Aortic Regurgitation Case Study |, Respiratory Assessment, Coronary Artery Disease

Which intervention is most important for the nurse to include in the client's plan of care to decrease risk of having a myocardial infarction?

-Arrange a follow-up appointment with a healthcare provider. Follow up will be key upon discharge; however, if risks are not modified, follow up will not help reduce the risk. -Obtain a consult for social worker to provide community resources. Resources are important, but will not directly reduce the risk. -Call the local pharmacy to identify the antihypertensive that the client was prescribed. Knowing what medication the client was taking will not directly decrease his risk. -Identify the client's risk factors for having an acute myocardial infarction. Identifying and informing the client of the risk factors that can be modified is priority. Smoking, drinking, and hypertension are modifiable and/or controllable risk factors. Family history will also increase the client's risks.

In addition to nitroglycerin, the HCP orders morphine sulfate 4mg IV. Which reaction requires immediate intervention by the nurse?

-Blood pressure 100/68 mmHg. The BP is not significantly low. -Onset of sudden drowsiness. Drowsiness is an expected effect of morphine. -Unrelieved pain 15 minutes after injection. While this warrants further assessment, it is not an immediate intervention. -Respiratory rate slowing to 10 breaths/min. Profound respiratory depression is an adverse reaction of opioids such as morphine sulfate. Respiratory rate should remain 12 breaths/min or higher.

Calcium channel blockers enhance the action of digoxin by increasing the serum digoxin levels. Which assessment finding provides the earliest indication that the client is experiencing digoxin toxicity?

-Low potassium level. Potassium can increase or decrease the effects of digoxin but is not a sign of toxicity. -Yellow halos around lights. Early signs of toxicity include anorexia, nausea and vomiting, fatigue, headache, depression, and visual changes. -Slow heart rate. Late signs of toxicity include cardiac dysrhythmias such as bradycardia or heart blocks. -Increased liver function test. Digoxin is metabolized by the kidneys and liver. If the client has kidney or liver disease, they have an increase in risk for toxicity. However, this is not a sign of toxicity.

The nurse notices that the client's urine is greenish in appearance when a urine sample is collected. Which intervention(s) should the nurse implement? (Select all that apply. One, some, or all options may be correct.)

-Notify the HCP. Some infectious processes such as urinary tract infections (UTIs) caused by pseudomonas can cause the urine to turn green, but this is not indicated at this time. -Recollect the urine sample to be analyzed again. The urine specimen was properly collected; therefore, it is not necessary to collect another sample. -Ask the client to list the food he has eaten in the last 24 hours. Certain foods, such as asparagus and black licorice, as well as medications such as cimetidine and indomethacin can cause urine to appear green. -Record the color and amount of urine in the medical record. The appearance of the urine needs to be documented, along with information the client provides about oral intake from the previous 24 hours. -Prepare to place a urinary catheter. The presence of a urinary catheter is the most important risk factor for bacteriuria. The nurse cannot place a urinary catheter without a prescription from the HCP. A urinary catheter would exacerbate an infection which has not been confirmed at this point.

When providing education for the prescribed transdermal nitroglycerin, which intervention is most important for the nurse to include?

-Report any redness under the patch site. This is a common side effect that can be managed by rotating patch application sites. -Expect a mild headache after application. This is a common side effect that may be more noticeable when applying a new patch. -Tell the healthcare provider (HCP) of persistant dizziness when standing. Nitroglycerin is a nitrate, causing systemic vasodilation. This often leads to hypotension, which can cause the client to feel dizzy. She should be instructed to change positions slowly and to avoid prolonged standing. If the dizziness is persistant when standing, the client's blood pressure may be too low, requiring the HCP to adust the dosage or change the medication. -Inform HCP of rash around the transdermal patch. This is a common side effect. The HCP should be informed; however, this is not life threatening.

Client Teaching: Hyperlipidemia The client's lab results include: Serum cholesterol 280 mg/dL (7.25 mmol/L). Low-density lipoproteins (LDL) 180 mg/dL (4.66. mmol/L). High-density lipoproteins (HDL) 32 mg/dL (0.83 mmol/L). The client asks the nurse if these results are bad. Which nursing intervention best promotes effective communication?

-Serum cholesterol under 300 mg/dL (7.77 mmol/L) is considered a healthy heart level. Serum cholesterol less than 200 mg/dL (5.18 mmol/L) is the desired level. -Serum cholesterol greater than 200 mg/dL (5.18 mmol/L) requires medical intervention. While 200 mg/dL (5.18 mmol/L) or less is considered desirable, medical intervention is not generally initiated for levels under 240 mg/dL (6.22 mmol/L). Clients with cholesterol levels between 200 to 240 mg/dl (5.18 - 6.22 mmol/L) should be advised to begin lifestyle modifications. -LDL less than 200 mg/dL (5.18 mmol/L) is within an acceptable range. This is too high. LDL is the "bad" cholesterol that can accumulate in the arteries, eventually leading to angina, infarction, or CVA. Less than 100 mg/dL (2.59 mmol/L) is considered the optimal level, with readings above 190 (4.92 mmol/L) considered very high. -HDL less than 50 mg/dL (1.29 mmol/L) for women indicates an increased risk. HDL is considered the "good" cholesterol, which reduces the risk of heart disease. Current guidelines state that an HDL of less than 50 mg/dL (1.29 mmol/L) for women is too low to safeguard the arteries.

The HCP prescribes a stress echocardiogram. When preparing the client for the test, which instruction is most important for the nurse to provide?

-Tell the client to have nothing by mouth four hours before the test. Food and drink within hours of test may cause nausea and discomfort, but will not affect the outcome of the test. -Instruct the client not to smoke on the day of the test. The client smokes and should be specifically instructed not to smoke prior to test. Nicotine can interfere with the heart rate. -Wear loose-fitting clothes and good walking shoes. Wearing loose-fitting clothes and good walking shoes may be more comfortable for completing the test but should not affect the outcome of the test. -Avoid drinking caffeine-containing beverages prior to the test. Caffeine may affect the heart rate, but not as pronounced as nicotine. Caffeine should be reported prior to the test but should not affect the outcome.

he patient with COPD is expected to remain free from serious respiratory infection. Indicators include that the patient consistently demonstrates these behaviors:

• Verbalizes clinical manifestations of respiratory infection • Describes respiratory infection-monitoring procedures • Uses prevention activities such as pneumonia and influenza vaccination and crowd avoidance • Seeks medical assistance when manifestations of respiratory infection first appear

ASSESS NUTRITIONAL STATUS

• Weight maintenance, loss, or gain • Food and fluid intake • Use of nutritional supplements • General condition of the skin • Assess patient's and caregiver's adherence and understanding of illness and treatment, including: • Correct use of supplemental oxygen • Correct use of inhalers • Drug schedule and side effects • Manifestations to report to the health care provider indicating the need for acute care • Increasing severity of resting dyspnea • Increasing severity of usual symptoms • Development of new symptoms associated with poor oxygenation • Respiratory infection • Failure to obtain the usual degree of relief with prescribed therapies • Unusual change in condition • Use of pursed-lip and diaphragmatic breathing techniques • Scheduling of rest periods and priority activities • Participation in rehabilitation activities

pulmonary disease (COPD)

A group of lung diseases that block airflow and make it difficult to breath -Ask about risk factors such as age, gender, occupational history, and ethnic-cultural background when taking a history from a patient -more often in older men. some types of emphysema occur in families, especially those with alpha1-antitrypsin (AAT) deficiency. Obtain a thorough smoking history, because tobacco use is a major risk factor. Ask about the length of time the patient has smoked and the number of packs smoked daily. Use these data to determine the pack-year smoking history. If the patient smokes, use this opportunity as a teachable moment to discuss smoking cessation strategies (see Chart 32-3). Ask the patient to describe his or her breathing problems. Assess whether the patient has any difficulty breathing while talking. Can he or she speak in complete sentences, or is it necessary to take a breath between every one or two words? Ask about the presence, duration, or worsening of wheezing, coughing, and shortness of breath. Determine what activities trigger these problems. Assess the patient's cough pattern. If the cough is productive, ask whether sputum is clear or colored and how much is produced each day. Ask the patient to recall the time of day when the sputum production is greatest. Smokers often have a productive cough when they get up in the morning; nonsmokers generally do not. Ask whether sputum production has increased or changed during the past year. Check the relationship between activity tolerance and dyspnea by asking the patient to compare his or her activity level and shortness of breath now with those of a month ago and a year ago. Likewise, ask about any difficulty with eating and sleeping. Many patients sleep in a semi-sitting position because breathlessness is worse when lying down (orthopnea). Ask about usual daily activities and any difficulty with sleeping, bathing, dressing, or sexual activity. Document this initial assessment to serve as a starting point for determining the intervention plan and its effectiveness. Weigh the patient, and compare this weight with previous weights. Unplanned weight loss occurs with an increase in COPD severity. COPD increases metabolic needs as a result of the increased work of breathing. Dyspnea and mucus production often result in poor food intake and inadequate nutrition. Ask the patient to recall a typical day's meals and fluid intake. When heart failure is present with COPD, general edema with weight gain may occur. -General appearance can provide clues about the patient's respiratory status and energy level. Observe his or her weight in proportion to height, posture, mobility, muscle mass, and overall hygiene. The patient with increasingly severe COPD is thin, with loss of muscle mass in the extremities, although the neck muscles may be enlarged. He or she tends to be slow moving and slightly stooped. Usually the person sits with a forward-bending posture, sometimes with the arms held forward (Fig. 32-8). When dyspnea becomes severe, activity intolerance may be so great that bathing and general grooming are neglected. -Respiratory changes occur as a result of obstruction, changes in chest size, and fatigue. Inspect the chest to assess the breathing rate and pattern. The patient with respiratory muscle fatigue breathes with rapid,

FEF25%-75% records the forced expiratory flow over the 25%-75% volume (middle half) of the FVC.

