Adult Health Theory II Exam. I
Interpret arterial blood gas results using the steps outlined in the Lewis textbook.
1. Look at values if they appear to be in a normal range they are fine. IF ANY VALUE IS OUT OF NORMAL CONTINUE. 2. Determine if pH is acidotic or alkalotic. A normal pH may indicate normal acid-base status, compensation is occurring, or a mixed disorder is present. 3. Determine the cause. First, analyze the PaCO2 to see if the patient has respiratory acidosis or alkalosis. Since the lungs control PaCO2, it is the respiratory component of the ABG. Because CO2 forms carbonic acid when dissolved in blood, high PaCO2 levels decrease pH and indicate respiratory acidosis. Low PaCO2 levels increase pH and indicate respiratory alkalosis. If the pH value moves in the appropriate direction for the PaCO2 change (e.g., ↓ pH with ↑ PaCO2; ↑ pH with ↓ PaCO2), a respiratory problem is the primary disturbance. 4. Analyze the HCO3 − level to see if the patient has metabolic acidosis or alkalosis. Since the kidneys primarily control HCO3 −, it is the metabolic component of the ABG. Because HCO3 − is a base, high levels of HCO3 − increase pH and result in metabolic alkalosis. Low levels decrease pH and result in metabolic acidosis. If the pH value moves in the appropriate direction for the change (e.g., ↓ pH with ↓ HCO3 −; ↑ pH with ↑ HCO3 −), a metabolic problem is the primary disturbance. 5. Determine if the patient is compensating or a mixed disorder is present. Look at the component (CO2 or HCO3 −) that is not the cause of the primary disturbance. If the component that does not match the pH is moving in the opposite direction, the body is attempting to compensate. For example, if the pH is slightly acidotic (7.33), the CO2 is high (55 mm Hg), and the HCO3 − is high (36 mEq/ L), the CO2 is the parameter that matches the acidotic pH. The patient's underlying acid-base imbalance is respiratory acidosis. The HCO3 − level is alkalotic. Since this is in the opposite direction of respiratory acidosis, compensation is occurring. If both parameters match the pH, consider the possibility that a combined respiratory or metabolic acidosis or alkalosis is present. For example, if the pH is acidotic (7.28), the CO2 is high (55 mm Hg), and the HCO3 − is low (16 mEq/ L), the patient's underlying acid-base imbalance is combined respiratory-metabolic acidosis. 6.Assess the PaO2 and O2 saturation. If these values are abnormal, hypoxemia is present.
How long (in minutes) must the artery be opened when a STEMI occurs?
90 minutes
Percutaneous coronary intervention (PCI)
A catheter with a deflated balloon tip is inserted into the appropriate coronary artery. The deflated balloon is positioned in the blockage and inflated. This compresses the plaque against the artery wall, resulting in vessel dilation and larger vessel diameter Must be done within 120 minutes
Sudden cardiac death (SCD)
A sudden disruption in heart function produces an abrupt loss of CO and cerebral blood flow.
Arterial blood gases (ABGs)
ABG is a blood test that measures the acidity, or pH, and the levels of O2 and CO2 from an artery. normal values: pH: 7.35-7.45 PO2: 80-100 pCO2: 35-45 HCO3: 22-26 O2 Sat: 95-100%
Discuss the psychologic issues that clients experience during and after an AMI.
Denial May have history of ignoring signs and symptoms related to heart disease Minimizes severity of health condition Ignores activity restrictions Avoid discussing illness or its significance Depression Mourns loss of health, altered body function, and changes in lifestyle Begins to worry about future implication of health problem Shows manifestation of withdrawal, crying, apathy May be more evident after discharge Anger and hostility Is commonly express as, "Why did this happen to me?" May be directed at family, staff, or medical regimen Anxiety and fear Fear long-term disability and death Overtly displays apprehension, restlessness, insomnia, tachycardia Less overtly displays increased verbalization, projection of feelings to others, hypochondriasis Fear activity Fear recurrent chest pain, heart attacks, and sudden death Dependency Is totally reliant on staff Is unwilling to perform task or activities unless approved by HCP Wants to be monitored by ECG at all times Is hesitant to leave the intensive care or telemetry unit or hospital Realistic acceptance Focuses on optimum rehabilitation Plans changes compatible with altered cardiac function Actively engages in lifestyle changes to address modifiable risk factors
What is the role of nitrates in management of CAD, angina?
