Presentation on theme: "By three methods we may learn wisdom:"— Presentation transcript:
1By three methods we may learn wisdom: First, by reflection, which is noblest;Second, by imitation, which is easiest;and Third by experience, which is the bitterest.--Confucius
2The Three Apprenticeships of Nursing Education* Intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession.A skill-based apprenticeship of practice, including clinical judgment.An apprenticeship to the ethical standards, ethical comportment, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession's fundamental purposes.* Carnegie Foundation for Advancement of Teaching
3I have never been “just anything.” Dear Nurse,I am Someone.I am not just a Patient.I have never been “just anything.”I have a past, and hopefully, a future.I am a Unique Human Being.There never has been,Nor ever will be,Anyone just like me.Today, you , the nurse, will touch myLife.How will I remember you?What are your concerns about the patient?What is the cause of the concern?What are you going to do about it?What is the patient experiencing?
4This is Someone’s Mother. You are her nurseWhat are your concerns about the patient?What is the cause of the concern?What are you going to do about it?What is the patient experiencing?
5This Someone’s Father. You are his nurse What are your concerns about the patient?What is the cause of the concern?What are you going to do about it?What is the patient experiencing?
6This is Someone’s Sister, Someone’s Mother,And Someone’sDaughterYou are her nurseWhat are your concerns about the patient?What is the cause of the concern?What are you going to do about it?What is the patient experiencing?
7This is someone’s Brother You are his nurseWhat are your concerns about the patient?What is the cause of the concern?What are you going to do about it?What is the patient experiencing?
10Concept Map: Selected Topics in Cardiovascular Nursing ASSESSMENTPhysical AssessmentInspectionPalpationPercussionAuscultationCardiac MonitoringLab MonitoringPHARMACOLOGYCardiac GlycosidesACE InhibitorsBeta BlockersAntiarrhythmicsCatecholaminesAnticoagulantsPATHOPHYSIOLOGYMyocardial InfarctionAcute Coronary SyndromeValvular Heart DiseasePacemakersCABGAbdominal Aortic AneurysmPericarditisPeripheral Vasc Disease (PVD)Fem-Pop Bypass GraftShock / Fluid DeficitRaynaud’s PhenomenonArrhythmias / DysrhythmiasCare PlanningPlan for client adl’s,Monitoring, med admin.,Patient education, more…Nursing Interventions & EvaluationExecute the care plan, evaluate forEfficacy, revise as necessary
11CARDIAC MONITORING Page R. 78 y.o. Sick Sinus Syndrome S/P Pacemaker InsertionRenee C. 29 y.o.PericarditisAdmission PendingPre-Op CABGCARDIAC MONITORINGHaynes H. 55 y.o.PVDS/P Femoral-Popliteal BypassKam H. 48 y.o.AAAJames H. 68 y.o.R/O MI ,Atrial Fibrillation
12James H. M.A.R. Patient Record Name: James H. Age: 68 y.o Male TreatmentsV.S. &GraphicsReportsMISCI & OAssessmentsConsultsNurse’sNotesHistory &PhysicalDr’sOrdersLabs & DxM.A.R.PatientRecordName: James H.Age: 68 y.o MaleOccupation: ArchitectAdm: 11 Feb 2009DX: R/O MI, R/O CVA,S/P CABG X 4 (1/22/2009)OTHER DX: DM, AAA,PVD, Atrial FibrillationJames H.Name:
13Dr’s Orders Admit to Telemetry Unit; continuous cardiac monitoring DX: R/O MI, R/O Embolic CVAActivity: BR, BSCDiet: Clear Liquids, adv as tol to 1500 calorie ADA DietFSBG q ac & hs with Moderate SSRI CoverageMeds:Humulin 70/30 35 units sq q am / 20 units sq q pmDigoxin mg po dailyAmiodarone 400 mg po bidColace 200 mg po dailyHeparin IV per weight-based protocolNTG 0.4 mg sl q5 min x 3, PRN CPMorphine SO4 2 mg IVP PRN CPLidocaine 2 mg / minute IV / continuousIV: Saline LockLabs / Diagnostics: Continue Serial Cardiac Enzymes; BMP q day; CBC; Coag studies per heparin weight-based protocol; schedule for CT of brainTelemetry Protocols; ACLS Protocols10. Daily EKG; EKG with any chest painWhat are your concerns about the patient?What is the cause of the concern?What are you going to do about it?What is the patient experiencing?
