Medical Surgical Nursing Tionko

University of Santo Tomas
College of Nursing
MICHAEL JOHN VALLARIT
MEDICAL SURGICAL NURSING Mrs. Ida Tionko
ACID BASE ALTERATIONS
- Hyrdrogen ions
o Expressed as pH negative logarithm
o Circulate in the body in 2 forms
Volatile H of carbonic acid union of water and carbon dioxide
Excreted by lungs 13000 30000mEq/day as CO2
With respiratory failure- more at risk for acidosis
Maintain ventilator function, gas exchange to manage hydrogen ion
ABG- PCO2
Non volatile form of H and organic acid
Excreted by the kidney 50mEq/day
Metabolic acidosis
ABG- Bicarbonate
- Acids
o End product of metabolism
o Contains H iono Hydrogen ion donors
o Strength determined by the amount of H ions present
o Determines pH of body fluids by its H content
- Bases
o Contain NO H ions
o H ion acceptors
- Acid and base balances
o 1% of carbonic acid: 20% of bicarbonate (1:20)
o Bircarbonate domain of kidneys
Hydrogen + Bicarbonate kidneys
o Henderson- Hasselbalch relationship**
o DEATH <> ACIDOSIS <>7.4 <> ALKALOSIS <> DEATH
Acidosis respiratory component
Beyond 6.8 - death
Alkalosis metabolic component
Normal value compensation 7.35- 7.45
Compensation- what will body do to correct the balance buffers
Correction intervention that is done
o There is continuous acid production
Ways to remove acis:
Respiratory lungs; volatile acids
Kidneys (vomit)
Buffers
Co2 is acid respiratory
Urine is acid
Stomach is acid ulcer- relieved by vomiting
Gastric ulcer- decrease in mucosal barrier
Stress ulcer gastric ischemia brought about by decrease perfusion
NOYNOY FOR PRESIDENT

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Intestines are alkaline duodenal ulcer: to neutralize acid from the stomach;
alkaline from pancreatic juices and bile; related to rapid emptying of
stomach
HCO3 is alkaline: Metabolic
Urea loses bicarbonate acidotic
Prolonged vomiting yellow green color blious vomitus- acidotic state
o Regulation
Buffers- chemical sponges in the body
Example: H2CO3 HCO3 buffers N= 1:20
CHON buffers
Lungs through ventilation
Decreases CO2 >> decreased RR >> decreased release of CO2 >> ^
CO2
^ CO2 >> ^RR >> ^ release of CO2 >> decrease CO2
Kidneys
H2CO3 >> H (acid) + HCO3 (base)
ACIDOSIS: released
retained**
ALKALOSIS: retained released **
Potassium
ACIDOSIS associated with hyperkalemia- explosive diarrhea caused
by hyoeractivity of bowel activity
o EC H >> IC >> IC K >> EC >> HYPER K
ALKALOSIS oozing diarrhea
o IC H >> EC >> EC K >> IC >> HYPO K
- ARTERIAL BLOOD GASES- arterial blood from artery
o pH 7.35 (7.4) to 7.45
o PaCO2 35 (40) to 45 mmHg
What the lungs are doing to maintain balance
o Oxygen saturation - >94%
o Base excess or deficit: +- 2 mEq/L
- Respiratory acidosis and alkalosis
o CO2 + H20 <> H2CO3 <> H + HCO3
Respiratory acidosis
Respiratory alkalosis
Increased PCO2
Decreased PCO2 - hyperventilate
Increase carbonic acid
Decrease carbonic acid
Increased H low pH
Decreased H high pH loss of hydrogen ion
Compensation
Compensation
Increased bicarbonate
Decreased bicarbonate
- Respiratory acidosis
o Cause: hypoventilation COPD, MG, poliomyelitis, cervical injury, GBSneuromuscular disease; too much anesthesia and narcotics; patient with apnea
o Signs and symptoms
Restless, confusion, apprehension, somnolence
Asterixis
Coma
HA, papilledema, decreased reflexes calcium resorption increases
Dyspnea and tachypnea due to hypoxia
CV tachycardia, HTN, atrial and ventricular arrhythmias

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Increased serum K and Ca
ACIDOSIS SX indicative of CNS Depression
Treatment
Correct underlying cause of alveolar hypoventilation
Artificial airway and MV with adequate humidification facilkitate clearing of
airway and prevent dryness
Removal of foreign body or secretions
Suctioning
Bronchoscopy
Oxygen inhalation at low flow rate
Chronic CO2 retention medulla is not responding >> hypoxic drive
O2 60-80%
Low oxygen concentration
Maintain adequate hydration IV (Lactate Ringers)/PO
LR convert lactate to bicarbonate in healthy liver
Meds
Bronchodilators opens airways
Sodium bicarbonate - SIVP
Low CHO, Hi-fat diet- reduces CO2 production
Not for patient with CAD
Respiratory alkalosis
o Most common A-B disturbances in critically patients
o Causes
Pulmonary hyperventilation
Non pulmonary anxiety and fear
Deep rapid breathing
Light headedness or dizziness du to decreased cerebral blood flow
Agitation, hyperactive reflexes
Circumoral and peripheral persthesia
Carpopedal spams
Tremors and spasms
Decreased serum K and Ca
o ALKALOSIS: symptom indicative of CNS irritability
o Treatment
Prevent hyperventilation during MV fight the pressure>> hyperventilate
Correct breathing pattern- paper bag > plastic bag
DBCE and coaching your patient
Safety and seizure precautions
Metabolic acidosis and alkalosis
o ^metabolic acids raise H levels
o Some H combines with HCO3, decreasing it
o Breathing adjusts CO2 levels to bring pH back to normal
o
o
Metabolic Acidosis
Increase H = low pH ; <7.35
Decreased bicarbonate
Compensation
Heavier breathing causes decreased PC02
M. alkalosis
Decreased H high pH
Increased bicarbonate
Compensation
Lighter breathing causes increased PC02

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Metabolic acidosis
o Causes- HCO3 loss; acid retention
Hypeventilation, HA, dizziness, kussmaul respiration fruity odor in the
breath, weakness, hyperkalemia and Ca
o Treatment: treat cause: NaHCO3
DKA- insulin; glucose will get into the cell with the CHON
o Acidosis: symptom indicative of CNS respiration
Metabolic alkalosis
o Causes
Acid loss excessive vomiting
HCO3 retention- too much intake of bicarbonate, antacid
o S and s
Hypoventilation
Numbness
Bradycardia
Confusion
Twitching
Tremors
Hypo K and hypo Ca
o Treatment
Treat cause
Administration Na, K, ammonium Cl
Diamox- increase excretion of HCO3
o ALKALOSIS: SX indicative of CNS irritability
acidosis >> increase myocardial depressant factor >> depressed cardiac activity
Hyper Ca in acidosis due to increase bone resorption of Ca >> increased ionized Ca
ABG Interpretation
o First name
o Middle name
o Last name
o STEP 1: Identify the problem
Check the pH
Last name
>> Acidosis - <7.35
>> Alkalosis- >7.45
First name
>> compensated pH normal
>> uncompensated ph <7.35; >7.45
o STEP 2: identify the source of the problem middle name
Check the:
pCO2 respiratory
o acidosis: >45mmHg
o alkalosis: <35mmHg
HCO3 metabolic
o Acidosis - <22 mmHg
o Alkalosis - >26 mmHg
WHOSE NAME DOES THE LAST NAME MATCH
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Mixed and combined respiratory and metabolic acidosis
Multi organ failure
Ph 7.30
PCO2- 60
HCO3- 18
Complete compensation pH- 7.4 perfect; however changes easily - dynamic
ALTERATIONS IN FLUID AND ELECTROLYTES