Dilating peripheral blood vessels: This results in decreased SVR, venous pooling, and decreased venous blood return to the heart (preload). Therefore myocardial O2 demand is decreased because of the reduced cardiac workload. Dilating coronary arteries and collateral vessels: this may increase blood flow the ischemic areas of the heart. However, when the coronary arteries are severely atherosclerotic, coronary dilation is difficult to achieve
What classifications of medications are used to manage ACS?
Dual antiplatelet therapy (ex. chewable aspirin, clopidogrel), IV NTG, atorvastatin, and systemic anticoagulation with either subcutaneous LMWH or IV UH are drug treatments of choice.
Discuss the complications of MI. How does heart failure occur?
Dysrhythmias. Any conditions that affects the heart cells' sensitivity to nerve impulses can cause dysrhythmias that adversely affect the damage heart muscle. Heart failure. Is a complication that occurs when the right or left heart's pumping action is reduced. Depending on the severity and extent of the injury, left-sided HF occurs initially with subtle sign such as mild dyspnea, restlessness, agitation, or slight tachycardia. Left-sided HF include pulmonary congestion on chest x-ray, S3 or S4 heart sound on auscultation of the heart, crackles on auscultation of the lung, paroxysmal nocturnal dyspnea, and orthopena Right-sided HF include jugular venous distention, hepatic congestion, or lower extremity edema Cardiogenic shock. Occurs when O2 and nutrient supplied to the tissues are inadequate because of the severe LV failure, papillary muscle rupture, ventricular infarction. This occurs less often with the early and rapid treatment of STEMI and PCI or thrombolytic therapy. When it does occur is associated with a high death rate. Require aggressive management. This includes therapy, and support of contractility with vasoactive drugs. Goals of therapy are to maximize O2 delivery reduce O2 demand, and prevent complication. Papillary Muscle Dysfunction or Rupture. May occur if the infarcted area includes or is near the papillary muscle that attaches to the mitral valve. Suspected papillary muscle dysfunction if you hear a new murmur at the cardiac apex.
Describe the interventions for emergency management of MI and the role of the interdisciplinary team in assisting with these interventions.
ECG: monitor the heart Oxygen Nitrogen x3 5 minutes apart Chewable aspirin total 325 Morphine
Hypertonic (hyper - excessive) (tonic - concentration of a solution) Higher percentage of Saline
Fluids with solutes more concentrated than in cells, or an increased osmolality Side effect: Cell is going to shrink Too much shrinking can cause the cell to die Fluid types: 3% saline 5% Saline 10% Dextrose in water 5% Dextrose in 0.9% saline 5% Dextrose ½ normal saline 5% Dextrose in Lactate Ringer Give in ICU via central line ** Very hard on the veins** ** Must be monitored very closely can cause fluid overload** Pulmonary Edema Treats: Hyponatremia Cerebral edema ** Patients who have very swollen cells** ** Pulls sodium back out of the cell and into the intravascular system so the body can discrete it **
Isotonic (Iso - equal) (tonic - concentration of solution)
Fluids with the same osmolality as the cell's interior (same fluids are inside the cells as they are outside the cell) Fluid Types: 0.9 Saline 5% dextrose in water 5% dextrose in 0.228 saline Lactate Ringers Why they are used: To increase extracellular fluid volume loss through Blood loss Dehydration (Vomiting, Diarrhea) Surgery
What is the pathophysiology of sudden cardiac death (SCD)?