This measure provides a more sensitive index of obstruction in the smaller airways.

Physiological Integrity The client's chest x-ray reveals consolidation in the lower bases, scattered infiltrates throughout, and an enlarged cardiac silhouette. Based on the diagnostic findings with the physical assessment of dullness with percussion, which assessment finding warrants immediate intervention by the nurse?

-Progressive dry cough. A dry cough is a common symptom for pleural effusions, but is not life threatening. -Decreased breath sounds. The infiltrates are areas of the lungs where there are decreased breath sounds caused by pulmonary edema as a result of heart failure. -Use of accessory muscles. Use of accessory muscles is a sign that the client is failing to compensate and may require life-saving measures. -Dyspnea on exertion. The client can limit activities that cause dyspnea and may need to be placed on bed rest if oxygenation falls below 94% with activity.

After discussing these test results with the healthcare provider (HCP) and the nurse, the client expresses interest in learning how to lower her cholesterol and lose weight. The HCP prescribes the antihyperlipidemic agent lovastatin 20 mg PO daily. Which intervention is most important for the nurse to include in the client's plan of care related to the use of an antihyperlipidemic?

-TSH 3.9 mclU/mL (3.9 mIU/L). This is a normal TSH level. Antihyperlipidemics do not affect thyroid function. -ALT 60 U/L (1.0 mckat/L). Normal ALT is 4 - 36 U/L (0.07 - 0.60 mckat/L). Antihyperlipidemics can cause increased liver enzymes and should be monitored periodically during treatment. -Amylase 44 U/L (0.73 mckat/L). This is a normal amylase level. Antihyperlipidemics do not affect pancreatic function. -Potassium 4.8 mEq/L (4.8 mmol/L). This is a normal potassium level. Electrolytes and potassium are not affected by antihyperlipidemic therapy.

Which intervention is most important for the nurse to reinforce when assisting the client in achieving their goal to quit smoking?

-Provide the client with a list of local smoking cessation programs. Prescribed and over-the-counter medications work best when taken in conjunction with a smoking cessation program. -Review a list of over-the-counter smoking cessation aids with the client. Over-the-counter medications work best when taken in conjunction with a smoking cessation program. -Encourge the client to start taking a prescribed nicotinic agonist. Prescribed medications work best when taken in conjunction with a smoking cessation program. -Identify the triggers that cause the client to use nicotine. Even though smokers indicate that they would like to quit, the addictive quality of nicotine makes it very difficult to do so without having support with medication and a program.

FRC (functional residual capacity) is the amount of air remaining in the lungs after normal expiration. FRC test requires use of the helium dilution, nitrogen washout, or body plethysmography technique.

Increased FRC indicates hyperinflation or air trapping, which may result from obstructive pulmonary disease. FRC is normal or decreased in restrictive pulmonary diseases.

Thoracentesis

Position for thoracentesis. Before the procedure, ask the patient about any allergy to local anesthetic agents. Verify that the patient has signed an informed consent. The entire chest or back is exposed, and the aspiration site is shaved if necessary. The actual site depends on the volume and location of the effusion (determined by x-rays, sonography, and percussion). Procedure. Thoracentesis is often performed at the bedside by a nurse practitioner or a physician, although computed tomography or ultrasound may be used to guide it. The person performing the procedure and any assistants wear goggles and masks to prevent accidental eye or oral splash exposure to the pleural fluid. After draping the patient and cleaning the skin with an antiseptic agent, a local anesthetic is injected into the selected site. Keep the patient informed of the procedure while observing for shock, pain, nausea, pallor, diaphoresis, cyanosis, tachypnea, and dyspnea. The short 18- to 25-gauge thoracentesis needle (with an attached syringe) is advanced into the pleural space. Gentle suction is applied as the fluid in the pleural space is slowly aspirated. A vacuum collection bottle is sometimes needed to remove larger volumes of fluid. To prevent re-expansion pulmonary edema, usually no more than 1000 mL of fluid is removed at one time. If a pleural biopsy is to be performed, a second, larger needle with a cutting edge and collection chamber is used. After the needle is withdrawn, pressure is applied to the puncture site and a small sterile dressing is applied. Follow-up Care. After thoracentesis, a chest x-ray is performed to rule out possible pneumothorax and mediastinal shift (shift of central thoracic structures toward one side). Monitor vital signs, and auscultate breath sounds for absent or reduced sounds on the affected side. Check the puncture site and dressing for leakage or bleeding. Also assess for complications, such as reaccumulation of fluid in the pleural space, subcutaneous emphysema, infection, and tension pneumothorax. Urge the patient to breathe deeply to promote expansion of the lung. Document the procedure, including the patient's response; the volume and character of the fluid removed; any specimens sent to the laboratory; the location of the puncture site; and respiratory assessment findings before, during, and after the procedure (Rushing, 2006). Teach the patient about the manifestations of a pneumothorax (partial or complete collapse of the lung), which can occur within the first 24 hours after a thoracentesis. Manifestations include: • Pain on the affected side that is worse at the end of inhalation and the end of exhalation • Rapid heart rate • Rapid, shallow respirations • A feeling of air hunger • Prominence of the affected side that does not move in and out with respiratory effort • Trachea slanted more to the unaffected side instead of being in the center of the neck Instruct the patient to come to the emergency department immediately if these manifestations occur. Lung Biopsy A lung biopsy is performed to obtain tissue for histologic analysis, culture, or cytologic examination. The tissue samples are used to make a definite diagnosis about the type of cancer, infection, inflammation, or lung disease. There are several types of lung biopsies. The site and extent of the lesion determine which one is used. Transbronchial biopsy (TBB) and transbronchial needle aspiration (TBNA) are performed during bronchoscopy. Transthoracic needle aspiration is an approach through the skin (percutaneous) for areas that cannot be reached by bronchoscopy. An open lung biopsy is performed in the operating room. Patient Preparation. The patient may worry about the outcome of the biopsy and may associate the term biopsy with cancer. Explain what to expect before and after the procedure, and explore the patient's feelings and fears. To reduce discomfort and anxiety, an analgesic or sedative may be prescribed before the procedure. Inform the patient undergoing percutaneous biopsy that discomfort is reduced with a local anesthetic agent but that pressure may be felt during needle insertion and tissue aspiration. Open lung biopsy is performed in the operating room with the patient under general anesthesia, and the usual preparations before surgery apply (see Chapter 16). Procedure. Percutaneous lung biopsy may be performed in the patient's room or in the radiology department after an informed consent has been obtained. Fluoroscopy or CT is often used to visualize more clearly the area undergoing biopsy and to guide the procedure. Positioning of the patient is similar to that for thoracentesis. The skin is cleansed with an antiseptic agent, and a local anesthetic is given. Under sterile conditions, a spinal-type 18- to 22-gauge needle is inserted through the skin into the desired area (e.g., tissue, nodule, lymph node) and tissue needed for microscopic examination is obtained. Apply a dressing after the procedure. An open lung biopsy is performed in the operating room. The patient undergoes a thoracotomy in which lung tissue is exposed. At least two tissue specimens are taken (usually from an upper lobe and a lower lobe site). A chest tube is placed to remove air and fluid so the lung can re-inflate, and then the chest is closed. Follow-up Care. Monitor the patient's vital signs and breath sounds at least every 4 hours for 24 hours, and assess for signs of respiratory distress (e.g., dyspnea, pallor, diaphoresis, tachypnea). Pneumothorax is a serious complication of needle biopsy and open lung biopsy. Report reduced or absent breath sounds immediately. Monitor for hemoptysis (which may be scant and transient) or, in rare cases, for frank bleeding from vascular or lung trauma.

FEV1/FVC is the ratio of expiratory volume in 1 sec to FVC.

This ratio provides a much more sensitive indication of obstruction to airflow. This ratio is the hallmark of obstructive pulmonary disease. It is normal or increased in restrictive disease.

FEV1 (forced expiratory volume in 1 sec) records the maximum amount of air that can be exhaled in the first second of expiration.

is effort dependent and declines normally with age. It is reduced in certain obstructive and restrictive disorders.

Classification of COPD Severity

Mild Moderate Severe Very severe

RV (residual volume) is the amount of air remaining in the lungs at the end of a full, forced exhalation.

RV is increased in obstructive pulmonary disease such as emphysema.

The severity of the client's pleural effusions are confirmed with the enlarged cardiac silhouette on the chest x-ray. The client is having difficulty taking deep breaths and is short of breath when speaking. Which intervention is most important for the nurse to include in the client's plan of care?

-Daily weights. Daily weights will help monitor fluid retention but will not improve the client's symptoms. -Sodium restricted diet. Diet restrictions will decrease complications of further fluid retention due to diet. However, this intervention is not immediately helpful. -Daily fluid restrictions. Fluid restrictions will decrease complications of further fluid retention due to diet. However, this intervention is not immediately helpful. -High Fowler's position. Positioning the client to promote ease of breathing is immediately effective and a priority while treating the underlying cause.

In addition to the ECG, the nurse sent blood to the laboratory to evaluate the client's cardiac isoenzyme. Which serum laboratory values requires intervention by the nurse?

-Myoglobin 60 mcg/L (3.49 nmol/L). Myoglobin (Female) 10 - 65 mcg/L (0.58 - 3.78 nmol/L) (onset: 1-3 hrs, peak: 6-10 hrs, return to normal: 12-24 hrs). -Creatine kinase - MB (CK-MB) 3.0 ng/mL (3.0 mcg/L). Normal CK-MB < 5.0 ng/mL (5.0 ug/L). This is the most sensitive creatine kinase to the cardiac muscle, but is also found in skeletal muscle. -Lactate dehydrogenase (LDH) 200 U/L (3.34 mckat/L). Normal LDH is 140 U/L (0.67 ukat/L) to 280 U/L (4.68 ukat/L). LDH, like creatine phosphokinase (CPK), is an enzyme that is nonspecific to cardiac muscle injury. However, LDH1 is a sensitive cardiac isoenzyme, which is often compared with LDH2 as a ratio during the diagnosis of MI. -Troponin T 0.4 ng/mL (0.4 mcg/L). Troponin T 0 - 0.2 ng/mL (0.2 ug/L) (onset: 2-4 hrs, peak: 10-24 hrs, return to normal: 10-14 days). This indicates acute myocardial injury and requires immediate intervention.

The client is transferred from the ED to the medical unit. The ED nurse gives the admitting nurse a hand-off report. Which nursing intervention best promotes effective communication?

-Relay a complete review of the client's past medical history. Handoff communication should be problem focused. A complete history may not be appropriate at handoff. -Report off on all abnormal laboratory and diagnostic procedure results. Handoff of abnormal results can be limited to critical values and results that require nursing intervention. -Use SBAR (Situation-Background-Assessment-Recommendation) when reporting to receiving nurse. SBAR (Situation-Background-Assessment-Recommendation) technique provides a systematic, effective way to report off when a client is moving within units of the hospital. SBAR is a way to communicate the client's condition among members of the healthcare team that is predictable and structured. -Elaborate on the history of smoking and alcohol consumption. Smoking and alcohol consumption can be included in the SBAR if it is immediatly necessary .

COPD is expected to increase activity to a level acceptable to him or her. Indicators include:

• Maintenance of baseline SaO2 with activity • Performance of ADLs with no or minimal assistance • Performance of selected activities with minimal dyspnea or tachycardia • Participation in family, work, or social activities as desired

Therapeutic Communication: Noncompliance The client is post-menopausal and smokes two packs of cigarettes a day. Her hypertension is uncontrolled even with the prescribed ACE inhibitor. The client took the clinic's online learning course on reducing the risk for heart disease. At the conclusion of the course, the client tells the nurse that she does not need classes because she knows she is going to be healed. Which nursing intervention best promotes effective communication?

-"I believe that God helps those who help themselves." Therapeutic communication should be free of the nurse's personal values. This blocks further communication. -"You will have a heart attack if you don't change your lifestyle." This statement is overly threatening and confrontational, and it does not promote further communication. -"Do you feel that you do not need to be involved in your health care?" Clarification of the client's statement is a useful therapeutic technique that encourages further communication. -"You must accept that you have a responsibility to care for yourself." This statement is confrontational and does not promote further communication.

Which information in the client's history indicates an increased risk for coronary artery disease (CAD) and requires the nurse to provide disease management education? (Select all that apply. One, some, or all options may be correct.)

-Episodes of hypoglycemia. Hypoglycemia does not increase the risk for CAD. A history of diabetes mellitus is a contributing risk factor. -Family history of hyperlipidemia. Genetic predisposition is a significant factor in the development of CAD. -Consumption of a high-fat diet. Unhealthy habits, such as consuming fatty foods, are contributing risk factors to CAD. -Hypertension controlled with an oral antihypertensive. High blood pressure is a modifiable risk factor. If controlled, then it is not an active risk. -Smoking two packs of cigarettes per day. Smoking is a modifiable risk factor for coronary artery disease.

While taking the prescribed antihyperlipidemic, which serum laboratory value requires intervention?

-Heart healthy diet Hearth healthy diet is only one component of the critical healthy lifestyle habits that are needed in conjunction with cholesterol-lowering medication. -Healthy lifestyle habits Lifestyle modifications should be used in conjunction with a cholesterol-lowering medication. Lifestyle modificatios include heart healthy diet, regular exercise, avoiding tobacco products, and maintaining a healthy weight. -Avoid use of tobacco products Avoiding tobacco is only one component of the critical healthy lifestyle habits that are needed in conjunction with cholesterol-lowering medication. -Maintain a healthy weight Maintaining a healthy weight is only one component of the critical healthy lifestyle habits that are needed in conjunction with cholesterol-lowering medication.

The healthcare provider (HCP) orders IV nitroglycerin for the client. What changes in the client's cardiac function should the nurse tell the client to expect?

-An increase in the strength of the heart muscle to contract. Increasing the force and velocity of myocardial systolic contraction is not an action of nitroglycerin. -Improved perfusion of oxygenated blood to the heart muscle. Nitrates cause the coronary blood vessels to dilate, allowing improved oxygen delivery to cardiac muscle. In addition, nitrates cause systemic vasodilation, reducing the workload on the heart, which in turn reduces the myocardium's need for oxygen. -Causes the heart muscle to relax between contractions. Nitroglycerin perfuses cardiac muscle, but it does not relax the muscle. -Dissolves the blockage inside the coronary arteries. Nitroglycerin is not a thrombolytic and does not dissolve what is blocking the arteries.

What steps should the nurse take to minimize the development of these adverse effects? (Select all that apply. One, some, or all options may be correct.)

-Monitor serum lidocaine levels. Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/mL (6.4 to 21.34 mcmol/L). -Continue the infusion as prescribed. The infusion must be stopped immediately if signs of overdose are present. -Monitor ECG, blood pressure, and respiratory status. Heart rhythm and VS, especially blood pressure and respirations, must be monitored closely. -Monitor the client's anxiety level. Nervousness and excitation are adverse effects of lidocaine and the nurse should monitor the client closely for these developments.

HUMAN NEEDS ASSESSMENT REVIEW

What should you expect to NOTICE in a patient with adequate oxygenation and tissue perfusion related to respiratory function? Vital Signs • Respiratory rate and heart rate within normal range • Oxygen saturation of 95% or higher Physical Assessment • Able to speak a sentence of 12 words without stopping for breath • Able to walk and talk without stopping for breath • Skin color normal (no cyanosis, pallor, or jaundice) • Oral mucous membrane and nail beds pink with rapid capillary refill • Fingertips and nails normal-shaped, no clubbing • Anterior to posterior diameter of chest about two-thirds smaller than lateral diameter • Space between each rib no larger than the breadth of the patient's finger • Usually breathes in through the nose and out through the mouth or nose • Breathing quiet • Air movement heard (with a stethoscope) in all lobes of both lungs • Sputum production minimal, clear or white • Muscle development even with no muscle loss on arms and legs • Weight proportionate to height; does not appear underweight Psychological Assessment • Oriented and not confused • Energy level good, can engage in desired work, recreational, and personal activities Laboratory Assessment • Red blood cell, hemoglobin, hematocrit, and white blood cell levels within normal limits for age and gender

Later that day, the client reports to the nurse less abdominal pain and nausea, a severe headache, blurry vision, and feels really tired. The nurse assesses the client and notes an irregular heart rate of 56 bpm. Which laboratory tests does the nurse anticipate the HCP will prescribe for the client? (Select all that apply. One, some, or all options may be correct.)

-Digoxin serum level. The client is prescribed digoxin and is congruently taking captopril and diltiazem, which has the potential to increase the levels of the digoxin, leading to toxic levels. Sodium level. Sodium levels are not directly associated with these symptoms. The signs and symptoms that the client is experiencing are related to digoxin and the other medications that increase the potential for digoxin toxicity. -Potassium serum level. Low potassium levels increase the chance of digoxin toxicity. Furosemide may cause hypokalemia, which increases the potential of the occurrence of digoxin toxicity. -Phosphorus serum level. Phosphorus levels are not directly associated with these symptoms. The signs and symptoms that the client is experiencing are related to the prescribed digoxin and other medications that increase the potential for digoxin toxicity. -Calcium serum level. Calcium levels are not directly associated with these symptoms. The signs and symptoms that the client is experiencing are related to the prescribed digoxin and other medications that increase the potential for digoxin toxicity.

The nurse completes a problem focused assessment. Which finding warrants immediate intervention by the nurse?

-Irregularly, irregular atrial dysrhythmia. An irregularly, irregular atrial dysrhythmia, known as Atrial Fibrillation is a complication of heart failure. Atrial fibrillation increases as the severity of heart failure increases and promotes thrombus formation within the atria which can break loose and place the client at risk for a life-threatening stroke. -Progressive weight gain. Progressive weight gain is a clinical manifestation of chronic heart failure and is not immediately life-threatening. -Fatigue with usual activities. Fatigue with usual activities is a clinical manifestation of chronic heart failure and is not immediately life-threatening -Dyspnea with mild exertion. Dyspnea with mild exertion is a clinical manifestation of chronic heart failure and is not immediately life-threatening.

Upon reviewing the prescriptions and laboratory results, which intervention(s) should the nurse include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.)

-Keep the client on bedrest until oxygen can be weaned. The client does not need to be placed on bedrest unless there is a suspicion of a more serious problem such as a pulmonary embolism. Mobility as tolerated decreases risk of pulmonary complications. -Ensure NPO instructions are clarified with HCP. The client should be on NPO status for a minimum of 8 hours for the fasting glucose and 12 hours for the lipid profile. -Discuss plan to correct abnormal laboratory values with HCP. The client's abnormal sodium, potassium, and phosphorus need to be addressed. Abnormalities can cause cardiac irritability and lethal arrhythmias. -Increase the frequency of vital signs. The order for vital signs every four hours should be sufficient unless the client's condition decompensates. -Clarify rate of IV fluids while NPO. Increasing the client's IV fluid would exacerbate his congestive heart failure.

The client is settled in and the nurse is planning the client's care. Based on the prescriptions provided, which actions should the nurse delegate to the unlicensed assistive personnel (UAP)?

-Weigh the client on the medical unit's scale. This is within the scope of responsibility for the UAP. -Place the cardiac monitor on the client. This is within the scope of responsibility for the UAP. -Put a fluid restriction sign at the head of bed. This is within the scope of responsibility for the UAP. -Set up the oxygen delivery system at 10 liters/minute. This is not within the scope of responsibility for the UAP. -Adjust oxygen rate if oxygen saturations decrease while ambulating. This is not within the scope of responsibility for the UAP.

Ethical-Legal Considerations: Client Rights While the nurse is assessing the client, a group of people dressed in street clothes and lab coats enters the client's room. They are carrying clipboards and pens, and they begin to ask the client questions related to her hospitalization. The client seems unsure how to respond. The nurse should immediately intervene to prevent violation of which client right?

-The right to be free from assault and battery. This client right is not being violated in this situation. -The right to sufficient information to make an informed decision about treatment. This client right is not being violated in this situation. -The right to have information about the qualifications of caregivers. The individuals in the group should wear name tags that clearly identify their roles, they should introduce themselves, and they should explain to the client why they would like to ask her some questions. Clients have the right to privacy during examination and treatment, as well as the right to refuse observation by those not directly involved in their care -The right to healthcare without discrimination. This client right is not being violated in this situation.

Discharge planning is started with the admission process. With the information that the nurse has gathered, which intervention is most important for the nurse to include in the client's discharge plan?

-identify available community resources. Once the client is discharged, community resources can address his healthcare, financial, and transportation needs. The resources will be key in the client's overall well-being. -Ensure the client that they will have a room at the homeless shelter. Discharging the client to the street is not an option; however, community resouces may be able to identify adequate housing. -Teach the client about foods high in protein. It is important for the client to increase foods that will improve the dietary anemia. However, without resources to purchase food, other choices are more important to address first. -Schedule follow-up appointments. The client will need to follow-up with a HCP after discharge. However, without resources he will not have transportation.

priority nursing diagnoses for patients with chronic obstructive pulmonary disease (COPD):

1. Impaired Gas Exchange related to alveolar-capillary membrane changes, reduced airway size, ventilatory muscle fatigue, and excessive mucus production 2. Ineffective Breathing Pattern related to airway obstruction, diaphragm flattening, fatigue, and decreased energy 3. Ineffective Airway Clearance related to excessive secretions, fatigue, decreased energy, and ineffective cough 4. Imbalanced Nutrition: Less Than Body Requirements related to dyspnea, excessive secretions, anorexia, and fatigue 5. Anxiety related to dyspnea, a change in health status, and situational crisis 6. Activity Intolerance related to fatigue, dyspnea, and an imbalance between oxygen supply and demand • Fatigue related to a change in metabolic energy or hypoxemia • Deficient Knowledge (disease process, prescribed treatments, activity limitations) related to unfamiliarity with information resources • Sexual Dysfunction related to extreme fatigue • Impaired Spontaneous Ventilation related to ventilatory muscle fatigue • Sleep Deprivation related to dyspnea or an unfamiliar environment (hospitalization) • Disturbed Thought Processes related to hypoxemia or sleep deprivation • Ineffective Coping related to high degree of threat, inadequate level of perception of control, changes in lifestyle, situational crisis, or knowledge deficit expected... - Maintenance of SpO2 of at least 88% -Absence of cyanosis -Maintenance of cognitive orientation Monitor results of pulmonary function tests, particularly vital capacity, maximal inspiratory force, forced expiratory volume in 1 second (FEV1), and FEV1/FVC, as appropriate. • Assist patient to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed. • Encourage patient to take several deep breaths. • Encourage patient to take a deep breath, hold it for 2 seconds, and cough two or three times in succession. • Instruct the patient to inhale deeply several times, to exhale slowly, and to cough at the end of exhalation. • Instruct patient to follow coughing with several maximal inhalation breaths.

The ED nurse looks up the prescribed medications and notes that the recommended dosage for losartan is 50 mg PO daily, or 25 mg PO daily in combination with a diuretic. A precaution listed for this medication is increased risk of hypotension and syncope with concurrent use of ACE inhibitors. What action should the nurse implement?

-Acknowledge the losartan medication prescription. Acknowledging prescriptions only verifies the nurse is aware of what has been prescribed. It does not address the issue. A medication that needs to be clarified should not be acknowledged until clarified to prevent the client from receiving an incorrect dose. -Contact the HCP to clarify medication prescriptions. The nurse is responsible for researching potential drug interactions and verifying that the prescribed medication is the appropriate dose and route, prior to administering it to the client. -Administer medications after pharmacy verifies orders. Pharmacy may review the medications and seek clarification; however, it is the nurse's primary responsibility to clarify with the HCP. -Prepare first dose of losartan to be administered. The medication should not be administered until the dosage has been clarified

Safe and Effective Care Upon arrival to the ED, the nurse notices that the client is leaning forward in the wheelchair. The client is pale, somnolent, and having difficulty breathing. Q: Which intervention should the nurse initiate first?

-Apply an oxygen mask on the client at 6 liters per minute. The client may need oxygen but getting the client's airway open is priority. -Place the client on a stretcher and open airway. The nurse needs to place the client on a solid, flat surface to align his airway in a neutral position to open his airway for a visual inspection to assess for an airway obstruction. -Check the client's oxygen saturation level. Knowing the client's oxygen saturation will provide the information needed to determine how much supplemental oxygen the client needs, however getting the client's airway open is priority. -Auscultate the client's lung sounds. Lung sounds are important to determine the movement of air, however, getting the client's airway open is a priority.

The HCP plans to keep the client in the hospital for a few days. The ED nurse is preparing to transfer the client to a medical unit. Which intervention should the nurse implement first?

-Call to provide a report to the receiving nurse. Notifiying the receiving nurse of readiness to transfer will alert all the nurses to obtain any needed equipment prior to the client's arrival on the medical unit. Handoff communication is priority. -Document the transfer in the medical record. Documentation of transfer should be done when client is leaving the ED. -Obtain and apply portable oxygen. Oxygen will be needed for transport but should not be discontinued from the wall oxygen until the client is ready to leave the room. -Administer first dose of prescribed medications. First doses may not all be due or ready for administration. This should not delay transfer to the medical unit.

Psychosocial Integrity/Therapeutic Communication The admitting nurse completes the client's assessment, orients them to the unit, and discusses the plan of care. The nurse also verifies the client's medical and surgical history, updates personal history, and documents a person of contact. It is important for the nurse to develop a therapeutic relationship with the client. When conducting the admission interview, what actions best facilitate the process? (Select all that apply. One, some, or all options may be correct.)

-Clarify information by asking the client more focused questions. Accepting information without questioning and/or clarifying could lead to misunderstanding and lack of pertinent information. Use focused questions when more specific information is needed in an area. -Stand at the foot of the client's bed to conduct the interview. Standing at the foot of the client's bed is an intimidating posture that insinuates the nurse is in a hurry. Sitting in a chair by the bedside will place the nurse at eye level with the client, which helps facilitate conversation and sends the message that the nurse is there to communicate. -Reassure the client that everything will be alright and that he is going to get better. The nurse should not give the client false reassurance. Giving false reassurance could lead to feelings of mistrust and anger. -Let the client do most of the talking and actively listen. The most important element of effective communication is active listening. Watching, observing, and listening to the client's verbal and nonverbal language is very important. -Use open-ended questions that will allow the client to "lead" the conversation. Open-ended questions allow clients to take the conversational lead and introduce pertinent information about a topic. Use focused questions when more specific information is needed in an area.

Nursing Diagnoses and Interventions The nurse assesses the client for changes in vital signs and for dysrhythmias. Other assessment findings related to MI include: Dyspnea Pallor Diaphoresis Weakness Fatigue Nausea Vomiting Fever The client is transferred to the critical care unit for treatment and monitoring. She is still receiving oxygen at 2 L/min and IV nitroglycerin infusion. Her vital signs are stable. Her oxygen saturation is 94%, her breath sounds are clear, and she denies any pain at the present time. The client's nurse develops a plan of care based on the following nursing problems: Pain related to an imbalance between myocardial oxygen supply and demand. Alteration in tissue perfusion (cardiac) related to blood flow interruption. Activity intolerance related to imbalance between oxygen supply and demand. Anxiety related to pain and fear. Which intervention is most important for the nurse to include in the client's plan of care?

-Continuous cardiac monitoring of heart rate and rhythm. The heart rate and rhythm should be continuously monitored. Lethal arrhythmias are the most common immediate complication following an acute myocardial infarction that can be life threatening. -Auscultate lungs for adventitious sounds such as crackles. Auscultating the lungs for crackles or other adventitious sounds can reveal pulmonary edema which is a possible complication following an acute myocardial infarction. Pulmonary edema is often gradual and not immediately life threatening. -Titrate oxygen to keep oxygen saturation greater than 93%. Monitoring and titrating oxygen will help provide the myocardial tissue the oxygen it needs to prevent further injury. A gradual drop in oxygen can be managed and is not immediately life threatening. -Obtain blood to evaluate scheduled serum cardiac markers. Monitoring serum cardiac markers will determine if the mycardial tissue injury is resolving. Knowing the cardiac marker levels will aid in prompt intervention but is a scheduled intervention.

Clinical Manifestations The nurse reviews the client's symptoms during the myocardial infarction. Her pain was first noted as a discomfort during the first presentation. She was weak and short of breath. The ECG revealed ST elevation. Later her chest pain increased and the ECG revealed ST elevation in the lower lateral leads which indicated a STEMI. Elevated cardiac specific laboratory findings, ECG findings, and physical assessment confirmed that the client was having an acute myocardial infarction. After 2 doses of sublingual nitroglycerin and 4 mg IV morphine sulfate, the client's pain is 1 out of 10. The nurse is monitoring the client for complications that are common after a myocardial infarction. Which focused assessment finding warrants immediate intervention by the nurse?

-Dysrhythmias. The most common complication after an MI is dysrhythmias. Lethal dysrhythmia often occur within 4 hours from onset of chest pain. Premature ventricular contractions may precede the lethal dysrhythmias ventricular tachycardia and fibrillation. -Bilateral pulmonary crackles. Heart failure is a complication that occurs when the heart's pumping action is reduced and can produces crackles, extra heart sounds (S3 or S4) and jugular vein distention. Heart failure is not immediately life threatening. -Distended jugular vein. Heart failure is a complication that occurs when the heart's pumping action is reduced and can produces crackles, extra heart sounds (S3 or S4) and jugular vein distention. Heart failure is not immediately life threatening. -Pericardial friction rub. Pericarditis is a complication that can occur following an acute myocaridal injury. Signs and symptoms include ECG changes including diffuse ST-segment elevations and an audible pericardial friction rub. Pain is aggrivated with inspiration and is typically described differently than classic chest pain. Pericarditis is not immediately life threatening.

The client is scheduled for percutaneous transluminal coronary angioplasty (PTCA) via femoral insertion. PTCA involves the insertion of a balloon-tipped catheter into the diseased coronary artery. When the balloon is inflated, it compresses the plaque against the vessel wall, resulting in an increase in the inner diameter of the blood vessel so blood can flow more easily. Which nursing intervention should be implemented first when the client returns to her room?

-Encourage intake of oral fluids. For the first 24 hours following the procedure, intake and output should be monitored, but forcing fluids is not indicated. -Immobilize the affected leg. The prevention of catheter dislodgement and of bleeding or oozing at the insertion site is a high priority in the immediate post-procedure period. The site should be immobilized and closely monitored for signs of hematoma formation (bleeding, inflammation, tenderness, or swelling). In addition, distal circulation should be monitored closely by assessment of pedal pulses, color, warmth, and capillary refill. -Obtain apical pulse every 15 minutes. The client should be continuously monitored for the onset of any dysrhythmias, but frequent (every 15 minutes) assessment of the apical pulse is not necessary. -Limit visitors to one per hour. Limiting visitors is not routine or necessary, but it should be implemented if the client's comfort or safety is jeopardized.

ECG findings reveal ST segment elevation in leads II and III, and a VF indicating that the client is having an inferior acute myocardial infarction (AMI). Which intervention should the nurse implement first?

-Have the client chew four 81 mg chewable acetylsalicylic acid. The first intervention according to American Heart Association standard is to administer acetylsalicylic acid 160-325 mg PO that acts on the platelets, keeping them from clumping together at the site of the coronary blockage. -Apply oxygen 2 L/nasal cannula. Oxygen is the second intervention according to American Heart Association standard, if the client's oxygen saturation level is less than 94%. Give the client one nitroglycerin tablet to dissolve under her tongue. Nitroglycerin is the third intervention according to American Heart Association standard, and is given to vasodilate the coronary arteries and relieve pain. -Administer morphine sulfate 4 mg IV. Morphine is given if pain is unrelieved by the nitroglycerin, according to American Heart Association standard.

Acute Myocardial Infarction (AMI) The client's angina remains stable, and she undergoes a hysterectomy for dysmenorrhea related to uterine fibroids. The day after being discharged from the hospital, the client comes to the ED with crushing substernal chest pain radiating down her left arm. She is dyspneic, pale, and diaphoretic. Which nursing intervention should be implemented first?

-IV access and administer morphine sulfate as ordered by the HCP. Acute chest pain related to myocardial infarction, ischemia, or reduced coronary artery blood flow is the most important nursing problem to address for the client with Acute Coronary Syndrome (ACS). Treating pain is critical, as pain activates the sympathetic nervous system and aggravates diaphoresis, weakness, light-headedness, and palpitations which, in turn, increases cardiac workload. -Administer oxygen. Oxygenation to the myocardial tissue is important for pumping activity and tissue damage repair. Rest also helps to improve oxygenation. However, recent guidelines suggest that routine use of supplemental oxygen may not be necessary in clients with uncomplicated ACS without signs of heart failure, hypoxemia, respiratory distress, or for an oxyhemoglobin saturation rate of 94% or greater. -Obtain a 12 lead electrocardiogram (ECG). While this intervention will be useful in establishing the client's baseline rhythm upon arrival in the ED, and will be helpful in locating the area of MI, circulation is the third priority for emergency care. -Assess the client's blood pressure. Obtaining the client's baseline vital signs, including blood pressure, heart rate, and temperature, is important and monitored continuously, but is not the priority.

Psychosocial Integrity/Client-Centered The nurse completes the client's admission interview discovering that the client is homeless and without a job. The client's spouse died after a long battle with cancer leaving the client in financial crisis which lead to being homless. The client has one son who lives out of the country and unaware of the client's current status. Therapeutic communication involves listening and analyzing what the client is conveying. Based on the information provided by the client, which nursing interventions best promote effective communication? (Select all that apply. One, some, or all options may be correct.)

