210 Test 1

TB Sputum culture

A sputum specimen may be used to screen for TB. The presence of AFB on a sputum smear may indicate disease but does not confirm the diagnosis of TB because some AFB are not M. tuberculosis. A culture is done to confirm the diagnosis. For all patients, the initial M. tuberculosis isolate should be tested for drug resistance

Complications

Complications that can occur during a PCI procedure include coronary artery dissection, perforation, abrupt closure, or vasospasm. Additional complications include acute MI, serious arrhythmias (e.g., ventricular tachycardia), and cardiac arrest. Some of these complications may require emergency surgical treatment. Complications after the procedure may include abrupt closure of the coronary artery and a variety of vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion (Urden et al., 2019). In addition, there is a risk of acute kidney injury from the contrast agent used during the procedure

Medical Management MI

The goals of medical management are to minimize myocardial damage, preserve myocardial function, and prevent complications. These goals are facilitated by the use of guidelines developed by the ACC and the AHA (see Chart 23-7). The goal for treating patients with acute MI is to minimize myocardial damage by reducing myocardial oxygen demand and increasing oxygen supply with medications, oxygen administration, and bed rest. The resolution of pain and ECG changes indicate that demand and supply are in equilibrium; they may also indicate reperfusion. Visualization of blood flow through an open vessel in the catheterization laboratory is evidence of reperfusion.

Status Asthmaticus

An asthma exacerbation can range from mild to severe with potential respiratory arrest (GINA, 2019a). The term status asthmaticus is sometimes used to describe rapid onset, severe, and persistent asthma that does not respond to conventional therapy. The attacks can occur with little or no warning and can progress rapidly to asphyxiation. Infection, anxiety, inhaler abuse, dehydration, increased adrenergic blockage, and nonspecific irritants may contribute to these episodes. An acute episode may be precipitated by hypersensitivity to medications, such as aspirin, beta-blockers, and nonsteroidal anti-inflammatory drugs (NSAIDs)

cont

AUSCULTATION Auscultation may reveal a variety of adventitious breath sounds. Fine or coarse crackles and scattered or localized wheezing might be present. With progressive obstructive pulmonary involvement, breath sounds might be diminished. Tachycardia might be present. Note the presence of a gallop (might occur with cor pulmonale). Note the adequacy of bowel sounds.

Myocardial Infarction

Acute coronary syndrome (ACS) is an emergent situation characterized by an acute onset of myocardial ischemia that results in myocardial death (i.e., MI) if definitive interventions do not occur promptly. (Although the terms coronary occlusion, heart attack, and myocardial infarction are used synonymously, the preferred term is myocardial infarction.) The spectrum of ACS includes unstable angina, NSTEMI, and ST-segment elevation myocardial infarction (STEMI).

Surgical Procedures: Coronary Artery Revascularization

Advances in diagnostics, medical management, and surgical and anesthesia techniques, as well as the care provided in critical care and surgical units, home care, and rehabilitation programs, have continued to make surgery an effective treatment option for patients with CAD. CAD has been treated by myocardial revascularization since the 1960s, and the most common CABG techniques have been performed for more than 40 years. Coronary artery bypass graft (CABG) is a surgical procedure in which a blood vessel is grafted to an occluded coronary artery so that blood can flow beyond the occlusion; it is also called a bypass graft. The major indications for CABG are: - Alleviation of angina that cannot be controlled with medication or PCI - Treatment for left main coronary artery stenosis or multivessel CAD - Prevention of and treatment for MI, arrhythmias, or heart failure - Treatment for complications from an unsuccessful PCI The recommendation for CABG is determined by a number of factors, including the number of diseased coronary vessels, the degree of left ventricular dysfunction, the presence of other health problems, the patient's symptoms, and any previous treatment. CABG and PCI have shown similar results in outcomes, such as MI rate, mortality, and improvement of angina post-intervention. However, the requirement of a second reperfusion intervention has been shown to be lower with CABG compared to PCI therapy

Coronary Artery Stent

After PTCA, the area that has been treated may close off partially or completely—a process called restenosis. The intima of the coronary artery has been injured and responds by initiating an acute inflammatory process. This process may include release of mediators that leads to vasoconstriction, clotting, and scar tissue formation. A coronary artery stent may be placed to overcome these risks. A stent is a metal mesh that provides structural support to a vessel at risk of acute closure. The stent is initially positioned over the angioplasty balloon. When the balloon is inflated, the mesh expands and presses against the vessel wall, holding the artery open. The balloon is withdrawn, but the stent is left permanently in place within the artery (see Fig. 23-7). Eventually, endothelium covers the stent and it is incorporated into the vessel wall. The original stents do not contain medications and are known as bare metal stents. Some stents are coated with medications, such as sirolimus or paclitaxel, which may minimize the formation of thrombi or scar tissue within the coronary artery lesion. These drug-eluting stents (DES) have increased the success of PCI (Mishra, Edla, Tripathi, et al., 2019). Because of the risk of thrombus formation within the stent, the patient receives antiplatelet medications, usually aspirin and clopidogrel. Aspirin should be continued indefinitely and clopidogrel is continued for 1 year following stent placement (Urden et al., 2019).

TB patho cont

After initial exposure and infection, active disease may develop because of a compromised or inadequate immune system response. Active disease also may occur with reinfection and activation of dormant bacteria. In this case, the Ghon tubercle ulcerates, releasing the cheesy material into the bronchi. The bacteria then become airborne, resulting in the further spread of the disease. Then, the ulcerated tubercle heals and forms scar tissue. This causes the infected lung to become more inflamed, resulting in the further development of bronchopneumonia and tubercle formation. Unless this process is arrested, it spreads slowly downward to the hilum of the lungs and later extends to adjacent lobes. The process may be prolonged and is characterized by long remissions when the disease is arrested, followed by periods of renewed activity. Approximately 10% of people who are initially infected develop active disease (Pozniak, 2019). Some people develop reactivation TB (also called adult-type progressive TB). The reactivation of a dormant focus occurring during the primary infection is the cause.

CAD risk factors

Although many people with CAD have one or more risk factors, some do not have classic risk factors. Elevated low-density lipoprotein (LDL), also known as bad cholesterol, is a well-known risk factor and the primary target of cholesterol-lowering therapy. People at the highest risk for having a cardiac event are those with known CAD or those with diabetes, peripheral arterial disease, abdominal aortic aneurysm, or carotid artery disease. The latter diseases are referred to as CAD risk equivalents, because patients with these diseases have the same risk for a cardiac event as patients with CAD. The likelihood of having a cardiac event is also affected by factors, such as age, gender, systolic blood pressure, smoking history, level of total cholesterol, and level of high-density lipoprotein (HDL), also known as good cholesterol. A cluster of metabolic abnormalities known as metabolic syndrome has emerged as a major risk factor for cardiovascular disease. A diagnosis of this syndrome is made when a patient has three of the following five risk factors: Enlarged waist circumference (greater than 35.4 inches in males, greater than 31.4 inches in females) Elevated triglycerides (greater than or equal to 175 mg/dL, or currently on drug treatment for elevated triglycerides) Reduced HDL (less than 40 mg/dL in males, less than 50 mg/dL in females, or currently on drug treatment for reduced HDL) Hypertension (systolic blood pressure greater than or equal to 130 mm Hg and/or diastolic blood pressure greater than or equal to 80 mm Hg on an average of two to three measurements obtained on two to three separate occasions, or currently on antihypertensive drug treatment for a history of hypertension) Elevated fasting glucose (greater than or equal to 100 mg/dL on two separate occasions, or current drug treatment for elevated glucose)

Angina pectoris Pathophysiology

Angina is usually caused by atherosclerotic disease and most often is associated with a significant obstruction of at least one major coronary artery. Normally, the myocardium extracts a large amount of oxygen from the coronary circulation to meet its continuous demands. When demand increases, flow through the coronary arteries needs to be increased. When there is a blockage in a coronary artery, flow cannot be increased and ischemia results. The types of angina are listed in Chart 23-2. Several factors are associated with typical anginal pain: Physical exertion, which precipitates an attack by increasing myocardial oxygen demand Exposure to cold, which causes vasoconstriction and elevated blood pressure, with increased oxygen demand Eating a heavy meal, which increases the blood flow to the mesenteric area for digestion, thereby reducing the blood supply available to the heart muscle; in a severely compromised heart, shunting of blood for digestion can be sufficient to induce anginal pain.Stress or any emotion-provoking situation, causing the release of catecholamines, which increases blood pressure, heart rate, and myocardial workload.

Angina Pectoris

Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest. The cause is insufficient coronary blood flow, resulting in a decreased oxygen supply when there is increased myocardial demand for oxygen in response to physical exertion or emotional stress. In other words, the need for oxygen exceeds the supply.

Medical Management: CF cont

Anti-inflammatory agents may be used to treat inflammatory response in the airways. There is insufficient evidence for the use of routine inhaled or oral corticosteroids. IV corticosteroids are used during acute exacerbations and only for those patients with asthmalike symptoms (Simon et al., 2019b). Inhaled bronchodilators (e.g., salmeterol, tiotropium bromide) may be used in patients who have a significant bronchoconstrictive component; this is confirmed by spirometry before and after therapy is instituted Pancreatic exocrine insufficiency occurs frequently in people with CF and requires oral pancreatic enzyme supplementation with meals. Given the fat malabsorption in CF and increased caloric needs due to the work of breathing, nutritional counseling and weight monitoring are extremely important. Supplements of fat-soluble vitamins A, D, E, and K are also used. CFTR modulators are a class of drugs that help prevent the progression of CF (Simon et al., 2019c). These agents are novel in that they aim to address the cause of CF as opposed to treating symptoms. There are two classes of modulators used in treating CF: potentiators (help salt and water flow through the CFTR protein channel at the cell surface) and correctors (help the CFTR protein to form the right 3D shape so that it is able to move to the cell surface). The selection of the CFTR modulator depends on the patient's specific CFTR mutation and the patient's age. Ivacaftor, a potentiator, improves salt and water movement across the membrane (thus improving hydration and clearing of mucus from the airways). The drug does not correct the gene mutation; it only helps in the movement of salt and water across the membrane. Monotherapy of ivacaftor is approved for patients with CF who are 6 months of age and older.

Nursing Considerations for Patients Receiving Mucolytics

Assessment: History and Examination • Assess for possible contraindications or cautions: any history of allergy to the drugs and the presence of acute bronchospasm, which are contraindications to the use of these drugs. • Perform a physical examination to establish baseline data for assessing the effectiveness of the drug and the occurrence of any adverse effects associated with drug therapy. • Assess skin color and lesions to monitor for adverse reactions. • Monitor blood pressure and pulse to evaluate cardiac response to drug treatment. • Evaluate respirations and adventitious sounds to monitor drug effectiveness. Nursing Conclusions Nursing conclusions related to drug therapy might include • Impaired comfort related to GI, CNS, or skin effects of the drug • Altered sensory perception (kinesthetic) related to CNS effects • Ineffective airway clearance related to bronchospasm • Knowledge deficit regarding drug therapy Planning • The patient will receive the best therapeutic effect from the drug therapy. • The patient will have limited adverse effects from the drug therapy. • The patient will have an understanding of the drug therapy, adverse effects to anticipate, and measures to relieve discomfort and improve safety.

