Acute coronary syndrome Acute coronary syndrome is a term used for any condition brought on by sudden, reduced blood

flow to the heart. Acute coronary syndrome can describe chest pain you feel during a heart attack, or chest pain you feel while you're at rest or doing light physical activity (unstable angina). Acute coronary syndrome is often diagnosed in an emergency room or hospital. Acute coronary syndrome is treatable if diagnosed quickly. Acute coronary syndrome treatments vary, depending on your signs, symptoms and overall health condition. Symptoms

greater the chance you will survive and lessen the damage to your heart.

Nitroglycerin. This medication for treating chest pain and angina temporarily widens narrowed blood vessels, improving blood flow to and from your heart. Beta blockers. These drugs help relax your heart muscle, slow your heart rate and decrease your blood pressure, which decreases the demand on your heart. These medications can increase blood flow through your heart, decreasing chest pain and the potential for damage to your heart during a heart attack. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These drugs allow blood to flow from your heart more easily. Your doctor may prescribe ACE inhibitors or ARBs if you've had a moderate to severe heart attack that has reduced your heart's pumping capacity. These drugs also lower blood pressure and may prevent a second heart attack. Calcium channel blockers. These medications relax the heart and allow more blood to flow to and from the heart. Calcium channel blockers are generally given if symptoms persist after you've taken nitroglycerin and beta blockers. Cholesterol-lowering drugs. Commonly used drugs known as statins can lower your cholesterol levels, making plaque deposits less likely. The goal of statin therapy is to reduce the low density lipoprotein (LDL, or "bad") cholesterol levels to under 100 milligrams per deciliter (mg/dL).

Chest pain (angina) that feels like burning, pressure or tightness and lasts several minutes or longer

Pain elsewhere in the body, such as the left upper arm or jaw (referred pain) Nausea Vomiting Shortness of breath (dyspnea) Sudden, heavy sweating (diaphoresis) Unusual symptoms

Abdominal pain Pain similar to heartburn Clammy skin Lightheadedness, dizziness or fainting Unusual or unexplained fatigue

Feeling restless or apprehensive Causes Acute coronary syndrome may develop slowly over time by the building up of plaques in the arteries in your heart. These plaques, made up of fatty deposits, cause the arteries to narrow and make it more difficult for blood to flow through them. This buildup of plaques is known as atherosclerosis. Eventually, this buildup means that your heart can't pump enough oxygen-rich blood to the rest of your body, causing chest pain (angina) or a heart attack. Another medical term closely related to acute coronary syndrome is coronary artery disease. Coronary artery disease refers to the damage to your heart arteries from atherosclerosis. If one of the plaques in your coronary arteries ruptures, it can cause a heart attack. In fact, many instances of coronary artery syndrome develop after a plaque ruptures. A blood clot will form on the site of the rupture, blocking the flow of blood through that artery. Risk factors

Clopidogrel. The medication clopidogrel (Plavix) can help prevent blood clots from forming by making your blood platelets less likely to stick together. However, clopidogrel increases your risk of bleeding, so be sure to let everyone on your health care team know that you're taking it, particularly if you need any type of surgery. Surgery and other procedures If medications aren't enough to restore blood flow through your heart, your doctor may recommend one of these procedures:

Angioplasty and stenting. In this procedure, your doctor inserts a long, thin tube (catheter) into the blocked or narrowed part of your artery. A wire with a deflated balloon is passed through the catheter to the narrowed area. The balloon is then inflated, compressing the deposits against your artery walls. A mesh tube (stent) is usually left in the artery to help keep the artery open. Angioplasty may also be done with laser technology. Coronary bypass surgery. This procedure creates an alternative route for blood to go around a blocked coronary artery.

