Cardiac

Ineffective airway clearance.

Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations.

left subclavian, triple lumen catheter

The nurse should first assess for bilateral breath sounds since a complication of central line insertion is a pneumothorax which would cause an increase in respiratory rate and drop in oxygen, causing irritability. The nurse should also assess blood pressure and heart rate for the complication of bleeding. A chest x-ray will be performed to determine correct placement and complications. A central line was most likely placed because peripheral IV access was not available or adequate for the client.

A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because:

This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal.

Hypothermia-hyperthermia machines

are used to cool or warm clients with abnormalities in temperature regulation.

Cardiac pacemakers

are used to maintain the heartbeat at a predetermined rate

An ejection click

associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.

dilated aorta

cause a murmur.

third heart sound

decreased myocardial contractility. irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex and it is one of the first clinical findings in left ventricular failure.

Graham Steell's murmur

is a high-pitched, blowing murmur with a decrescendo pattern; heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect.

tissue plasminogen activator (t-PA)

t t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical.

Pericardial friction rub

A pericardial friction rub, which sounds like squeaky leather, may occur during the first week following an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other.

A fourth heart sound (S4) indicates a:

An S4 occurs as a result of increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased ventricular compliance. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction.

legionnaires' disease

Azithromycin is the drug of choice for treating legionnaires' disease. Rifampin is used to treat tuberculosis. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterial infection.

Opening snap sound

Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole.

clonidine

Clonidine is a central-acting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects.

Intra-aortic balloon pump

Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. It increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock?

percutaneous transluminal coronary angioplasty

During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm