NURS 405B Final
Cavitation
-A phenomenon in which speed causes a bullet to generate pressure waves, which cause damage distant from the bullet's path. -In addition to causing damage to the tissues they contact, medium- and high-velocity projectiles cause a secondary cavitation injury: as the object enters the body, it creates a pressure wave which forces tissue out of the way, creating a "temporary cavity" that can be much larger than the object itself. -A brand new space in the skull that wasn't there before because of the tissue damage
The Pennsylvania Trauma Systems Foundation
-Accreditation -This is the foundation that credits trauma centers in PA***
Cardiomyopathy (CMP)
-Affect myocardial structure or function -Diagnosis based on clinical manifestations & diagnostic procedures -Primary CMP: idiopathic -Secondary CMP: known cause -Dilated - cardiotoxic agent, CAD, genetic, HTN, etc. -Hypertrophic - AS, genetic, HTN -Restrictive - amyloidosis, sarcoidosis, fibrosis, etc. -Can lead to cardiomegaly & heart failure** -Primary reason for heart transplant
Aortic aneurysm risk factors
-Age (increased age) -Male gender (bc of HTN) -Hypertension (HTN) -Coronary artery disease (CAD) - most common cause -Family history (strong genetic tendency) -Tobacco use (most important modifiable risk factor) -Hyperlipidemia -Lower extremity PAD -Carotid artery disease -Previous stroke -Obesity
Blunt trauma
-An impact on the body by objects that cause injury without penetrating soft tissues or internal organs and cavities. •Caused by a combination of forces •Deceleration, shearing, crushing, and compression -Ex. getting hit, motor vehicle accident •Multiple injuries are common •Injuries not always obvious and diagnosis is more difficult •Blunt trauma is often more life-threatening
Hypertrophic CMP assessment and diagnostics
-Apical pulse exaggerated & displaced to axillary (right sternal border, 2nd intercostal space) -S4 & systolic murmur -EKG: ventricular hypertrophy, ST-T wave abnormalities, prominent Q-waves in inferior or precordial leads, ventricular and/or atrial dysrhythmias -ECHO: EF, wall hypertrophy, wall motion abnormalities, diastolic dysfunction** -Cardiac cath or nuclear stress testing if needed
Trimodal Distribution of Trauma Deaths
-As we think about the patients who do die from trauma, this gives us a great depiction of how this unfolds. -First peak is the curve of death before definitive medical care could be provided. The trauma was so extensive that in seconds to minutes the person does not survive. -The second peak is people who die minutes to several hours following the injury. This is known as the "golden hour of trauma!" This is the most critical time to intervene!!* Get to this patient, get them stabilized appropriately, get them to a trauma center, and get their injuries taken care of! Ultimate golden hour to treat that patient. -The third peak (not as high) is days to weeks after the trauma. Usually these deaths are associated with infection, sepsis, MODS, so many issues that we can't bring them back.
Hypertrophic CMP
-Asymmetrical LV hypertrophy without ventricular dilation -Thickening of the septum and ventricle walls -May be Non-obstructive or Obstructive -Obstructive = hypertrophied septum and incompetent mitral valve which obstructs left ventricle outflow -Idiopathic but approximately 50% of cases is a single-gene autosomal dominant disorder -Less common than dilated CMP -Male > Female -Young adults who are active & athletic -Most common cause of sudden cardiac death in presumed healthy young adults (3% of deaths in young competitive athletes) -Myocardium wall + septum thickens... can be non-obstructive (blood flows without any issues) or obstructive (cant get any blood pumped out of L ventricle)!