-
Fluid distribution by weight

o Adult women - 50-55%
o Adult men 66-72%
o Elderly 47%
o Infants 75-80%
Body fluid distribution by compartment
o Extracellular 30%
Intravascular -6%
Interstitial 24%
o Intracellular 70%
Electrolytes
o Active chemicals that carry positive and negative charges
Fluid balance
o Mechanism of fluid balance
Kidney renal failure
Lungs
Skin
o Hormonal control
ADH fluid retention
Aldosterone fluid and sodium retention
RAAS auto regulatory
Decrease CO, decrease circulating volume, decrease in serum sodium
>> affects juxtaglomerular cells >> renin >> angiotensin I >> ACE
>> Angiotensin II
o >> BV >> Vasoconstriction >> ^peripheral vascular resistance
>> ^BP
o >> adrenal cortex >> Aldosterone >> sodium retention >>
increase serum sodium/ serum osmolarity >> ADH of AP >>
water retention >> increase BV >> increase BP
ANP Atrial natriuretic peptide
Cardiac hormone stored in atrial cells
Released when atrial pressure increases
o CHF , CRF, hi-Na intake
Counteracts effects of RAA system >> decrease BP and decreased IV
volume
Thirst, ADH and aldosterone
Mechanism controlling fluid movement
o Diffusion
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High to low
Movement of particles from higher to lower concentration across a semipermeable membrane
o Osmosis
o Movement of fluid through the capillary walls depends on
Hydrostatic greater volume, greater HP
Pressure exerted on the wall of BV
Osmotic pressure pressure exerted by the CHON in the plasma- albumin
The direction of fluid movement depends on the differences of hydrostatic
and osmotic pressure
o Active transport
Physiologic pump that moves fluid from an area of lower concentration to one
of higher concentration
Movement against the concentration gradient
Sodium potassium pump maintain the higher concentration of EC sodium and
IC potassium
Requires ATP for energy continuous oxygen supply
Fluid shifts
o Plasma to ITF (edema)
Due to:
Increased venous HP - pushes
Decreased plasma OP - pulls
^ IT OP
o BURNS first stage hypovolemic or burn shock phase
Give isotonic- LR or NSS
o Diuretic phase give albumin to help pull the electrolytes to the
IV expand can have circulatory overload
Check breath sounds crackles acute pulmonary edema
o IT to plasma
Due to:
^ plasma OP
^ IT HP
Fluid movement B/W ECF and ICF
o Increased ECF osmolality (water deficit) >> cell shrinks
o Decreased ECF osmolality (water excess) >> cell swells
Average daily fluid sources
o 1200-1500 ml- ingested fluids
Losses
o 1200-1700- urine
o 100-250 feces
o 350-400 skin- insensible loss
o 100-150-perspiration
o 350-400- lungs- insensible loss
o Total 2100-2900ml
Daily weight most reliable indicator of fluid loss or gain in all ages
o Same time- before breakfast
o Same scale
o Same amount of clothing
Assessment of fluid balance

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o
o
o
o
Types
o
o
o
BP measurement
Indirect
Direct- pulmonary cartery caths
Swan ganz
PAP- 15-20mm Hg
PACWP / PAWP 6-12 mmHg left side of the heart pressure
pulmonary congestion >> decreased CO
CVP 0-7 mmHg; 5-10 cm H20
PE- breath sounds
UO 30-60ml per hour; 1ml/kg BW/ hour
Weight 1000ml = 1kg
of solutions
Hypotonic
Hydrates cells
Cellular DHN
Tap water
.45% NaCl
.33% NaCl
Isotonic
Stays put
IV DHN
D5%W
RL
.9NSS/ PNSS
Hypertonic
Expands volume
IV DHN with IT and IC overload
D10%W
D5%NSS
Albumin
D5 LR
Increased UO - monitor UO and breath sounds (pulmonary congestion)
NOTE: D5W is metabolized rapidly, leaving free water to be absorbed.
NOT used in the head injured client >>> increase ICP
IV infusions
D5W
Urine ouput
Infusion site
Glow rate
IV container
IV tubing
NR
Infiltration- with pain, no warmth, cold
o DC IV
o Remove catheter
o Apply cold compress within 30 minutes >> warm moist heat to
decrease swelling
Phlebitis painful with warmth and swelling
o Apply warm compress
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CVP line
o Flush daily with saline or heparin to prevent formation of clots
o Change dressing 3x per week
o Check for infection- secretions, warmth, redness
o Discard 5-10ml when drawing blood more like there is IV fluid
o Use port for designated purpose
o Valsalvas maneuver when removing or changing tubing
Dehydration
o Causes
Vomiting
Diarrhea
Dieresis
Decrease IV replacement
o Symptoms
Thirst, dry and warm skin
Poor skin turgor
Dark, odorous urine
Weight loss
o Care
Hydrate
Daily weight
Skin care
o Intracellular fluid volume deficit (ICFVD)
Circulatory overload
o Causes
^IV fluids
Kidney failure
Heart failure
o Symptoms congestion
o Management
Fluid restriction
Na restriction
Diuretics
Digoxin
o ICFVE - excess
Referred to water intoxication or hypotonic dehydration
Less frequent
Results from either
Water excess
Solute deficit often sodium- dilutional hyponatremia
Sodium
o Fluid balance
o A-b balance
o Nerve conduction
o Sodium is in all body
o NV: 135-145meq/L
o Major source: table salt
Postassium
o Neuromuscular activity
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o Acid-base balance
o 80% excreted renal
o 20% excreted GI- diarrhea
o NV: 3.5-5meq/L
o Major source: fruits watermelon
Sodium imabalances
o Hypernatremia
Sodium excess
Cause: water loss or sodium gain- DHN
Manifestations
Thirst
Restlessness
Weight changes
Management plain water, D5W- cerebral edema
Diuretics excretion of Na
Dilute sodium
Promote excretion
o Hyponatremia
Due to absorption of large volume of isotonic, Na free irrigating solution
Inadequate Na intake
Increase Na excretion
Manifestations
Diarrhea, hyperactive BS, abdominal cramps
Elevated BP
Adventitious lung sounds
Lethargy, confusion
Weaknesss and tremor
Dry skin related to dec fluid volume; pale, dry, musous membranes
Treatment
IV infusion of saline if with hypovolemia
Diuretics if with hypervolemia
Oral sodium replacement
If due to SIADH, give lithium
Potassium
o Effect of potassium on ECG page 96 saunders
Peaked T wave- hyperkalemia
Extreme hypokalemia prominent U
Hypokalemia
Flat T
U wave
Hyperkalemia
Wide flat P wave
QRS widens
o Hypokalemia
Manifestations
Anorexia, Vomiting, Diarrhea, distention, ileus
Muscle weakness, paralysis, leg cramps, muscle flabbiness
Fatigue, lethargy, decreased tendon reflexes
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Confusion and depression