Is a sudden disruption in heart function produces an abrupt loss of CO and cerebral blood flow. The affected person may or may not have known history of heart disease. Acute ventricular dysrhythmias causes the majority of cases of SCD. Structural heart disease account for 10% of cases. Patient in this group include those with LV hypertrophy, myocarditis, and hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy is a risk for SCD, especially in young athletic people.
Coronary artery disease (CAD)
Is a type of blood vessel disorder that is included in the general category of atherosclerosis
Stent
Is an expandable mesh-like structure designed to keep the vessel open after balloon angioplasty. It provides support to the arterial wall
How is thrombolytic therapy used to manage MI?
Is indicated only for STEMI patients. Aims to limit the infarction size by dissolving the thrombus in the coronary artery and reperfusion the heart muscle. Goal is to give the thrombolytic within 30 minutes of the patient's arrival to ED. Depending on the drug selected, therapy is given in on IV bolus or over time. Note the time at which therapy begins. Monitor the patient during and after giving. Asssess the heart and lungs frequently to evaluate the patient's response to therapy. Regularly asses for changes in neurological status, since this may indicate cerebral bleeding. Most reliable sign is the return of the ST segment to baseline on the ECG. Other signs include a resolution of chest pain and an early rapid rise of serum cardiac biomarkers within 3 hours of therapy peaking within 12 hrs.
Osmosis
Is the movement of water "down" a concentration gradient, that is, from a region of low solute concentration, across a semipermeable membrane. **No energy is required**
How does the renal system regulate acid base balance?
Kidney Buffers Kidneys are the third line of defense This buffering system is much slower to respond but it is the most effective buffering system with the longest duration Kidney control the movement of bicarbonate in the urine. Bicarbonate can be reabsorbed into the blood stream or excreted in the urine in response to blood levels of hydrogen Kidney can also produce more bicarbonate when need. High hydrogen ions: Bicarbonate reabsorption and production Low hydrogen Ions: Bicarbonate excretion The body depends on the kidney to reabsorb and conserve all the HCO3- they filter and excrete a portion of the acid produced by cellular metabolism. Three mechanisms of acid elimination are: Secretion of small amounts of free hydrogen into renal tubule Combination of H+ with ammonia (NH3) to form ammonium (NH4-) Excretion of weak acids To compensate for acidosis, the kidney can reabsorb additional HCO3- and eliminate excess H+. This increases the blood pH and decreases the urine pH.
What are the risk factors (modifiable and non-modifiable) for CAD?
Modifiable: Elevated serum lipids Total Cholesterol >200mg/dL Triglycerides >150 mg/dL LDL cholesterol >160 mg/dL HDL cholesterol <40 Elevated BP >140/90 Tobacco use Physical inactivity Obesity Diabetes Metabolic syndrome Obesity Hypertension Abnormal serum lipids Elevated fasting blood glucose Psychological states (stress, anger, hostility, depression) Nonmodifiable: Increasing Age Gender More common in men than in women until 75 yr of age Ethnicity More common in white men than in African men Family history genetics
How long (in minutes) must the artery be opened when a STEMI occurs?
Must be opened within 90 minutes of presentation
Do all clients experience chest pain, why or why not?
No. If a patient has experienced nerve damage from another disease such as diabetes the patient would not feel the pain. Despite efforts to increase awareness, women's symptoms continue to be underrecognized as heart related. These symptoms include fatigue, shortness of breath, indigestion, and anxiety. Fatigue is the most prominent symptoms but all these symptoms can relate to many different disease and syndrome.
Infarction
Obstruction of the blood supply to an organ or region of tissue, typically by a thrombus or embolus, causing death of tissue
Myocardial infarction (MI)
Occurs because of abrupt stoppage of blood flow through a coronary artery from a thrombus caused by platelet aggregation. This causes irreversible myocardial cell death (necrosis) in the heart muscle beyond the blockage
How does the respiratory system regulate acid base balance?