14History & Physical CO = HR & R X SV BP = CO X SVR SEE CONCEPT MAP Admitted 2/10/2009 after c/o crushing, substernal chest pain rated as 9 on a scale of (Presented with Cardiac Rhythm as noted on ( ER rhythm strip #1 and ER rhythm strip #2 );( later, developed (Rhythm strip #3) while being transported from the Emergency Department to the telemetry unit.) Also was noted to have rhythm noted on Rhythm strip #4. Rhythm strip #5 is attached for your enlightenment.Client was successfully resuscitated, including use of ACLS protocols andDefibrillation with 360 joules x 2. Converted to atrial fibrillation w/controlled ven-tricular response. After defibrillation and transfer to the nursing unit, pt exhibited s/s disorientation-see Rhythm Strip #6.Five hours after admission to the telemetry floor, became agitated and c/o (R)-side chest pain:See Nurse’s Notes.Surgical history includes 4 vessel CABG in 1/2008; PTCA with 3 stents in2002; Laparascopic Cholecystectomy in 1999.Other pertinent Medical History includes diagnosis of DM in 1990; blood sugars controlled moderately well with Humulin 70/30 35 units q am / 20 units q pm. Long history of atrial fibrillation with concomitant control via digoxin 0.25 mg daily.CO = HR & R X SV BP = CO X SVR
15The Patient airway, breathing, LOC RHYTHM STRIP #1 Awake and alert; BP= 112/72
16Check The Patient airway, breathing, LOC RHYTHM STRIP #2 Awake & Alert C/O Chest Pressureand Feeling NervousBP = 106/68Check The Patientairway, breathing, LOC
17The Patient airway, breathing, LOC RHYTHM STRIP #3The Patient airway, breathing, LOCAwake and alert; BP= 88/40C/O “Feeling Funny”
18The Patient (!) airway, breathing, LOC RHYTHM STRIP #4NON-RESPONSIVEBP=The Patient (!) airway, breathing, LOCCO = HR&R x SVBP = CO x SVR
19CHEST LEAD RECONNECTED RHYTHM STRIP #5AWAKE & ALERTBP = 112/78CHEST LEAD RECONNECTED(It fell off…)(Oops, MY BAD!)The Patient (!)Airway, breathing, LOCTREAT THE PATIENT, NOT THE MONITOR !
21Nurse’s Notes SEE CONCEPT MAP What are your concerns about the patient?What is the cause of the concern?What are you going to do about it?What is the patient experiencing?SEE CONCEPT MAP0700: Unable to initiate additional peripheral IV line, attempts x 3. VS: P=90,irregular; R=22, unlabored; BP= 118/78; SaO2=95%. Monitor displayingatrial fibrillation with occasional PVC. Physician notified re: IV; will continueLidocaine 2 mg/min per available site on (L) forearm; Heparin infusion perWBP on hold until additional IV site accessed. Consult for central line placementpending J. Nurse, RN0900: C/O sharp pain, pointing to area (R) thorax; became agitated and dis-oriented . VS: BP = 90/50; P = 110, irregular; R = 32, labored; T =98*;SaO2 = 86 %. ABG’s obtained, results pending. O2 increased to 4L/NC.Note absent breath sounds, RLL;Cardiac monitor: Atrial fibrillation w/ rapidventricular response. Physician notified and enroute to hospital. Will continue to Monitor J. Nurse, RN0920: Non-responsive; VS: BP = 80/40, P = 156, irreg, R = 10,SaO2 = 80%; central cyanosis noted. Intubated and ventilated with 100% 02. Absent lung sounds RLL & RML. Cardiac monitor shows atrial fibrillation w/uncontrolled ventricular response. Report provided to ICU nurse,Transported via gurney to ICU for ventilator support J. Nurse, RN
28Nursing Care: AAA Repair ??NSG DX #1:Fear / Anxiety?Abdominal Aortic Aneurysm(Pathophysiology)Other Nursing Diagnoses That May Apply:?KEY ASSESSMENTS?