Hypertrophic CMP clinical manifestations
-Asymptomatic -Dyspnea most common symptom **Caused by elevated LV diastolic pressure -Fatigue **Caused by decreased CO & flow obstruction -Angina **Caused by compression of coronary arteries -Syncope (especially with exertion) **Caused by decreased CO & flow obstruction = decreased perfusion -Dysrhythmias: SVT, a-fib, V-tach, V-fib -Young, presumed healthy individuals who fall over dead and then realize they have hypertrophic CMP -> many asymptomatic and had no idea this was going on
Aortic aneurysms
-Common problem involving aorta -Outpouching or dilation of arterial wall -Permanent & localized -Rare in peripheral arteries -May occur in more than 1 location -Males > Females -Whites > African Americans -Incidence ↑ with age
Dilated CMP clinical manifestations
-Decreased exercise capacity -Fatigue -Dyspnea at rest -Paroxysmal nocturnal dyspnea -Orthopnea -With disease progression (further decrease in CO): -Dry cough, palpitations, abdominal bloating, nausea, vomiting, anorexia -Late signs = right sided heart failure -Decreased blood flow = stasis
Aortic aneurysms etiology + pathophysiology
-Dilated aortic wall becomes lined with thrombi that can embolize -Leads to acute ischemic symptoms in distal branches -Causes: *Degenerative: Atherosclerosis most common cause *Congenital *Mechanical: Penetrating or blunt trauma *Inflammatory: aortitis *Infectious: Chlamydia, HIV
Major types of CMP
-Dilated: most common; enlargement of all cardiac chambers; systolic dysfunction -Restrictive: least common; rigid ventricular walls; diastolic dysfunction -Hypertrophic: in between; risk of sudden death in young adults; thickened left ventricular wall -Each type has its own pathogenesis
Important considerations
-Do no harm! •Assume cervical spine injury •Do not aggravate existing injuries •Treat worst-case scenario (always think the worst) -Do not become a victim! Survey the scene •Airway maintenance •Circulation •Shock •Immobilization with a backboard •Splint extremities •Transport as soon as possible (Load and Go)
CMP recap
-ECHO to assess LV function, wall thickness & motion (gold standard!) -Dilated CMP: Heart failure with frequent exacerbations despite medications, diet compliance -Hypertrophic CMP: Sudden cardiac death in young adults, ICDs *No NTG, treat CP with LE elevation & rest -Restrictive CMP: Least common, sarcoidosis/amyloidosis -Takotsubo: Broken heart, mimics ACS, no CAD
MVP diagnosis & treatment
-ECHO to confirm diagnosis... watch valves open and close + look for that parachuting up into the left atrium -Beta blockers to control palpitations and chest pain -Patient education: stay hydrated, routine exercise, & avoid caffeine and stimulants**** (cough and cold meds, coffee, chocolate, soda)
Diagnostic studies
-Echocardiogram (ECHO)***** -Chest x-ray (CXR) -EKG -B-type natriuretic peptide (BNP) -Cardiac catheterization -Biopsy to rule out infectious organism -Multiple gated acquisition nuclear scan (MUGA) *Determine EF *EF < 20% associated with 50% mortality within 1 year
FAST (Focused Abdominal Sonography for Trauma)
-Focused Abdominal Sonography for Trauma -May not be able to send patient to CT if they are unstable, but need to look at abdomen! -Least invasive and initial step -Portable (Ultrasound tech and machine in trauma room) -Detects as little as 100 ml of blood in abdomen -Views liver, spleen, pelvis -Decreased accuracy in obese patients -Great, quick screening tool!
Primary prevention
-Focuses on eliminating the traumatic event -Eliminate risky behaviors through education programs
Secondary prevention
-Focuses on reducing the severity of injuries -Improving car designs using air bags and helmets
Hypertrophic CMP treatment
-Goal = increase ventricular filling by decreasing ventricular contractility & relieving LV outflow obstruction -Medications: *Beta-blockers or calcium channel blockers *Digoxin if a-fib *Antidysrhythmics (amiodarone or sotalol) -ICD placement if at risk for sudden cardiac death** -Prohibit strenuous exercise due to increased risk of sudden death -Avoid dehydration -Avoid nitroglycerin** *Decreases venous return & further increases outflow obstruction -Treat chest pain with rest & LE elevation to increase venous return**
Takotsubo CMP
-In Japanese "tako-tsubo" means "fishing pot for trapping octopus" -LV of a patient diagnosed with this condition resembles that shape -Transient & typically precipitated by acute emotional stress -Also known as "stress cardiomyopathy" or "broken-heart syndrome" -Mimics acute coronary syndrome & is accompanied by reversible LV apical -Once we resolve emotional stress, heart goes back to normal size and no long term effects -If go for cardiac cath, you'll find their coronary arteries are clean (no plaque)
Penetrating trauma
-Injury caused by an object that passes through the skin or other body tissues •Injury produced by foreign objects in motion •Mechanism is the energy created and dissipated by the object into the surrounding areas Factors: (determine the extent of the injury**) •Velocity of the missile (bullet) - how fast it's going •Bullet yawing (tumbling) - spinning •Mushrooming and fragmentation of bullet - breaking down Types: •Gunshot wound (GSW) •Stabbing wounds •Impalements •Shrapnel and debris
Tertiary prevention
-Minimizes scope of injury after it has occurred -Developing regional trauma centers & initiating rehab efforts
Ischemic CMP
-Most common type of dilated CMP -LV enlargement, dilation, & weakness -Ischemia due to CAD & MI
Dilated CMP
