the legs seen in HF or chronic venous insufficiency

Localized edema in one extremity is venous obstruction (thrombosis) or lymphatic blockage

(lymphedema)
Edema may be dependent and located in sacrum
Dependent foot and ankle edema is common SE of antihypertensive drugs such as amlodipine

BP

Postural (orthostatic) hypotension occurs when BP is not adequately maintained while moving from
lying to sitting or standing position
o Decrease of more than 20 mm Hg of systolic pressure of more than 10 mm Hg diastolic
pressure and 10-20% increase in HR
Pulse pressure is the difference b/t systolic and diastolic values and is an indirect measure of CO
o Narrowed PP results from HF or hypovolemia/shock
o Increased PP results from atherosclerosis, HTN, aging
Ankle-brachial index (ABI) is used to assess vascular status of LE (peripheral vascular disease)
o BP cuff is placed to LE just above malleolus
o SBP by Doppler is done at both dorsalis pedis and posterior tibial. Higher of these two
pressures is divided by the higher of the two brachial pulses to get ABI
o Normal ABI is 1.00 or higher b/c BP in legs is higher than BP in arms
o ABI <0.8 indicate moderate vascular disease and < 0.5 = severe vascular compromise
Toe brachial pressure index (TBPI) may be done instead or in addition to ABI
o Determines arterial perfusion in feet and toes
o TBPI = toe systolic pressure/brachial (arm) systolic pressure
Any presence of troponin T and I indicates MI (not normal to have this)
Microalbuminuria (small protein in urine)
Marker of widespread endothelial dysfxn in cardiovascular disease (along with CRP)
Should be screened annually for pts with HTN, metabolic syndrome, or diabetes
Marker for renal disease, particularly in pts with HTN and diabetes

Cardiac Catheterization

Tell pt. that during procedure you will feel palpitations as catheter is passed through left ventricle, a feeling
of heat or a hot flas as the medium is injected into heart, and a desire to cough as medium is injected into
right side of heart.

See tables 35-4 & 35-5 on pg. 704

Complications
MI, stroke, arterial bleeding, thromboembolism, lethal dysrhythmias, arterial dissection, death
Fluids/mucomyst given 12-24 hrs before procedure for renal protection
Contrast die can cause renal dysfxn
ECG, x-ray, labs done before and pt. is NPO
Before procedure: take VS, assess peripheral pulse, and ask about allergy to iodine
Get consent signed, give mild sedative (dig and diuretics held before procedure)
Procedure
Pt is supine on x-ray table and strapped down b/c table moves like cradle during procedure
MD injects local anesthetic at insertion site
Pt asked to report any chest pain, pressure, or other sx to staff during procedure
RIGHT side of heart is catheterized first and may be only side
o MD inserts catheter through femoral vein to inferior vena cava or through basilic vein to
superior vena cava

o Catheter is guided by fluoroscopy and advanced through right atrium, through right ventricle,
and at times into pulmonary artery
o Intracardiac pressures (R atrial, R ventricular, pul. Artery, and pul artery wedge pressure) and
blood samples obtained
o Contrast medium is injected to detect any cardiac shunts or regurgitation from pulmonic or
tricuspid valves
LEFT sided heart cath
o MD advances catheter against blood flow from femoral or brachial artery up the aorta, across
aortic valve, and into left ventrical. (can also be done from R side of heart through septum
w/a needle)
o Intracardiac pressures and blood samples obtained from L atrium, L ventricle, aorta, and
mitral and aortic valve status evaluated
o MD injects contrast dye into ventricle; cineangiograms (rapidly changing films) evaluate L
ventricular motion to find SV, EF
Technique for coronary arteriography is same for L sided heart cath.
o Catheter is advanced into aortic arch and positioned in right or left coronary artery.
o Contrast dye is injected to view coronary arteries and flow of blood through them
Alternative to dye is intravascular ultrasonagraphy (IVUS)
o Flexible catheter with miniature transducer at tip is put in coronary arteries
o Transducer emits sound waves that reflect off plaque and arterial wall to create image of
blood vessel
o More reliable than angiography in indicating plaque distribution
F/U care
Restrict pt to bed rest and keep insertion site extremely straight
Soft knee brace can be applied to prevent bending of extremity
HOB can be elevated 30 degrees during bedrest, other MDs say supine only
Pts remain in bed 2-6 hrs depending on type of vascular closure device used (i.e. collagen plug)
Monitor VS Q15 for 1H, then Q30 for 2H or until VS stable, then Q4H
Assess insertion site for bloody drainage or hematoma formation
Assess peripheral pulses in affected extremity, as well as skin temp, color
If pt experiences sx of cardiac ischemia (chest pain, dysrhythmias, bleeding, hematoma formation,
dramatic change in peripheral pulses in affected extremity) call RRT or MD for prompt intervention!
o Neuro changes of possible stroke (visual disturbance, slurred speech, swallowing difficulties,
and extreme weakness) need to report immediately
Contrast dye acts like osmotic diuretic so monitor urine output and make sure pt gets enough oral/IV
fluids to excrete medium
Home mgmt
Limit activity for several days, including avoiding lifting and exercise
Leave dressing in place for at least first day at home
Observe insertion site over next few days for increased swelling, redness, warmth, and pain.
Bruising or small hematoma is EXPECTED