Older age (older than 45 for men and older than 55 for women) High blood pressure High blood cholesterol Cigarette smoking Lack of physical activity Type 2 diabetes

Family history of chest pain, heart disease or stroke Treatment Medications It's likely that your doctor will recommend medications that can relieve chest pain and improve flow through the heart. These could include:

Aspirin. Aspirin decreases blood clotting, helping to keep blood flowing through narrowed heart arteries. Aspirin is one of the first things you may be given in the emergency room for suspected acute coronary syndrome. You may be asked to chew the aspirin, so it's absorbed into your bloodstream more quickly. If your doctor diagnoses your symptoms as acute coronary syndrome, he or she may recommend taking aspirin daily. Thrombolytics. These drugs, also called clotbusters, help dissolve a blood clot that's blocking blood flow to your heart. If you're having a heart attack, the earlier you receive a thrombolytic drug after a heart attack, the

Acute renal failure is a syndrome of varying causation that results in a sudden decline in renal function. It is frequently associated with an increase in BUN and creatinine, oliguria (less than 500 ml urine/24 hours), hyperkalemia, and sodium retention (Williams & Wilkins, 2006). Acute renal failure (ARF) is a sudden and almost complete loss of kidney function (decreased Glomerular filtration rate GFR) over a period of hours to days. Acute Renal Failure ARF manifests with oliguria, anuria, or normal urine volume. Oliguria (less than 400 ml/day of urine) is the most common clinical situation seen in Acute Renal Failure ARF; anuria (less than 50 ml/day of urine) and normal urine output are not as common. Regardless of the volume of urine excreted, the patient with ARF experiences rising serum creatinine and BUN levels and retention of other metabolic waste products (azotemia) normally excreted by the kidneys (Brunner and Suddarth,2003 ). Acute renal failure (ARF) is the abrupt deterioration of renal function that results in the accumulation of fluids, electrolytes, and metabolic waste products. The sudden interruption of renal function resulting from obstruction, reduced circulation, or renal parenchymal disease. This condition is classified as prerenal, intrarenal, or postrenal and normally passes through three distinct phases: oliguric, diuretic, and recovery. Its usually

reversible with medical treatment. If not treated, it may progress to end-stage renal disease, uremia, and death. Causes for Acute Renal Failure Prerenal Failure Prerenal conditions occur as a result of impaired blood flow that leads to hypoperfusion of the kidney and a drop in the Glomerular filtration rate GFR. Volume depletion resulting from: 1. Hemorrhage 2. Renal losses (diuretics, osmotic diuresis) 3. Gastrointestinal losses (vomiting, diarrhea, nasogastric suction) Impaired cardiac efficiency resulting from: 1. Myocardial infarction 2. Heart failure 3. Dysrhythmias 4. Cardiogenic shock Vasodilation resulting from: 1. Sepsis 2. Anaphylaxis 3. Antihypertensive medications or other medications that cause 4. Vasodilation Intrarenal Failure Intrarenal causes of ARF are the result of actual parenchymal damage to the glomeruli or kidney tubules. Intrarenal causes result from injury to renal tissue and are usually associated with intrarenal ischemia, toxins, immunologic processes, systemic and vascular disorders. Prolonged renal ischemia resulting from: 1. Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures) 2. Myoglobinuria (trauma, crush injuries, burns) 3. Hemoglobinuria (transfusion reaction, hemolytic anemia) Nephrotoxic agents such as: 1. Aminoglycoside antibiotics (gentamicin, tobramycin) 2. Radiopaque contrast agents 3. Heavy metals (lead, mercury) 4. Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) 5. Nonsteroidal anti-inflammatory drugs (NSAIDs) 6. Angiotensin-converting enzyme inhibitors (ACE inhibitors) Infectious processes such as: 1. Acute pyelonephritis 2. Acute glomerulonephritis Postrenal Failure Postrenal causes of ARF are usually the result of an obstruction somewhere distal to the kidney. Pressure raises in the kidney tubules eventually, the Glomerular filtration rate GFR decreases. Urinary tract obstruction, including: 1. Calculi (stones) 2. Tumors 3. Benign prostatic hyperplasia 4. Strictures 5. Blood clots Pathophysiology of Acute Renal Failure There are four clinical phases of Acute Renal Failure ARF: 1. The initiation period begins with the initial insult and ends when oliguria develops. 2. The oliguria period is accompanied by a rise in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 ml. In this phase uremic symptoms first appear life-threatening conditions such as hyperkalemia develop. 3. The diuresis period, the third phase, the patient experiences gradually increasing urine output which signals that Glomerular filtration has started to recover. Laboratory values stop rising and eventually decrease. Although the volume of urinary output may reach normal or elevated levels, renal function may still be markedly abnormal. Because uremic symptoms may still be present,

the need for expert medical and nursing management continues. 4. The recovery period signals the improvement of renal function and may take 3 to 12 months. Laboratory values return to the patients normal level. Although a permanent 1% to reduction in the GFR is common, it is not clinically significant. Clinical Manifestations