-Most common: 5-8 cases per 100,000 people -Heart failure in 25-40% of cases -Affects middle-aged African Americans & men -30% autosomal dominant cases -May be autoimmune component -Hypertension is the biggest cause -Other causes: -Cardiotoxic agents such as alcohol, cocaine, doxorubicin -CAD -Metabolic disorders -Muscular dystrophy -Myocarditis -Pregnancy -Valvular disease
Trauma Care Designation - Level II
-Multidisciplinary treatment and specialized resources for trauma patients -Do not require the research and residency components -Annual volume of 350 major trauma patients per year
Trauma Care Designation - Level I
-Multidisciplinary treatment and specialized resources for trauma patients -Require trauma research, a surgical residency program, and an annual volume of 600 major trauma patients per year
Abdominal aortic aneurysm - clinical manifestations
-Often asymptomatic -Frequently detected: *On routine physical exam *When patient examined for unrelated problem (i.e., CT scan, abdominal x-ray) -Pulsatile mass -Bruit -Difficult to detect in obese patients -May mimic pain associated with abdominal or back disorders -May cause back pain, epigastric discomfort, altered bowel elimination, intermittent claudication -May spontaneously embolize plaque -Causing "blue toe syndrome"
Thoracic Aortic Aneurysm (TAA) s/s
-Often asymptomatic -Most common manifestation: *Deep diffuse chest pain *Pain may radiate to interscapular area ("straight through" pain)
Aortic aneurysm - care
-Primary Goal - prevent rupture -Early detection & treatment imperative -Once detected: -Diagnostic studies done to determine size and location -ROS to determine co-morbidities especially of heart, kidneys, or lungs which may influence patient's surgical risk -Aneurysm < 4 cm diameter: US to monitor every 2-3 years -Small aneurysm (4- 5.4 cm diameter): Conservative medical therapy, Risk factor modification, Monitor size with Ultrasound, MRI, CT scan every 6 to 12 months -↓ growth rate with medication therapy: Beta-blockers ACE inhibitors ARBs Statins
Nursing interventions
-Prophylactic antibiotic therapy before any procedure! -Manage HF! (backup flow) -Appropriate exercise program & avoid strenuous activities -Help them quit tobacco/smoking to control their BP -Conserve their energy! Rest periods! Can't do it all at one time -Following their EKG -PT/INR checks or CBC checks for anticoagulation therapy effectiveness -Teach when they should seek care, daily wts go up 2-3 lbs in one day or 5 lbs in one week to double diuretics, if they get a fever, any s/s of bleeding (rectal bleeding, hematuria, hematemesis, hemoptysis) Medic alert bracelet (especially when on anticoagulation)
Aortic aneurysm complications
-Rupture is the most serious complication related to untreated aneurysm -Rupture into thoracic or abdominal cavity -Most die from massive hemorrhage -If reach hospital, hypovolemic shock -Treat with simultaneous resuscitation & immediate surgical repair -In-hospital mortality = 53% -More likely to occur in smokers -Rupture into retroperitoneal space -Bleeding may be tamponaded by surrounding structures, thus preventing exsanguination and death -Severe back pain -May/may not have back/flank ecchymosis (Grey Turner's sign)
Dilated CMP assessment findings
-S3 and/or S4 (big boggy heart) -Dysrhythmias -Heart murmur -Pulmonary crackles -Edema -Weak peripheral pulses -Pallor -Hepatomegaly (once R side is affected) -JVD *Heart failure s/s
Trauma Care Designation - Level III
-Smaller community hospitals that have services to care for patients with moderate injuries and the ability to stabilize the severe trauma patient in preparation for transport to a higher-level trauma center -Do not require neurosurgical resources
Prevention
-Ultimate cure for traumatic injuries** -Key component of a comprehensive trauma system
Dilated CMP Characteristics
-Ventricular dilation -Impaired systolic function -Atrial enlargement -Stasis of blood in left ventricle (risk of clot) -Systolic function impaired & cardiac output -Ventricles have elevated systolic & diastolic volumes....BUT decreased ejection fraction (EF) -Muscle fibers have stretched and atria enlarge
Abdominal Aortic Aneurysm (AAA)
-¾ occur in abdominal aorta -¼ occur in thoracic aorta -Most occur below renal arteries -The larger the aneurysm, the greater the risk of rupture -Growth rates increase in patients who smoke
Nurse's role: Peri-operative nursing care
•OR nurse's role is more difficult with multiple trauma •Level I and II Trauma Centers •OR must be staffed 24 hours •Others - may need to be "on call" and come in for emergency surgeries •The multiply-injured trauma client may require multiple surgeries to treat and stabilize •The client arrives in the OR with little prior knowledge: Assessment is more difficult •Patient is in coma or intubated •Patient is unstable and OR nurse's first contact with the patient is on the table in OR •Patient may have been sedated secondary to trauma circumstances •Patient may be so anxious/afraid that teaching is impossible, therefore, the main information received by the OR nurse is from the ED personnel •The OR nurse's responsibility is to Facilitate and Coordinate: -Room availability -Equipment preparation -Required surgical teams •Addressing complications: Patient may be on the table 16-18 hours, must think about positioning, blood loss, hypothermia, etc. •Liaison with family
1.Which type of CMP is associated with childbirth? 2.Patients with CMP are at high risk for developing which condition? 3.An ECHO report reveals hypertrophy of the ventricular septum. The nurse understands that this patient should be further evaluation for which condition?