Diagnosis

Based on the clinical manifestations, history, and diagnostic assessment data, major nursing diagnoses may include: •Acute pain associated with increased myocardial oxygen demand and decreased myocardial oxygen supply •Risk for impaired cardiac function associated with reduced coronary blood flow •Risk for hypovolaemia •Impaired peripheral tissue perfusion associated with impaired cardiac output from left ventricular dysfunction •Anxiety associated with cardiac event and possible death •Lack of knowledge about post-ACS self-care

BOX 54.5 Targeted Treatment of Cystic Fibrosis

Between 2012 and 2019, several medications were approved by the FDA for treatment of cystic fibrosis. Ivacaftor (Kalydeco) and combination medications that include ivacaftor (Orkambi, Symdeko, and Trikafta) are designed as targeted treatment for patients with cystic fibrosis. Ivacaftor is a cystic fibrosis transmembrane conductance regulator (CFTR) that facilitates increased chloride transport at the surface of epithelial cells in multiple organs. In cystic fibrosis patients taking this drug, the end result was improved lung function. Ivacaftor is approved for patients 4 months of age and older who have a type of CFTR gene mutation that is responsive to ivacaftor. If the patient's genotype is not known, tests should be run to attempt to detect a CFTR mutation. The FDA has approved a cystic fibrosis mutation test that can be used to determine the appropriateness of this drug. It is an oral agent and needs to be used with caution in patients with liver impairment or those also using CYP3A inhibitors. The most common adverse effects include abdominal pain, rash, nausea, dizziness, headache, and sore throat. A serious but rare effect can be the development of noncongenital lens opacities/cataracts in pediatric patients.

CABG

CABG is performed less frequently in women (Angraal, Khera, Wang, et al., 2018). Compared with men, women referred for this surgery tend to be older and have more comorbidities such as diabetes. In addition, they have a higher risk of surgical complications and increased mortality (Angraal et al., 2018). Although some women have good outcomes following CABG, men generally have a better rate of graft patency and symptom relief. For a patient to be considered for CABG, the coronary arteries to be bypassed must have at least a 70% occlusion, or at least a 50% occlusion in the left main coronary artery (Urden et al., 2019). If significant blockage is not present, flow through the artery will compete with flow through the bypass, and circulation to the ischemic area of myocardium may not improve. The artery also must be patent beyond the area of blockage or the flow through the bypass will be impeded.

Complications of Coronary Artery Bypass Graft

CABG may result in complications such as hemorrhage, arrhythmias, and MI (see Table 23-4). The patient may require interventions for more than one complication at a time. Collaboration among nurses, physicians, pharmacists, respiratory therapists, and dietitians is necessary to achieve the desired patient outcomes. Although most patients improve symptomatically following surgery, CABG is not a cure for CAD, and angina, exercise intolerance, or other symptoms experienced before CABG may recur. Medications required before surgery may need to be continued. Lifestyle modifications recommended before surgery remain important to treat the underlying CAD and for the continued viability of the newly implanted grafts.

CAD Clinical Manifestations

CAD produces symptoms and complications according to the location and degree of narrowing of the arterial lumen, thrombus formation, and obstruction of blood flow to the myocardium. This impediment to blood flow is usually progressive, causing an inadequate blood supply that deprives the cardiac muscle cells of oxygen needed for their survival. The condition is known as ischemia. Angina pectoris refers to chest pain that is brought about by myocardial ischemia. Angina pectoris usually is caused by significant coronary atherosclerosis. If the decrease in blood supply is great enough, of long enough duration, or both, irreversible damage and death of myocardial cells may result. Over time, irreversibly damaged myocardium undergoes degeneration and is replaced by scar tissue, causing various degrees of myocardial dysfunction. Significant myocardial damage may result in persistently low cardiac output and heart failure where the heart cannot support the body's needs for blood. A decrease in blood supply from CAD may cause the heart to abruptly stop beating; this is known as sudden cardiac death.

Pathophysiology: CF

CF is caused by mutations or dysfunction in the protein cystic fibrosis transmembrane conductance regulator (CFTR), which normally transports chloride ions across epithelial cell membranes. Gene mutations affect transport of these ions, leading to CF, which is characterized by thick, viscous secretions in the lungs, pancreas, liver, intestine, and reproductive tract as well as increased salt content in sweat gland secretions. The most common mutation is ΔF508; however, researchers have identified more than 1700 mutations of the disease (CFF, 2019a). The numerous mutations of the CFTR gene create multiple variations in the presentation and progression of the disease. The ability to detect the common mutations of this gene allows for routine screening for CF and the detection of carriers of the disease. Genetic counseling is an important part of health care for couples at risk (see Chapter 6). People who are heterozygous for CF (i.e., have one defective gene and one normal gene) do not have the disease but can be carriers and pass the defective gene on to their children. If both parents are carriers, their risk of having a child with CF is one in four (25%) with each pregnancy. Any biologic offspring of a patient with CF will have CF. Genetic testing should be offered to adults with a positive family history of CF and to partners of people with CF who are planning a pregnancy or seeking prenatal counseling. The hallmark pathology of CF is bronchial mucus plugging, inflammation, and eventual bronchiectasis. Commonly, the bronchiectasis begins in the upper lobes and progresses to involve all lobes.

Cystic Fibrosis

CF is the most common fatal autosomal recessive disease among Caucasians. It is less frequently found among Hispanic, Asian, and African Americans. A person must inherit a defective copy of the CF gene (one from each parent) to have CF. Approximately 30,000 children and adults in the United States have CF and half are over the age of 18. CF was once a fatal childhood disease; however, the median expected survival age is now 37. The improved survival rate is due to advances in medical management and procedures such as lung transplantation. Now that the median survival age has increased to 37 years for patients with CF, issues that were not present in past generations have arisen. These issues include antibiotic resistance and the desire for patients with CF to have their own biologic children. Although most patients are diagnosed by 2 years of age, this disease may not be diagnosed until later in life (CFF, 2019b). Respiratory symptoms are frequently the major manifestation of CF when it is diagnosed later in life. These patients will not demonstrate the classic symptoms of CF, which may potentially cause a diagnostic dilemma.

Medical Management: CF

CF requires both acute and chronic therapy. Cornerstones of treatment include multimodal antibiotic regimens, airway clearance measures, bronchodilators, CFTR modulators, nutritional support, and exercise (Simon et al., 2019a). Multimodal antibiotic regimens use different types of antibiotics and routes (oral, inhaled, and IV) to help control, suppress, and treat exacerbation of bacterial infections. Airway clearance measures entail the use of the mucolytics (e.g., dornase alfa; see later discussion), inhaled hypertonic saline, and various pulmonary techniques that promote mucus expectoration. Because chronic infection (viral and bacterial) of the airways occurs in CF, control of infections is essential to treatment. It is best to prevent viral infections. Administering viral influenza vaccinations is essential for CF patients. Due to the increased risk of viral influenza, some CF patients may benefit from prophylactic treatment with a neuraminidase inhibitor (e.g., zanamivir, oseltamivir)

Cystic Fibrosis patho book

CF, which is the major cause of severe chronic respiratory disease in children, is an autosomal recessive disorder involving the exocrine glands in the epithelial lining of the respiratory, gastrointestinal, and reproductive tracts.31 CF affects about 30,000 children and adults in the United States, and more than 10 million persons are asymptomatic carriers of the defective gene.31 The defective gene, cystic fibrosis transmembrane regulator (CFTR), and its protein product cause excessive thick mucus that obstructs lungs and the pancreas. In addition to chronic respiratory disease, CF is manifested by pancreatic exocrine deficiency and elevation of sodium chloride in the sweat. Nasal polyps, sinus infections, pancreatitis, and cholelithiasis also are seen with CF. Most boys with CF have congenital bilateral absence of the vas deferens with azoospermia.

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: •Acute pulmonary edema (see Chapter 25) •Heart failure (see Chapter 25) •Cardiogenic shock (see Chapter 11) •Arrhythmias and cardiac arrest (see Chapters 22 and 25) •Pericardial effusion and cardiac tamponade (see Chapter 25)

Cardiac Rehabilitation

Cardiac rehabilitation programs are categorized into three phases (Dickins & Braun, 2017). Phase I begins with the diagnosis of atherosclerosis, which may occur when the patient is admitted to the hospital for ACS. Because of brief hospital lengths of stay, mobilization occurs early and patient education focuses on the essentials of self-care rather than instituting behavioral changes for risk reduction. Priorities for in-hospital education include the signs and symptoms that indicate the need to call 911 (seek emergency assistance), the medication regimen, rest-activity balance, and follow-up appointments with the primary provider. The patient is reassured that although CAD is a lifelong disease and must be treated as such, they can likely resume a normal life after an MI. The amount and type of activity recommended at discharge depend on the patient's age, his or her condition before the cardiac event, the extent of the disease, the course of the hospital stay, and the development of any complications.

Nursing Management

Cardiac surgery patients have many of the same needs and require the same perioperative care as other surgical patients. Preoperative Management Comprehensive preoperative medical management prevents complications and improves outcomes. This is particularly important because patients undergoing CABG surgery tend to be older and often have multiple comorbidities. The use of aspirin, beta-blockers, and statins during the preoperative period is associated with better outcomes. Preoperative use of aspirin is associated with a reduction in perioperative morbidity and mortality (Aboul-Hassan, Stankowski, Marczak, et al., 2017). Beta-blockers, when given at least 24 hours before CABG, reduce the incidence of postoperative atrial fibrillation (Urden et al., 2019). Perioperative use of statins has been shown to reduce the rates of postoperative MI, atrial fibrillation, neurologic dysfunction, renal dysfunction, infection, and death

MI Clinical Manifestations

Chest pain that occurs suddenly and continues despite rest and medication is the presenting symptom in most patients with ACS. Some of these patients have prodromal symptoms or a previous diagnosis of CAD, but others report no previous symptoms. Patients may present with a combination of symptoms, including chest pain, shortness of breath, indigestion, nausea, and anxiety. They may have cool, pale, and moist skin. Their heart rate and respiratory rate may be faster than normal. These signs and symptoms, which are caused by stimulation of the sympathetic nervous system, may be present for only a short time or may persist. In many cases, the signs and symptoms of MI cannot be distinguished from those of unstable angina; hence, the evolution of the term acute coronary syndrome.

Children TB cont

Children considered to be at high risk for contracting tuberculosis should be screened using the Mantoux test. High-risk children are those who: are infected with HIV. are incarcerated or institutionalized. have a positive recent history of latent tuberculosis infection. are immigrants from or have a history of travel to endemic countries. are exposed at home to HIV-infected or homeless persons, illicit drug users, persons recently incarcerated, migrant farm workers, or nursing home residents. Evaluate the health history for symptoms such as fever, malaise, weight loss, anorexia, pain and tightness in the chest, and rarely hemoptysis. Note whether cough is present or not, and if present if it has progressed slowly over several weeks to months. As tuberculosis progresses, note an increase in respiratory rate, diminished breath sounds and crackles with poor aeration in the affected lung. Percussion may reveal dullness. Keep in mind that some children are asymptomatic. Diagnosis is confirmed with a positive Mantoux test, positive gastric washings for acid-fast bacillus, interferon-gamma release assay (IGRA), and/or a chest radiograph consistent with tuberculosis.

Children with TB

Children usually contract the disease from an immediate household member. Homeless and impoverished children are at higher risk, as are those exposed to an adult with TB infection (Batra & Ang, 2018). After exposure to an infected individual, the incubation period is 2 to 10 weeks. The inhaled tubercle bacilli multiply in the alveoli and alveolar ducts, forming an inflammatory exudate. The bacilli are spread by the bloodstream and lymphatic system to various parts of the body. Though pulmonary tuberculosis is the most common, children may also have infection in other parts of the body, such as the gastrointestinal tract or central nervous system. Children who test positive for tuberculosis but who do not have symptoms or radiographic/laboratory evidence of disease are considered to have latent infection. In the case of drug-sensitive tuberculosis, the American Academy of Pediatrics (AAP) recommends a 6-month course of oral therapy. The first 2 months consist of isoniazid, rifampin, and pyrazinamide given daily. This is followed by twice-weekly isoniazid and rifampin; administration must be observed directly (usually by a public health nurse). In the case of multidrug-resistant tuberculosis, ethambutol or streptomycin is given via intramuscular injection (AAP, 2018). Children will latent tuberculosis are treated with isoniazid for 9 months to prevent progression to active disease.

