CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION

(PART 2)

Mr. Jayesh Patidar

DIAGNOSTIC TESTS

CK-MB (CREATININE KINASE, MYOCARDIAL MUSCLE)

An elevation in value indicates myocardial damage

An elevation occurs within 4 to 6 hours and peaks 18 to 24 hours following an acute ischemic attack

Normal value is 0% to 5% of total; total CK is 26 to 174 units/L

LACTATE DEHYDROGENASE (LDH) Elevations in LDH levels occur 24 hours

following myocardial infarction and peak in 48 to 72 hours

Normally, LDH1 is lower than LDH2; when the serum concentration of LDH1 is higher than LDH2, the pattern is indicated as “flipped”, signifying myocardial necrosis

140 to 280 IU/L

TROPONIN Is composed of troponin C, cardiac

troponin I, and cardiac troponin T

Has a high affinity for myocardial injury; it rises within 3 hours and persists for up to 7 days

Troponin I – lower than 0.6ng/mL Troponin T – 0 to 0.2ng/mL

COMPLETE BLOOD COUNT RBC decreases in rheumatic heart

disease and infective endocarditis and increases in conditions characterized by inadequate tissue oxygenation

The WBC increases in infectious and inflammatory diseases of the heart and after MI to dispose necrotic tissue resulting from infarction

Elevated hematocrit level can result from vascular volume depletion

Decreases in hematocrit and hemoglobin levels can indicate pneumonia

SERUM LIPIDS The lipid profile measures serum

cholesterol, triglyceride, and lipoprotein levels

Is used to assess the risk of developing coronary artery disease

Serum cholesterol – lower than 200mg/dL

LDL – lower than 130mg/dL HDL – 30 to 70 mg/dL

B-TYPE NATRIURETIC PEPTIDE (BNP) Is released in response to atrial and

ventricular stretch; it serves as a marker for congestive heart failure

Should be lower than 100pg/mL

The higher the level, the more severe the congestive heart failure

ELECTROCARDIOGRAPHY Noninvasive test that records the

electrical activity of the heart and is useful for detecting cardiac dysrhythmias, location and extent of MI, and cardiac hypertrophy and for evaluation of the effectiveness of medications

INTERVENTIONS

Determine the client’s ability to lie still; advise the client to lie still, breathe normally, and refrain from talking during the test

Reassure the client that an electrical shock will not occur

Document any cardiac medications the client is taking

ECHOCARDIOGRAPHY

Noninvasive procedure based on the principles of ultrasound and evaluates structural and functional changes in the heart

Heart chamber size is measured, ejection fraction is calculated, and flow gradient across the valve is determined

EXERCISE TESTING (STRESS TEST) Noninvasive test that studies the heart

during activity and detects and evaluates coronary artery disease

Treadmill testing is the most commonly used mode of stress testing

INTERVENTIONS

Obtain an informed consent if required

Provide adequate rest the night before the procedure

Instruct the client to eat a light meal 1 to 2 hours before the procedure

Instruct the client to avoid smoking, alcohol and caffeine before the procedure

Instruct client to wear nonconstrictive, comfortable clothing and supportive rubber-soled shoes for the exercise stress test

Instruct the client to notify the physician if any chest pain, dizziness, or shortness of breath occurs during the procedure

Instruct client to avoid taking a hot bath or shower for at least 1 to 2 hours after the procedure

DIGITAL SUBTRACTION ANGIOGRAPHY

This test combines x-ray techniques and a computerized subtraction technique with fluoroscopy for visualization of the cardiovascular system

A contrast media (dye) is injected

INTERVENTIONS

Assess for allergies to seafood, iodine, or radiopaque dyes. Premedicate client with antihistamines or corticosteroids to prevent a reaction

Obtain informed consent

Monitor vital signs

Assess injection site for bleeding or discomfort

MAGNETIC RESONANCE IMAGING Noninvasive diagnostic test that

produces an image of the heart or great vessels through interaction of magnetic fields, radio waves, and atomic nuclei

Provides information on chamber size and thickness, valve and ventricular function, and blood flow through the great vessels and coronary arteries

INTERVENTIONS

Evaluate client for the presence of pacemaker or other implanted items that present a contraindication to the test

Ensure client has removed all metallic objects such as watch, jewelry, clothing with metal fasteners, and metal hair fasteners

Inform client that she or he may experience claustrophobia while in scanner

SICKLE CELL ANEMIA

Constitutes a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S

Caused by inheritance of a gene for a structurally abnormal portion of the hemoglobin chain

Hemoglobin S is sensitive to changes in the oxygen content of the RBC

Insufficient oxygen causes the cells to assume a sickle cell shape and the cells become rigid and clumped together, obstructing capillary blood flow

Situations that precipitate sickling include fever and emotional or physical stress; any condition that increases the need for oxygen or alters the transport of oxygen can result in sickle cell crisis

At risk are those having parents heterozygous for hemoglobin S or being of African American descent

Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency ; these include vaso-occlusive crisis, splenic sequestration, and aplastic crisis

VASO-OCCLUSIVE CRISIS

Caused by stasis of blood with lumping of the cells in the microcirculation, ischemia, and infarction

Fever, painful swelling of the hands, feet, and joints, and abdominal pain

SPLENIC SEQUESTRATION

Caused by the pooling and clumping of blood in the spleen (hypersplenism).