1.DILATED MYOPATHY is associated with childbirth (from all of the stress, volume overload, increased HTN) 2.CMP pts at risk for developing HEART FAILURE 3.Hypertrophy of ventricular septum -> HYPERTROPHIC CMP (wall thickening of septum and down around left ventricle)
Hypertrophic CMP characteristics
1.Marked LV hypertrophy 2.Rapid, forceful LV contraction 3.Impaired relaxation or diastole 4.Aortic outflow obstruction (not all patients) -Thickened intraventricular septum & ventricular wall -End result = ventricle unable to relax and fill -Diastolic dysfunction due to LV stiffness -Always under pressure, can't relax, can't pump blood out
Legislative Development
3 legislative acts that are still very much a part of what we do today -1966: Highway Traffic Safety Act -1973: Emergency Medical Services Act -1990: Trauma Care Systems Planning and Development Act
The nurse is caring for a patient with mitral regurgitation. Referring to the figure below, where should the nurse listen to best hear a murmur typical of mitral regurgitation?
5th intercostal space, midclavicular line (apex)
Normal ejection fraction
60-65% or greater
Role of Trauma Nurse in Injury Prevention
•Participate in community educational programs •Role model preventative behaviors •Educate parents regarding pediatric injury prevention •Initiate a prevention program •Participate in prevention research •Confront patients by linking risk-taking behaviors with consequences •Support national, state, or local prevention programs and professional organizations •Be politically active regarding injury prevention issues
Conservative therapy continued
•Percutaneous Transluminal Balloon Valvuloplasty (PTBV): put balloon in and try to open that stenosed valve (all valves except aortic); minimally invasive; go through the femoral artery and hopefully alleviate what the stenosis is to improve their heart function Sapien Transcatheter Heart Valve (THV): specific to aortic valve; -Select patients with AS -Femoral artery to heart -Expand balloon at aortic valve -Patient eligible for surgery but high risk for complications (multiple comorbidities)`
Nursing & trauma care
•Performance of a rapid, initial assessment to identify injuries •Institution of appropriate life-saving interventions •Monitoring of patient's responses to resuscitative efforts •Continual communication with health team members in the emergency care setting and adjunct departments •Patient advocate •Accurate and thorough documentation of the care provided to the trauma patient
Conservative therapy
•Prevent recurrent rheumatic fever & infective endocarditis (IE) •Treatment dependent on valve involved & disease severity •Prevent HF exacerbations, acute pulmonary edema, thrombo-embolisms, & recurrent endocarditis •HF treatment: -Vasodilators, ➕ inotropes, beta-blockers, diuretics, & low sodium diet •Anticoagulant therapy -Prevent and/or treat systemic or pulmonary emboli -Prophylaxis in patients with a-fib •Atrial dysrhythmias common - antidysrhythmic therapy -CCB, beta-blocker, antidysrhythmics, or cardioversion`
Mechanisms of blunt trauma
•Rapid forward deceleration (ex. car accident) •Rapid vertical deceleration (ex. falling from building) •Blast injuries (ex. explosion) -Primary effect: initial air blast; usually to air-filled organs -Secondary effect: shrapnel striking person -Tertiary effect: body displacement and impact
Surgical therapy
•Repair or replacement •Dependent on: 1.Valve 2.Pathology & severity of disease 3.Patient's clinical condition •Palliative, NOT curative •Lifelong healthcare required -Opening up their chest, opening up their heart, putting them on heart-lung machine, and going in to give them a new valve -So many different kinds of valves... pig valve, mechanical valve -As we do go in and replace this valve, it is NOT curative....could continue to develop some heart disease.... PALLIATION to alleviate their symptoms*** -Whether or not they get a pig valve or mechanical valve, it is life-long follow-up to make sure valve is working appropriately, that we're not having episodes where it is failing, not having endocarditis
Chronic aortic regurgitation clinical manifestations
•Severe: bounding, water-hammer pulse •Soft or absent S1 , S3 , or S4 •Soft, high-pitched diastolic murmur •Asymptomatic for years •Exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea -After considerable damage has occurred •Angina less frequently than with AS
Chronic mitral regurgitation
•May be asymptomatic for years - monitor •Early LV failure = weakness, fatigue, palpitations, dyspnea •Disease progression = orthopnea, paroxysmal nocturnal dyspnea, peripheral edema •Increased LV volume = S3 (even with normal LV function) •Loud holosystolic murmur at apex that radiates to left axilla •Valve repair or replacement BEFORE significant LV failure or pulmonary HTN develop *Monitor what the level of regurgitation is!!!** Once we know this, we will continue to monitor them and look at lifestyle changes and make sure BP under control and get an echo periodically to make sure its not progressing. Will want to eventually replace or fix that valve before they do progress to severe LV failure or pulmonary hypertension