Treatment
Administer oral or IV K as prescribed
Oral K can cause nausea
o Should be with food in the stomach
o Oral liquid preparation should be taken with juice has
unpleasant taste
IV potassium
Never given per IVP, IM or SC
A dilution of no more than 1meq/10ml of solution is recommended
When incorporated to IV solution, invert and shake Iv bag to mix it
Max recommended infusion rate: 5-10meq/hour not to exceed
20meq/hour
If receiving 10meq/hr, connect patient to cardiac monitor
Check site for infiltration. Can cause phlebitis
o Hyperkalemia
Manifestations
Hypotension
Weaker cardiac contractions
Explosive diarrhea, intestinal colic
Hyperactive BS
Treatment
Discontinue all K preparations
K excreting diuretic
Kayexalate preparation (H ion in exchange for K in the intestine):
cleansing enema first
Dialysis severe hyperK
IV administration of D10% or 20% 100ml with 10-20 U regular insulin
Use fresh blood if BT is needed by patient; old blood releases
potassium
Avoid foods rich in K
Calcium
o 99% bones and teeth
o 1% serum and soft tissue ionized calcium
o Inversely related to phosphorus
o Source: dairy products and green leafy vegetables
o Most activity carried out by ionized Ca
o Hypocalcemia- more common - <4.5mg/dl
Tetany symptoms
Twitching around mouth, tingling and numbness of fingers, carpopedal
spasms, facial spasm, laryngospasm- laryngeal stridor- crowing like
sound indicating respiratory obstruction, and later convulsions
Trousseaus & Chvosteks signs
T: 10-20mmHg above systolic
Dysrhythmias, palpitations
Pathologic fractures
Prolonged bleeding time
Management
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Monitor organ functions

Administer oral and IV calcium as Rx
If given per IV
o Warm injection to body temperature
o Given slowly and monitor EKG
Admin meds that increase Ca absorption
o AIOH gel phosphate binder and vitamin D
10% ca for tx of severe Ca deficit
Take oral ca 1-2 hours pc or HS for maximal intestinal absorption
Increase oral intake of Ca
o Hypercalcemia
Manifestations
NM
o Mild to moderate hypercalcemic state; weakness, fatigue,
depression
o Severe: extreme lethargy, depressed sensorium, confusion, and
coma
CV
o Dysrhytmia, heart block
o Critical: cardiac arrest
Renal
o Polyuria, kidney stones, renal failure
MS
o Bone pain, fracture
Management
Discontinue all ca preparation
Administer IV infusion of normal saline
Administer medications that inhibit Ca resorption from the bones like
phosphorus and calcitonin
Move patient gently to prevent fractures
If severe, dialysis or blood transfusion
Post operation LRS- best IV
BURNS
-
Factors determining the severity of burn

o Depth of burn
Degree of burn:
partial thickness - painful
full thickness
o Healing time
1st degree: 1-3 days normal skin- superficial burn
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2nd 21-28 days >> absent- minimal scarring by spontaneous epithelial
regeneration deep partial burn
3rd does not heal spontaneously; required grafting; with scarring
Classification based on extent of burn: adult
o Major: 2nd 15-25%BSA
3rd 2-10%
o Minor burn
2nd degree- less than 15%BSA
3rd- less than 2%
o Size of the burn
Rule of nine
Lund browder chart
Berkow formula
o Burn location
Upper part of body: inhalation burns >> respiratory obstruction - stridor
Highest mortality- immediate intubation
o Age
Under 2 and greater than 60 higher mortality- fluid and electrolyte
imbalance
o Past medical history
Check history of CV, pulmonary, renal, metabolic and neuro problems
o Cause of burn
Thermal
Chemical
Electrical worst internal tissue damage; cardiac arrest
Entrance and exit wounds
Cardiac arrest/ dysrhythmias: immediate or delayed 24-48 hours
(electrolyte changes)
Severe metabolic acidosis in minutes >> myocardial depression >>
cardiac arrest
Fractures: long bones and vertebra nerve compression
Myoglobinuria: can block renal tubules >> renal failure
Fluids: LR 75-100ml/hr to flush kidney: can resolve acidotic condition of
the patient
Radiation cobalt treatment; nuclear flow out
First aid for minor burns: Run cool water over area of burn or immerse in cool water; COOL,
not cold
o Large area: avoid immersion
Emergency care:
o Goals:
o Provide patent airway
o Provide pain relief
o Minimize wound contamination
o Transport quickly
Initial care (pre hospital)
o Stop the burn, remove from area
Stop drop and Roll
Flush pour water
Turn off power
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Airway: check for patency and inhalation burns
Breathing
Circulation. Check pulses
Assess and initiate treatment for injuries requiring immediate attention
Cool the burn; avoid ice; no immersion in water
Remove restrictive objects and jewelries
Wrap patient in dry, clean materials
Immobilize patient as found, do not attempt to re-align fractures
Avoid oral intake; upright position to promote ventilation
Transport to nearest facility; note time of burn great effect on computation of
fluids
Phases
o Shock phase or hypovolemic phase
24-48 hours
Fluid shift: IVF to ITF
Hypoproteinemia
Acidosis
^Hct and K
Decrease Na
Oliguria
Management
Monitor UO
Check VS, CVO HcT
o Shock
Give of first days fluids in 8 hours
o Diuretic phase circulatory overload
48-72
Fluid shift IT to IVF
Hypoproteinemia
Decrease Hct and K
Hyponatremia
Diuresis
Management
Monitor UO
Check VS, CVP, Hct
o Increase CVP
Monitor pulmonary edema
Decrease fluids as Rx
o Recovery phase
Chemical burn
o Remove clothing with chemical, rinse area with cool running water for 10-15
minutes
o Early treatment
Airway
Fluid therapy
Formula
o
o
o
o
o
o
o
o
o
o
Baxter Parkland
1st 24 hours
4ml/kg/%
LR
2nd 24 hours
D5W+Colloids
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Strict isolation: reverse
Pain relief: morphine; IV meds
NPO, dastric decompression
Check for Curlings ulcer
o Foley catheter
Titrate fluids to UO
o Lab Tests:
CBC, blood chem, ABG, BT & X-matching, UA
EKG, CXR, myoglobin det.
o Wound cultures
o Prophylactic antimicrobial
o Bath
o ATS
With TT within 5 years: booster dose:
After 5 years: hyperimmune human tetanus globulin
o Wound care
Topical cream and biological dressings
Biological dressings
Xenograft / heterograft porcine
Homograft / allograft cadaver
Synthetic dressing hydron spray
Human amniotic membrane
o Body warmth
o Special care
Avoid contact between 2 burned surface put vaselinized gauze; abducted
Eleveate circumferential burns above heart level
o Nutrition
25Kcal X kg BW + 40 Kcal X % TBSA
*of the total, 20-25% = CHON
Complication
o Infection: (+) Staph & Strep- local
(-) E. Coli & Pseudo
Controlled by:
removal of eschar
wound cleaning
topical antimicrobial
o Sepsis involve blood
3. Respiratory: Pneumonia, atelectasis, Pul emboli,
Resp. Acidosis/Alkalosis
4. Contractures
5. Stress Ulcer: Curlings
6. Paralytic Ileus NGT insertion
7. CNS disturbances
THERAPEUTIC MODALITIES:
o Hydrotherapy: Tanking
o Topical antimicrobials
silver sulfadiazine(SE: transient leukopenia)
mafenide acetate (SE: met. Acidosis, severe pain)
silver nitrate (SE: elect. prob., black staining)
o
o
o
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o
o
o
povidone iodine
Subeschar clysis with antimicrobial for large burns
- for burns of >40% TBSB
Biologic dressing
Debridement
Methods:
Primary done upon admission
Surgical at OR
Mechanical: wet dsgs/hydrotherapy
Enzymatic: digest necrotic tissue
Skin grafting: Autograft
Donor site / recipient site same appearance or quality of the recipient site
Post-op care:
care of:
o Donor site:
cover for 24-48 hrs
bed cradle
remove outer dressing in 24-72 hrs
analgesics PRN
allow fine mesh gauze to fall off; do not take it off
ice pack to decrease the pain
o Recipient site:
Elevate decrease swelling
Bed cradle
Warm compresses
Note factors that interfere with successful
o graft: motion
Infection
Trauma
o Elastic garments: Jobst garments elastic sleeves to suppress the growth of
scar- flattens the scar
o Reconstructive surgery
o Psychological & spiritual care
o Rehabilitation
RESPIRATORY SYSTEM
- Oxygenation
- Supply
o Ventilation
- Transport
o Diffusion
o Perfusion
Lungs to blood
Blood to cells
- Utilization
o Aerobic metabolism >> ATP >> energy
o Anaerobic metabolism >> LACTIC ACID
- Assessment
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o
o
o
Health history
Note risk factors
Asthma in the family, TB
PE
Inspection:
General Assessment in distress, cyanotic:
o Central - pathologic
o Peripheral cheeks, ears, nailbeds decrease in capillary
oxygenation; physiologic; exposure to extremes of temperature;
emotions
Respiratory movement
Digital clubbing chronic hypoxia
o Compensatory to chronic hypoxia: tachypnea, tachycardia,
polycythemia
Palpation: sense of touch- preferably on the back; movement of chest
Chest excursion; fremitus vibrations in chest wall
Atelactasis or COPD only one side if expanding
Percussion
Resonance: normal
Dull: fluid
Flat: mass PNM lobar consolidation
Ausculatation
Normal BS:
o Bronchial loud high pitched sounds
o Bronchovesicular lower, soft pitched
o Vesicular
Abnormal or adventitious
o Crackles or rales
o Ronchi large diameter gurgling sounds
o Stridor laryngospasm
o Wheeze bronchospasm musical sounds
Getting worse: higher pitch
Diagnostic tests
CBC RBC, Hct, Hgb, WBC
Acute neutrophils
Chronic- lymphocytes
Allergy and parasitism - eosinophils
5G Hg desaturated with 02 >> cyanosis even with normal Hgb
Chest x ray
Sputum exam
15ml; early am
Oral rinse with water before collection
Collect before AB treatment
Bronchoscopy
Maintain NPO until gag reflex returns
Check for bloody sputum
o Normal for sometime; but eventually fades
Pulmonary angiography
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Check for iodine allergies before