Chapter 55

Abdominal assessment: inspect, auscultate, percuss, palpate

Bulging, pulsating mass present, DO NOT touch area b/c AAA and its life threatening. Call MD!
Presence of ecchymosis around umbilicus (Cullens sign) is an indication of intra-abdominal bleeding
GI bleed is most frequent cause of anemia and is assoc. w/GI cancer, PUD, and IBD
FOBT (fecal occult blood test)

Avoid foods before test: raw fruits/veggies, red meet, vit C, juices.
Warfarin and NSAIDs should be d/c 7 days before testing
Steatorrhea (fatty stool) indicates malabsorption
Upper GI radiographic series
Xray visualization from mouth to duodenojejunal jxn
Used to detect disorders of structure or fxn of esophagus (barium swallow), stomach or duodenum.
o Small bowel follow through (SBFT) cont tracing barium through small intestine up to
ileocecal jxn (detect problems in jejunum or ileum)
Tell pt to be NPO 8 hrs before test
Opioid analgesics and anticholinergic meds withheld for 24 hrs b/c they slow motility
Instruct pt about barium prep and the need to drink 16 oz of barium
Tell pt rotating table will be used during test
Initial procedure takes 30 min
Fluoroscopy is used to trace barium through esophagus and stomach (pt stands against x-ray table)
o Table then made flat for more views of stomach and duodenum
o Pt then drinks more barium as quickly as possible while x-rays are taken
o Position changes help coat mucosa and identify GERD and hiatal hernia
o If SBFT is done, more barium is swallowed and takes time to get to cecum
After procedure, pt needs to drink lots of fluids to eliminate the barium (may give laxatives)
Tell pt. stool will be chalky white for 24-72 hrs as barium is excreted (then turns brown)
Report abdominal fullness, pain, or a delay in rtn to brown stool
Barium enema (lower GI series)
X-ray of large intestine
Same procedure as colonoscopy but pt expels barium
Endoscopy
Direct visualization of GI tract using flexible fiberoptic endoscope
Used to evaluate bleeding, ulceration, inflammation, tumors, and cancer or esophagus, stomach,
biliary system, or bowel
You can also obtain biopsy for H.Pylori
Needs informed consent
Esophagogastroduodenoscopy (EGD)
o Visual examination of esophagus, stomach, and duodenum
o If EGD finds GI bleed, MD can inject sclerotherapy to affected area and stop bleeding
o If EGD finds esophageal stricture, it can be dilated during EGD
o Teach prep
NPO 6-8 hrs before
HTN meds ok to take before
Avoid anticoagulants (aspirin, NSAIDs) for several days before
Tell pt flexible tube will go down esophagus while under moderate sedation
Local anesthetic spray used to inactivate gag reflex (swallowing may be difficult)
After drugs given, pt. is placed on left side (Sims or lateral) with towel or basin at
mouth for secretions
Bite block is inserted to prevent biting down on endoscope and to protect teeth
Procedure takes 20-30 min
Check VS frequently after test (Q30 min) until sedation wears off
Siderails are up and pt is NPO until gag reflex rtns (1-2 hrs)
PRIORITY care after EGD is prevent aspiration