29AAA: PathophysiologyAn abdominal aortic aneurysm is an abnormal dilation of the wall of the abdominal aorta. The aneurysm usually develops in the segment of the vessel that is between the renal arteries and the iliac branches of the aorta. The most common cause of an abdominal aortic aneurysm is atherosclerosis. The plaque that forms on the wall of the artery causes degenerative changes in the medial layer of the vessel. These changes lead to loss of elasticity, weakening, and eventual dilation of the affected segment. Some other causes of abdominal aortic aneurysm include inflammation (arteritis), trauma, infection, congenital abnormalities of the vessel, and connective tissue disorders that cause vessel wall weakness.Most abdominal aortic aneurysms are asymptomatic and are discovered during a routine physical examination (signs include palpation of a pulsatile mass in the abdomen and/or auscultation of a bruit over the abdominal aorta) or during a review of x-ray results of the abdomen or lower spine. The presence of symptoms such as mild to severe abdominal, lumbar, or flank pain and/or lower extremity arterial insufficiency is usually indicative of a large aneurysm that is exerting pressure on surrounding tissues or an aneurysm that is leaking.Surgical repair of an aneurysm is usually performed if the aneurysm is growing rapidly and/or reaches a size of 5-6 cm or larger or if the client experiences symptoms. The procedure often involves the use of a synthetic graft, which is inserted to replace or support the weakened vessel.Ulrich & Canale: (2006)Nursing Care Planning Guides:For Adults in Acute, Extended, and Home Care Settings, 6th Edition
30NURSING DIAGNOSIS: Fear/Anxiety related to: Desired Outcome The client will experience a reduction in fear and anxietyNursing Actions and Selected Purposes/Rationales 1. Preoperative Care Plan, for measures related to the assessment and reduction of fear and anxiety. 2. Implement additional measures to reduce fear and anxiety: a. orient client to critical care unit if appropriate b. describe and explain the rationale for equipment and tubes that may be present postoperatively (e.g., cardiac monitor, ventilator, intravenous and intra-arterial lines, nasogastric tube, urinary catheter) c. explain that B/P may be taken in both arms and thighs in order to better evaluate circulatory status d. reinforce physician's explanations and clarify misconceptions client has about effects of the surgery on sexual functioning (impotence can result from diminished blood flow in the mesenteric or internal iliac arteries during or after surgery and/or from nerve damage during surgery).1. unfamiliar environment and separation from significant others;2. lack of understanding of diagnostic tests, surgical procedure, and postoperative care;3. anticipated loss of control associated with effects of anesthesia;4. risk of disease if blood transfusions are necessary; 5. anticipated postoperative discomfort and potential change in sexual functioning;6. possibility of death.
31COLLABORATIVE DIAGNOSIS: Potential complication: hypovolemic shock R/T related to excessive blood loss if the aneurysm ruptures.Desired Outcome: The client will not develop hypovolemic shock as evidenced by: 1. usual mental status 2. stable vital signs 3. skin warm and usual color 4. palpable peripheral pulses 5. urine output at least 30 ml/hour.NURSING ACTIONS:(next page)
32Nursing Actions and Selected Purposes/Rationales 1. Assess for and immediately report signs and symptoms of conditions that indicate impending aneurysm rupture:A. Leaking aneurysm: a. increasing abdominal girth b. ecchymosis of flank area or perineum c. frank or occult gastrointestinal bleeding (occurs if the aneurysm ruptures into the duodenum) d. decreasing RBC, Hct, and Hgb levels e. new or increased reports of lumbar, flank, abdominal, pelvic, or groin pain (accumulation of blood in the peritoneum and/or retroperitoneal spaces causes irritation of and pressure on the tissues and nerves) f. diminishing or absent peripheral pulses g. further decline in thigh B/P as compared with B/P in arm (thigh B/P is usually slightly lower than B/P in arm of a client with an abdominal aortic aneurysm)B..Expanding aneurysm: a. new or increased reports of lumbar, flank, or groin pain (results from pressure on lumbar nerves) b. increased size of pulsating mass in abdomen c. increasing sense of abdominal and/or gastric fullness (results from pressure on duodenum) d. decreasing motor or sensory function of lower extremities (results from pressure on lumbar and/or sacral nerves).C. Assess for and report signs and symptoms of hypovolemic shock: a. restlessness, agitation, confusion, or other change in mental status b. significant decrease in B/P c. postural hypotension d. rapid, weak pulse e. rapid respirations f. cool skin g. pallor, cyanosis h. diminished or absent peripheral pulses i. urine output less than 30 ml/hour.