May feel urge to cough, flushing, nausea or salty taste after dye
injection
o Epinephrine should be available
Avoid taking BP for 24 hours on the extremity used for injection
o To prevent dislodging a clot: straighten the arm, bedrest for 6-8
hours
Check insertion site for bleeding
Can be used for pulmonary embolism
Mantoux test
Reading 48-72 hours
Read the induration of the wheal >> mm
o 0-5 negative
o 5-10 doubtful repeat procedure
o More than 10- positive
Thoracentesis
CXR or UTZ before procedure
No coughing, deep breathing, moving during procedure
Check for pneumothorax, air embolism, pulmonary edema
Tube is in the pleural cavity only
Remove air or fluid in the pleural cavity
Valsalva when removing
Prepare vaselinized gauze after removing
Lung biopsy
Check site for drainage or bleeding
Monitor for respiratory distress
Pulmonary Function test
Void before procedure
Check for intake of analgesics that can depress RR
No smoking and eating heavy meal 4-6 hours before the test
Remove dentures
o TV: 500ml
o RV: 1200ml dead space
o VC- 4000 -4800ml
o TLC: 5400-5800ml
o NC: 2900-3000ml
ABG
Before
o Allen test for radial extraction
o Rest for 30 minutes
o No suctioning; syringe requirements
Heparinized syringes; no bubbles
.1ml behind- to prevent clotting of blood
After
o Specimen on ice
o Note clients temperature, 02 and type of ventilation on
laboratory form
Pulse oximetry- measures amount of 02 attached to Hgb
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Alerts nurse to hypoxemia before clinical signs appear

o Normal 95 to 100
o <91% - immediate treatment needed
o <85 difficulty in tissue oxygenation shock patients
o < 70% life threatening severe state of tissue hypoxia
Nailbeds are free of nail polish
Respiratory problems
o Requirements of respiration
Ventilation or breathing
Depends on
o Patent airway
Cartilaginous structures air passages; DBE most potent
and cheapest bronchodilator
Upper airway up to upper part of trachea
Cilia and the goblet cells
GC mucus cells settle on the mucosal lining; can
increae in inflammation and irritation- smoking
Cilia- hairlike projections from GC; vibrate 1200
times minute >> creates wavelike motion that
propels mucus upward the oropharynx
Surfactants decreases surface tension of the alveolar
walls; seals the alveolo-capillary membrane to prevent
entry of fluid coming from capillaries- ARDS acute
respiratory distress syndrome hyaline membrane
disease lack of surfactants
ACM- semi permeable membrane; can pass through
gas; fluid cannot pass thru
o Bellows Function of the thorax
Compliance expansion
Recoil resting state
Elastin produces elastic substance to recoil lungs
Elastase breaks elastin
Emphysema loss of elastic recoil retained CO2
increased residual volume
o Requirements
Ventilation
Regulation of ventilation
o Neural
Medulla control of respiration stimulated by CO2
Hering breuer reflex controls the extent of inspiration
Cough keeps airway patent and open all the time
o Chemical
Chemoreceptors
Central: medulla; CO2
o ^co2, ^medulla stimulation, ^RR
Peripheral: carotid and aortic; decrease 02
Effect of 02 inhalation in COPD chronic CO2
retention
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C02 narcosis- medulla is not responsive to co2