Mitral regurgitation
•Mitral valve function is dependent on intact: -Mitral leaflets, mitral annulus, chordae tendineae, papillary muscles, LA, & LV •A defect in ANY structure = regurgitation •Backward blood flow from LV to LA secondary to incomplete closure during systole •May be acute or chronic & causes include: -Myocardial infarction (MI) -Chronic RHD -Mitral valve prolapse (MVP) -Ischemic papillary muscle dysfunction -Infective endocarditis (IE)
Mitral stenosis
•Most cases caused by rheumatic heart disease (RHD) •Other causes: congenital, rheumatoid arthritis, lupus •In RHD: -Endocarditis causes scarring of valve leaflets & chordae tendineae -Contractures & adhesions develop between commissures -Stenotic mitral valve looks like a "fish mouth" -Deformities block blood flow •Pressure difference between LA and LV during diastole •Increased LA pressure & volume = increased pulmonary pressure •Increase risk of a-fib secondary to LA overload •Chronic: LA increased pressure causes increased pulmonary and RV pressure
Highway Traffic Safety Act
•National Highway Traffic Safety Administration (NHTSA) •EMS education guidelines developed •Presidential Commission on Drunk Driving (1982) •Minimum drinking age & zero-tolerance for underage drunk driving •BAC lase •Child passenger safety laws •Seat belt legislation •Five-Star Safety Ratings
Valvular dysfunction
•Normal -Pressure on either side of the valve is equal •Stenosis -Smaller valve opening -Forward flow impaired -Amount of stenosis is seen in the pressure difference: the greater the difference, the greater the stenosis •Regurgitation -Incompetence or insufficiency -Incomplete valve closure -Backward flow of blood -Normally we have a nice wide opening (valve) and a good seal so when blood goes through and moves forward where its supposed to, it closes so nothing goes backward -Stenosis: small opening (problem with blood moving forward) -Regurgitation: doesn't close completely (problem with blood flowing backward); incompetent... doesn't close together nicely to make a seal
Nurse's role: Initial plan & implementation
•Stabilize life-threatening conditions •Remove client's clothing and valuables (document!) •Place on cardiac monitor •Do not remove backboard until C-spine definitively cleared on x-ray •Insert NG tube •Insert Foley catheter (strict u/o monitoring) •Draw and send labs •Administer medications per order •Ensure completion of EKG and X-rays •Assist with peritoneal lavage and other procedures if indicated •Assist with transport and monitor client in CT, MRI, etc. •Document resuscitation effort thoroughly •Address psychosocial aspects of the patient's care and be liaison with family •Transport to OR or call report to another facility or nursing unit
Acute aortic regurgitation clinical manifestations
•Sudden onset of CV collapse characterized by: -Severe dyspnea, chest pain, hypotension -LV failure & cardiogenic shock •Life-threatening emergency
Aortic stenosis clinical manifestations
•Symptoms appear when orifice 1/3 normal size •Classic Triad of symptoms reflects LV failure: -Angina, syncope, & exertional dyspnea*** •Poor prognosis with symptoms and no treatment or repair •Caution NTG use - decreased preload = increased chest pain & hypotension •Normal or soft S1 with diminished or absent S2 , systolic murmur, prominent S4 -2nd intercostal space, right sternal border
Prophylactic antibiotic therapy
•Target Groups -Prosthetic heart valve or prosthetic material for valve repair -Previous history of IE -Congenital heart disease -Heart transplant recipient with valvular disease •Conditions or Procedures -Oral •Dental manipulation of gums or roots & puncture of oral mucosa -Respiratory •Respiratory tract incisions (biopsy) or tonsillectomy & adenoidectomy -Surgery •Any procedure involving infected skin, skin structures, or MSK tissue *****One-time dose of Amoxicillin 2 grams PO 30-60 mins before procedure
Trauma Care Systems Planning and Development Act
•Encourages states to initiate/continue implementation of EMS & trauma care systems
Aortic aneurysm repair
-5.5 cm is threshold for repair Earlier surgical intervention: -Patients with a genetic disorder -Rapidly expanding aneurysm -Symptomatic patients -High rupture risk
Mitral stenosis clinical manifestations
•Exertional dyspnea (primary symptom) •Hemoptysis •Loud S1 with low pitched diastolic murmur heard best at apex (5th intercostal space, midclavicular line) •Hoarseness, hemoptysis, chest pain •Emboli with a-fib and possible CVA •Fatigue and palpitations from a-fib
Critical care assessment
•Frequent evaluation to detect trends and subtle changes •Know and anticipate possible complications of injuries the patient has sustained •Psychosocial evaluation begins to take on added significance as adjustment to injury occurs
Blast injury
An injury caused by an explosion; may occur because of the energy released, the debris or the impact of the person falling against an object or the ground.