33D. Implement measures to decrease risk of aneurysm rupture: a D. Implement measures to decrease risk of aneurysm rupture: a. instruct client to avoid elevating legs when in bed, using knee gatch, and crossing legs in order to prevent restriction of blood flow to the lower extremities and subsequent increase in vascular pressure at the aneurysm site b. perform actions to prevent an increase in blood pressure: c. limit client's activity as ordered d. nstruct client to avoid activities that create a Valsalva response (e.g., straining to have a bowel movement, holding breath while moving up in bed, lifting heavy objects)E. implement measures to reduce fear and anxiety (see Preoperative Diagnosis 1)F. administer antihypertensives if ordered to reduce pressure in the dilated vessel.G. If signs and symptoms of hypovolemic shock occur:a. place client flat in bed unless contraindicated b. monitor vital signs frequently c. administer oxygen as ordered d. administer blood and/or volume expanders as ordered (these need to be used with caution since increased vascular pressure can extend a tear at site of rupture) e. prepare client for insertion of hemodynamic monitoring devices (e.g., central venous catheter, intra-arterial catheter) if indicated f. prepare client for emergency surgical repair of aneurysm if indicated.
34NURSING DIAGNOSIS: Risk for imbalanced fluid and electrolytes Excess fluid volume related to:1. vigorous fluid replacementFluid retention associated with:1. increased secretion of antidiuretic hormone (output of ADH is stimulated by trauma, pain, and anesthetic agents)2. renal insufficiency (can occur if there is inadequate blood flow to the kidneys during or after surgery)3. reabsorption of third-space fluid (occurs about the 3rd postoperative day);Deficient fluid volume related to restricted oral fluid intake before, during, and after surgery; blood loss; and loss of fluid associated with nasogastric tube drainage;Electrolyte Imbalance: hypokalemia, hypochloremia, and metabolic alkalosis related to loss of electrolytes and hydrochloric acid associated with nasogastric tube drainage.Third-spacing of fluid related to:1. increased capillary permeability in surgical area associated with the inflammation that occurs following extensive dissection of tissue during major abdominal surgery2. increased vascular hydrostatic pressure associated with excess fluid volume if present3. hypoalbuminemia associated with the escape of proteins from the vascular space into the peritoneum (a result of increased capillary permeability in the surgical area);
35Desired Outcome The client will experience resolution of third-spacing as evidenced by: 1. absence of ascites 2. B/P and pulse within normal range for client and stable with position change.
38Peripheral Arterial Disease PathophysiologyPAD results from atheroclerosis in the arteries of the lower extremities, characterized by inadequate blood flow (ischemia).Intermittent Claudication:pain caused by insufficient arterial blood supply
53PTCA percutaneous transluminal coronary angioplasty Patient has had a history of CAD for several years.Underwent PTCA with stent placement x 1 year agoIncreasing anginaPTCA last week shows near occlusion of four coronary arteries
55Nursing Care After PTCA Monitor Cardiac RhythmMaintain Bedrest for Specified timeFrequent assessment of affected leg / groin site for bleedingFrequent assessment of affected leg for tissue perfusion distal to cath insertion site
56The goal of treatment for heart disease is to maximize cardiac output. Surgically this may be done by improving myocardial muscle function and blood flow through procedures such as the traditional CABG (or via less invasive procedures such as MIDCAB, percutaneous transmyocardial revascularization [PTMR], and/or port access requiring four small incisions under the left breast), wrapping the latissimus dorsi muscle around the heart, and/or repair or replacement of defective valves.Of the three types of cardiac surgery—(1) reparative (e.g., closure of atrial or ventricular septal defect, repair of mitral stenosis), (2) reconstructive (e.g., CABG, reconstruction of an incompetent valve), and (3) substitutional (e.g., valve replacement, cardiac transplant)—reparative surgeries are more likely to produce cure or prolonged improvement.
58An open heart bypass surgery is performed under general anesthesia, which requires that the patient be on a ventilator during surgery.Surgery begins with harvesting the blood vessels that will become the grafts. The saphenous vein in the leg is commonly used because it is long enough to create multiple grafts. If the saphenous vein cannot be used, vessels from the arm can be used instead. The left internal mammary artery is used for a single graft and is taken once the chest is opened for surgery.Once the saphenous vein has been recovered, the chest is opened by making an incision along the sternum, or breastbone. The surgeon then cuts the sternum, allowing the chest cavity to be opened, giving the surgeon access to the heart.In the traditional CABG procedure, the heart is stopped with a potassium solution so the surgeon is not attempting to work on a moving vessel, and the blood is circulated by a heart-lung machine. At this time the heart-lung machine does the work of the heart and the lungs, and the ventilator is not used.