stimulation
o Hypoxic drive- decrease in o2 level 6080mmHg
COPD- problem: hypercapnea
Alterations in ventilation
Airway alterations (obstructive)
o OBSTRUCTION
Regardless of cause >> change in Respiratory status
Causes
Mucus plug
Aspiration of foreign body
Epiglotitis, tonsillitis, sinusitis
Infections >> increase secretion
Laryngeal paralysis
Allergy chemical mediators histamine- they
cause edema, bronchospasm and ^secretions
o Give epinephrine - ^BP; bronchial dilation
Neoplasms
o Goiter
o Esophageal tumors
Epistaxis
o NC
Sit up lean forward and head tilted
down
Pressure over the soft tissue of the
nose
Cold compress over the bridge of the
nose
Nasal pack with neosynephrine (3-5
days)
Nursing dx: Ineffective airway clearance
Partial obstruction: coughing, choking, breathing, can talkwhispered voice
No Heimlich maneuver
Coughing to clear airway
Total obstruction
Abdominal thrusts turn to side; xiphoid process
Rhinitis - sipon
Allergic more common increasing incidence of allergens
Chronic rhinitis >> nasal polyps
Infectious
Sinusitis frontal, maxillary, ethmoidal
HA, fullness, pain in area affected
Management
Rest
Increase OFI
Hot wet packs
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College of Nursing
Anti-infectives, antihistamine
Nasal decongestants rebound
Irrigation with warm NSS
Surgery: Caldwell Luc operation, FESS
Tonsilitis pedia
Post op care
Position: prone hear turned to sides if GA
o HOB 45 degree if local anesthesia
No suctioning, no sucking
Ice collar to the neck
Analgesics; no ASA
Diet: clear, cool, non citrus, non- red liquids
o Sherbets and gelatins
o No milk and milk products, spices, hot, spicy, cold and rough
foods
No clearing of throat or harsh gargles may use alkaline mouthwashes
Check for bleeding
o Frequent swallowing, hemoptysis, tachycardia, low BP
Cancer of larynx
Occurs frequently in men than in women;persons 50-70%
Symptoms
Hoarseness or other voice changes
A lump in the neck
A sore throat or feeling that something is stuck in your throat
Persistent throat
Pain and burning in the throat
Management
Surgery laryngectomy temporary tracheostomy - partial ; total T
permanent trache
Radiation therapy
Chemotherapy
Speech therapy alaryngeal speech
Nursing priorities
o Airway
o Communication
o Nutrition
Radical neck dissection- cancer affecting neck and head- parotid
tumor, salivary gland tumor
o Excision of:
Sternocleidomastoid nad omohyoid muscles
Muscles of the floor of the mouth
Submaxilalry gland
Internal jugular vein
External carotid artery
Cervical chain of lymph nodes
o Management post op
Turning, coughing and DBE
High fowlers position
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College of Nursing
Tracheal suction
Observe for hemorrhage and edema in the neck
High humidity oxygen
Maintain position and patency of drainage tubes
Assess gag and cough reflexes and ability to swallow
Verbalization regarding changes in his body image
Laryngectomy
Obstruction during sleep: sleep apnea syndrome
Types
Obstructive- lack of airflow due to pharyngeal occlusion
Central no airflow and respiratory movement neurological in nature
Mixed- combination of obstructive and central
OSA
Frequent loud snoring and breathing cessation for 10 secs or more for
5 episodes per hour or more >> blood 02 level drops >> awaken
abruptly with loud snort
Symptoms
o Loud snoring
o Dry mouth in the morning
o Daytime sleepiness
o HA on awakening
o Decreased libido
Risks
o High BP
o Heart attack
o CHF
o Strokes
Treatment
o For mild cases
Sleep on ones side instead of back
Avoid drinking alcohol and using sleeping pills before
sleeping
Avoid smoking or using other tobacco products
Lose weight if overweight
Portable CPAP placed inside the nose
Near drowning
Problems: asphyxia and aspiration
Hypoxemia- within 3-5 minutes
Brain death within 5-10 minutes
Fresh water: hypotonic rapidly absorbed from alveoli >> hypervolemia and
hemodilution
Salt water: hypertonic fluid drawn into the alveoli >> hypovolemia and
hemoconcentration >>ARDS lack of oxygen and lack of surfactants
atelactasis and pulmonary edema
EMERGENCY CARE: CPR; 100% 02 and PEEP positive end expiratory
pressure prevents further atelactasis
Alterations of bellows function (restrictive) affects the elasticity of the
lungs and relaxation and contraction of lungs
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College of Nursing
Paralysis or weakness of respiratory muscles neuromuscular disorders
SCI C1-C5
GBS, poliomyelitis
Overuse of narcotic analgesics, spinal anesthesia
Loss of muscle tissue
Decreased fibroelasticity- scarring; pulmonary fibrosis, consolidation in PNM
Anatomical: scoliosis, kyphosis
Pneumothorax, hydrothorax pleural cavity
Unequal ventilation decreased rate of 02 transport hypoxemia
Nursing Diagnosis: Ineffective Breathing Pattern
Pneumothorax
Loss of negative intrapleural pressure increased intrathoracic pressure and
reduced vital capacity
Types
Spontaneous rupture of bleb (bullae- over-expanded alveoli)
Open communication between atmosphere and pleural cavity
o Cause: stab wound, trauma, fractured rib, surgery
Tension
decreased surface area for gas exchange hypoxia and hypercapnia
Treatment
Less than 30% collapse:
o Bedrest
o Oxygen
o Air aspiration with large bore needle
o Thoracentesis
More than 30% collapse
o Chest tube to water sealed drainage
o Thoracotomy and pleurectomy removal of one layer of pleura
(if recurrent)
Open Pneumothorax
o High fowlers
o Chest tube drainage
o Surgical lung repair
Tension air goes in but trapped inside; continuous trapping
increased intrapleural pressure mediastinal shift (more and more
DOB) emergency
o High fowlers
o Immediate thoracentesis and thoracostomy drainage
o Analgesics for comfort
o DBCE
o Monitor for hypotension (shifting of mediastinum torsion of
blood vessels), tachycardia and tachypnea; with possible
crackles (pulmonary congestion)
o Sign: Tracheal shift
Thoracentesis
o Air 2-3 ICS anterior
o Fluid 5-6 ICS posterior
Chest Tube is in the pleural cavity not in the lungs
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College of Nursing
Bottle Systems
o Maintain:
Patency of tubes
Drainage
Amount and color
Sterility
o Check
Fluctuation in tube
Air bubbles
None:
? Suction on
? Obstructed
? Lungs Ok
Continuous: ?Leaks
Patient Response: GA, BS, RR
Position
TCDB
o One bottle
Air vent short tube open
Immersed in water long tube
Patent: fluctuations; intermittent bubbles
If continuous bubbles- possible air leaks
o Get a new set up
Water sterile water
o 2 bottle system
Water sealed bottle
Drainage
Put a tape to measure the drainage at the end of each
shift
If with suction suction control
Long tube is immersed in 20cm water
Greater immersion, greater suction
o if with extra tube coil it on the bed gravity drain
o Precautions
CT OUT: cover site of CT with petrolatum gauze and air
tight dressing
o Bottle Breaks: immerse tube in water need not to be sterile
o No clamping
o No milking
o CT accidentally pulled out: pinch skin together, apply sterile
occlusive dressing and call MD.
Pneumonectomy no chest tube needed; position on affected side
Lobectomy needs chest tube
Pleurisy or Pleuritis inflammation of pleura
Types
Fibrinous no pleural fluid; fibrinous exudates present pleural
friction rub
Pleural effusion
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College of Nursing
o Auscultation: crackles and rales

o CXR = fluid in base
Bronchogenic Cancer
Leading cause related to malignancy
Leading Cause: Smoking
Genetic predisposition
Assesment
Symptoms appear late
Persistent cough with or without hemoptysis
Unilateral wheeze
Dysphagia
No percussion can induce bleeding
Post op care for lung resection
Pneumonectomy removal of entire lung
Reasons: CA and abscess
Post op: dorsal recumbent or semi fowlers on affected side adequate
ventilation
ROM to shoulder
No chest tube
Avoid full turning = halfway and put pillow underneath
Gas exchange between alveoli and blood
Requirements
Effective ventilation
o Alteration related to ventilation
Perfusion of blood in both lungs
o Alterations
Decreased pO2 capillary VC pulmonary HPN ^RV
workload ^RVH RSHF (COR PULMONARE) =
preceded by respiratory failure
Thickness and permeability of alveolar membrane
Amount of aerating surface
o Alterations: decreased aerating surface
Pulmonary edema
Crackles
Tx
o High concentration of 02 increase pressure
o Assisted ventilation
o Diuretics
o Digoxin
o Anti-arrhythmic
o Vasodilators: Nipride
o Morphine pain reliever and vasodilator
Emphysema lungs full of CO2
PNM lower consolidation
Surgery
Atelactasis
ARDS
Pneumothorax, hydrothorax
o Nursing diagnosis
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College of Nursing
Altered gas exchange