Coronary Artery Disease

Coronary artery disease (CAD) is a term used to describe conditions that affect the arteries that provide nutrients, blood, and oxygen to the heart. Atherosclerosis, a known cause of CAD, is characterized by lipid deposits within the walls of the arteries. These plaques narrow arteries, obstructing blood flow. It increases the risk of angina and myocardial infarction. CAD is a progressive disease that develops over time. The condition is often advanced before the patient exhibits symptoms like angina, shortness of breath, and fatigue. When blood flow through the coronary arteries becomes partially or completely blocked, ischemia and infarction in the heart muscles occur. When insufficient blood and oxygen supply (ischemia) to the myocardium, decreased tissue perfusion and necrosis (infarction) will develop, requiring immediate intervention.

CABG continued

Current guidelines recommend use of the internal thoracic arteries (formerly called the internal mammary arteries) for CABG, because of their histologic characteristics and increased production of vasoactive molecules and anti-inflammatory cytokines which improve arterial patency. Recent studies demonstrate increased survival when using internal thoracic artery grafting. The left internal thoracic artery graft has been shown to have greater than 90% patency after 20 years and is the recommended conduit to use first (Gaudino et al., 2019). Arterial grafts are preferred to venous grafts because they do not develop atherosclerotic changes as quickly and remain patent longer. The surgeon leaves the proximal end of the thoracic artery intact and detaches the distal end of the artery from the chest wall. This end of the artery is then grafted to the coronary artery distal to the occlusion. The internal thoracic arteries may not be long enough to use for multiple bypasses. Because of this, many CABG procedures are performed with a combination of venous and arterial grafts.

CF PED

Cystic fibrosis is an autosomal recessive disorder that affects 30,000 children and adults in the United States (Cystic Fibrosis Foundation [CFF], n.d.). A deletion occurring on the long arm of chromosome 7 at the cystic fibrosis transmembrane conductance regulator (CFTR) is the responsible gene mutation. DNA testing can be used prenatally and in newborns to identify the presence of the mutation. The American College of Obstetrics and Gynecology (2020) currently recommends screening for cystic fibrosis to any person seeking preconception or prenatal care. At present, all states include testing for cystic fibrosis as part of newborn screening. Cystic fibrosis is the most common debilitating disease of childhood among those of European descent. Medical advances in recent years have greatly increased the length and quality of life for affected children, with median age for survival being 39.3 years (Katkin, 2020). Complications include hemoptysis, pneumothorax, bacterial colonization, cor pulmonale, volvulus, intussusception, intestinal obstruction, rectal prolapse, gastroesophageal reflux disease, diabetes, portal hypertension, liver failure, gallstones, and decreased fertility.

Diagnosis and Treatment CF

Early diagnosis and treatment are important in delaying the onset and severity of chronic illness in children with CF. Diagnosis is based on the presence of respiratory and gastrointestinal manifestations typical of CF, a history of CF in a sibling, or a positive newborn screening test result. Confirmatory laboratory tests include the sweat chloride test, CFTR functional testing, and CFTR genetic analysis. The sweat test is performed by collecting the individual's sweat, followed by chemical analysis of its chloride content. Sweat with a sodium and chloride content more than twice of normal is consistent with CF. The sweat test remains the standard approach to diagnosis. Newborns with CF have elevated blood levels of immunoreactive trypsinogen, presumably because of secretory obstruction in the pancreas. Newborn screening consists of a test for determination of immunoreactive trypsinogen. treatment measures are directed toward slowing the progression of secondary organ dysfunction and sequelae, such as chronic lung infection and pancreatic insufficiency. They include the use of oral and inhaled antibiotics to prevent and manage infections, bronchodilators, anti-inflammatory medications, the use of chest physical therapy (chest percussion and postural drainage) and mucolytic agents to prevent airway obstruction, and nutritional therapy.35 People with CF who have complete loss of exocrine pancreas function and have inadequate digestion of fats and proteins require diet adjustment, pancreatic enzyme replacement, and supplemental vitamins and minerals. Many people with CF have a higher-than-normal caloric need because of the increased WOB and perhaps because of the increased metabolic activity related to the basic defect.

Assessment and Diagnostic Findings ACS/MI cont

Echocardiogram The echocardiogram is used to evaluate ventricular function. It may be used to assist in diagnosing an MI, especially when the ECG is nondiagnostic. The echocardiogram can detect hypokinetic and akinetic wall motion and can determine the ejection fraction

Education

Educating Patients About Self-Care. The most effective way to increase the probability that the patient will implement a self-care regimen after discharge is to identify the patient's priorities, provide adequate education about heart-healthy living, and facilitate the patient's involvement in a cardiac rehabilitation program (Ibanez et al., 2018). Patient participation in the development of an individualized program enhances the potential for an effective treatment plan

Inpatient Management

Following PCI or thrombolytic therapy, continuous cardiac monitoring is indicated, preferably in a cardiac intensive care unit (ICU). Continuing pharmacologic management includes aspirin, a beta-blocker, and an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors prevent the conversion of angiotensin I to angiotensin II. In the absence of angiotensin II, the blood pressure decreases and the kidneys excrete sodium and fluid (diuresis), decreasing the oxygen demand of the heart. The use of ACE inhibitors in patients after MI decreases mortality rates and prevents remodeling of myocardial cells that is associated with the onset of heart failure. Blood pressure, urine output, and serum sodium, potassium, and creatinine levels need to be monitored closely. If an ACE inhibitor is not suitable, an angiotensin receptor blocker (ARB) should be prescribed (Ibanez et al., 2018). Nicotine replacement therapy and tobacco cessation counseling should also be initiated for all tobacco users.

Patho continued

Following the transport of lipid into the arterial wall, smooth muscle cells proliferate and form a fibrous cap over a core filled with lipid and inflammatory infiltrate. These deposits, called atheromas, or plaques, protrude into the lumen of the vessel, narrowing it and obstructing blood flow (see Fig. 23-1). Plaque may be stable or unstable, depending on the degree of inflammation and thickness of the fibrous cap. If the fibrous cap over the plaque is thick and the lipid pool remains relatively stable, it can resist the stress of blood flow and vessel movement. If the cap is thin and inflammation is ongoing, the lesion becomes what is called vulnerable plaque. At this point, the lipid core may grow, causing the fibrous plaque to rupture. A ruptured plaque attracts platelets and causes thrombus formation. A thrombus may then obstruct blood flow, leading to acute coronary syndrome (ACS), which may result in an acute myocardial infarction (MI). When an MI occurs, a portion of the heart muscle no longer receives blood flow and becomes necrotic. The anatomic structure of the coronary arteries makes them particularly susceptible to atherosclerosis. As Figure 23-2 shows, the three major coronary arteries have multiple branches. Atherosclerotic lesions most often form where the vessels branch and with turbulent blood flow, suggesting a hemodynamic component is involved in their formation (Norris, 2019). Although heart disease is most often caused by atherosclerosis of the coronary arteries, other phenomena may also decrease blood flow to the heart. Examples include vasospasm (sudden constriction or narrowing) of a coronary artery and profound hypotension.

CF peds Nursing assessment: Health history

Health History Elicit a description of the present illness and chief complaint. Common signs and symptoms reported during the health history in the undiagnosed child might include: A salty taste to the child's skin (resulting from excess chloride loss via perspiration) Meconium ileus or late, difficult passage of meconium stool in the newborn period Abdominal pain or difficulty passing stool (infants or toddlers might present with intestinal obstruction or intussusception at the time of diagnosis) Bulky, greasy stools Poor weight gain and growth despite good appetite Chronic or recurrent cough and/or upper or lower respiratory infections Children known to have cystic fibrosis are often admitted to the hospital for pulmonary exacerbations or other complications of the disease. The health history should include questions related to: respiratory status: has cough, sputum production, or work of breathing increased? appetite and weight gain. activity tolerance. increased need for pulmonary or pancreatic medications. presence of fever. presence of bone pain. any other changes in physical state or medication regimen.

TB peds Nursing management

Hospitalization of children with tuberculosis is necessary only for the most serious cases. Nursing management is aimed at providing supportive care and encouraging adherence to the treatment regimen. Most nursing care for childhood tuberculosis is provided in outpatient clinics, schools, or a public health setting. Supportive care includes ensuring adequate nutrition and adequate rest, providing comfort measures such as fever reduction, preventing exposure to other infectious diseases, and preventing reinfection. Isolate hospitalized children with tuberculosis according to hospital policy to prevent nosocomial spread of tuberculosis infection. TAKE NOTE! Administration of Bacille Calmette-Guérin (BCG) vaccine can provide incomplete protection against tuberculosis, and it is not widely used in the United States (AAP, 2018).

Nursing Interventions cont

IMPROVING RESPIRATORY FUNCTION Regular and careful assessment of respiratory function detects early signs of pulmonary complications. The nurse monitors fluid volume status to prevent fluid overload and encourages the patient to breathe deeply and change position frequently to maintain effective ventilation throughout the lungs. Pulse oximetry guides the use of oxygen therapy. PROMOTING ADEQUATE TISSUE PERFUSION Bed or chair rest during the initial phase of treatment helps reduce myocardial oxygen consumption. This limitation on mobility should remain until the patient is pain free and hemodynamically stable. Skin temperature and peripheral pulses must be checked frequently to monitor tissue perfusion. REDUCING ANXIETY Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Less sympathetic stimulation decreases the workload of the heart, which may relieve pain and other signs and symptoms of ischemia. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Complications that can occur after acute MI are caused by the damage that occurs to the myocardium and to the conduction system from reduced coronary blood flow. Because these complications can be life-threatening, close monitoring for and early identification of their signs and symptoms are critical (see Chart 23-9). The nurse monitors the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, skin color and temperature, mental status, ECG changes, and laboratory values. Any changes in the patient's condition must be reported promptly to the primary provider and emergency measures instituted when necessary.

Cf peds nursing assessment: Physical Examination

INSPECTION Observe the child's general appearance and color. Check the nasal passages for polyps. Note respiratory rate, work of breathing, use of accessory muscles, position of comfort, frequency and severity of cough, and quality and quantity of sputum produced. The child with cystic fibrosis often has a barrel chest (anterior-posterior diameter approximates transverse diameter) (Fig. 40.13). Clubbing of the nail beds might also be present. Note whether rectal prolapse is present. Does the child appear small or thin for his or her age? The child might have a protuberant abdomen and thin extremities, with decreased amounts of subcutaneous fat. Observe for the presence of edema (sign of cardiac or liver failure). Note distended neck veins or the presence of a heave (signs of cor pulmonale). PERCUSSION AND PALPATION Percussion over the lung fields usually yields hyperresonance due to air trapping. Diaphragmatic excursion might be decreased. Percussion of the abdomen might reveal dullness over an enlarged liver or mass related to intestinal obstruction. Palpation might yield a finding of asymmetric chest excursion if atelectasis is present. Tactile fremitus may be decreased over areas of atelectasis. Note if tenderness is present over the liver (might be an early sign of cor pulmonale).