59The surgeon places the grafts, either rerouting blood around the blockage, or removing and replacing the blocked vessel. The amount of time on the heart-lung bypass machine is determined by the speed at which the surgeon is able to work, primarily, how many grafts are needed.Once the grafts are complete, the heart is started and provides blood and oxygen to the body. The sternum is returned to its original position and closed using surgical wire, to provide strength the bone needs to heal, and the incision is closed.
63Care PlanningDISCHARGE GOALS 1. Activity tolerance adequate to meet self-care needs. 2. Pain alleviated/managed. 3. Complications prevented/minimized. 4. Incisions healing. 5. Postdischarge medications, exercise, diet, therapy understood. 6. Plan in place to meet needs after discharge.NURSING PRIORITIES 1. Support hemodynamic stability/ventilatory function. 2. Promote relief of pain/discomfort. 3. Promote healing. 4. Provide information about postoperative expectations and treatment regimen.
67Overview: Pericarditis Pericarditis - inflammation of the lining surrounding the heart (the pericardial sac).Pericardial effusion - a collection of fluid in the pericardial sac. This fluid may be produced by inflammation.The etiology of pericarditis in most patients is unknown, although many diseases can cause pericarditis.The diagnosis of pericarditis is made by history and physical examination including presence of a pericardial friction rub. It may confirmed by EKG and echocardiogram.Pericarditis is treated with anti-inflammatory medications and by treating any underlying disease.Pericardial tamponade occurs when enough fluid accumulates in the sac to compromise the heart's ability to adequately pump blood.Tamponade is treated by pericardiocentesis, removing the fluid with a needle.
68EtiologyIdiopathicThe cause of the illness is not identified (although often it's the result of a minor viral illness or "cold")Mechanical injury to the heartHeart attack (myocardial infarction) and Dressler's syndromeHeart surgery and post pericardiotomy syndromeTraumaInfectionBacterialViralFungalTumors or cancerPrimary (rare)MetastaticConnective Tissue DiseaseRheumatoid arthritisSystemic Lupus Erythematosus (SLE)SarcoidosisSclerodermaMetabolic diseasesUremia (kidney failure)HypothyroidismMedication Reactions (next page)
69EtiologySide effects of certain medications can cause an immune response causing an inflammation of the pericardial sac and pericarditis.Medicines that have been implicated include phenytoin (Dilantin), hydralazine (Apresoline) and procainamide (Pronestyl, Procan-SR, Procanbid).
70Symptoms Chest pain is the most common symptom of pericarditis. The pain is usually sharp and stabbing.It can arise slowly or suddenly and can radiate directly to the back, to the neck or to the arm.The pain can be made worse with deep breaths (pleuritic).The pain is frequently positional and made worse when lying flat and better when leaning forward.The most common physical finding that almost always confirms the diagnosis is a pericardial friction rub.
71Medicines that reduce inflammation are the primary treatment for pericarditis. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, are used to decrease the inflammation and fluid accumulation in the pericardial sac. process.Occasionally, a short course of narcotic pain medication [codeine, hydrocodone (Vicodin) or oxycodone (OxyContin, Roxicodone)] will be needed.In recurrent cases, especially in immunologically-mediated causes, corticosteroids are often very effective.Treatment of the underlying cause of pericarditis is essential and will be based on the disease
72Cardiac tamponadeIf there is enough fluid in the pericardia sac, there may be enough pressure on the outside of the heart to prevent it from beating adequately to push blood to the body and lungs.The pressure within the sac itself needs to be higher than the pressure within the heart chambers, but symptoms gradually progress as the heart function is compromised.Treated by pericardiocentesis, a procedure where a long needle is inserted through the chest wall into the pericardial sac and fluid is removed.This relieves the pressure within the sac and temporarily resolves the acute emergency. A plastic tube or catheter may be left in the chest until the underlying illness that cause the tamponade is addressed and further accumulation of fluid in the pericardium is prevented.
73PericarditisCardiac Tamponade: Most serious complication of pericarditisPulsus ParadoxusPulsus Paradoxus (PP) is an exaggeration ofthe normal variation in the pulse during theinspiratory phase of respiration, in which the pulsebecomes weaker as one inhales and stronger asone exhales.It is a sign that is indicative of severalconditions including cardiac tamponade, pericarditis,chronic sleep apnea, croup, and obstructive lungdisease (e.g. asthma, COPD).