Pressure gradient determines the movement of gas; difference of
pressure of same gas in different compartment
o Oxygen:
Alveoli 104 torr
PG 64 amount of pressure that will move oxygen from
the alveoli to the blood
Capillary 40 torr
o CO
A: 40 torr
PG: 6 from capillary to alveoli
C: 46 torr
o Alterations
Altered intrapulmonic pressure impaired gas exchange
hypoxemia and hypercapnea
Gas Transport
Adequate amount hemoglobin anemia
Aerobic metabolism ATP
Effective CO
Efficient and adequate vascular network
COPD:
Chronic Bronchitis
o Persistent cough for at least a month
o Edema of the mucous membranes
o Hypersecretions of mucus
o Blue boaters
o Fluid and cellular exudation
o Cigarette smoking is a predisposing factor
o Thick yellow or green mucus
o EXCESSIVE MUCUS PRODUCTION WITH COUGH FOR AT
LEAST 3 MONTHS A YEAR FOR 2 CONSECUTIVE YEARS.
COPD: Emphysema
o Over distended and non functional alveoli leading to rupture
o Elastin destruction in lung parenchyma no recoil
o Increase compliance; decrease recoil
o Retention of CO2 and hypoxia leading to respiratory acidosis
o Pink puffers
o Cigarette smoking is predisposing factor
o Barrel Chest transverse < antero posterior; 2:1
o Decreased tactile fremitus
Typical posture of COPD patients
o Use of accessory muscles
Risk factors
o Tobacco smoke causes 80-90% of COPD cases
o Passive smoking
o Occupational exposure
o Ambient air pollution
o Genetic abnormalities
Alpha 1 antitrypsin decreased
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College of Nursing
Bronchiectasis
Assessment
o Cough bronchitis
o Barrel chest E
o Exertional dyspnea
o Wheezing and crackles
o Sputum production
o Use of Accessory muscles for breathing
o Cyanosis
o Clubbing of fingers
o Orthopnea
o Congestion and hyperinflation on CXR
o Decreased vital capacity
NC
o Low 02 concentration 2-3L
o Breathing techniques diaphragmatic, abdominal, pursed lip
o Monitor VS, pulse oximetry, sputum charac, weight
o Hi cal, hi CHON, increase fluids, SFF
o Position: fowlers, leaning forward
o Bronchodialtors, corticosteroid short term; mucolytics
o Antibiotics expectorant
o Oral hygiene
o Client education
Stop smoking and avoid pollutants
Activity limitations with adequate rest
Asthma
Types:
o Intrinsic Nonatopic
o Extrinsic
Processes
o Bronchoconstriction
o Inflammation
Signs and symptoms
o Wheezing; percussion may yield hyperresonance
o Cough can be NP or P of tenacious mucus; abundant
eosinophils and debris cause yellow discoloration in absence of
infection
o Pa 02 <60mmHg; Sa02 <90%; Pa CO2 ,= 40 mmHg
Early: hyperventilation; later: hypoventilation
o Dyspnea
Medications
o Quick relief medications
Act quickly; last 4-5 hours
o Beta adrenergic agonists- albuterol
o Anticholinergic- ipatropium
o Oral cant be long term- and IV corticosteroids decreased
inflammation or swelling
Treatment
o Prevention
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College of Nursing
Desensitization to specific allergen
Medications
Bronchodilators
Corticosteroids
Mast cell stabilizers Intal
Leukotrienes modifiers
Anti cholinergic
Immunotherapy
Anti-IgE monoclonal antibodies
o Low humidified oxygen
Amount delivered should maintain Pa 02 between 65-85
mmHg as determined by ABG
o Use of peak flow meter
Measure maximum ability to exhale (PEFR)
Respiratory Failure
Difference between respiratory insufficiency and respiratory failure
Causes
o Impaired ventilation
o Impaired diffusion and Gas exchange
o Ventilation perfusion balance PNM, COPD, atelactasis, post
perfusion syndrome (after heart lung machine)
Physiologic criteria
o Sudden onset of
Hypoxia Pa 02 <60 torr
Hypercapnea Pa CO2 >50 torr
Respiratory acidosis
o NC
Identify and treat cause
Administer oxygen to maintain Pa 02 level >60-70 torr
High Fowlers
Deep Breathing
Bronchodilators
Mechanical Ventilators as needfed ARDS
o
o
CIRCULATORY SYSTEM
- Heart Sounds
o S1 AV valve sounds
o S2 SL valve sounds
o S3 ventricular gallop - CHF
Normal: younger than 30
Pathologic in older person
o S4 Atrial gallop
Resistance to ventricular filling
Ventricular hypertrophy, MI
- Blood Volume
o Veins: holds 2/3 of the bodys blood
Easily distensible
o Arteries and arterioles: 15%
o Capillaries: 5%
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College of Nursing
-
Cardiac output = SV x HR
o N= 4-8L/minute
o Stoke volume- amt of blood ejected by V per beat
N= 70-130 ml/beat
Preload: Venous return
Amt of blood in the V that enter in diastole (resting part of the heart)
After load: PVR
Contractility
HR: 60-100/minute
Preload is directly proportional to the CO; inverse: after load and CO
Two factors that affect the BP
o CO = SV x HR
o TPR (PVR) total peripheral resistance
o BP = CO x TPR
Pulse pressure = SBP = DBP
o Correlates with SV
o N = 30-40 mmHg
MAP
o N= 90-100mmHg average pressure in the artery during ventricular contraction
and relaxation
o MABP = Diastolic P + 1/3 PP
o Correlate with tissue perfusion
Postural hypotension: BP fall of
o >10-15mmHg SBP Or
o >10 mmHg DBP
o Elderly patients
o Anti HPN drugs
o Anesthesia
Key psychosocial impact of CV disorders
o Fear of dying
o Financial issues related to loss of wages and medical costz
o Restrictions in activity
o Change in role performance
Physiologic responses to cardiac dysfunction
o Chest pain
Often related to ischemia
o Dyspnea
Increase need of myocardium for 02
Early sign of CHF
o Syncope
Insufficient 02 to the brain related to decreased CO
o Palpitation
o Abnormal heart sounds
o Crackles pulmonary edema
o Edema r/t ^vascular pressure
o EKG changes
o Dysrhythmias
o Abnormal cardiac enzymes
o Decreased CO
Tachycardia, weak peripheral pulses
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College of Nursing
o
o
Gerontologic changes
Diagnostics
ECG = memorize
Blood tests
RBC, WBC, HCT
Cardiac Markers
Enzymes
o CK-MB (0-8.8/ml)
Elevates 4-6 hours
Good indicator of heart attack
o LDH 24 hours
o Troponin
I 3 hours
T
Highly suggests heart attack
o Myoglobin 1 hour
Electrolytes
ESR
C- reactive CHON
Lipid Profile
HDL carry lipid away from arteries
o 40-60mg/dl
LDL transport cholesterol from liver arteries
o < 100mg/dl
Triglycerides: <150mg/dl precursors of cholesterol
Cholesterol: ,200mg/dl
Coagulation
PT: 11-15 seconds
o Coumadin reaction: 2-2.5X control
PTT: 60-70 seconds
APTT: 30-40 Seconds
o 1.5 -3X control
Coagulation time: 5-15 minutes
Heparin reaction: 20 minutes
Stress Test
ECG during exercise
No heavy meal for 4 hours
No stimulants before and after the test
No smoking before and after test
Cardiac Catheterization
Purposes
o Oxygen levels
o Pulmonary blood flow
o Cardiac output
o Heart structures
o Coronary arteries
o PAWP lung pressure
o PCWP left sided pressure
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College of Nursing
Pre
o
o
o
o
o
Post
o
o
o
o
o
CVP
o
Assess for iodine allergy