CF Patho peds

In cystic fibrosis, the CFTR mutation causes alterations in epithelial ion transport on mucosal surfaces, resulting in generalized dysfunction of the exocrine glands. The epithelial cells fail to conduct chloride, and water transport abnormalities occur. This results in thickened, tenacious secretions in the sweat glands, gastrointestinal tract, pancreas, respiratory tract, and other exocrine tissues. The increased viscosity of these secretions makes them difficult to clear. The sweat glands produce a larger amount of chloride, leading to a salty taste of the skin and alterations in electrolyte balance and dehydration. The pancreas, intrahepatic bile ducts, intestinal glands, gallbladder, and submaxillary glands become obstructed by viscous mucus and eosinophilic material. Pancreatic enzyme activity is lost, and malabsorption of fats, proteins, and carbohydrates occurs, resulting in poor growth and large, malodorous stools. Excess mucus is produced by the tracheobronchial glands. Abnormally thick mucus plugs the small airways, and then bronchiolitis and further plugging of the airways occur. Secondary bacterial infection with Staphylococcus aureus, Pseudomonas aeruginosa, and Burkholderia cepacia often occurs. This contributes to obstruction and inflammation, leading to chronic infection, tissue damage, and respiratory failure. Nasal polyps and recurrent sinusitis are common. Boys have tenacious seminal fluid and experience blocking of the vas deferens, often making them infertile. In girls, thick cervical secretions might limit penetration of sperm. Table 40.3 gives further details of the pathophysiology and resulting respiratory and gastrointestinal clinical manifestations of cystic fibrosis.

Percutaneous Transluminal Coronary Angioplasty

In percutaneous transluminal coronary angioplasty (PTCA), a balloon-tipped catheter is used to open blocked coronary vessels and resolve ischemia. It is used in patients with angina and as an intervention for ACS. Catheter-based interventions can also be used to open blocked CABGs (see later discussion). The purpose of PTCA is to improve blood flow within a coronary artery by compressing the atheroma. The procedure is attempted when the interventional cardiologist determines that PTCA can improve blood flow to the myocardium.PTCA is carried out in the cardiac catheterization laboratory. Hollow catheters called sheaths are inserted, usually in the femoral artery (and sometimes the radial artery), providing a conduit for other catheters. Catheters are then threaded through the femoral or radial artery, up through the aorta, and into the coronary arteries. Angiography is performed using injected radiopaque contrast agents (commonly called dye) to identify the location and extent of the blockage. A balloon-tipped dilation catheter is passed through the sheath and positioned over the lesion. The physician determines the catheter position by examining markers on the balloon that can be seen with fluoroscopy. When the catheter is properly positioned, the balloon is inflated with high pressure for several seconds and then deflated. The pressure compresses and often "cracks" the atheroma (see Fig. 23-7). The media and adventitia of the coronary artery are also stretched.

Quality and Safety Nursing Alert

In status asthmaticus, increasing PaCO2 (to normal levels or levels indicating respiratory acidosis) is a danger sign signifying impending respiratory failure.

Pathophysiology MI

In unstable angina, there is reduced blood flow in a coronary artery, often due to rupture of an atherosclerotic plaque. A clot begins to form on top of the coronary lesion, but the artery is not completely occluded. This is an acute situation that can result in chest pain and other symptoms that may be referred to as preinfarction angina because the patient will likely have an MI if prompt interventions do not occur. In an MI, plaque rupture and subsequent thrombus formation result in complete occlusion of the artery, leading to ischemia and necrosis of the myocardium supplied by that artery. Vasospasm (sudden constriction or narrowing) of a coronary artery, decreased oxygen supply (e.g., from acute blood loss, anemia, or low blood pressure), and increased demand for oxygen (e.g., from a rapid heart rate, thyrotoxicosis, or ingestion of cocaine) are other causes of MI. In each case, a profound imbalance exists between myocardial oxygen supply and demand. The area of infarction develops over minutes to hours. As the cells are deprived of oxygen, ischemia develops, cellular injury occurs, and the lack of oxygen results in infarction, or the death of cells. The expression "time is muscle" reflects the urgency of appropriate treatment to improve patient outcomes. Approximately every 40 seconds, an American will have an MI (Benjamin et al., 2019), and many of these people will die as a result. Early recognition and treatment of patients presenting with an MI will improve their chances of survival.

Mucolytics

Intervention With Rationale • Avoid combining with other drugs in the nebulizer to avoid the formation of precipitates and the potential loss of effectiveness of either drug. • Dilute the concentrate with sterile water for injection if buildup becomes a problem that could impede drug delivery. • Note that patients receiving acetylcysteine by face mask should have the residue wiped off the face mask and off the face with plain water to prevent skin breakdown. • Review use of the nebulizer with patients receiving dornase alfa at home to ensure the most effective use of the drug. Patients should be cautioned to store the drug in the refrigerator, protected from light. • Caution cystic fibrosis patients receiving dornase alfa about the need to continue all therapies for their cystic fibrosis because dornase alfa is only a palliative therapy that improves respiratory symptoms and other therapies are still needed. • Provide thorough patient teaching, including the drug name and prescribed dosage, measures to help avoid adverse effects, warning signs that may indicate problems, and the need for periodic monitoring and evaluation, to enhance patient knowledge about drug therapy and to promote adherence. • Offer support and encouragement to help the patient cope with the disease and the drug regimen. Evaluation • Monitor patient response to the drug (improvement of respiratory symptoms and loosening of secretions). • Monitor for adverse effects (CNS effects, skin rash, bronchospasm, and GI upset). • Evaluate the effectiveness of the teaching plan (patient can name drug, dosage, adverse effects to watch for and specific measures to avoid them, and measures to take to increase the effectiveness of the drug). • Monitor the effectiveness of comfort and safety measures and adher

Percutaneous Coronary Interventions

Invasive interventional procedures to treat CAD include PTCA and intracoronary stent implantation. These procedures are classified as percutaneous coronary interventions (PCIs), as they are performed through a skin puncture rather than a surgical incision.

Angina Pectoris Clinical Manifestations

Ischemia of the heart muscle may produce pain or other symptoms, varying from mild indigestion to a choking or heavy sensation in the upper chest. The severity ranges from discomfort to agonizing pain. The pain may be accompanied by severe apprehension and a feeling of impending death. It is often felt deep in the chest behind the sternum (retrosternal area). Typically, the pain or discomfort is poorly localized and may radiate to the neck, jaw, shoulders, and inner aspects of the upper arms, usually the left arm. The patient often feels tightness or a heavy choking or strangling sensation that has a viselike, insistent quality. The patient with diabetes may not have severe pain with angina because autonomic neuropathy can blunt nociceptor transmission, dulling the perception of pain. A feeling of weakness or numbness in the arms, wrists, and hands, as well as shortness of breath, pallor, diaphoresis, dizziness or lightheadedness, and nausea and vomiting, may accompany the pain. An important characteristic of angina is that it subsides with rest or administration of nitroglycerin. In many patients, anginal symptoms follow a stable, predictable pattern. Unstable angina is characterized by attacks that increase in frequency and severity and are not relieved by rest and administration of nitroglycerin. Patients with unstable angina require medical intervention.

Prophylactic Isoniazid

Isoniazid also may be used as a prophylactic (preventive) measure for people who are at risk for significant disease, including: Household family members of patients with active disease Patients with HIV infection who have a PPD test reaction with 5 mm of induration or more Patients with fibrotic lesions suggestive of old TB detected on a chest x-ray and a PPD reaction with 5 mm of induration or more Patients whose current PPD test results show a change from former test results, suggesting recent exposure to TB and possible infection (skin test converters) Patients who use IV/injection drugs who have PPD test results with 10 mm of induration or more Patients with high-risk comorbid conditions and a PPD result with 10 mm of induration or more Other candidates for preventive isoniazid therapy are those 35 years or younger who have PPD test results with 10 mm of induration or more and one of the following criteria: Individuals who are foreign-born from countries with a high prevalence of TB Populations that are high-risk and medically underserved Patients living in institutions Prophylactic isoniazid treatment involves taking daily doses for 6 to 12 months. Liver enzymes, blood urea nitrogen (BUN), and creatinine levels are monitored monthly. Sputum culture results are monitored for AFB to evaluate the effectiveness of treatment and the patient's adherence to the treatment regimen.

Controlling Cholesterol Abnormalities

It is important to remember the different types of cholesterol and the role of each as a risk factor for heart disease. HDL is the "good cholesterol," and higher levels are better; LDL is the "bad cholesterol," and lower levels are better. LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very high risk patients) Total cholesterol less than 200 mg/dL HDL cholesterol greater than 40 mg/dL for males and greater than 50 mg/dL for females Triglyceride less than 150 mg/dL Dietary Measures consider the AHA's diet recommendations or the Mediterranean diet, which are reported to reduce mortality from cardiovascular disease. Both eating plans provide similar key elements: an emphasis on plant foods (fruits, vegetables, whole-grain breads or other forms of cereals, beans, nuts, and seeds), minimally processed foods, seasonally fresh foods, inclusion of fish, and minimal intake of red meat. Individuals needing to lower LDL and blood pressure should also limit the intake of sweets and sugar sweetened beverages (Arnett et al., 2019). Adopting a strict vegetarian diet can significantly reduce blood lipids, blood glucose, body mass index, and blood pressure; however, this type of intensive dietary program may not be acceptable to all patients who need to modify risk factors.

key points mucolytics

Key Points • Mucolytics work to break down mucus to aid high-risk respiratory patients in coughing up thick, tenacious secretions. • Dornase alfa is specific for the treatment of patients with cystic fibrosis, which is characterized by a thick, tenacious mucus production that can block airways.

CF peds Laboratory and Diagnostic Tests

Laboratory and Diagnostic Tests Common laboratory and diagnostic studies ordered for the diagnosis and assessment of cystic fibrosis include: Sweat chloride test: considered suspicious if the level of chloride in collected sweat is above 50 mEq/L and diagnostic if the level is above 60 mEq/L. Pulse oximetry: oxygen saturation might be decreased, particularly during a pulmonary exacerbation. Chest radiograph: may reveal hyperinflation, bronchial wall thickening, atelectasis, or infiltration. PFTs: might reveal a decrease in forced vital capacity and forced expiratory volume, with increases in residual volume.

Nursing Management Peds CF continued

Maintaining Growth - Administer pancreatic enzyme supplements (pancrelipase [Creon, Pancreaze, Zenpep]) must be administered with all meals and snacks to promote adequate digestion and absorption of nutrients. The number of capsules required depends on the extent of pancreatic insufficiency and the amount of food being ingested. The dosage can be adjusted until an adequate growth pattern is established and the number of stools is consistent at one or two per day. Children will need additional enzyme capsules when high-fat foods are being eaten. In the infant or young child, the enzyme capsule can be opened and sprinkled on cereal or applesauce. Provide a well-balanced, high-calorie, high-protein diet is necessary to ensure adequate growth. Some children require up to one and a half times the recommended daily allowance of calories for children their age. A number of commercially available nutritional formulas and shakes are available for diet supplementation. In infants, breastfeeding should be continued with enzyme administration. Some infants will require fortification of breast milk or supplementation with high-calorie formulas. Commercially available infant formulas can continue to be used for the formula-fed infant and can be mixed to provide a larger number of calories if necessary. Administer vitamins A, D, E, and K supplementation. Administer gavage feedings or total parenteral nutrition as prescribed to provide for adequate growth.

Nursing Management Peds CF

Maintaining Patent Airway - Provide CPT, use of the vest airway clearance system, use of the flutter-valve devise, and/or positive expiratory pressure therapy in order to clear secretions and maintain airway patency. For children with cystic fibrosis, CPT is a critical intervention. CPT involves percussion, vibration, and postural drainage, and either it or another bronchial hygiene therapy must be performed several times a day to assist with mobilization of secretions. Nursing Procedure 40.2 gives instructions on the CPT technique. The vest airway clearance system provides high-frequency chest wall oscillation to increase airflow velocity to create repetitive cough-like shear forces and to decrease the viscosity of secretions. For older children and adolescents, the flutter valve device provides high-frequency oscillation to the airway as the child exhales into a mouthpiece that contains a steel ball. Positive expiratory pressure therapy involves exhaling through a flow resistor, which creates positive expiratory pressure. The cycles of exhalation are repeated until coughing yields expectoration of secretions. Breathing exercises are also helpful in promoting mucus clearance. Encourage physical exercise, as it helps to promote mucus secretion as well as provides cardiopulmonary conditioning. Ensure that Pulmozyme is administered, as well as inhaled bronchodilators and anti-inflammatory agents, if prescribed. Preventing Infection - Ensure parents and older children understand that vigorous pulmonary hygiene to mobilize of secretions is critical to prevent infection. Administer aerosolized antibiotics as prescribed either in the hospital or teach parents to provide them at home. Children with frequent or severe respiratory exacerbations might require lengthy courses of intravenous antibiotics.