Respiratory Buffers Second line of defense Control the level of hydrogen ions in the blood through control of CO2, a signal is sent to the brain to alter the rate and depth of respiration Hyperventilation: decrease in hydrogen ions ( helps to blow off excess hydrogen ions) Hypoventilation: Increase in hydrogen ions The lungs help maintains a normal pH by control the CO2 levels. The amount of CO2 in the blood directly relates to carbonic acid concentration and subsequently to H+ concentration. If increased amounts of CO2 or H+ are present, the respiratory center stimulates an increased rate and depth of breathing to "blow off" CO2 through hyperventilation. If the center sense low H+ or CO2 retained.
What is a stress test and when is it used?
Shows how your heart works during physical activity. Because exercise makes your heart pump harder and faster, an exercise stress test can reveal problem with blood flow within your heart. Many HCP order low-level exercise stress test before discharge to assess readiness for discharge, optimal HR for an exercise program, and potential for ischemia or reinfarction. If tests are positive (i.e ischemia at a low level of energy expenditure), the patient is evaluated for cardiac catheterization before discharge. If the test is negative, a catheterization may still be done before discharge or several weeks after discharge.
Hypotonic (hypo- under/beneath) (tonic - concentration of solution) Low percentage of saline
Solutions in which the solutes are less concentrated than in the cell. If a cell is surrounded by hypotonic fluid, water moves into the cell, causing it to swell and possibly burst. Side effects of hypotonic solutions: Causes a cell to lyses (rupture/death) Deplete circulatory system fluid (make them hypovolemic) Fluid Types: 0.45% Saline (1/2 Normal saline) 0.225% Saline (1/4 Normal saline) 0.33% Saline (1/3 Normal saline) Why are they used: To rehydrate the cell Patients who are going through DKA Hyperosmolar hyperglycemia Don't Give To: Patients who have increase cranial pressure (because it will shift fluid to brain tissue and cause swelling) Burns (already hypovolemic) Trauma (already hypovolemic)
Angioplasty
Surgical repair or unblocking of a blood vessel, especially a coronary artery
When is physical activity including sexual activity resumed post MI?
Tell the patient to always "listen to what your body is saying"—most important part of recovery In the hospital the activity level is gradually increased to that by the time of discharge the patient can tolerate moderate energy activity of 3 to 6 METs. By day 2 the patient can walk in the hallway and begin stair climbing. The patient should always listen to their bodies Sex depends on the patient and his or her partner's emotional readiness and on the HCP's assessment of the extent of recovery. It is generally safe to resume sexual activity 7 to 10 days after an uncomplicated MI.
Discuss the role of age, gender, genetics, and ethnicity in the development of CAD.
The incidence of CAD is highest among middle-aged men. After age 75, the incidence of serious heart events in men and women equalizes, although CAD causes more deaths in women than men. Genetic predisposition is an important factor in the occurrence of CAD. Family history is a risk factor for CAD and MI. Often patient with angina or MI can name a parent or sibling who died from CAD.
What is ventricular remodeling?
The infarcted heart muscle also causes chanes in the unaffected areas. In an attempt to compensate for damage muscle, the normal myocardium hypertrophies and dilates. Remodeling of normal myocardium can lead to the development of late HF, especially in the person with atherosclerosis of other coronary arteries and/or an anterior MI. ACE inhibitors are given to limit ventricular remodeling.
Discuss components of patient and family teaching post MI.
Timing is important. When a patients and caregivers are in crisis (either physiologic or psychologic), they may not be ready to learn new information. Limit use of medical terms. Explain to the patient the chest tightness or pain is the heart message that it is having trouble doing it work. Use models of the heart to support what you explaining to the patient Anticipatory guidance involves the patient and caregiver for what to expect in the course of recovery and rehabilitation. By learning what to expect during treatment and recovery gives the patient a senses of control over his or her life. The idea of perceived control is operationalized as the process by which the patient making decision by cutting back. Cutting back is one way of reducing the psychologic and physiologic losses after ACS In additional to teaching the patient and caregiver what they wish to known, several types of information are essential in achieving optimal health
What factors contribute to the formation of collateral circulation?