Baseline VS
Void
Sedatives
Mark distal pulses
Peripheral pulses
Extremities: extended; no bending
Check color and temp, tingling
Puncture site
ECG VS
Value: 4-10cm H20; abnormal: >15

The normal ECG
o A typical ECG tracing of a normal HB consists of a P wave, a QRS and a T wave. A
small U wave is normally visible in 5-75% of ECGs
Sinus Rhythm
o Sinus Node is pacemaker
o NSR
Less than 60 sinus bradycardia
Sinus tachycardia
Sinus dysrhythmia
Sinus arrest
Atrial Dysrhythmia
o PAC : Ectopic Arterial Beats
o Atrial Tachycardia 150-250
o Atrial Flutter 250 -350
o Atrial Fibrillation: > 350
Ventricular dysrhythmia
o PVC Ectopic Focus
o V. tachycardia 101-250
o V. Fibrillation: Chaotic
o Asystole: no electrical activity
Heart Blocks
o 1st degree impulse slow to go thru AV node, longer P-R interval
o 2nd degree some impulse got thru AV node, some do not; more P less QRS
o 3rd degree impulse get thru AV node; asynchronous A And V contraction
o Pacemaker
Types
Fixed
Demand
Parts
Electrodes detects and transmit the impulse
Generator generates the impulse
Check basal HR; diary of PR
Avoid sources of electricity microwave, CP
No contact sports
Minimize R arm and shoulder activity
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College of Nursing
Wear loose clothing

Note for battery failure, infection at insertion site
o Management
Precordial shock
Cardioversion and defibrillation
o C: synchronized countershock
Elective procedure
Synchronized on the R wave; avoid T wave VF
200-300 joules
o D: Asynchronous countershock to create a powerful
ventricular contraction
For VF and pulseless VT
360 joules
Stop 02 during the procedure
o Paddle placement for defibrillation
R 2-3ICS on the left of sternum
L apex of the heart
Successful CPR depends on the forceful compressions to the chest and
correctly timed inflation of the lungs
2-2.5 inches; 2.5 -3 inches: compression
Antidysrhythmic drugs
Sympathomimetics for bradycardia
BB, cardiac glycosides, Ca channel blockers for tachycardia
Digitalis , pronestyl , anti coagulants for atrial dysrhythmias
Lidociane, procainamide, quinidine, phenytoin, amiodarone watch
for barycardia Isuprel
o For VD PVC and V tachy with pulse
Bretelium Tosylate
o For V fibrillation
IV or endotracheal
Coronary Arteries
o Supple = Demand
o Posterior wall infarct RA
CHD
o chronic ischemic HD
stable angina
variant angina
silent myocardial ischemia (reversible)
o acute coronary syndrome
no ST segment elevation
unstable angina
acute MI
ST segment elevation acute MI
ST segment elevation acute MI
More than 30 minutes
Angina
o Insufficient BF to myocardium Myocardial ischemia angina
o Precipitating events
Exertion
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College of Nursing
Eating
Environment
Excitement
Early warning signs
Pressure in center of chest
Pain shoulder, neck and arms
Nursing care
Oxygen
Analgesics
VS, ECG
Semi- High Fowlers position
Nitrites and Nitrates
Action
o Decrease myocardial oxygen needs
o Dilates large coronary vessles
Give SL ever y5 minutes for 3 doses
o Dark glass container
o Cool storage
Patch: on-off pattern
SL spray: 1-2 spray ever y5 mintues (upto 3x)
SE:
o HA
o Hypotension
o Tolerance
Calcium Channel Blockers
Action:
o Decreased myocardial need for oxygen
o Decrease BP
SE
o Decrease BP
o Increase or decrease PR
o HA
o Withhold if SBP ,90; PR ,60
Nifedipine PO
Diltizem
Verapamil IV, PO
Key Features:
The major difference in the clinical presentation of angina and AMI is on the onset, severity and
duration.
ANGINA
MI
Substernal chest discomfort
Substernal chest pressure
Radiating to the left arm
Radiating to the L arm, back or jaw
Precipitated by exertion or stress
Occurring without cause, usually in the AM
Relieved by NTG or rest
Relieved only by opioids
-
Myocardial Infarction
o Coronary Occlusion
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College of Nursing
o
o
Heart Attack
Symptoms
Pain: substernal, radiating, not relieved by rest or NTG
NV
SOB
Cool clammy ashen skin
BP: up at 1st, then decreases
Low grade fever
Restlessness
ECG changes ST segment
Elevated ESR and cholesterol
Treatment
MONA
Morphine
Oxygen
Nitrates upto 3x
Aspirin start at home 2 tablets of aspirin
Oxygen: nasal 2-4 LPM- 96-98% o2 sat
Pain relief morphine IV
Patent IV line
Bed rest in semi fowlers
ECG monitor for arrhythmia
VS
I and O hourly urine cardiac output
Stool softeners
Reduce anxiety
Drugs
Thrombolytics
Must be given within 6 hours of infarct
Initiated within 30 minutes followed by diagnosis
Most effective when given within 3 hours
Heparin
Anti coagulants
Heparin
o Block conversion of prothrombin to thrombin
o Prolongs clotting time
o Antidote: protamine sulfate
Coumadin: blocks prothrombin synthesis
o AD: vitamin K
Glycoprotein IIb/ III a Inhibitors
Beta blockers
Dec force of contraction, CR, BP, hearts need for oxygen
With food
Platelet aggregation inhibitors
Aspirin
Assess for signs of bleeding and symptoms of bleeding
Avoid straining stool
Do not give ASA with Coumadin
ASA should be given with food
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College of Nursing
Angioplasty
Insertion of a balloon tipped catheter into the narrowed coronary artery
Balloon inflated opening of artery and squashing of plaque stent insertion
Re-stenosis common
Life style changes
Diet
Exercise
Stress management
Open the BV in less than 90 minutes after admission
Post
Monitor VS peripheral pulses
NTG- prevent aarterial spasm
o CABG
Commonly used:
Greater saphenous vein
Lesser saphenous vein
Cephalic and basilica vein
Vein: Check for edema decrease venous return to the heart
internal mammary artery
post procedure
CP, neurology status
VS
Pain level of patient
Labs
I and o
Cardiac rhythm and ECG
Hemodynamic variables
Daily weight
Pulse oximetry
Water seal chest drainage system
Cardiac tamponade
o Compression of ventricles caused by pericardial effusion decreased CO
CHF
o RHF: venous backup (SVC, IVC), RVH
Systemic congestion
o LHF: lung congestion, LVH
Decreased CO
Pulmonary congestion
o Management
Oxygenation
Rest and activity
Fluid balance
Nutrition sodium restriction
Mild 2grams
Mod 1 gram per day
Severe 200-500 mg per day
Elimination stool softener
Skin care prevent pressure sores
o
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College of Nursing
Decrease anxiety
For acute pulmonary edema
High fowlers
Morphine
Oxygen therapy
Relieve bronchospasm
Phlebotomy / rotating tourniquet
o Reduction of preload
o Three extremities occluded at a time 45 minutes
o Rotate every 15 minutes
Digitalis
Check drug level
o Therapeutic: 0.8-2.0 ng/ml
o Toxic: >2.5ng/ml
Antibind: Digibind
Days in the body for a week
Check k levels, toxicity
Triggering factors for toxicity
o Hypokalemia
Diuretics
Thiazides
Loop
Potassium sparring
Endocarditis
o Predisposes factors
RF. Bacterial infection IV, drug abuse
Treatment
AB, salicylates, corticosteroids
Risk for clots, valve defects (MS), CHF
Pericarditis
o Bacterial, fungal, viral
o Symptoms
Chest pain
Pericardial friction rub
Pericardial effusion
Dull chest pain
Low grade fever
o Tx
NSAIDS
Cardiac tamponade
o Accumulation of fluid in the pericardium
o Sx
Severe drop in BP
Reapid and DOB
Weak pulse
Decreased heart sounds
Distended or bulging veins
Shock
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College of Nursing
o
o
o
o
Inadequate BS to the vital organs brain, heart, liver