Mucolytics

Mucolytics (Table 54.5) increase or liquefy respiratory secretions to aid the clearing of the airways in high-risk respiratory patients who are coughing up thick, tenacious secretions. Patients may be suffering from conditions such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, pneumonia, or tuberculosis. Mucolytics include acetylcysteine (generic) and dornase alfa (Pulmozyme).

CAD modifiable and nonmodifiable risk factors

Nonmodifiable Risk Factors Family history of CAD (first-degree relative with cardiovascular disease at 55 years of age or younger for men and at 65 years of age or younger for women) Increasing age (more than 45 years for men; more than 55 years for women) Gender (men develop CAD at an earlier age than women) Race (higher incidence of heart disease in African Americans than in Caucasians) History of premature menopause (before age 40) and history of pregnancy-associated disorders such as preeclampsia Primary hypercholesterolemia (a genetic condition resulting in elevated LDL) Modifiable Risk Factors Hyperlipidemia Tobacco use Hypertension Diabetes Metabolic syndrome Obesity Physical inactivity Chronic inflammatory conditions (e.g., rheumatoid arthritis, lupus, HIV/AIDS) Chronic kidney disease C-reactive protein (CRP) is known to be an inflammatory marker for cardiovascular risk, including acute coronary events and stroke. The liver produces CRP in response to a stimulus such as tissue injury, and high levels of this protein may occur in people with diabetes and those who are likely to have an acute coronary event

Nursing Management: CF

Nursing management is crucial to the interdisciplinary approach required for care of adults with CF. Nursing care includes helping patients manage pulmonary symptoms and prevent complications. Specific measures include strategies that promote removal of pulmonary secretions, CPT (including postural drainage, chest percussion, and vibration), and breathing exercises (which are implemented and taught to the patient and family when the patient is very young). The patient is reminded of the need to reduce risk factors associated with respiratory infections (e.g., exposure to crowds or to people with known infections). In addition, the patient is taught the early signs and symptoms of respiratory infection and disease progression that indicate the need to notify a primary provider. The nurse emphasizes the importance of an adequate fluid and dietary intake to promote removal of secretions and to ensure an adequate nutritional status. Because CF is a lifelong disorder, patients often have learned to modify their daily activities to accommodate their symptoms and treatment modalities. As the disease progresses, periodic reassessment of the home environment may be warranted to identify modifications required to address changes in the patient's needs, increasing dyspnea and fatigue, and nonpulmonary symptoms. As with any chronic disease, palliative care and end-of-life issues and concerns need to be addressed with the patient when warranted. For the patient whose disease is progressing and who is developing increasing hypoxemia, preferences for end-of-life care should be discussed, documented, and honored (see Chapter 13). Patients and family members require support as they face a shortened lifespan and an uncertain future (Tomaszek, Debska, Cepuch, et al., 2019).

The Patient with Acute Coronary Syndrome

Nursing process

TB Assessment and Diagnostic Findings

Once a patient presents with a positive skin test, blood test, or sputum culture for acid-fast bacilli (AFB; see later discussion on these), additional assessments must be done. These tests include a complete history, physical examination, tuberculin skin test, chest x-ray, and drug susceptibility testing. Clinical manifestations of fever, anorexia, weight loss, night sweats, fatigue, cough, and sputum production prompt a more thorough assessment of respiratory function—for example, assessing the lungs for consolidation by evaluating breath sounds (diminished, bronchial sounds; crackles), fremitus, and egophony. If the patient is infected with TB, the chest x-ray usually reveals lesions in the upper lobes. For all patients, the initial M. tuberculosis isolate should be tested for drug resistance. Drug susceptibility patterns should be repeated at 3 months for patients who do not respond to therapy.

Assessment

One of the most important aspects of care of the patient with ACS is the assessment. It establishes the patient's baseline, identifies the patient's needs, and helps determine the priority of those needs. Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, dyspnea (difficulty breathing), palpitations, unusual fatigue, syncope (faintness), or other possible indicators of myocardial ischemia. Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. A focused physical assessment is critical to detect complications and any change in patient status. Chart 23-6 identifies important assessments and possible findings. Two IV lines are typically placed for any patient with ACS to ensure that access is available for administering emergency medications. Medications are administered IV to achieve rapid onset and to allow for timely adjustment. After the patient's condition stabilizes, IV lines may be changed to a saline lock to maintain IV access.

Assessment and Diagnostic Findings ACS/MI cont

Patient History The patient history includes the description of the presenting symptom (e.g., pain), the history of previous cardiac and other illnesses, and the family history of heart disease. The history should also include information about the patient's risk factors for heart disease. Electrocardiogram The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored. The ECG changes that occur with an MI are seen in the leads that view the involved surface of the heart. The expected ECG changes are T-wave inversion, ST-segment elevation, and development of an abnormal Q wave (see Fig. 23-5). Because infarction evolves over time, the ECG also changes over time. The first ECG signs of an acute MI are usually seen in the T wave and ST segment. The appearance of abnormal Q waves is another indication of MI. Using the information presented, patients are diagnosed with one of the following forms of ACS: Unstable angina: The patient has clinical manifestations of coronary ischemia, but ECG and cardiac biomarkers show no evidence of acute MI. STEMI: The patient has ECG evidence of acute MI with characteristic changes in two contiguous leads on a 12-lead ECG. In this type of MI, there is a significant damage to the myocardium. NSTEMI: The patient has elevated cardiac biomarkers (e.g., troponin) but no definite ECG evidence of acute MI. In this type of MI, there may be less damage to the myocardium.

Postprocedure Care

Patient care is similar to that for a diagnostic cardiac catheterization (see Chapter 21). Patients who are not already hospitalized are admitted the day of the PCI. Those with no complications go home the same day. When the PCI is performed emergently to treat ACS, patients typically go to a critical care unit and stay in the hospital for a few days. During the PCI, patients receive IV heparin or a thrombin inhibitor (e.g., bivalirudin) and are monitored closely for signs of bleeding. Patients may also receive a GP IIb/IIIa agent (e.g., eptifibatide) for several hours following the PCI to prevent platelet aggregation and thrombus formation in the coronary artery (Urden et al., 2019). Hemostasis is achieved, and femoral sheaths may be removed at the end of the procedure by using a vascular closure device (e.g., Angio-Seal, VasoSeal) or a device that sutures the vessels. Hemostasis after sheath removal may also be achieved by direct manual pressure, a mechanical compression device (e.g., C-shaped clamp), or a pneumatic compression device (e.g., FemoStop).

Assessing the Patient

Patients are frequently admitted to the hospital the day of the procedure. Therefore, most of the preoperative evaluation is completed in the physician's office and during preadmission testing. Nursing and medical personnel perform a history and physical examination. Preoperative testing consists of a chest x-ray; ECG; laboratory tests, including coagulation studies; and blood typing and cross-matching. The preoperative history and health assessment should be thorough and well documented because they provide a basis for postoperative comparison. The nurse assesses the patient for disorders that could complicate or affect the postoperative course, such as diabetes, hypertension, and lung disease. The health assessment focuses on obtaining baseline physiologic, psychological, and social information. Cognitive status is carefully assessed, as patients with impaired cognitive status will need more assistance after surgery and may require subacute care prior to returning home. Older adults are at a high risk for suffering adverse cognitive outcomes following cardiac surgery

Postprocedure Care cont

Patients may return to the nursing unit with the large peripheral vascular access sheaths in place. The sheaths are then removed after blood studies (e.g., activated clotting time) indicate that the heparin is no longer active and the clotting time is within an acceptable range. This usually takes a few hours, depending on the amount of heparin given during the procedure. The patient must remain flat in bed and keep the affected leg straight until the sheaths are removed and then for a few hours afterward to maintain hemostasis. Because immobility and bed rest may cause discomfort, treatment may include analgesics and sedation. Nonpharmacologic interventions include repositioning and heat application for back pain. Sheath removal and the application of pressure on the vessel insertion site may cause the heart rate to slow and the blood pressure to decrease (vasovagal response). A dose of IV atropine is usually given to treat this response. Some patients with unstable lesions and at high risk for abrupt vessel closure are restarted on heparin after sheath removal, or they receive an IV infusion of a GP IIb/IIIa inhibitor. These patients are monitored closely and may have a delayed recovery period. After hemostasis is achieved, a pressure dressing is applied to the site. Patients resume self-care and ambulate unassisted within a few hours of the procedure. The duration of immobilization depends on the size of the sheath inserted, the type of anticoagulant given, the method of hemostasis, the patient's condition, and the physician's preference. On the day after the procedure, the site is inspected and the dressing removed. The patient is instructed to monitor the site for bleeding or development of a hard mass indicative of hematoma.

Mucolytics

Pharmacokinetics The medication may be administered by nebulization or by direct instillation into the trachea via an endotracheal tube or tracheostomy. Acetylcysteine is metabolized in the liver and excreted somewhat in the urine. It is not known whether it crosses the placenta or enters human milk. Dornase alfa is metabolized by proteases, and its half-life is 3 to 4 hours. Contraindications and Cautions The medications are contraindicated in patients who have history of hypersensitivity reactions to the medications or components in the medications. Caution should be used with patients who have asthma due to potential for bronchospasm. There are no adequate human studies to evaluate risk during pregnancy or lactation, but there has been no evidence of fetal harm in animal studies. Adverse Effects Adverse effects most commonly associated with mucolytic drugs include GI upset, stomatitis, rhinorrhea, bronchospasm, and occasionally a rash. Clinically Important Drug-Drug Interactions There are no known drug interactions with acetylcysteine or dornase alfa.

Cardiac rehab cont

Phase II occurs after the patient has been discharged. The patient attends sessions three times a week for 4 to 6 weeks but may continue for as long as 6 months. The outpatient program consists of supervised, often ECG-monitored, exercise training that is individualized. At each session, the patient is assessed for the effectiveness of and adherence to the treatment. To prevent complications and another hospitalization, the cardiac rehabilitation staff alerts the referring primary provider to any problems. Phase II cardiac rehabilitation also includes educational sessions for patients and families that are given by cardiologists, exercise physiologists, dietitians, nurses, and other health care professionals. These sessions may take place outside a traditional classroom setting. For instance, a dietitian may take a group of patients to a grocery store to examine labels and meat selections or to a restaurant to discuss menu offerings for a heart-healthy diet. Phase III is a long-term outpatient program that focuses on maintaining cardiovascular stability and long-term conditioning. The patient is usually self-directed during this phase and does not require a supervised program, although it may be offered. The goals of each phase build on the accomplishments of the previous phase.