The nurse understands that certain medications protect the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation. Which class of medications serve this function? A.Beta-blockers B.Calcium channel blockers C.Opioids Nitrates
A. Beta blockers
What would you expect to see on the CXR of a patient with dilated cardiomyopathy? SATA. A. Cardiomegaly B. Pulmonary vascular hypertension C. Pleural effusion D. Pulmonary consolidation or infiltrates
A. Cardiomegaly B. Pulmonary vascular hypertension C. Pleural effusion
Diagnostics
•History & Physical Exam •CXR -Heart size, altered pulmonic circulation, & valve calcification •CBC •EKG -HR, rhythm, ischemia, ventricular hypertrophy •ECHO -Valve structure, function, chamber size -Cardiac Catheterization *Pressures in chambers, pressure difference across valves, size of valve openings -CT chest with contrast *Gold standard to evaluate aortic disorders -TEE & color flow doppler *Diagnose and monitor -Real-time 3-D ECHO *Assess mitral valve and congenital heart disease
Mitral valve prolapse
•Abnormality of mitral valve leaflets & papillary muscles or chordae -Result is leaflet prolapse or buckle into the LA during systole •Most common valvular disease in US -Usually benign •Affects males & females equally •Familial incidence - autosomal dominant -Connective tissue defect (Marfan's)
Components of secondary exam
•Assess victim's complaint •Brief neurologic assessment (AVPU, Glasgow scale) •Complete vital signs (HR, RR, BP) •Head, face and neck •Chest (flail chest?) •Abdomen •Spine and back •Pelvis •Extremities -Any open wounds?
The nurse is caring for a 64-yr-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? A.The patient has 4+ peripheral edema. B.The patient has diffuse bilateral crackles. C.The patient has a palpable thrill felt over the left anterior chest. D.The patient has a loud systolic murmur across the precordium.
B. The patient has diffuse bilateral crackles. As the valve disorder progresses, and patient has backflow, pressure builds and backward flow -> acute exacerbation of heart failure Report that right away! Don't want them to think they'll feel better tomorrow and continue to progress and get worse
A patient with a small abdominal aortic aneurysm (AAA) is not a good surgical candidate. What should the nurse teach the patient is one of the best ways to prevent expansion of the lesion? A. avoid strenuous physical exertion B. control hypertension with prescribed therapy C. comply with prescribed anticoagulant therapy D. maintain a low calcium diet to prevent calcification of the vessel
B. control hypertension with prescribed therapy
MVP clinical manifestations
•Broad range of severity •May be asymptomatic for life •10% of patients symptomatic •Murmur louder during systole •No alteration of S1 or S2 •Severe MR uncommon but serious complication MVP -Dysrhythmias -PVC, PSVT, VT -Palpitations, light-headedness, syncope -Chest pain sometimes - ? etiology -Along with dyspnea, palpitations, syncope -Does NOT respond to antianginals
Aortic regurgitation
•Causes -Primary disease of aortic valve leaflets, aortic root, or both -Acute AR caused by trauma, IE, or aortic dissection = LIFE THREATENING -Chronic AR caused by RHD, congenital bicuspid aortic valve, syphilis, or chronic rheumatoid disease •Backward blood flow from ascending aorta into LV during diastole -Volume overload -LV initial compensation = dilation & hypertrophy •Contractility declines over time which results in ↑ blood volume in LA & pulmonary bed -Seen as pulmonary HTN & RV failure
Acute mitral regurgitation
•Clinical Manifestations: -Thready, peripheral pulses -Cool & clammy -Decreased CO may mask new systolic murmur -Rapid onset of pulmonary edema & cardiogenic shock •Assessment & intervention critical -Cardiac cath & valve repair or replacement -LIFE-THREATENING! Need quick intervention!