Prerenal decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or anuria, flat neck veins, tachycardia Postrenal obstruction to urine flow, obstructive symptoms of BPH, possible nephrolithiasis Intrarenal presentation based on cause; edema usually present Changes in urine volume and serum concentrations of BUN, creatinine, potassium, and so forth, as described above Assessment and Diagnostic Findings Nursing Care Plans for Acute Renal Failure:

Anemia Complications

Changes in urine Change in kidney contour Increased bun and creatinine levels (azotemia) Hyperkalemia Metabolic acidosis Calcium and phosphorus abnormalities

Infection Arrhythmias due to hyperkalemia

Electrolyte (sodium, potassium, calcium, phosphorus) abnormalities GI bleeding due to stress ulcers Multiple organ systems failure Nursing Process Nursing Assessment Nursing Care Plans for Acute Renal Failure Determine if there is a history of cardiac disease, malignancy, sepsis, or intercurrent illness. Determine if patient has been exposed to potentially nephrotoxic drugs (antibiotics, NSAIDs, contrast agents, solvents). Conduct an ongoing physical examination for tissue turgor, pallor, alteration in mucous membranes, blood pressure, heart rate changes, pulmonary edema, and peripheral edema.

Monitor intake and output Nursing Diagnosis Nursing Care Plans for Acute Renal Failure Common nursing diagnosis found in Nursing Care Plans for Acute renal failure: 1. Excess Fluid Volume related to decreased glomerular filtration rate and sodium retention 2. Risk for Infection related to alterations in the immune system and host defenses 3. Imbalanced Nutrition: Less Than Body Requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure 4. Risk for Injury related to GI bleeding 5. Disturbed Thought Processes related to the effects of uremic toxins on the central nervous system (CNS)
COPD Chronic obstructive pulmonary disease (COPD) refers to a group of lung diseases that block airflow as you exhale and make it increasingly difficult for you to breathe.Emphysema and chronic asthmatic bronchitis are the two main conditions that make up COPD. In all cases, damage to your airways eventually interferes with the exchange of oxygen and carbon dioxide in your lungs. COPD is a leading cause of death and illness worldwide. Most COPD is caused by long-term smoking and can be prevented by not smoking or quitting soon after you start. This damage to your lungs can't be reversed, so treatment focuses on controlling symptoms and minimizing further damage.

Symptoms

Chronic cough Causes Chronic asthmatic bronchitis Chronic asthmatic bronchitis causes inflammation and narrowing of the airways that lead into your lungs. This may cause you to cough and wheeze. Chronic asthmatic bronchitis also increases mucus production, which can further block the narrowed tubes. Emphysema Emphysema damages the tiny air sacs in your lungs (alveoli) in two main ways. Alveoli are clustered like grapes and emphysema gradually destroys the inner walls of these clusters, reducing the amount of surface area available to exchange oxygen for carbon dioxide. In addition, emphysema also makes the alveoli walls weaker and less elastic, so they collapse with exhalation trapping air in the alveoli. Shortness of breath occurs because the chest wall muscles have to work harder to expel the air. Cigarette smoke and other irritants COPD is typically caused by long-term exposure to airborne irritants, such as:

Shortness of breath Wheezing Chest tightness

task may seem particularly daunting if you've tried to quit before. Talk to your doctor about nicotine replacement products and medications that might help. Medications Doctors use several basic groups of medications to treat the symptoms and complications of COPD. You may take some medications on a regular basis and others as needed:

Bronchodilators. These medications which usually come in an inhaler relax the muscles around your airways. This can help relieve coughing and shortness of breath and make breathing easier. Depending on the severity of your disease, you may need a shortacting bronchodilator before activities, a long-acting bronchodilator that you use every day, or both. Inhaled steroids. Inhaled corticosteroid medications can reduce airway inflammation and help you breathe better. But prolonged use of these medications can weaken your bones and increase your risk of high blood pressure, cataracts and diabetes. They're usually reserved for people with moderate or severe COPD.