Controlling Cholesterol Abnormalities continued

Physical Activity Management of an elevated triglyceride level focuses on weight reduction and increased physical activity. Regular, moderate physical activity increases HDL levels and reduces triglyceride levels, decreasing the incidence of coronary events and reducing overall mortality risk. The goal for most adults is to engage in moderate-intensity aerobic activity of at least 150 minutes per week or vigorous-intensity aerobic activity of at least 75 minutes per week, or an equivalent combination (Arnett et al., 2019). In addition, adults should engage in muscle-strengthening activities on 2 or more days each week that work all major muscle groups. The nurse helps the patient to set realistic goals for physical activity. Medications If diet alone cannot normalize serum cholesterol levels, medications can have a synergistic effect with the prescribed diet and control cholesterol levels. Lipid-lowering medications can reduce CAD mortality in patients with elevated lipid levels and in at-risk patients with normal lipid level. The various types of lipid-lowering agents affect the lipid components somewhat differently; these types include 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) (or statins), fibric acids (or fibrates), bile acid sequestrants (or resins), cholesterol absorption inhibitors, and proprotein convertase subtilisin-kexin type 9 (PCSK9) agents. Because of their high cost, PCSK9 agents are prescribed on a limited basis, but may be considered for those at high cardiovascular risk or who have familial hypercholesterolemia.

Pregnant w TB

Pregnant women with untreated TB are more likely to have an underweight infant, an infant with a low Apgar score, and perinatal death (Herchline, 2020). The newborn is at risk of postnatally acquired TB if the mother still has active TB at the time of birth. Therefore, prenatal diagnosis and effective treatment of the mother are essential. Therapeutic Management The WHO recommends that the treatment of TB in pregnant women should be the same as that in nonpregnant women and the rest of the general population. The only exception is that streptomycin should be avoided in pregnancy because it is ototoxic to the fetus. Medications are the cornerstone of treatment to prevent infection from progressing. The safety of the first-line drugs (isoniazid, rifampin, and ethambutol) for the management of active TB in pregnancy has been established, and therapy improves both maternal and neonatal outcomes.

Nursing Management Peds CF continued

Preparing the Child and Family for Adulthood with Cystic Fibrosis - With current technologic and medication advances, and the use of lung transplantation, children with cystic fibrosis are living well into adulthood. Children with cystic fibrosis should have the goal of independent living as an adult, as other children do. Making the transition from a pediatric medical home to an adult medical home should be viewed as a normal part of growing up, similar to completing school or finding a first job. Pediatric clinics are focused on family-centered care that heavily involves the child's parents, but adults with cystic fibrosis need a different focus, one that views them as independent adults. Those with cystic fibrosis can make the transition from pediatric to adult care with thoughtful preparation and coordination. They desire and deserve a smooth transition in care that will result in appropriate ongoing medical management of cystic fibrosis in an environment that is geared toward adults rather than children. Adults with cystic fibrosis are able to find rewarding work and pursue relationships. Most men with cystic fibrosis are capable of sexual intercourse, though unable to reproduce. Females might have difficulty conceiving, and when they do they should be cautioned about the additional respiratory strain that pregnancy causes. All children of parents with cystic fibrosis will be carriers of the gene.

Nursing management TB continued

Preventing Transmission of Tuberculosis Infection To prevent transmission of TB to others, the nurse carefully educates the patient about important hygiene measures, including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and hand hygiene. TB is a disease that must be reported to the health department so that people who have been in contact with the affected patient during the infectious stage can undergo screening and possible treatment, if indicated.

Nursing Management TB

Promoting Adherence to Treatment Regimen Adherence to the prescribed treatment regimen is key in treating the disease and controlling the spread of infection. The multiple-medication regimen that the patient must follow can be quite complex. Understanding of the medications, schedule, and side effects is important. The nurse educates the patient that TB is a communicable disease and that taking medications is the most effective means of preventing transmission. Risk factors for nonadherence to the drug regimen include patients who have previously failed to complete the course of therapy; patients who are physically, emotionally, or mentally challenged; patients unable to pay for medication; patients actively abusing illicit substances; and patients who do not understand the importance of treatment . The nurse educates the patient to take the medication either on an empty stomach or at least 1 hour before meals, because food interferes with medication absorption (although taking medications on an empty stomach frequently results in gastrointestinal upset). Patients taking isoniazid should avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts), because eating them while taking isoniazid may result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis. Patients should also avoid alcohol because of the high potential for hepatoxic effects. In addition, rifampin can alter the metabolism of certain other medications, making them less effective. These medications include beta-blockers, oral anticoagulants such as warfarin, digoxin, quinidine, corticosteroids, oral hypoglycemic agents, oral contraceptives, theophylline, and verapamil.

Nursing management TB Cont

Promoting Airway Clearance Copious secretions obstruct the airways in many patients with TB and interfere with adequate gas exchange. Increasing the fluid intake promotes systemic hydration and serves as an effective expectorant. The nurse instructs the patient about correct positioning to facilitate airway drainage, referred to as postural drainage (see Chapter 20). Postural drainage allows the force of gravity to assist in the removal of bronchial secretions. Promoting Activity and Adequate Nutrition Patients with TB are often debilitated from prolonged chronic illness and impaired nutritional status. The nurse plans a progressive activity schedule that focuses on increasing activity tolerance and muscle strength. Anorexia, weight loss, and malnutrition are common in patients with TB. The patient's willingness to eat may be altered by fatigue from excessive coughing; sputum production; chest pain; generalized debilitated state; or cost, if the patient has few resources. Identifying facilities (e.g., shelters, soup kitchens, Meals on Wheels) that provide meals in the patient's neighborhood may increase the likelihood that the patient with limited resources and energy will have access to a more nutritious intake. A nutritional plan that allows for small, frequent meals may be required. Liquid nutritional supplements may assist in meeting basic caloric requirements.

Nursing Management Peds CF continued

Promoting Family Coping - Assist families to learn to cope with the daily interventions required for the serious chronic illness of cystic fibrosis. Help families develop a schedule for provision of pulmonary hygiene several times daily as well as close attention to appropriate diet and enzyme supplementation. Adjusting to the demands that the illness places on the child and family is difficult. Continual adjustments within the family must occur. Children are frequently hospitalized, and this may place an additional strain on the family and its finances. Children with cystic fibrosis may express fear or feelings of isolation, and siblings may be worried or jealous. Encourage the family to lead a normal life through involvement in activities and school attendance during periods of wellness. Starting at the time of diagnosis, families often demonstrate significant stress as the severity of the diagnosis and the significance of disease chronicity become real for them. Involve the family in the child's care from the time of diagnosis, whether in the outpatient setting or in the hospital. Ongoing education about the illness and its treatments is necessary. Once the initial shock of diagnosis has passed and the family has adjusted to initial care, the family usually learns how to manage the requirements of care. Powerlessness gives way to adaptation. As family members become more comfortable with their understanding of the illness and the required treatments, they will eventually become the experts on the child's care. It is important for the nurse to recognize and respect the family's changing needs over time.

Medical Management TB

Pulmonary TB is treated primarily with anti-TB agents for 6 to 12 months. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. The increasing prevalence of drug resistance points out the need to begin TB treatment with four or more medications, to ensure completion of therapy, and to develop and evaluate new anti-TB medications. In current TB therapy, four first-line medications are used (see Table 19-4): isoniazid, rifampin, pyrazinamide, and ethambutol. Combination medications, such as isoniazid and rifampin or isoniazid, pyrazinamide, and rifampin and medications given twice a week (e.g., rifapentine) are available to help improve patient adherence. However, these medications are more costly. Multidrug-resistant TB is difficult to treat. Treatment is guided by sputum specimen culture and sensitivity testing as the patient typically is resistant to isoniazid and rifampin. The World Health Organization (WHO, 2019) recently published recommendations for treatment consisting of multiple medications to combat drug-resistant organisms. It is important to consult current recommendations for treatment (WHO, 2019).

Angina pectoris nursing interventions continued

REDUCING ANXIETY Patients with angina often fear loss of their roles within society and the family. They may also fear that the pain (or the prodromal symptoms) may lead to an MI or death. Exploring the implications that the diagnosis has for the patient and providing information about the illness, its treatment, and methods of preventing its progression are important nursing interventions. Various stress reduction methods, such as guided imagery or music therapy, should be explored with the patient (Meghani, 2017). Addressing the spiritual needs of the patient and family may also assist in allaying anxieties and fears. PREVENTING PAIN The nurse reviews the assessment findings, identifies the level of activity that causes the patient's pain or prodromal symptoms, and plans the patient's activities accordingly. If the patient has pain frequently or with minimal activity, the nurse alternates the patient's activities with rest periods. Balancing activity and rest is an important aspect of the educational plan for the patient and family. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE

Nursing Interventions

RELIEVING PAIN AND OTHER SIGNS AND SYMPTOMS OF ISCHEMIA Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the patient with an ACS. Although administering medications as described previously is required to accomplish this goal, nursing interventions are also important. Collaboration among the patient, nurse, and primary provider is critical in evaluating the patient's response to therapy and in altering the interventions accordingly. Oxygen should be given along with medication therapy to assist with relief of symptoms. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. The route of administration (usually by nasal cannula) and the oxygen flow rate are documented. A flow rate of 2 to 4 L/min is usually adequate to maintain oxygen saturation levels of at least 95% unless chronic pulmonary disease is present.Elevation of the head and torso is beneficial for the following reasons: •Tidal volume improves because of reduced pressure from abdominal contents on the diaphragm and better lung expansion. •Drainage of the upper lung lobes improves. •Venous return to the heart (preload) decreases, reducing the work of the heart.

Medical management TB cont

Recommended treatment guidelines for newly diagnosed cases of pulmonary TB have two phases: an initial treatment phase and a continuation phase (CDC, 2019d). The initial phase consists of a multiple-medication regimen of isoniazid, rifampin, pyrazinamide, and ethambutol plus vitamin B6 50 mg. All are taken once a day and are oral medications. This initial intensive-treatment regimen is given daily for 8 weeks, after which options for the continuation phase of treatment include isoniazid and rifampin or isoniazid and rifapentine. The continuation regimen lasts for an additional 4 or 7 months. The 4-month period is used for the large majority of patients. The 7-month period is recommended for patients with cavitary pulmonary TB whose sputum culture after the initial 2 months of treatment is positive, for those whose initial phase of treatment did not include pyrazinamide, and for those being treated once weekly with isoniazid and rifapentine whose sputum culture is positive at the end of the initial phase of treatment. People are considered noninfectious after 2 to 3 weeks of continuous medication therapy. The total number of doses taken, not simply the duration of treatment, more accurately determines whether a course of therapy has been completed (CDC, 2019d). Isoniazid also may be used as a prophylactic (preventive) measure for people who are at risk for significant disease.

Clinical Manifestations CF

Respiratory manifestations of CF are caused by an accumulation of viscid mucus in the bronchi, impaired mucociliary clearance, and lung infections. Chronic bronchiolitis and bronchitis are the initial lung manifestations. However, after months and years, structural changes in the bronchial wall lead to bronchiectasis. In addition to airway obstruction, the basic genetic defect that occurs with CF predisposes to chronic infection with a surprisingly limited number of organisms, the most common being Pseudomonas aeruginosa.23,32 Pseudomonas aeruginosa, in particular, has a propensity to undergo pathogenesis. Early colonization can cause recurring pulmonary infections.23 Pulmonary inflammation is another cause of decline in respiratory function in people with CF and may precede the onset of chronic infection. Pancreatic function is often abnormal to some degree with people with CF. Malabsorption and malnutrition may often be present along with symptoms of abdominal discomfort and diarrhea. Steatorrhea, diarrhea, and abdominal pain and discomfort are common associated symptoms. In the newborn, meconium ileus may cause intestinal obstruction, a fatal condition if left untreated. The degree of pancreatic involvement is highly variable. In some children, the defect is relatively mild, and in others, the involvement is severe and impairs intestinal absorption. In addition, people with CF should be tested for diabetes mellitus because 30% of adults develop diabetes.