Aortic stenosis
•Congenital AS •Older adult AS (rheumatic fever or degeneration) •Obstruction of blood flow from LV to aorta during systole •Results in: -LV hypertrophy, ↑ myocardial oxygen consumption -Progression results in compensatory mechanism failure -Not able to get the blood from the left ventricle out into the aorta to get to your systemic circulation... hard for left ventricle to keep pumping against that high pressure from small, narrow, tight valve -Pressure in aorta gets higher and higher... left ventricle gets full, pressure difference causes LV to enlarge... more chest pain bc under high demand -> demand ischemia.... If we cant get that blood out, CO goes down.... Everything backs up (pulmonary edema, pleural effusions)
Causes of VHD
•Congenital in children & adolescents •Acquired -Degenerative disease (mechanical stress, CAD, HTN) -Rheumatic disease (fibrotic changes & calcification of cusps) -Infective endocarditis (infectious organism destroys the valve, strep common cause) •Heart disease in older adults -Aortic stenosis (AS) & Mitral regurgitation (MR) common •Other causes -AIDS: opportunisitic infections -Antiparkinsonian drugs: fibrous tissue forms (banned in U.S.) •dopamine agonists - ergot derivatives: cabergoline & pergolide -When given in high doses Two biggest reasons why we see VHD is rheumatic heart disease (usually in childhood) and infective endocarditis **
A 21-yr-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? A.Ongoing cardiac care by a health care provider is not necessary after valvuloplasty. B.Mechanical mitral valves need to be replaced sooner than biologic valves. C.Biologic valves will require immunosuppressive drugs after surgery. D.Lifelong anticoagulant therapy is needed after mechanical valve replacement.
D. Lifelong anticoagulant therapy is needed after mechanical valve replacement. Valvuloplasty: going up through groin or femur and using balloon to open and fix the stenosis (don't need anticoagulation therapy) If we fix the valve, we don't necessarily need anticoagulation after we go in there and balloon that valve open so that we have a nice opening to return everything back to even pressures.... Versus if we do open up the chest, open up the heart, put the new valve in, that's foreign so body will try to wall that off and do have to use anticoagulation therapy life long for those valves
While caring for a 23-yr-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to A.take an aspirin a day to prevent clots from forming on the valve. B.limit physical activity to avoid stressing the heart. C.take antibiotics before any dental appointments. D.avoid over-the-counter (OTC) drugs that contain stimulants.
D. avoid over-the-counter (OTC) drugs that contain stimulants. Don't want the heart to beat too fast... want to avoid tachycardia (stimulants and caffeine); need to teach to avoid OTC stimulants like cold medicine (ex. Sudafed) MVP: valve is still closing, but we see that up-pouching up into the left atria but our valve is still closing and doing okay
The nurse is obtaining a health history from a 24-yr-old patient with hypertrophic cardiomyopathy (CMP). Which information obtained by the nurse is most important? A.The patient has a history of a recent upper respiratory infection. B.The patient reports using cocaine a "couple of times" as a teenager. C.The patient's 29-yr-old brother died from a sudden cardiac arrest. D.The patient has a family history of coronary artery disease (CAD).
C. The patient's 29-yr-old brother died from a sudden cardiac arrest. Huge genetic tendency, anyone who died young from a sudden cardiac arrest
A surgical repair is planned for a patient diagnosed with a 5.5cm AAA. On physical exam of the patient, what should the nurse expect to find? A. hoarseness and dysphagia B. severe back pain with flank ecchymosis C. presence of a bruit in the periumbilical area D. weakness in the lower extremities progressing to paraplegia
C. presence of a bruit in the periumbilical area
The nurse will plan discharge teaching about prophylactic antibiotics before dental procedures for which patient? A.Patient being discharged after an exacerbation of heart failure B.Patient admitted with a large acute myocardial infarction C.Patient who had a mitral valve replacement with a mechanical valve D.Patient being treated for rheumatic fever after a streptococcal infection
C.Patient who had a mitral valve replacement with a mechanical valve
Which aneurysm is uniform in shape and a circumferential dilation of the artery?
Fusiform
Hemostatic resuscitation
Crystalloid Transfusions: •Infuse to increase perfusion •BP and urinary output •Too much has adverse results: ARDS Transfuse blood, FFP, Platelets to increase hematocrit and other end points •Transfuse: •pRBCs, FFP, Platelets - 1:1:1
Primary survey
•Initial assessment concerned with the priorities of first aid for trauma victims: Breathing, Bleeding, Shock Breathing (AcBC's) A airway; Maintain open airway c cervical spine; Assume C-spine injury B breathing; Check respirations C circulation; Check for a pulse Bleeding Control any obvious hemorrhaging Shock Begin treatment for shock
A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder? A.Notify the health care provider about symptoms such as shortness of breath. B.Elevating the legs above the heart will help relieve dyspnea. C.A heart transplant should be scheduled as soon as possible. D.Careful compliance with diet and medications will NOT prevent heart failure.
D. Careful compliance with diet and medications will NOT prevent heart failure. Sometimes no matter how compliant they are, they will still have HF exacerbations
A thoracic aortic aneurysm is found when a patient has a routine chest x ray. The nurse anticipates that additional diagnostic testing to determine the size and structure of the aneurysm will include which test? A. angiogram B. ultrasound C. ECHO D. CT scan
D. Computed tomography (CT) is the most accurate test to determine the diameter of the aneurysm and whether a thrombus is present.
