NUR 2243C Exam 2 Study Guide- Florida State College at Jacksonville
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Nursing
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Nursing
NUR 2243C Exam 2 Study Guide- Florida State College at Jacksonville/NUR 2243C Exam 2 Study Guide- Florida State College at Jacksonville/NUR 2243C Exam 2 Study Guide- Florida State College at Jacksonville/NUR 2243C Exam 2 Study Guide- Florida State College at Jacksonville
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NUR2243: Exam 2 Study
Perfusion
o Mean Arterial Pressure (MAP)
What does it mean?
The arterial blood pressure (between 60- and 70-mm Hg) necessary to
maintain perfusion of major body organs, such as the kidneys and brain.
Must be at least 60 mm HG to maintain adequate blood flow
MAP = (2Xdiastolic) + systolic / 3
How does it correlate with disease processes?
Low blood volume = low MAP; If a patient has severe blood loss (low blood
volume), MAP will be low
During shock, MAP decreases
Heart Transplants
o 1st choice for end stage HF
o Leave R atrium in place
o Anastomose the transplant heart to R atrium
o Nursing Intervention
Monitor for tamponade
Report signs and symptoms of rejection immediately
Patients are immunosuppressed- wash hands and use aseptic technique
Prevent/manage pulmonary edema
o Patient Education
a patient who has had a heart transplant should move positions slowly because
the new heart cannot detect blood pressure changes (the heart has not connected
to the nervous system yet)
To suppress natural defense mechanisms (especially T- and B-cell function) and
prevent transplant rejection, patients require a combination of
immunosuppressants for the rest of their lives.
Daily weights, diet, transplant site management
o Signs and symptoms of rejection
Clinical manifestations of heart transplant rejection include shortness of breath,
fatigue, fluid gain (edema, increased weight), abdominal bloating, new
bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance,
and decreased ejection fraction (late sign).
Myocardial Infarction (Heart Attack)
o Misc:
occurs when myocardial tissue is abruptly and severely deprived of oxygen.
two types of MI: non–ST-segment elevation MI (NSTEMI) and ST elevation MI
(STEMI 100% blockage=emergency).
Most serious acute coronary syndrome
Infarction is a dynamic process that does not occur instantly. Rather, it evolves
over a period of several hours
Scar tissue permanently changes the size and shape of the entire left ventricle,
called ventricular remodeling.
o Signs and Symptoms
Pain or discomfort occurring without cause, usually in the morning, relieved only
by opioids, lasting 30+ minutes, or substernal chest pain/pressure radiating to the
left arm, pain or discomfort in jaw, back, shoulder, or abdomen
Frequent associated symptoms: Nausea/vomiting, diaphoresis, dyspnea, feelings
of fear and anxiety, dysrhythmias, fatigue, palpitations, epigastric distress,
anxiety, dizziness, disorientation/acute confusion, feeling “short of breath”
Elevated Troponin and CK-MB levels
o Nursing Interventions
Assess ABCs
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, Defibrillate as needed
Provide continuous ECG monitoring
Obtain VS and pain level
Assess/provide vascular access
Obtain a 12-lead ECG within 10 minutes of report of chest pain
Provide pain relief medication and aspirin as prescribed
Administer oxygen therapy to maintain oxygen saturation ≥90%
Remain calm. Stay with the patient if possible
Assess VS and pain 5 minutes after administration of medication
Re-medicate with prescribed drugs (if VS stable) and check the patient every 5
minutes
Notify the provider if vital signs deteriorate
Drug Therapy: nitrates, beta blockers, antiplatelets
Pain relief increases oxygen supply to the myocardium; administer morphine as a
priority in managing pain in the client having an MI.
in an inferior wall MI (heart attack) patients will often exhibit bradycardia or heart
blocks, this leads to decreased blood flow/perfusion; if a rhythm strip on an EKG
shows bradycardia in a patient with an inferior wall MI… check their blood
pressure and LOC
if a patient is having chest pain with N/V; priority intervention is airway
maintenance
know normal parameters (RR 12-24, HR 60-100, etc.); If patient has normal VS
while doing an activity… let them continue the activity
o Patient Education
ace inhibitors inhibit potassium secretion; so patients are prone to hyperkalemia;
patients should avoid salt substitutes, bananas, green leafy veggies, etc.
Report change in mental status, urinary output >1mL/kg/Hr, cool/clammy
extremities with decreased/absent pulse, unusual fatigue, recurrent chest pain
Normal anatomy and physiology of the heart, the pathophysiology of angina and
MI, risk factor modification, activity and exercise protocols, cardiac drugs, and
when to seek medical assistance.