Types of Angina

Stable angina: predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin •Unstable angina (also called preinfarction angina or crescendo angina): symptoms increase in frequency and severity; may not be relieved with rest or nitroglycerin •Intractable or refractory angina: severe incapacitating chest pain •Variant angina (also called Prinzmetal's angina): pain at rest with reversible ST-segment elevation; thought to be caused by coronary artery vasospasm •Silent ischemia: objective evidence of ischemia (such as electrocardiographic changes with a stress test), but patient reports no pain

important

TAKE NOTE! Children 6 years and older who have the G551D, R117H, G178R, G551S, S549, G1284E, S1251N, S1255P, G1349D mutation of the cystic fibrosis gene may be prescribed oral ivacaftor (Kalydeco). Use of ivacaftor results in thinning of lung mucus, resulting in easier airway clearance via coughing. It is the first drug to act directly on the defective gene. For those with the F508 del mutation in the CFTR gene, lumacaftor may be added to the regimen (Merlo, 2018).

TB Pathophysiology

TB begins when a susceptible person inhales mycobacteria and becomes infected. The bacteria are transmitted through the airways to the alveoli, where they are deposited and begin to multiply. The bacilli also are transported via the lymph system and bloodstream to other parts of the body (kidneys, bones, cerebral cortex) and other areas of the lungs (upper lobes). The body's immune system responds by initiating an inflammatory reaction. Phagocytes (neutrophils and macrophages) engulf many of the bacteria, and TB-specific lymphocytes lyse (destroy) the bacilli and normal tissue. This tissue reaction results in the accumulation of exudate in the alveoli, causing bronchopneumonia. The initial infection usually occurs 2 to 10 weeks after exposure. Granulomas, new tissue masses of live and dead bacilli, are surrounded by macrophages, which form a protective wall. They are then transformed to a fibrous tissue mass, the central portion of which is called a Ghon tubercle. The material (bacteria and macrophages) becomes necrotic, forming a cheesy mass. This mass may become calcified and form a collagenous scar. At this point, the bacteria become dormant, and there is no further progression of active disease.

TB Transmission and Risk Factors

TB spreads from person to person by airborne transmission. An infected person releases droplet nuclei (usually particles 1 to 5 mcm in diameter) through talking, coughing, sneezing, laughing, or singing. Larger droplets settle; smaller droplets remain suspended in the air and are inhaled by a susceptible person. Chart 19-10 lists risk factors for TB. Chart 19-11 summarizes the CDC's recommendations for the prevention of TB transmission in health care settings.

Angina pectoris Nursing Interventions

TREATING ANGINA If the patient reports pain (or cardiac ischemia is suggested by prodromal symptoms, which may include sensations of indigestion or nausea, choking, heaviness, weakness or numbness in the upper extremities, dyspnea, or dizziness), the nurse takes immediate action. The patient experiencing angina is directed to stop all activities and sit or rest in bed in a semi-Fowler position to reduce the oxygen requirements of the ischemic myocardium. The nurse assesses the patient's angina, asking questions to determine whether the angina is the same as the patient typically experiences. A change may indicate a worsening of the disease or a different cause.The nurse then continues to assess the patient, measuring vital signs and observing for signs of respiratory distress. If the patient is in the hospital, a 12-lead ECG is usually obtained and assessed for ST-segment and T-wave changes. If the patient has been placed on cardiac monitoring with continuous ST-segment monitoring, the ST segment is assessed for changes. Nitroglycerin is given sublingually, and the patient's response is assessed (relief of chest pain and effect on blood pressure and heart rate). If the chest pain is unchanged or is lessened but still present, nitroglycerin administration is repeated up to three doses. Each time blood pressure, heart rate, and the ST segment (if the patient is on a monitor with ST-segment monitoring capability) are assessed. The nurse administers oxygen therapy if the patient's respiratory rate is increased or if the oxygen saturation level is decreased. Oxygen is usually given at 2 L/min by nasal cannula, even without evidence of desaturation, although there is no current evidence of a positive effect on patient outcome.

Tuberculin Skin Test

The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The Mantoux method is a standardized, intracutaneous injection procedure and should be performed only by those trained in its administration and reading. Tubercle bacillus extract (tuberculin), purified protein derivative (PPD), is injected into the intradermal layer of the inner aspect of the forearm, approximately 4 inches below the elbow. Intermediate-strength PPD, in a tuberculin syringe with a half-inch 26- or 27-gauge needle, is used. The needle, with the bevel facing up, is inserted beneath the skin. Then, 0.1 mL of PPD is injected, creating an elevation in the skin, a well-demarcated wheal 6 to 10 mm in diameter. The test result is read 48 to 72 hours after injection. Tests read after 72 hours tend to underestimate the true size of induration (raised hard area or swelling). A reaction occurs when both induration and erythema (redness) are present.

Coronary Atherosclerosis

The most common cause of cardiovascular disease in the United States is atherosclerosis, an abnormal accumulation of lipid, or fatty substances, and fibrous tissue in the lining of arterial blood vessel walls. These substances block and narrow the coronary vessels in a way that reduces blood flow to the myocardium. Atherosclerosis involves a repetitious inflammatory response to injury of the artery wall and subsequent alteration in the structural and biochemical properties of the arterial walls. New information that relates to the development of atherosclerosis has increased the understanding of treatment and prevention of this progressive and potentially life-threatening process.

Angina pectoris Medical Management

The objectives of the medical management of angina are to decrease the oxygen demand of the myocardium and to increase the oxygen supply. Medically, these objectives are met through pharmacologic therapy and control of risk factors. Alternatively, reperfusion procedures may be used to restore the blood supply to the myocardium. These include PCI procedures (e.g., percutaneous transluminal coronary angioplasty [PTCA] and intracoronary stents) and CABG (see later discussion).

Assessment and Diagnostic Findings ACS/MI

The diagnosis of ACS is generally based on the presenting symptoms (see Chart 23-6); the 12-lead ECG and laboratory tests (e.g., serial cardiac biomarkers) are performed to clarify whether the patient has unstable angina, NSTEMI, or STEMI (Ibanez et al., 2018). The prognosis depends on the severity of coronary artery obstruction and the presence and extent of myocardial damage. Physical examination is always conducted, but the examination alone does not confirm the diagnosis.

Assessment and Diagnostic Findings: CF

The diagnosis of CF requires a clinical picture consistent with the CF phenotype and laboratory evidence of CFTR dysfunction. Key assessment findings in adults include (Katkin, Mallory, & Hoppin, 2019): - Chronic sinopulmonary disease as manifested by chronic cough and sputum production, persistent infection consistent with typical CF pathogens, and x-ray evidence of bronchiectasis and chronic sinusitis, often with nasal polyps - Gastrointestinal tract and nutritional abnormalities (pancreatic insufficiency, recurrent pancreatitis, biliary cirrhosis and portal hypertension, CF-related diabetes) - Male urogenital problems as manifested by congenital bilateral absence of the vas deferens; reduced female fertility

Assessment and Diagnostic Findings Angina pectoris

The diagnosis of angina begins with the patient's history related to the clinical manifestations of ischemia. A 12-lead electrocardiogram (ECG) may show changes indicative of ischemia, such as T-wave inversion, ST-segment elevation, or the development of an abnormal Q wave (Norris, 2019). Laboratory studies are performed; these generally include cardiac biomarker testing to rule out ACS (see later discussion). The patient may undergo an exercise or pharmacologic stress test in which the heart is monitored continuously by an ECG, echocardiogram, or both. The patient may also be referred for a nuclear scan or invasive procedure (e.g., cardiac catheterization, coronary angiography).

Nursing Management: Status Asthmaticus

The main focus of nursing management is to actively assess the airway and the patient's response to treatment. The nurse should be prepared for the next intervention if the patient does not respond to treatment. The nurse vigilantly monitors the patient for the first 12 to 24 hours, or until the severe exacerbation resolves. The nurse also assesses the patient's skin turgor for signs of dehydration. Fluid intake is essential to combat dehydration, to loosen secretions, and to facilitate expectoration. Nurses administer IV fluids as prescribed, up to 3 to 4 L/day, unless contraindicated. Blood pressure and cardiac rhythm should be monitored continuously during the acute phase and until the patient stabilizes and responds to therapy. The patient's energy needs to be conserved, and his or her room should be quiet and free of respiratory irritants, including flowers, tobacco smoke, perfumes, or odors of cleaning agents. Nonallergenic pillows should be used. An asthma attack may also be precipitated or aggravated by exposure to latex if the patient has a latex allergy; therefore, this type of hypersensitivity must be identified and latex-free products used, as warranted. Once the exacerbation is resolved, the factors that precipitated the exacerbation should be identified and strategies for their future avoidance implemented. In addition, the patient's medication plan should be reviewed.

Planning and Goals

The major goals for the patient include relief of pain or ischemic signs (e.g., ST-segment changes) and symptoms, prevention of myocardial damage, maintenance of effective respiratory function, maintenance or attainment of adequate tissue perfusion, reduced anxiety, adherence to the self-care program, and early recognition of complications. Care of the patient with ACS who has an uncomplicated MI is summarized in the Plan of Nursing Care

TB Clinical Manifestations

The signs and symptoms of pulmonary TB are insidious. Most patients have a low-grade fever, cough, night sweats, fatigue, and weight loss. The cough may be nonproductive, or mucopurulent sputum may be expectorated. Hemoptysis (i.e., coughing up blood) also may occur. Both the systemic and the pulmonary symptoms are chronic and may have been present for weeks to months. Older adult patients usually present with less pronounced symptoms than younger patients. Extrapulmonary disease occurs in up to 20% of cases in the United States (Bernardo, 2019). In patients infected with HIV, extrapulmonary disease is more prevalent.

CAD clinical manifestations continued

The most common manifestation of myocardial ischemia is the onset of chest pain. However, a study of the people in Framingham, Massachusetts, showed that nearly 15% of men and women who had coronary events, which included unstable angina, MIs, or sudden cardiac death events, were totally asymptomatic prior to the coronary event. Patients with myocardial ischemia may present to an emergency department (ED) or clinic with a variety of symptoms other than chest pain. Some complain of epigastric distress and pain that radiates to the jaw or left arm. Patients who are older or have a history of diabetes or heart failure may report shortness of breath. Many women have been found to have atypical symptoms, including indigestion, nausea, palpitations, and numbness. Prodromal symptoms may occur (e.g., angina a few hours to days before the acute episode), or a major cardiac event may be the first indication of coronary atherosclerosis.

Angina pectoris Gerontologic Considerations

The older adult with angina may not exhibit a typical pain profile because of the diminished pain transmission that can occur with aging. Often the presenting symptom in older adults is dyspnea. Sometimes there are no symptoms ("silent" CAD), making recognition and diagnosis a clinical challenge. Older patients should be encouraged to recognize their chest pain-like symptom (e.g., weakness) as an indication that they should rest or take prescribed medications. Pharmacologic stress testing and cardiac catheterization may be used to diagnose CAD in older patients. Medications used to manage angina are given cautiously in older adults because they are associated with an increased risk of adverse reactions. Invasive procedures (e.g., PCI) that were once considered too risky in older adults are now being performed successfully, and many older adults benefit from symptom relief and longer survival.

2. Emergent Percutaneous Coronary Intervention

The patient with STEMI is taken directly to the cardiac catheterization laboratory for an immediate PCI (if a cardiac catheterization laboratory is on site). The procedure is used to open the occluded coronary artery and promote reperfusion to the area that has been deprived of oxygen. Superior outcomes have been reported with the use of PCI when compared to thrombolytic agents (Urden et al., 2019) (also called fibrinolytic agents; see the Thrombolytics section). Thus, PCI is preferred as the initial treatment method for acute MI in all age groups (Urden et al., 2019). The procedure treats the underlying atherosclerotic lesion. Because the duration of oxygen deprivation determines the number of myocardial cells that die, the time from the patient's arrival in the ED to the time PCI is performed should be less than 60 minutes. This is frequently referred to as door-to-balloon time. A cardiac catheterization laboratory and staff must be available if an emergent PCI is to be performed within this short time.