Two factor contribute to the growth and extent of collateral circulation: inherited predisposition to develop new blood vessels (angiogenesis) presence of chronic ischemia
Compare and contract unstable angina, non-ST segment elevation MI (NSTEMI), ST segment elevation MI (STEMI).
Unstable angina (UA): is chest pain that is new in onset, occurs at rest, or occurs with increasing frequency, duration, or with less effort than the patient's chronic stable angina pattern. The pain usually last 10 minutes or more. Prompt treatment is needed for patients with suspected UA. UA is unpredictable. Women seek medical attention for symptoms of UA more often than men. Despite efforts to increase awareness, women's symptoms continue to be underrecognized as heart related. These symptoms include fatigue, shortness of breath, indigestion, and anxiety. Fatigue is the most prominent symptoms, but all these symptoms can relate to many different disease and syndrome. Non-ST segment elevation MI (NSTEMI): caused by nonocclusive thrombus, does not cause ST segment elevation on the 12-lead ECG. Patient may or may not develop ST-T wave changes in the leads affect by the infarction. NSTEMI patients do not go to the catheterization laboratory emergently but usually undergo the procedure 12-72 hrs if there are no contraindications. Thrombolytic therapy is not indicated for NSTEMI patient. ST segment elevation (STEMI): caused by an occlusive thrombus creates ST-elevation in the ECG lead facing the area of infarction. This is an emergency situation. To limit the infarct size, the artery must be opened withing 90 minutes of presentation. This can be done by either PCI or thrombolytic (fibrinolytic) therapy. PCI is the first line treatment if a hospital is capable of performing PCI
Cardiac catheterization
Uses radiation and IV contrast to provide images of the coronary circulation and identify the location and severity of any blockage. This procedure should only e done if the patient is a candidate for percutaneous or surgical coronary revascularization
When is a cardiac catheterization performed?
When a patient is a candidate for percutaneous or surgical coronary revascularization
What role does collateral circulation play in an AMI?
When blockages in coronary arteries occur slowly over a long period, there is a greater chance of collateral circulation developing and the heart muscle may still receive an adequate amount of blood and O2
Acute coronary syndrome (ACS)
When ischemia is prolonged and not immediately reversible ACS develops. This is a term used to describe a range of conditions associated with sudden, reduced blood flow to the heart. ACS includes the spectrum of UA, non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment-elevation myocardial infraction (STEMI) Often causes severe chest pain or discomfort.
How is an ECG useful in management of ACS and AMI?
When possible, it should be compared to a previous ECT. Changes in the QRS complex, ST segment, and T waves caused by ischemia and infarction can develop slowly or quickly with UA and MI. STEMI patient usually have a complete coronary occlusion. ST elevation is first seen on the 12 lead ECG. Within a few hour to days, T wave inversion and pathologic Q waves develop. Patient with NSTEMI or UA usually have transient thrombosis or incomplete coronary occlusion. These patients often develop ST depression or T wave inversion on the initial ECG. They usually do not develop pathologic Q waves. MI is a dynamic process that evolves over time, serial ECGs are done to show the evolution of ischemia, injury, infarction, and resolution of the infarction.
What are normal ranges for pH, PaCO2, PaO2, HCO3, SaO2 (use the Lewis text as a reference)?
pH: 7.35-7.45 PaCO2: 35-45 PaO2: 80-100 HCO3: 22-26 SaO2: >95%
Sudden cardiac death
results when treatment of cardiac arrest is not provided within a few minutes
How long does it take for irreversible heart damage to occur without adequate blood flow?
After 20 minutes
How are ABGs obtained?
An ABG is a blood test carried out by taking blood from an artery rather than a vein. It is performed so that an accurate measurement of oxygen and carbon dioxide levels can be obtained. ABG test require a small volume of blood to be drawn from the radial artery but sometime a femoral artery in the groin or another site is used.