When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for A.diastolic murmur. B.peripheral edema. C.right upper quadrant tenderness. D.shortness of breath on exertion.
D. Heart failure symptoms (as volume overload becomes more and more pronounced, more and more SOB with limited physical activity... everything they do is going to make them feel more SOB)
Nurse's role: Planning & implementation
•Connect to monitor and evaluate "high-tech" aspect of care •Administer, monitor, and evaluate IV therapy •Document care and note trends •Administer medications per order •Complete routine care to prevent complications: •Wound care using aseptic technique •Aseptic technique with central lines, trach/suctioning care, etc. •Decreased mobility: ROM, splinting, special beds/mattresses, turning, PT/OT consult, etc. •Incentive spirometry, deep breathing and/or chest physiotherapy •Safely transport patient to tests and procedures •Efficiently carry out emergency procedures ("codes") if patient's condition suddenly deteriorates
Three collision event
Ex. motor vehicle accident 1. Machine collision - machine hits a tree 2. Body collision - body hits the steering wheel 3. Organ collision - organs move forward, backward, and then back into place
Trauma Care Designation - Level IV
Provide initial care and stabilization of traumatic injury while arranging transfer to a higher level of trauma care
Patient profile of multiple trauma
The injury occurs suddenly and unexpectedly -No time to prepare or plan Drug and alcohol use are often involved -May affect family's ability to cope Patient may require long-term rehab -Increased risk of systemic complications and/or physical disabilities -Detection and prevention are priorities of care Psychologic complications are common -Adaptation to injuries often difficult Trauma affects the young adult -Highest incidence of injury between ages 15 and 24 Number of elderly patients with trauma is increasing -Patients over 75 have highest incidence of traumatic deaths Trauma fatalities may require an investigation due to violence or the type of accident -Legal implications are inherent Trauma injuries are not always evident -Assessment is vitally important* Trauma injuries and their treatment may create further problems which affect the plan of care -Communication, infection, disability -Standard interventions may be difficult to implement because of multiple injuries -The treatments may create economic hardships on the patient and family
Dilated CMP treatment
Treat Heart Failure -Nitrates & diuretics = preload (Lasix, Spironolactone) -ACE inhibitors = afterload -Beta-blockers & aldosterone agonists = control neurohormonal stimulation -Anticoagulants to prevent emboli (bc stasis of blood) -Anti-dysrhythmics for life-threatening ventricular dysrhythmias (Amioadarone, beta blocker, calcium channel blocker) -Dobutamine or milrinone infusions) -Diet & cardiac rehab -If secondary CMP, treat cause (example - no alcohol) -VAD (ventricular assist device): -ICD and/or biventricular pacing (ICD senses the arrythmia and delivers a shock) -Heart transplantation
Aortic aneurysm diagnostic studies
X-rays -Chest - any abnormal widening of thoracic aorta -Abdomen - aortic calcifications EKG - to rule out MI -TAA or dissection can mimic MI ECHO -Assess aortic valve Ultrasound -Useful in screening for aneurysms -Monitors aneurysm size CT scan** -Most accurate test to determine: *Anterior-to-posterior length *Cross-sectional diameter *Presence of thrombus *Best type of surgical repair MRI -Diagnose and assess location and severity Angiography -Anatomic mapping of aortic system using contrast -Not reliable method of determining diameter or length -Can provide accurate information about involvement of intestinal, renal, or distal vessels
Aortic aneurysm classification
a.True -Wall of artery forms aneurysm with at least 1 vessel layer still intact -Fusiform: circumferential and relatively uniform shape (looks equal on both sides) -Saccular: pouchlike protrusion with narrow neck connecting bulge to one side of arterial wall b.False or psuedoanuerysm -Disruption of all arterial wall layers with bleeding that is contained by surrounding anatomic structures (looks like an aneurysm, but is really a collection of a clot that walls itself off) -Result from trauma, infection, peripheral artery bypass graft surgery (anastomosis site), or arterial leakage after removal of cannulae (from arterial catheter, intra-aortic balloon pump)
Overall goal: Optimal functioning with increased independence
•Continue to assess VS, PE and document •Monitor I/O and note imbalances, changes •Assess pain, administer analgesics per order •Increase patient's activity per order •Complete routine care in appropriate manner to prevent complications (infection) •Maintain nutrition •Request consults as needed •Contract with patient for time: teaching, discussing feelings, etc. •Permit increased family involvement with care
Secondary survey
•A complete head-to-toe assessment to determine quantity and severity of injuries •It is conducted with the victim in the position found!* •Do not interrupt the secondary survey unless the client's condition changes or hidden bleeding is found •Continually interact with the client to denote mental status
Emergency Medical Services Act
•Emergency medicine emerged as a specialty (1972)