-Inquire about the client's work history including specific job duties. Individuals who had worked in naval and civilian shipyards were exposed to asbestos in the construction of naval ships, which is known to cause mesothelioma. Asbestos was also used in construction material for buildings. Studies have suggested that individuals who worked in the farming industry and were exposed to pesticides are at increased risk of developing cancers, especially prostate cancer. -Ask the client to elaborate on his son's line of work. The client's son's employment and location should not have a direct impact on the client developing cancer and/or blood anomalies. -Assist the client in recalling his diet intake over the last few weeks. Because of his anemia, it is important to ask about protein intake. Iron deficiency anemia is the most common nutritional disorder in the world and adequate protein intake can prevent this condition. -Review with the client any family history of cancer. It is important to ask about family history of cancer because of the risk factor for some cancers. Question the client regarding history of military enlistments. Studies have shown that some individuals who served in Vietnam were exposed to Agent Orange (herbicide). Those individuals are more likely to develop a precursor disease to multiple myelomas.

Several months later, the client visits the clinic for routine lab work. After walking into the clinic on a very hot day, she reports to the nurse that she is experiencing chest pain. After resting for five minutes, the pain is relieved. Following assessment and ECG evaluation, the client is diagnosed with stable angina and receives two prescriptions: Nitroglycerin 0.2 mg/hour transdermal patch. Apply every morning and remove at bedtime daily. Nitroglycerin 0.3 mg SL as needed for chest pain Which intervention is most important for the nurse to include in the client's plan of care for the self-administration of sublingual nitroglycerin?

-Place one tablet at a time under the tongue. Sublingual tablets are placed under the tongue. It is most important to know to take 1 tablet every 5 minutes for 15 minutes, for a total maximum dose of 3 tablets. -Allow tablet to dissolve completely before swallowing. Tablets must completely dissolve to be effective. It is most important to know to take 1 tablet every 5 minutes for 15 minutes, for a total maximum dose of 3 tablets. -Put one tablet every 5 minutes under tongue up to 3 tablets. Nitroglycerin tablets should be placed under the tongue when chest pain occurs. They may be taken one tablet every 5 minutes for 15 minutes, for a total maximum dose of three tablets. If the pain is not relieved after three doses, the client should be instructed to go to the Emergency Department. -Do not drink anything until tablet is completely dissolved. Drinking may cause some of the medication to be swallowed and not absorbed sublingually, slowing the absorption of the nitroglycerin dose. It is most important to know to take 1 tablet every 5 minutes for 15 minutes, for a total maximum dose of three tablets.

A Complication Occurs On the client's second day post-MI, the nurse notes a change in the client's cardiac monitor. The client's rhythm strip changes from normal sinus rhythm to sinus rhythm with short runs of ventricular tachycardia (VT). The nurse assesses the client, whose blood pressure is now 100/54 mmHg. The client is lethargic, but she is able to be aroused. Which intervention should the nurse initiate first?

-Place the crash cart in close proximity to the room. Since the client's condition may be a life-threatening dysrhythmia, this intervention may be required if the client's dysrhythmia does not respond to medication. However, this is not the best initial action. -Administer amiodarone IV. The treatment of choice for frequent premature ventricular contractions (PVCs) and ventricular tachycardia is an immediate IV bolus of amiodarone. -Hang an IV infusion of dopamine. Dopamine is a vasopressor and inotropic agent that is used to treat severe hypotension and shock. This intervention may be required if the client's dysrhythmia is not controlled and cardiogenic shock develops. However, this is not the best initial action. -Charge the defibrillator to 200 joules. Since the client's condition may be a life-threatening dysrhythmia, this intervention may be required if the client's dysrhythmia does not respond to medication. However, this is not the best initial action.

The client continues to recover in the intensive care unit. Which interventions should the nurse implement for the client? (Select all that apply. One, some, or all options may be correct.)

-Provide pain medication with onset of pain. Providing optimal pain relief with prescribed analgesics is important because pain can exacerbate tachycardia and increases blood pressure. -Administer anti-anxiety medication as needed. Identify when level of anxiety increases. Anxiety increases the need for oxygen. -Encourage the client to maintain complete bedrest Monitor exercise and provide rest periods to avoid fatigue and to increase activity tolerance without rapidly increasing cardiac workload. Complete bedrest could lead to pulmonary complications. -Assess the client's level of knowledge and ability to learn. Knowledge related to disease process and prognosis is important but should also be realistic. Realistic expectations promotes realistic decision making. -Provide pamphlet listing non-modifiable risk factors. Instruct the patient on cardiac risk factors that are modifiable which include smoking cessation, diet, and exercise. Non-modifiable risk factors are good to know but will not increase patient's control of illness.

As the client is transferred to a stretcher the nurse notices the use of accessory muscles of the chest and neck and an exaggerated effort to breathe. Which intervention should the nurse implement first?

-Raise the head of the stretcher to a semi-Fowler's position. The first intervention is to raise the head of the stretcher to a semi-Fowler's position, allowing for full expansion of the client's lungs and taking pressure off his diaphragm, enhancing the delivery of oxygen to the lungs. -Apply a partial rebreather mask with oxygen at 10 liters per minute. Once positioned so the airway is open and the client is able to breathe easier, oxygen should be applied. -Auscultate the client's lungs bilaterally to assess for diminished breath sounds. Equal breath sounds are important; however, airway patency is a priority. -Monitor the client's oxygen saturation level. Knowing the level of oxygen will help the nurse titrate oxygen once the airway is patent.

The nurse teaches the client about their medications prior to administering them. Which intervention is most important for the nurse to include regarding the amlodipine and diltiazem, which are both calcium-channel blockers?

-Report any episodes of dizziness. Combination calcium-channel blocker therapy is prescribed to better control the client's blood pressure. Since amlodipine and diltiazem are both calcium-channel blockers, it is important for the client to report side effects such as dizziness, which may be a sign of low blood pressure. A very low heart rate may also occur, which will require an adjustment in the client's medications and/or dosages. While in the hospital and on a cardiac monitor, the nurse should monitor for a low, irregular heart rate. -Avoid drinking grapefruit juice. While this may cause an increase in the serum blood levels of calcium channel blockers, a low blood pressure requires immediate intervention. -Tell HCP of daily weight gain. Weighing daily is important to evaluate the amount of fluid retention that may increase as heart failure worsens. The HCP may need to change the medications and/or dosages to better manage these symptoms. Weight gain does not require an immediate intervention. -Keep a blood pressure diary. It will be important for the HCP to evaluate the effectiveness of this combination therapy. However, reporting serious side effects is priority.

Diagnostic Tests With the client's presenting symptoms, physical examination, electrocardiogram (ECG) findings, and elevated cardiac markers, the healthcare provider (HCP) confirms the diagnosis of myocardial infarction (MI). The client reports an increase in her chest pain as 8 out of 10. The nurse immediately obtains another ECG. Which ECG assessment finding warrants immediate intervention by the nurse?

-ST segment elevation and the development of Q waves. ST segment elevation is indicative of acute myocardial injury leading to infarction and requires immediate intervention (STEMI versus non-STEMI - STEMI causes more deaths). -Tall peaked T waves in all leads. Peaked T waves may indicate an elevated potassium level and should be further evaluated but is not priority over the myocardial injury that is occuring. -Notched P waves in various leads. Notched P waves may be evidence of atrial enlargement and should be further evaluated, but is not priority over the myocardial injury that is occuring. -Prolonged PR interval measuring 0.22 seconds. Prolongation of the PR interval is typical of a first-degree AV block, an electrical conduction disturbance within the heart. While development of a conduction block may occur as a result of myocardial injury, the presence of a prolonged PR interval is not itself indicative of myocardial injury.

During client education, the client reports to the nurse that even though breathing is easier, they do not like the dizzy feeling they experience when changing positions or when getting out of bed. Which nursing intervention best promotes effective communication?

-Tell the client to get into position quickly to minimize the dizziness. Rising quickly may cause syncope. -Explain to the client that the symptoms should start to decrease as the body gets used to the medications. This is not a symptom that gets better. It is a side effect of the medication. The orthostatic hypotension remains a risk for the client and he should be instructed to slowly change positions. -Have the client hold the medications and ask his HCP to decrease the dose of the medications to lessen the effect. This is a common side effect of the medications due to the mechanism of the medications. Medication should not be held unless instructed to do so by the HCP first. Decreasing the medications can cause the client's blood pressure to increase. -Instruct the client to change positions and stand slowly. This is a common side effect of the medications. The client needs to be aware of the orthostatic hypotension and be aware to slowly change his position and to rise slowly to a sitting and/or standing position.

The nurse verified the prescriptions and the dose to be given to the client. When preparing to administer the furosemide, which assessment finding(s) warrant intervention by the nurse? (Select all that apply. One, some, or all options may be correct.)