Collateral circulation
Are arterial anastomoses or connections that exist within the coronary circulation. Two factors contribute to the growth and extent. Inherited predisposition to develop new blood vessels Presence of chronic ischemia When plaque blocks the normal flow of blood through a coronary artery and the resulting ischemia is chronic, increased collateral circulation develop. When blockages in coronary arteries occur slowly over a long period, there is a greater chance of collateral circulation developing and the heart muscle may still receive an adequate amount of blood and O2
Electrolytes
Are substances whose molecules dissociate or split into ions when placed in water. They are: Sodium (Na+) Potassium (K+) Calcium (Ca2+) Magnesium (Mg2+) Bicarbonate (HCO3-) Chloride (Cl-) Phosphate (PO43-)
Discuss the components of client teaching to reduce risk factors for coronary artery disease.
Assess environmental factors, such as eating habits, type of diet, and level of exercise, to elicit lifestyle pattern. Include psychosocial history to determine tobacco use, alcohol intake, recent stressful events (eg, loss of a spouse) and any negative psychologic states (e.g. anxiety, depression, anger). Place of employment provide information on kind of activities performed, exposure to pollution or toxins, and degree of stress associated with work. Identify the patient's attitudes and beliefs about health and illness. Knowing the patients educational background and health literacy can help identify teaching needs. It is important to know the names and dosages and if the patient adheres to the drug regimen. Encourage people who have modifiable risk factors to make lifestyle changes to reduce their risk of CAD.
What is atherosclerosis and how does it contribute to CAD?
Atherosclerosis is soft deposits of fat that hardens with ages. It is a major cause of CAD. It is characterized by lipid deposits within the intima of the artery. Endothelial injury and inflammation play a central role in the development of atherosclerosis. Atherosclerosis causes narrowing or total occlusion of the vessel. Which may lead to an accumulation of platelets leading to a thrombus. Which will not allow blood to flow through.
Atherosclerosis
Begins as soft deposits of fat that harden with age
What is coronary artery bypass (CABG) and how does it help clients with an MI?
CABG surgery consists of the placement of arterial or venous grafts to provide blood between the aorta or other major arteries and the heart muscle distal to blocked coronary artery. It allows blood to bypass the blockage while restoring blood flow to the area of the heart muscle supplied by that artery.
Prioritize nursing interventions for each type of acid base imbalance. For example: in a client with COPD and respiratory acidosis what are your nursing priorities? A client with DKA? A client with excessive vomiting? A client with anxiety induced hyperventilation?
COPD and respiratory acidosis: DKA: Excessive vomiting: Anxiety induced hyperventilation: Nursing care: Oxygen therapy Anxiety reduction intervention Rebreathing techniques
What lab tests (serum cardiac biomarkers) are used to determine the presence of unstable angina, NSTEMI, and STEMI?
Cardiac-specific troponin: these biomarkers are highly specific indicators of MI and have greater sensitivity and specificity for myocardial injury Normal range 0-0.4 Creatine Kinase (CK) begin to rise about 6 hours after an MI peak abut 18 and return to normal within 24-36 hrs Normal range 22-198 Myoglobin is released 2 hours after an MI and peaks in 3 to 15 hrs Normal Range 25-72
What are Trousseau's and Chvostek's signs?
Caused by hypocalcemia which causes an increase in nerve excitability and sustained muscles contraction. Trousseau's sign refers to carpal spasms induced by inflating a BP cuff on the arm. When the cuff is inflated about the systolic pressure, carpal spasm occurs within 3 minutes if hypocalcemia is present. Chvostek's sign is contraction of the facial muscles in response to a tap over the facial nerve in front of the ear
Unstable angina
Chest pain that is new in onset, occurs at rest or occurs with increasing frequency, duration, or with less effort than the patient's chronic stable angina pattern. The pain usually last 10 minutes or more
Angina
Chest pain, is the clinical manifestation of myocardial ischemia. It is caused by either an increased demand for O2 or a decreased supply of O2. Most common reason for angina to develop is narrowing of one or more coronary arteries by atherosclerosis.
What is the difference between acidosis and alkalosis?