Antibiotics. Respiratory infections such as acute bronchitis, pneumonia and influenza can aggravate COPD symptoms. Antibiotics can help fight bacterial infections, but are recommended only when necessary. Therapy

Tobacco smoke Dust Chemical fumes

Air pollution Risk factors Exposure to tobacco smoke. The most significant risk factor for COPD is long-term cigarette smoking. The more years you smoke and the more packs you smoke, the greater your risk. Pipe smokers, cigar smokers and people exposed to large amounts of secondhand smoke also are at risk. Chronic inhalation of marijuana smoke also can be injurious. Occupational exposure to dusts and chemicals. Long-term exposure to chemical fumes, vapors and dusts can irritate and inflame your lungs. Age. COPD develops slowly over years, so most people are at least 40 years old when symptoms begin.

Oxygen therapy. If there isn't enough oxygen in your blood, you may need supplemental oxygen. There are several devices to deliver oxygen to your lungs, including lightweight, portable units that you can take with you to run errands and get around town. Some people with COPD use oxygen only during activities or while sleeping. Others use oxygen all the time. Pulmonary rehabilitation program. These programs typically combine education, exercise training, nutrition advice and counseling. If you are referred to a program, you'll probably work with a range of health care professionals, including physical therapists, respiratory therapists, exercise specialists and dietitians. These specialists can tailor your rehabilitation program to meet your needs. Exercising regularly can significantly improve the efficiency of your cardiovascular system.

Genetics. A rare genetic disorder known as alpha-1antitrypsin deficiency is the source of a few cases of COPD. Researchers suspect that other genetic factors may also make certain smokers more susceptible to the disease. Complications

Surgery Surgery is an option for some people with some forms of severe emphysema who aren't helped sufficiently by medications alone:

Respiratory infections. When you have COPD, you're more likely to get frequent colds, the flu or pneumonia. Plus, any respiratory infection can make it much more difficult to breathe and produce further irreversible damage to the lung tissue. High blood pressure. COPD may cause high blood pressure in the arteries that bring blood to your lungs (pulmonary hypertension). This puts great strain on the right ventricle of your heart and may cause your ankles and legs to swell. Heart problems. COPD also increases your risk of heart disease, including heart attack. This is in addition to the adverse effects of nicotine on the coronary arteries.

Lung volume reduction surgery. In this surgery, your surgeon removes small wedges of damaged lung tissue. This creates extra space in your chest cavity so that the remaining lung tissue and the diaphragm work more efficiently. The surgery has a number of risks, and long-term results may be no better than for nonsurgical approaches.

Depression. Difficulty breathing can keep you from doing activities that you enjoy. And it can be very difficult to deal with a disease that is progressive and incurable. Talk to your doctor if you feel sad, helpless or depressed. Treatments Stop smoking The most essential step in any treatment plan for smokers with COPD is to stop all smoking. It's the only way to keep COPD from getting worse which can eventually result in losing your ability to breathe. But quitting smoking is never easy. And this

Lung transplant. Single-lung transplantation may be an option for certain people with severe emphysema who meet specific criteria. Transplantation can improve your ability to breathe and be active, but it doesn't appear to prolong life and you may have to wait for a long time to receive a donated organ. So the decision to undergo lung transplantation is complicated. Managing exacerbations Even with ongoing treatment, you may experience times when symptoms suddenly get worse. This is called an acute exacerbation, and it may cause lung failure if you don't receive prompt treatment. Exacerbations may be caused by a respiratory infection, a change in outdoor temperatures or high air pollution levels. Seek medical attention if you notice more coughing or a change in your mucus or if you have a harder time breathing.