-Tenderness at the IV insertion site. The intravenous site should be assessed a minimum of every two hours and whenever getting ready to initiate an IV medication. Tenderness may be a sign of infection or infiltration and requires further assessment. Blood pressure 160/90 mmHg. The baseline blood pressure and pulse before administering the diuretic bolus and during the administration should be assessed. A diuretic may lower blood pressure which would be desirable in this scenario. Occasional premature ventricular complexes. Occasional premature ventricular complexes (PVCs) are a sign of cardic muscle irritability. The client has a low potassium and sodium level. Administering a diuretic will increase the urine output and may lower the value of the electrolyes more. PVCs should be reported and electrolytes assessed before administering a diuretic. -The client's bladder. Assessment of the bladder is not necessary unless the client is experiencing urinary retention, which may require a urinary catheterization prior to the administration of the furosemide 40 mg IV. -The client's potassium level for any preexisting hypokalemia. Monitor electrolytes, particularly potassium, before and during therapy.

Discharge Preparation The nurse determines that these individuals are beginning nursing students who are learning to interview clients and the nurse asks the group to leave the client's room. The nurse reviews the importance of promoting client rights and ways to achieve this. Upon learning the students' goals, the client welcomes the opportunity to visit with the nursing students. She talks with them at length about her impending discharge, the concerns she has, and her plans to engage in a healthier lifestyle. The nurse completes the client's discharge teaching and schedules the client to begin therapy at the cardiac rehabilitation unit the following week.

-The client chooses walking as her initial form of exercise. Walking is the best initial activity/exercise for the post-MI client. The client should be instructed to establish a gradually progressive walking schedule and to assess pulse and tolerance when increasing activity. Activities such as heavy lifting that cause straining should be avoided for several weeks. -The client recognizes the need to avoid all aspirin products. This is not an expected outcome, unless the client is taking a prescribed anticoagulant, such as warfarin. Daily low-dose aspirin is frequently prescribed to reduce the risk for thrombosis. -The client talks with her husband about avoiding sexual intercourse for the next six months. This is not an expected outcome. Sexual activity can be resumed once the client's tolerance to activity has been assessed. Generally, once the client can tolerate walking approximately one block or climbing two flights of stairs, intercourse can be resumed. The nurse should instruct the client regarding measures such as positioning, and waiting at least half an hour after eating to avoid undue strain, and using prophylactic nitroglycerin prior to intercourse. The client states that she feels confident about driving herself home from the hospital. This is not a desired outcome. Clients discharged post-MI can be weak and can become fatigued easily. Activities that could cause straining or excessive stress should be avoided. The client chooses a diet low in saturated fat and cholesterol. A diet low in saturated fat and cholesterol will reduce the risk for the client developing another MI.

Management Issues: Priorities The next day, the client is transferred to the Progressive Cardiac Unit. During report, the nurse is assigned four clients. Which client should the nurse assess first?

-This client, post-PTCA, whose pulse distal to the insertion site is +3, with capillary refill of 2 seconds. This client's condition is stable, and her circulation is strong, so assessment of this client is not the highest priority. -A client with unstable angina who is complaining of chest discomfort and who has been given one nitroglycerin tablet sublingually (SL). This is the least stable of the four clients. The nurse needs to assess for the effectiveness of the nitroglycerin and for other symptoms that may indicate the onset of an MI. -A client 5 days post-MI who is complaining that he is constipated and demands that his healthcare provider (HCP) be called. Although it is important to ensure that clients avoid straining post-MI, another client requires more immediate assessment. -A client recently started on propranolol and aspirin for coronary artery disease. This client's condition is stable. Propranolol is a beta-blocker frequently used to reduce myocardial oxygen demand, and aspirin is used to reduce the risk of thrombus formation. This client's response to the medications should be monitored, but this is not the nurse's most immediate priority.

Safe and Effective Care Policies and procedures are in place to assess, predict, and prevent falls from occuring. Healthcare facilities have fall risk assessments that are completed upon admission and regularly throughout the admission. A fall risk score is determined using a fall risk scale which provides vital information to the staff while caring for their clients. Due to the client's report of orthostatic hypotension, the HCP writes a prescription to place the client on fall precautions for the duration of their stay to include the following: A brightly colored wrist band signifying fall precautions. A sign placed outside the client's room so that staff members are aware. Instructions given to the client not get out of the bed without calling for assistance. The nurse assesses the client's fall risk factors and determines they score a moderate fall risk. What change(s) in the client's care should the nurse tell him to expect? (Select all that apply. One, some, or all options may be correct.)

-Two side rails up while in bed. For a low to high fall risk only two side rails should be up as a reminder to call for assistance unless the client is in the intensive care unit. -Four side rails up at all times. Only two side rails should be up. Clients can get wedged between rails while trying to get out of bed if they do not call for help. -Soft wrist restraints tied loosely. Restraints are not indicated unless the client is at risk of harming self or others. Not to be used as a reminder to call for help. -A UAP will assist with trips to the bathroom. Supervision and assistance to the bathroom is required while on moderate fall risk precautions. -Non-skid footwear to be worn while out of bed. Use of properly fitting nonskid footwear decreases the risk of falling when the client is walking, especially when unsteady.

oxygen therapy

Administration of oxygen and monitoring of its effectiveness. • Clear oral, nasal, and tracheal secretions, as appropriate. • Restrict smoking. • Maintain airway patency. • Set up oxygen equipment and administer through a heated, humidified system. • Monitor the oxygen liter flow. • Monitor position of oxygen delivery device. • Periodically check oxygen delivery device to ensure that the prescribed concentration is being delivered. • Monitor the effectiveness of oxygen therapy (e.g., pulse oximetry, ABGs), as appropriate. • Assure replacement of oxygen mask/cannula whenever the device is removed. • Monitor patient's ability to tolerate removal of oxygen while eating. • Observe for signs of oxygen-induced hypoventilation. • Monitor for signs of oxygen toxicity and absorption atelectasis. • Monitor oxygen equipment to ensure that it is not interfering with the patient's attempts to breathe. • Monitor patient's anxiety related to need for oxygen therapy. • Monitor for skin breakdown from friction of oxygen device. • Provide for oxygen when patient is transported. • Instruct patient and family about use of oxygen at home. • Arrange for use of oxygen devices that facilitate mobility and teach patient accordingly. Is prescribed for relief of hypoxemia (decreased blood oxygen levels) and hypoxia (decreased tissue oxygenation). The need for oxygen therapy and its effectiveness can be determined by arterial blood gas values and oxygen saturation by pulse oxymetry. The patient with COPD may need an oxygen flow of 2 to 4 L/min via nasal cannula or up to 40% via Venturi mask. The patient who is hypoxemic and also has chronic hypercarbia requires lower levels of oxygen delivery, usually 1 to 2 L/min via nasal cannula. A low arterial oxygen level is this patient's primary drive for breathing. Do not increase the oxygen flow rate in patients with hypercarbia because this may lower their respiratory rate or even make them stop breathing spontaneously. Ensure that there are no open flames or other combustion hazards in rooms in which oxygen is in use. More information on oxygen therapy is found in Chapter 30. Drug therapy for COPD involves the same inhaled and systemic drugs as for asthma. These drugs include beta-adrenergic agents, cholinergic antagonists, methylxanthines, corticosteroids, and NSAIDS (see Chart 32-5). The focus is on long-term control therapy with longer duration drugs, such as arformoterol (Brovana) and tiotropium (Spiriva). The patient with COPD is more likely to be taking systemic agents (in addition to inhaled drugs) than is the patient with asthma. An additional drug class for COPD is the mucolytics, which thin secretions, making them easier to expectorate. Mucolytic agents are prescribed for the patient with thick, tenacious (sticky) mucous secretions. Nebulizer treatments with normal saline or with a mucolytic agent such as acetylcysteine

The client is having periods of confusion and appears weak and fatigued. The client tells the nurse they feel like their heart is fluttering at times. Which laboratory value(s) could be related to the client's symptoms? (Select all that apply. One, some, or all options may be correct.)

Sodium. Common symptoms of low sodium (hyponatremia) include confusion, lethargy, headache, and dizziness. Potassium Common symptoms of low potassium (hypokalemia) include weakness, fatigue, and palpitations. Chloride. The chloride level is within normal limits. Blood urea nitrogen. Common symptoms of high blood urea nitrogen (BUN) levels include fatigue, edema, shortness of breath, confusion, and dehydration. Phosphorus. Common symptoms of high phosphorus (hyperphosphatemia) include fatigue, shortness of breath, anorexia, nausea, vomiting, and sleep disturbances.

digital clubbing

ardiac changes occur as a result of the anatomic changes associated with COPD. Assess the patient's heart rate and rhythm. Check for swelling of the feet and ankles (dependent edema) or other manifestations of right-sided heart failure. Examine nail beds and oral mucous membranes. The patient with later-stage emphysema may have pallor or frank cyanosis. Psychosocial Assessment COPD affects all aspects of a person's life. Socialization may be reduced when friends and family avoid the patient with COPD because of annoying coughs, excessive sputum, or dyspnea. The patient may choose to be isolated because dyspnea causes fatigue or because of embarrassment from coughing and excessive sputum production. In addition, because of the association with cigarette smoking and disease development, the patient may feel a social stigma. Ask the patient about interests and hobbies to assess whether socialization has decreased or whether hobbies cause exposure to inhalation irritants. Ask about home conditions for exposure to smoke or crowded living conditions that promote transmission of respiratory infections. Economic status may be affected by the disease through changes in income and health insurance coverage. If the patient is the head of the household, severe COPD may require role changes that have a negative impact on self-image. Drugs, especially the metered dose inhalers (MDIs) and dry powder inhalers (DPI), are expensive, and many patients with limited incomes may use them only during exacerbations and not as prescribed on a scheduled basis.