1. Initial Management

The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine is the drug of choice to reduce pain and anxiety. It also reduces preload and afterload, decreasing the work of the heart. The response to morphine is monitored carefully to assess for hypotension or decreased respiratory rate. Nurses should be aware that evolving research has suggested an association between morphine and potential adverse outcomes, including larger infarct size, increased length of hospital stay, and mortality, and should stay abreast of changes to clinical guidelines impacting its use (McCarthy, Bhambhani, Pomerantsev, et al., 2018; Neto, 2018). A beta-blocker may also be used if arrhythmias occur. If a beta-blocker is not needed in the initial management period, it should be introduced within 24 hours of admission, once hemodynamics have stabilized and it is confirmed that the patient has no contraindications (Ibanez et al., 2018). Unfractionated heparin or LMWH may also be prescribed along with platelet-inhibiting agents to prevent further clot formation.

Clinical Manifestations: CF

The pulmonary manifestations of CF include a productive cough, wheezing, hyperinflation of the lung fields on chest x-ray, and pulmonary function test results consistent with obstructive disease of the airways. Chronic respiratory inflammation and infection are caused by impaired mucus clearance. Colonization of the airways with pathogenic bacteria usually occurs early in life. S. aureus and H. influenzae are common organisms during early childhood. As the disease progresses, P. aeruginosa is ultimately isolated from the sputum of most patients (Simon, Mallory, & Hoppin, 2019b). Upper respiratory manifestations of the disease include sinusitis and nasal polyps. Pulmonary complications of CF are the primary cause of morbidity and mortality in the United States (Simon, Mallory, & Hoppin, 2019a). Nonpulmonary manifestations include gastrointestinal problems (e.g., pancreatic insufficiency, recurrent abdominal pain, biliary cirrhosis, vitamin deficiencies, recurrent pancreatitis, weight loss), CF-related diabetes, and genitourinary problems (male and female infertility). (See Chapter 44 for a discussion of pancreatitis.)

TB skin test continued

The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk. It is defined as positive in patients who are HIV positive or have HIV risk factors and are of unknown HIV status, in those who are close contacts of someone with active TB, and in those who have chest x-ray results consistent with TB. An induration of 10 mm or greater is usually considered significant in people who have normal or mildly impaired immunity. A significant reaction indicates past exposure to M. tuberculosis or vaccination with bacille Calmette-Guérin (BCG) vaccine. A significant (positive) reaction does not necessarily mean that active disease is present in the body. More than 90% of people who are tuberculin-significant reactors do not develop clinical TB (CDC, 2018b). Additional testing is needed to determine if the person has latent TB infection or active TB.t reaction indicates past exposure to M. tuberculosis or vaccination with bacille Calmette-Guérin (BCG) vaccine.

CF Therapeutic Management peds

Therapeutic management of cystic fibrosis is aimed toward minimizing pulmonary complications, maximizing lung function, preventing infection, and facilitating growth. All children with cystic fibrosis who have pulmonary involvement require chest physiotherapy (CPT) with postural drainage (or an alternate method) several times daily to mobilize secretions from the lungs. Physical exercise is encouraged. Recombinant human DNase (Pulmozyme) is given daily using a nebulizer to decrease sputum viscosity and help clear secretions. Inhaled bronchodilators and anti-inflammatory agents are prescribed for some children. Aerosolized antibiotics are often prescribed and may be given at home as well as in the hospital. Choice of antibiotic is determined by sputum culture and sensitivity results. Pancreatic enzymes and supplemental fat-soluble vitamins are prescribed to promote adequate digestion and absorption of nutrients and optimize nutritional status. Increased-calorie, high-protein diets are recommended, and sometimes supplemental high-calorie formula, either orally or via feeding tube, is needed. Some children require total parenteral nutrition to maintain or gain weight. Lung transplantation has been successful in some children with cystic fibrosis.

QuantiFERON-TB Gold® Plus and T-SPOT®

There are two TB blood tests (called interferon-gamma release assays or IGRAs) available in the United States: the QuantiFERON-TB Gold® Plus (QFT-Plus) test and the T-SPOT®. TB blood tests are the preferred diagnostic tests for patients who have received the BCG vaccine and for patients who are not likely to return for a second appointment to look for a reaction to the tuberculin skin test. The results of both of these tests are available within 24 to 36 hours. A positive IGRA signifies that the patient has been infected with TB bacteria and additional tests are needed. A negative IGRA means that the patient's blood did not react to the test and a latent or active TB infection is not likely

3. Thrombolytics

Thrombolytic therapy is initiated when primary PCI is not available or the transport time to a PCI-capable hospital is too long. These agents are administered IV according to a specific protocol (see Chart 23-8). The thrombolytic agents used most often are alteplase, reteplase, and tenecteplase. The purpose of thrombolytics is to dissolve (i.e., lyse) the thrombus in a coronary artery (thrombolysis), allowing blood to flow through the coronary artery again (reperfusion), minimizing the size of the infarction and preserving ventricular function. However, although thrombolytics may dissolve the thrombus, they do not affect the underlying atherosclerotic lesion. The patient may be referred for a cardiac catheterization and other invasive procedures following the use of thrombolytic therapy. Thrombolytics should not be used if the patient is bleeding or has a bleeding disorder. They should be given within 30 minutes of symptom onset for best results (Norris, 2019). This is frequently referred to as door-to-needle time.

MI Laboratory Tests

Troponin Troponin, a protein found in myocardial cells, regulates the myocardial contractile process. There are three isomers of troponin: C, I, and T. Troponins I and T are specific for cardiac muscle, and these biomarkers are currently recognized as reliable and critical markers of myocardial injury (Norris, 2019). An increase in the level of troponin in the serum can be detected within a few hours during acute MI. It remains elevated for a long period, often as long as 2 weeks, and it therefore can be used to detect recent myocardial damage. It should be noted that cardiac troponin levels may rise during inflammation and other forms of mechanical stress on the myocardium. These include sepsis, heart failure, and respiratory failure. Creatine Kinase and Its Isoenzymes There are three CK isoenzymes: CK-MM (skeletal muscle), CK-MB (heart muscle), and CK-BB (brain tissue). CK-MB is the cardiac-specific isoenzyme; it is found mainly in cardiac cells and therefore increases when there has been damage to these cells. Elevated CK-MB is an indicator of acute MI; the level begins to increase within a few hours and peaks within 24 hours of an infarct. Myoglobin Myoglobin is a heme protein that helps transport oxygen. Like the CK-MB enzyme, myoglobin is found in cardiac and skeletal muscle. The myoglobin level starts to increase within 1 to 3 hours and peaks within 12 hours after the onset of symptoms. An increase in myoglobin is not very specific in indicating an acute cardiac event; however, negative results can be used to rule out an acute MI.

Pulmonary Tuberculosis

Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma. It also may be transmitted to other parts of the body, including the meninges, kidneys, bones, and lymph nodes. The primary infectious agent, M. tuberculosis, is an acid-fast aerobic rod that grows slowly and is sensitive to heat and ultraviolet light. Mycobacterium bovis and Mycobacterium avium have rarely been associated with the development of a TB infection. TB is a worldwide public health problem that is closely associated with poverty, malnutrition, overcrowding, substandard housing, and inadequate health care. Mortality and morbidity rates continue to rise; M. tuberculosis infects an estimated one third of the world's population and remains the leading cause of death from infectious disease in the world.

Treatment Guidelines for Acute Myocardial Infarction

Use rapid transit to the hospital. •Obtain 12-lead electrocardiogram to be read within 10 minutes. •Obtain laboratory blood specimens of cardiac biomarkers, including troponin. •Obtain other diagnostics to clarify the diagnosis. •Begin routine medical interventions: •Supplemental oxygen •Nitroglycerin •Morphine •Aspirin •Beta-blocker •Angiotensin-converting enzyme inhibitor within 24 hours •Anticoagulation with heparin and platelet inhibitors •Statin •Evaluate for indications for reperfusion therapy: •Percutaneous coronary intervention •Thrombolytic therapy •Continue therapy as indicated: •IV heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux •Clopidogrel •Glycoprotein IIb/IIIa inhibitor •Bed rest for a minimum of 12-24 hours •Statin prescribed at discharge. ( Chart 23-7)

MI patho continued

Various descriptions are used to further identify an MI: the type (NSTEMI, STEMI), the location of the injury to the ventricular wall (anterior, inferior, posterior, or lateral wall), and the point in time within the process of infarction (acute, evolving, or old). The differentiation between NSTEMI and STEMI is determined by diagnostic tests and is explained later in this chapter. The 12-lead ECG identifies the type and location of the MI, and other ECG indicators, such as a Q wave, and patient history, identify the timing. Regardless of the location, the goals of medical therapy are to relieve symptoms, prevent or minimize myocardial tissue death, and prevent complications. The pathophysiology of CAD and the risk factors involved were discussed earlier in this chapter.

CAD Pathophysiology

he inflammatory response involved with the development of atherosclerosis begins with injury to the vascular endothelium and progresses over many years. The injury may be initiated by smoking or tobacco use, hypertension, hyperlipidemia, and other factors. The endothelium undergoes changes and stops producing the normal antithrombotic and vasodilating agents. The presence of inflammation attracts inflammatory cells, such as macrophages. The macrophages ingest lipids, becoming "foam cells" that transport the lipids into the arterial wall. Some of the lipid is deposited on the arterial wall, forming fatty streaks. Activated macrophages also release biochemical substances that can further damage the endothelium by contributing to the oxidation of low-density lipoprotein (LDL). The oxidized LDL is toxic to the endothelial cells and fuels progression of the atherosclerotic process.

Small-Volume Nebulizer

• Remove the nebulizer cup from the device and open it. • Place premeasured unit dose medication in the bottom section of the cup or use a dropper to place concentrated dose of medication in the cup and add prescribed fluid to dilute if required. • Screw the top portion of the nebulizer cup back in place and attach the cup to the nebulizer. • Attach one end of tubing to the stem on the bottom of the nebulizer cuff and the other end to the air compressor or oxygen source. • Turn on the air compressor or oxygen. • Check that a fine medication mist is produced by opening the valve. • Have the patient place the mouthpiece into mouth and grasp securely with teeth and lips. • Instruct the patient to inhale slowly and deeply through the mouth and hold each breath for a slight pause before exhaling. (A nose clip may be necessary if the patient is also breathing through the nose.) • Have patient continue this inhalation technique until all medication in the nebulizer cup has been aerosolized (usually about 15 minutes). When the medication in the nebulizer cup has been completely aerosolized, the cup will be empty. • Have the patient remove the nebulizer from the mouth, and gargle and rinse with tap water, as indicated. Clean and store the nebulizer according to the manufacturer's directions and facility policies.

Dry Powder Inhaler (DPI)

• Review the specific instructions the specific DPI to be administered. • Remove the mouthpiece cover (if present) and load a dose if necessary. Alternatively, activate the inhaler, if necessary, according to the manufacturer's directions. • Have the patient breathe out slowly and completely, without breathing into the DPI. The patient should place teeth over, and seal lips around, the mouthpiece. It is important to not block the opening with the tongue or teeth. • Have the patient breathe in strong, steady, and deeply through the mouth, for longer than 2 to 3 seconds. • Remove the inhaler from the mouth. Instruct the patient to hold their breath for 5 to 10 seconds, or as long as possible, and then to exhale slowly through pursed lips. • Wait 1 to 5 minutes, as indicated by the medication, before administering the next puff. After the prescribed amount of puffs has been administered, have the patient replace the cap or storage container. • Have the patient gargle and rinse with tap water after using a DPI, as indicated. Clean the DPI according to the manufacturer's directions.