Acidosis (below 7.35) Is too much acid High hydrogen ions Low PH Alkalosis (above 7.45) Is too much base Lower hydrogen ions Elevated pH
Discuss assessment findings associated with: Hypokalemia Hyperkalemia Hyponatremia Hypernatremia Hyperphosphatemia Hypocalcemia Hypercalcemia Hypomagnesemia Hypermagnesemia
Hypokalemia (below 3.5): Vital Signs: Decreased BP Thready weak pulse Orthostatic hypotension Neurologic: Altered mental status Anxiety Lethargy that progress to acute confusion and coma ECG: Flatten T wave Prominent U waves ST depression Prolonged PR interval Gastrointestinal: Hypoactive bowel sounds Nausea Vomiting Constipation Abdominal distention Paralytic ileus can develop Muscular: Weakness Deep-tendon reflexes can be reduced Respiratory: Shallow breathing Complications: Respiratory failure, cardiac arrest Hyperkalemia (above 5.0): Vital signs: Slow irregular pulse Hypotension Neuromusculoskeletal: Restlessness Irritability Weakness to the point of ascending flaccid paralysis paresthesia ECG: Premature ventricular contractions Ventricular fibrillation Peaked T waves Widened QRS Gastrointestinal: Increased motility Diarrhea Hyperactive bowel sounds Other Manifestations: Oliguria (low urine) Hyponatremia (below 135): Vital Signs: Hypothermia Tachycardia Rapid thread pulse Hypotension Orthostatic hypotension Diminished peripheral pulses Neuromusculoskeletal: Headache Confusion Lethargy Muscle weakness to the point of possible respiratory compromise Fatigue Decreased deep-tendon reflexes Seizures Lightheadedness Dizziness Gastrointestinal: Increased motility Hyperactive bowel sounds Abdominal cramping Nausea Complications: Coma, seizures, respiratory arrest can result if not treated immediately Hypernatremia (above 145): Vital Signs: Hyperthermia, Tachycardia Orthostatic Hypotension Neuromusculoskeletal: Restlessness Irritability Muscle twitch to the point of muscle weakness (including respiratory compromise) Decreased or absent DTRs Seizures Coma Gastrointestinal: Thirst Dry mucous membranes Nausea Vomiting Anorexia Occasional diarrhea Severe hypernatremia: Seizures, convulsion, and death can result if not treated immediately Hypocalcemia (below 8.6) Paresthesia of the fingers and lips Muscle twitches as hypocalcemia progress Seizure due to irritability of the central nervous system Frequent, painful muscle spasms at rest in the foot or calf Hyperactive DTRs Positive Chvostek's sign Positive Trousseau's sign Hypercalcemia (above 10.2) Hypomagnesemia (below 1.5) Hypermagnesmia (above 2.5)
How does cardiac catheterization contribute to the management of ACS, AMI?
Identifies the location and severity of any blockages. Any patient who is allergic to the dye must be premedicated with corticosteroids. Patient with chronic kidney disease need hydration pre-and postprocedure.
Acidosis
If the person blood pH drops below 7.35 With increase H+ levels, H+ enters the CELL in exchange for potassium. This may result in hyperkalemia.
Alkalosis
If the person blood pH is greater than 7.45 With decreased H+ levels, H+ enters the Plasma in exchange for potassium which can cause hypokalemia
Why are acid base imbalances harmful to clients?
In both types acidosis the CNS is depressed. Headache, lethargy, weakness, and confusion develop, leading eventually to coma and death. In both types of alkalosis it can affect the cardiovascular system causing tachycardia, and dysrhythmias. Patients may develop seizures, hypoventilation, and coma. If the electrolyte imbalance is not corrected.
What are arterial blood gases (ABGs)?
Is a blood test that measure the acidity, or pH, and the levels of oxygen (O2)and carbon dioxide (CO2) from an artery. The test is used to check the function of the patient's lung and how well they can move oxygen into the blood and remove carbon dioxide.