Myocardial healing after an MI begins early and is usually complete in 6 to 8
weeks.
Sternotomy from traditional CABG should heal in about 6 to 8 weeks, but upper
body exercise needs to be limited for several months.
CABG: incision care for sternum and the graft site, avoid crossing legs and wear
elastic stockings until edema subsides, elevate surgical limb when sitting in a
chair.
Radial artery graft: open and close hand vigorously 10x q2hr
o Post-Surgery Care
Use sterile technique when changing sternal or donor-site dressings
Assess for dysrhythmias
Assessing fluid and electrolyte balance is a high priority
Monitor and report complications – fluid and electrolyte imbalance, hypotension,
hypothermia, hypertension, bleeding, cardiac tamponade, change in level of
consciousness, anginal pain
Report: HR <50 after arising, wheezing or difficulty breathing, weight gain of 3 lb
in 1 week or 1-2 lbs overnight, persistent increase in NTG use, dizziness, faintness,
or SOB with activity, chest pain
Call 911 if: chest discomfort that does not improve after 5 minutes or one
sublingual NTG tablet or spray, extremely severe chest or epigastric discomfort
with weakness, nausea, or fainting
in addition to items listed, it is important for patients who have had surgery, of
any kind, to have running water in their home because they need to prevent
infection
o Usage of thrombolytic agents
Thrombolytic therapy using fibrinolytics dissolves thrombi in the coronary arteries
and restores myocardial blood flow.
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, Most effective when given within the first 6 hours of a coronary event
Contraindications include recent abdominal surgery or stroke, because bleeding
may occur when fresh clots are lysed (broken down or dissolved).
when a patient is given thrombolytics; they must be watched before and after the
medication is given; bleeding is a risk (monitor Hgb, Hct, BP)
indicated for chest pain longer than 30 minutes that is unrelieved by other
medications (i.e. nitroglycerin (NTG))
o Chest Tube Care
Signs and symptoms of difficulties with a chest tube
after a patient has CABG, they often have a chest tube… if the drainage
abruptly slows or stops you need to contact the physician because it may
be blocked by a blood clot
Nursing Interventions
monitor the amount and appearance of drainage from chest tubes and
change the dressing around these tubes as ordered
after a CABG, it is important to monitor the patient’s VS; you do not want
their BP to get too high because that runs the risk of opening their suture
line and cause bleeding
o Intra-arterial Blood Pressure Monitoring
Hemodynamic monitoring is an invasive system used in critical care areas to
provide quantitative information about vascular capacity, blood volume, pump
effectiveness, and tissue perfusion. It directly measures pressures in the heart and
great vessels.
Hemodynamic monitoring does involve significant risks, although complications
are uncommon. Informed consent is required.
Direct measurement of arterial BP is done by invasive arterial catheter in critically
ill patients. The physician or specially trained health care professional inserts an
intra-arterial catheter into the radial or femoral artery.
Intra-arterial catheters allow continuous blood pressure monitoring and are an
access for arterial blood sampling. They are inserted into an artery (radial,
brachial, femoral, or dorsalis pedis). The catheter is attached to pressure tubing
and a transducer, which converts arterial pressure into an electrical signal seen as
a waveform on an oscilloscope and as a numeric value.
Direct measurements of BP are usually 10 to 15 mm Hg greater than indirect (cuff)
measurements. The arterial catheter may also be used to obtain blood samples for
arterial blood gas values and other blood tests.
Note any bleeding around the intra-arterial catheter or any loose connections and
correct the situation immediately.
Carefully monitor color, pulse, and temperature distal to the insertion site for any
early signs of circulatory compromise.
Complications of systemic intra-arterial monitoring include pain, infection,
arteriospasm, or obstruction at the site with the potential for distal infarction, air
embolism, and hemorrhage.
Cardiomyopathy
o Dilated Cardiomyopathy (DCM)
Most common
Ventricular wall thickness normal, but both ventricles dilated (normally left worse
than right)
Systolic function impaired.
Causes: alcohol, chemotherapy, infection, inflammation, and poor nutrition
DCM causes symptoms of left ventricular failure
Signs/Symptoms: Fatigue and weakness, heart failure (left side), dysrhythmias or
heart block, systemic or pulmonary emboli, S3 and S4 gallops, moderate to severe
cardiomegaly
Treatment: heart transplant, symptomatic treatment of heart failure, vasodilators,
control of dysrhythmias
o Hypertrophic Cardiomyopathy (HCM)
Asymmetric ventricular hypertrophy and disarray of the myocardial fibers.
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