Type of shock
Distributive
Septic, neurogenic, anaphylactic
VD causes state of hypovolemia
Cardiogenic
LV cant maintain and adequate CO
Hypovolemic
Fluid loss from IV space thru ext loss or shift from IVS to ITS or ICS
dec. venous return
Preload decreases ventricular filling
Stages
Compensatory
Decrease arterial pressure, and tissue perfusion
o activates compensatory uechanism to maintain perfusion to
hear tand brain
E and NE secreted
RAAS mechanism
Sx: increased PR and RR
o Decreased BP, PP, UO
Progressive stage
Compensatory mechanism fails
Cells switch to anaerobic metabolism metabolic acidosis
Acidotic state depresses myocardial function
Tissue hypoxia release of chemical mediators ==? VD ==? Venous
pooling and increased permeability Sluggish BF increased risk of
DIC
Sx: hypotension, narrowed PP, reduced SV, rapid thread pulse
Irreversible stage
Permanent organ damage happens
Cells use anaerobic metabolism accumulation of lactic acid
increase capillary permeability fluid shifts from IV to IT further
hypotension
Treatment
Intubation and MV
02 inhalation
Shock position: modified Trendelenburg
Cardiac monitoring
Antiarrhythmics
2 IV lines- fluids and drug administrations
Cardiogenic Shock
Inotropic
VD
Thrombolytics
Septic shock AB
Neurogenic
Vasopressor drugs
Hypontension
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College of Nursing
Fluid replacement
Nursing care
Start IV with NS or LR using large bore catheters (14G)
If HUM <30ml/hr, increase IV infusion rate
Watch for impending coagulopathy
Hypertension
o Control of arterial BP
o Lifestyle modifications
o Weight reduction
Arteriosclerosis obliterans
o Intermittent claudication calf pain
o Tingling and numbness of toes
o Patient teaching
Stop smoking
Low fat diet
Legs straight and down
Buergers Disease
o Inflammation of arteries and veins
o Similar sx of A. Obltierans
o STOP smoking
o VD and Anticoagulants
o Beurgers exercise
Legs up
Legs down
Legs Flat
Raynauds Phenomenon
o Maybe seen in lupus
o Cold painful hands
o Stop smoking
o VD - treatment
o Mittens warmth
o Diminished blood supply causes damage death of tissue
o Aggravated by cold temperature and stress
Abdominal aortic aneurysm
o Congenital weakness, trauma or diseases damaged media layer of the vessel
aneurysm develops aneurysm enlarges
o Signs of impending rupture
Severe back pain or abd pain
Falling BP
Decreasing Hct
Rupture into the peritoneal cavity rapidly fatal
Retroperitoneal rupture hematomas in the scrotum, perineum, flank or
penis
o Prevent rupture decrease intra-abdominal pressure
Thrombophlebitis
o Prevention
Leg exercvises
Antiembolism hose
o Signs
Homans sign pain on calf with dorsiflexion of ankle
o
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College of Nursing
Swelling
Heat and redness along the course of the vein
o Treatment
Bedrest
tPA, streptokinase
Heparin
o The clot may become dislodges from the vein and travel pulmonary embolism
Sx: dyspnea, increase PR, sharp chest pain aggravated by deep breathing,
blood in sputum
o Medical management
Heparin
Warfarin
Fibrinolytic agents
o Surgical management
Vena Cava Filters traps blood clots
Venous valve incompetence
o BF and function of valves in veins. Note impaired blood return due to incompetent
valve.
Varicose Veins
Amputation
o Position to prevent hip flexion deformity prone position several times during the
day
o Keep stump elevated for 24 hours only
o Keep tourniquet at bedside
o Wrap stump to help shape for prosthesis and prevent swelling tighter at distal
part
o Teach patient to check stump for skin breakdown
MUSCULOSKELETAL SYSTEM
- Trauma
o Strain muscle overstretching
o Sprain ligament; more fatal
o Fracture
Signs
Pain aggravated by motion, tenderness
Loss of motion
Edema
Crepitus- sound of broken bone edges
Shortening of extremity
Compound Fracture: check for tetanus
Spiral fracture
Due to twisting
Check for child abuse
Compartment syndrome
Abnormal inc in pressure within a confined space impaired circulation
Causes
o Restrictive dressings, tight cast and severe swelling, hemorrhage
Tissue damage in 30 minutes
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College of Nursing
Permanent damage in 4 hours
6 Ps
o Pain
o Pallor
o Paresthesia
o Pulselessness
o Paralysis
o Poikilothermia
Permanent neuromuscular damage occur in 4-6 hours
Treatment
o Notify MD stat
Fasciotomy
Positioning affected extremity lower than the heart
Removal of dressings / casts Bi Valve Cast
Fat embolism
An embolism originating in the bone marrow
Occurs: first 72 hours after a fracture
o Long bone fractures
Sx: petechial rash over upper chest and neck
O2 and treat symptoms as needed
Call MD stat
Management
RICE
o Rest
o Ice
o Compression
o Elevation
Reduction
o Open
o Close (casting and traction)
Immobilization
o EFD
o Traction
o Splints
o Cast
o Braces
Rehabilitation
Traction pulling with a counter pull
o Ensure that the weights are hanging freely
o Maintain continuous traction
o Russell Traction: line of pull should be in line with deformity
o Bryants traction
o Cervical traction
Upright
Sitting
o Pelvic traction
o Balance Skeletal traction
Crutchfield tong
Pin care
39

College of Nursing
-
Rehabilitation
o Hand muscles grips
o Arm muscles sit ups, push ups
o Gaits
Partial wt bearing - both needs support
2 point and 4 point gait
o 4 points crutch opposite leg
o 2 point crutch AND same leg
3 point
Crutch leg crutch leg
o Cane good side
o Cane walks together with the weak leg
o Walker: With 2 wheels no need to lift the walker
Hip Fracture
40

Medical Surgical Nursing Tionko

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University of Santo Tomas

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University of Santo Tomas

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University of Santo Tomas

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ALTERATIONS IN FLUID AND ELECTROLYTES

Fluid distribution by weight

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Confusion and depression

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Monitor organ functions

Factors determining the severity of burn

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Check for iodine allergies before

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Alerts nurse to hypoxemia before clinical signs appear

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C02 narcosis- medulla is not responsive to co2

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o Auscultation: crackles and rales

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Altered gas exchange

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