Ischemia
Is a condition in which the blood flow and thus oxygen is restricted or reduced in part of the body
Buffers
Is a mixture of acid-base pair that can resist changes in pH when small volumes of strong acid or bases are added. There are three different type of buffers: Chemical (bicarbonate and intracellular fluid) and protein buffers ( albumin and globulins First line of defense Either bind or releases hydrogen ions as needed Respond quickly to changes in pH
Prinzmetal's angina
Is a rare form of angina that often occurs at rest and not with increased physical demand. It is sometimes seen in patient with a history of migraine headaches, Raynaud's phenomenon, and heavy smoking
Describe the clinical manifestations of MI?
Pain. Sever chest pain not relieved by rest, positional change, or nitrate administration is the hallmark of an MI. Persistent and unlike any other pain, it is usually described as heavy, pressure, tight, burning, constricted, or crushing feeling. Common location are substernal or epigastric areas. The pain may radiate to the neck, lower jaw, and arms or the back. Some patients may not experience pain but may have discomfort weakness, nausea, indigestion, or shortness of breath. Some women experience atypical discomfort, shortness of breath, or fatigue. Diabetics may experience silent MI because of cardiac neuropathy or may manifest a typical symptoms (e.g. dyspnea) An older patient may experience a change in mental status, shortness of breath, pulmonary edema, dizziness, or dysrhythmia. Sympathetic nervous system Stimulation. Increased HR and BP, and vasoconstriction of peripheral blood vessel. On physical examination, the patient's skin may be ashen, clammy, and cool to touch. Cardiovascular Manifestations. BP and HR may be elevated initially. Later, the BP may drop because of decrease cardiac output. If severe enough this may result in decrease renal perfusion and urine output. Crackles if present may persist for several hours to several days, suggesting LV dysfunction. Jugular venous distention, hepatic engorgement, and peripheral edema may indicate right ventricle dysfunction. Examination may reveal abnormal heart sounds that may seem distant. Other abnormal sound suggest LV dysfunction are S3 and S4. In addition a loud holosystolic murmur may develop. This may indicate a ventricular septal defect, papillary muscle rupture or valve dysfunction Nausea and vomiting. These symptoms can result from reflex stimulation of the vomiting centered by the severe pain Fever. May increase to 100.4F within 24 to 48 hrs. May last up to 4 to 5 days. The increased temperature is due to a systemic inflammatory process caused by the death of heart cells
What is the normal range of table values (using the Lewis textbook) for: Potassium Sodium Phosphate Calcium Magnesium
Potassium 3.5-5.0 mEq/L Sodium 135-145 mEq/L Phosphate 3.5-5.0 mEq/L Calcium 8.6-10.2 mg/dL Magnesium (MG2) 1.5-2.5 mEq/L
What happens to potassium levels with acidosis? Alkalosis?
Potassium Level Normal: 3.5-5 Acidosis Level: Hyperkalemia above 5 (cardia dysrhythmia) Alkalosis Level: Hypokalemia below 3.5
What is the difference between Prinzmetal's angina, chronic stable angina, and unstable angina?
Prinzmetal's angina: Etiology: Coronary vasospasm Occurs primarily at rest Triggered by smoking and increased level of some substances (e.g. histamine, epinephrine, cocaine) Chronic stable angina: Etiology: Myocardial ischemia (usually secondary to CAD) caused by an O2 supply/demand mismatch Episodic pain lasting a few minutes Provoked by exertion or stress Relieved by rest or nitroglycerin Unstable angina: Etiology: Rupture of unstable plaque, exposing thrombogenic surface New-onset angina Chronic stable angina that increase in frequency, duration, or severity Occurs at rest or even minimal exertion Last more than 10 mins
Chronic stable angina
Refers to chest pain that occurs with intermittently over a long period of time with a similar pattern of onset, duration, and intensity of symptoms. It is often provoked by physical exertion, stress, or emotional upset. When the physical exertion, stress or emotional upset is gone so is the pain When asked some patients may deny feeling pain but describe a pressure heaviness or discomfort in the chest.