Do not offer fluids or food by mouth until youre sure gag reflex is back
Monitor for signs of perforation (pain, bleeding, fever)
Tell pt not to drive for at least 12 hrs after procedure b/c of sedation.
Hoarse voice or sore throat may persist for several days after test
Use throat lozenges to relieve throat discomfort

Colonoscopy
o Endoscopic examination of entire large bowel
o Used to obtain tissue biopsy, remove polyps, evaluate cause of chronic diarrhea or locate
source of GI bleeding
o Patient prep
Teach pt to stay on clear liquid diet day before scheduled colonoscopy
Avoid red, orange, or purple beverages
Drink abundant amt of Gatorade or other sports drink to replace electrolytes lost
during bowel prep
NPO (except water) 4-6 hrs before procedure
Avoid aspirin, anticoagulants, and antiplatelet drugs for several days before
Diabetics need to check with MD about med day of exam b/c NPO
Pt drinks oral liquid bowel prep (sodium phosphate) the evening before exam and
repeats procedure in the morning of exam (1 gallon GoLYTELY can be used day
before but not for elderly)
Remind pt. to drink quickly to prevent nausea
Watery diarrhea begins about 1 hour after starting bowel prep process
Some pts may require laxatives, suppositories, or enemas
o Procedure
IV access for moderate sedation
Pt. placed on left side with knees drawn up while endoscope is placed in rectum and
moved to cecum
Air may be instilled for better visualization
Entire procedure lasts 30-60 min
Atropine sulfate is available in case bradicardia from vasovagal response
o F/U care
Check VS Q15 until stable
Keep siderails up until pt. fully alert
Maintain NPO
Look for signs of perforation (severe pain) and hemorrhage (rapid drop in BP)
Reassure pt that feeling of fullness, cramping, and passage of flatus are EXPECTED
for several hours after test
Fluids are allowed after pt passes flatus to indicate rtn of peristalsis
If polypectomy or tissue biopsy performed there will be a small amt of blood in first
stool after colonoscopy
Report any excessive bleeding or severe pain to MD ASAP
No driving for 12 hrs after procedure b/c of sedation
o See chart 55-4 on pg. 1190!!
Sigmoidoscopy
o Endoscopic exam of rectum and sigmoid colon using flexible scope
o Purpose is to screen for colon cancer, look for source of GI bleed, or diagnose IBD
o Patient prep
Clear liquid diet for 24 hrs before test

Cleansing enema or sodium biphsophate (Fleets) enema required morning of exam

Laxative given night before
o Procedure
Pt. placed on left sid in knee chest position
NO moderate sedation required
Endoscope is lubricated and inserted into anus to required depth
Tissue biopsy may be done during procedure but pt cant feel it
Exam lasts 30 min
o F/U care
Mild gas pain and flatulence EXPECTED from air instilled into rectum during exam
If biopsy was taken, small amount of bleeding may be present
Tell pt. if excessive bleeding happens call MD ASAP
Gastric analysis
o Measures HCL and pepsin content to evaluate aggressive gastric/duodenal disorders (i.e.
Zollinger Ellison syndrome)
o Consists of 2 tests: basal gastric secretion and gastric acid stimulation
Basal gastric secretion measures secretion of HCL b/t meals
If only small amts of secretion collected, f/u gastric stimulation done
o Patient prep
NPO for 12 hrs before test
Avoid alcohol, tobacco, drugs for 24 hrs before
NG tube inserted and gastric residual contents are aspirated and discarded
o Procedure
basal gastric secretion test
NG tube is attached to suction for collecting contents for 15 min intervals for
1 hr
Samples are collected and labeled w/basal acid output, time, and volume
gastric stimulation test
NG tube is left in place and a drug that stimulates gastric acid (pentagastrin) is
given
15 min after injection of drug, specimens are again collected Q15 for 1H
samples labeled w/maximal acid output, time, and volume
o Results
Depressed levels of gastric secretion suggest gastric cancer
Increased levels of gastric secretions indicate Zollinger-Ellison syndrome and
duodenal ulcers.