The primary healthcare provider (HCP) prescribes a continuous IV infusion of amiodarone 1 mg/min for the client. The available drug is amiodarone 900 mg in 500 mL of D5W. The nurse should set the IV pump at how many mL/hr? (Enter numerical value only. If rounding is necessary, round to the whole number.)

33

Breathing Exercises

DIAPHRAGMATIC OR ABDOMINAL BREATHING • Lie on your back with your knees bent. • Place your hands or a book on your abdomen to create resistance. • Begin breathing from your abdomen while keeping your chest still. You can tell if you are breathing correctly if your hands or the book rises and falls accordingly. PURSED-LIP BREATHING • Close your mouth, and breathe in through your nose. • Purse your lips as you would to whistle. Breathe out slowly through your mouth, without puffing your cheeks. Spend at least twice the amount of time it took you to breathe in. • Use your abdominal muscles to squeeze out every bit of air you can. • Remember to use pursed-lip breathing during any physical activity. Always inhale before beginning the activity and exhale while performing the activity. Never hold your breath.

DlCO (difusion capacity of carbon monoxide) reflects the surface area of the alveolocapillary membrane. The patient inhales a small amount of CO, holds for 10 sec, and then exhales. The amount inhaled is compared with the amount exhaled.

DlCO is reduced whenever the alveolocapillary membrane is diminished, such as occurs in emphysema, pulmonary hypertension, and pulmonary fibrosis. It is increased with exercise and in conditions such as polycythemia and congestive heart disease.

Health Promotion and Maintenance

Encourage all people to use masks and adequate ventilation when exposed to inhalation irritants. Psychosocial Integrity • Explain all diagnostic procedures, restrictions, and follow-up care to the patient scheduled for tests. Physiological Integrity • Assess the degree to which breathing problems interfere with the patient's ability to perform ADLs. • Document any known specific allergies that have respiratory manifestations. • Ask the patient about recent travel. • Assess the airway and breathing effectiveness for any patient who has shortness of breath or any change in mental status. • Assess the patient's respiratory status every 15 minutes for at least the first 2 hours after undergoing an endoscopic test for respiratory disorders.

TLC (total lung capacity) is the amount of air in the lungs at the end of maximum inhalation.

Increased TLC indicates air trapping associated with obstructive pulmonary disease. Decreased TLC indicates restrictive disease.

laboratory tests (Chart 29-3) are useful in assessing respiratory problem

Red blood cells Females: 4.2-5.4 million/mm3 Males: 4.7-6.1 million/mm3 Elevated levels (polycythemia) may be due to the excessive production of erythropoietin, which occurs in response to a hypoxic stimulus, as in COPD, and from living at a high altitude. Decreased levels indicate possible anemia, hemorrhage, or hemolysis. Hemoglobin, total Females: 12-16 g/dL, or 7.4-9.9 mmol/L Males: 14-18 g/dL, or 8.7-11.2 mmol/L Same as for red blood cells. Hematocrit Females: 37%-47%, or 0.37-0.47 SI units Males: 42%-52%, or 0.42-0.52 SI units Same as for red blood cells. White blood cell count (leukocyte count, WBC count) Total: 5,000-10,000/mm3 Elevations indicate possible acute infections or inflammations, pneumonia, meningitis, tonsillitis, or emphysema. Decreased levels may indicate an overwhelming infection, an autoimmune disorder, or immunosuppressant therapy. DIFFERENTIAL WHITE BLOOD CELL (LEUKOCYTE) COUNT Neutrophils 2500-8000/mm3 or 55%-70% of total Elevations indicate possible acute bacterial infection (pneumonia), COPD, or inflammatory conditions (smoking). Decreased levels indicate possible viral disease (influenza). Eosinophils 50-500/mm3 or 1%-4% of total Elevations indicate possible COPD, asthma, or allergies. Decreased levels indicate pyogenic infections. Basophils 25-100/mm3 or 0.5%-1% of total Elevations indicate possible inflammation; seen in chronic sinusitis, hypersensitivity reactions. Decreased levels may be seen in an acute infection. Lymphocytes 1000-4000/mm3 or 20%-40% of total Elevations indicate possible viral infection, pertussis, and infectious mononucleosis. Decreased levels may be seen during corticosteroid therapy. Monocytes 100-700/mm3 or 2%-8% of total Elevations: see Lymphocytes; also may indicate active tuberculosis. Decreased levels: see Lymphocytes. ARTERIAL BLOOD GASES Pao2 80-100 mm Hg Older adults: values may be lower Elevations indicate possible excessive oxygen administration. Decreased levels indicate possible COPD, asthma, chronic bronchitis, cancer of the bronchi and lungs, cystic fibrosis, respiratory distress syndrome, anemias, atelectasis, or any other cause of hypoxia. Paco2 35-45 mm Hg Elevations indicate possible COPD, asthma, pneumonia, anesthesia effects, or use of opioids (respiratory acidosis). Decreased levels indicate hyperventilation/respiratory alkalosis. pH Up to 60 yr: 7.35-7.45 60-90 yr: 7.31-7.42 >90 yr: 7.26-7.43 Elevations indicate metabolic or respiratory alkalosis. Decreased levels indicate metabolic or respiratory acidosis. HCO3 21-28 mEq/L Elevations indicate possible respiratory acidosis as compensation for a primary metabolic alkalosis. Decreased levels indicate possible respiratory alkalosis as compensation for a primary metabolic acidosis. Spo2 95%-100% Older adults: values may be slightly lower Decreased levels indicate possible impaired ability of hemoglobin to release oxygen to tissues.

Evaluate the care of the patient with COPD on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes are that the patient should:

• Attain and maintain gas exchange at a level within his or her chronic baseline values • Achieve an effective breathing pattern that decreases the work of breathing • Maintain a patent airway • Achieve and maintain a body weight within 10% of his or her ideal weight • Have decreased anxiety • Increase activity to a level acceptable to him or her • Avoid serious respiratory infections

ASSESS RESPIRATORY STATUS AND ADEQUACY OF VENTILATION

• Measure rate, depth, and rhythm of respirations. • Examine mucous membranes and nail beds for evidence of hypoxia. • Determine use of accessory muscles. • Examine chest and abdomen for paradoxical breathing. • Count number of words patient can speak between breaths. • Determine need and use of supplemental oxygen. (How many liters per minute is the patient using?) • Determine level of consciousness and presence/absence of confusion. • Auscultate lungs for abnormal breath sounds. • Measure oxygen saturation by pulse oximetry. • Determine sputum production, color, and amount. • Ask about activity level. • Observe general hygiene. • Measure body temperature.

ASSESS CARDIAC STATUS

• Measure rate, quality, and rhythm of pulse. • Check dependent areas for edema. • Check neck veins for distention with the patient in a sitting position. • Measure capillary refill.

The patient with COPD is expected to achieve an effective breathing pattern that decreases the work of breathing. Indicators include:

• Respiratory rhythm within normal limits for the patient's age • Presence of synchronous thoracoabdominal movement • Use of accessory muscles appropriate to the patient's activity level • Increased activity tolerance

Medication: Captopril 25 mg PO twice daily Losartan 25 mg PO daily Diltiazem 30 mg PO three times daily Digoxin loading dose: 500 mcg PO then 500 mcg PO 6 hours later Digoxin maintenance dose: 125 mcg PO daily Furosemide 40 mg IV to be administered over 15 mins; repeat in one (1) hour Furosemide maintenance dose: 80 mg PO every morning The nurse administered the first doses of digoxin and furosemide at 0800. What is the earliest time the second dose of digoxin can be given?

1400 as instructed. Pay attention to order details. First and second dose of digoxin prescription is the loading dose. The second dose should be administered 6 hours after the first dose at 1400.

FVC (forced vital capacity) records the maximum amount of air that can be exhaled as quickly as possible after maximum inspiration.

gives an indication of respiratory muscle strength and ventilatory reserve. FVC is often reduced in obstructive disease (because of air trapping) and in restrictive disease.