Profound anemia, hypovolemia, and shock

APLASTIC CRISIS

Caused by the diminished production and increased destruction of RBC, triggered by viral infection or the depletion of folic acid

Profound anemia and pallor

INTERVENTIONS

Maintain adequate hydration and blood flow with IV administered NSS and with oral fluids

Administer oxygen and blood products as prescribed

Administer analgesics as prescribed(ATC)

Administration of meperidine (Demerol) is avoided

Assist the child to assume a comfortable position so that the child keeps the extremities extended to promote venous return

Elevate the bed of the head 30 degrees, avoid putting strain on painful joints, and do not raise the knee gatch of the bed

Encourage consumption of high-calorie, high protein diet, with folic acid supplementation

Administer antibiotics as prescribed to prevent infection

Monitor for signs of complications, including increasing anemia, decreased perfusion, and shock

Instruct the child and parents about the early signs and symptoms of crisis and the measures to prevent crisis

IRON DEFICIENCY ANEMIA

Iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in RBC

Commonly results from blood loss, increased metabolic demands, syndromes of GI malabsorption and dietary inadequacy

SIGNS AND SYMPTOMS

Pallor

Weakness and fatigue

Irritability

INTERVENTIONS

Increase the oral intake of iron

Instruct the child and parents in food choices that are high in iron

Administer iron supplements as prescribed

Give iron supplements between meals for maximum absorption

Give iron supplements with a multivitamin or fruit juice because vitamin C increases absorption

Do not give iron supplements with milk or antacids because these items decrease absorption

Teach the child and parents that a liquid iron preparation stains the teeth and should be taken through a straw

Inform parents/client on side effects (constipation, black stools, foul aftertaste)

HEMOPHILIA

Refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins

Factor VIII deficiency (hemophilia A or classic hemophilia)

Factor IX deficiency (hemophilia B or Christmas disease)

Result as an X-linked recessive disorder

Most frequently transmitted by the union of an unaffected male with a trait-carrier female; however, it can result from the union between an affected male and a normal or carrier female

SIGNS AND SYMPTOMS

Abnormal bleeding in response to trauma or surgery (usually detected after circumcision)

Epistaxis

Joint bleeding causing pain, tenderness, swelling and limited ROM

Tendency to bruise easily

Platelet test is normal; clotting factor function may be abnormal

INTERVENTIONS

Monitor for bleeding and maintain bleeding precautions

Prepare to administer replacement factors as prescribed

Monitor for joint pain; immobilize the affected extremity if joint pain occurs

Assess neurological status (child is at risk for intracranial hemorrhage)

Control joint bleeding by immobilization, elevation, and the application of ice; in addition, apply pressure (15 minutes) for superficial bleeding

Instruct parents how to control bleeding

Instruct the parents on activities to be avoided by the child, emphasizing avoidance of contact sports and the need for protective devices while learning to walk

Instruct the child to wear protective devices such as helmets and knees and elbow pads when participating in sports such as bicycling and skating

KAWASAKI DISEASE

Is known as mucocutaneous lymph node syndrome and is an acute systemic inflammatory illness

The cause is unknown but may be associated with an infection from an organism or toxin

Cardiac involvement is the most serious complication; aneurysms can develop

SIGNS AND SYMPTOMS

Fever

Conjunctival hyperemia

Red throat acute stage

Swollen hands, rash, and enlargement of the cervical lymph nodes

Crackling lips and fissures

Desquamation of the skin on the tips of the fingers and toes subacute

stage Joint pain

Cardiac manifestations

Thrombocytosis

Convalescent stage

appears normal but signs of inflammation may be present

Irritability may last up for up to 2 months after the onset of symptoms

Peeling of the hands and feet may occur

Pain in the joints may persist for several weeks

Stiffness in the morning, after naps, and in cold temperatures may occur

INTERVENTIONS

Monitor temperatures frequently (refer if 101F or higher)

Assess heart sounds, rate, and rhythm

Assess extremities for edema, redness, and desquamation

Examine eyes for conjunctivitis

Monitor mucous membranes for inflammation

Monitor strict intake and output

Administer soft foods and liquids that are neither too hot nor too cold

Weigh the child daily

Provide passive range of motion exercises to facilitate joint movement

Administer ASA as prescribed

Administer immune globulin intravenously as prescribed to reduce the duration of the fever and the incidence of coronary artery lesions and aneurysms

CORONARY ARTERY DISEASE

Narrowing or obstruction of one or more coronary arteries as a result of atherosclerosis, which is an accumulation of lipid-containing plaque in the arteries

Causes decreased perfusion of myocardial tissue and inadequate myocardial oxygen supply

Symptoms occur when the coronary artery is occluded to the point that inadequate blood supply to the muscle occurs causing ischemia

Coronary artery narrowing is significant if the lumen diameter of the left main artery is reduced at least 50%, or if any major branch is reduced at least 75%

The goal of treatment is to alter atherosclerotic progression

Cardiac catheterization provides the most definitive source for diagnosis

SIGNS AND SYMPTOMS

Chest pain

Palpitations

Dyspnea

Syncope

Cough or hemoptysis

Excess fatigue

When blood flow is reduced and ischemia occurs, ST segment depression, T wave inversion, or both is noted; ST segment returns to normal when the blood flow returns

With infarction, cell injury results in ST segment elevation, followed by T wave inversion and an abnormal Q wave

Blood lipid levels may be elevated

INTERVENTIONS

Instruct the client regarding the purpose of diagnostic medical and surgical procedures and pre procedure and post procedure expectations

Assist the client to identify risk factors that can be modified

Assist the client to set goals to promote lifestyle changes to reduce the impact of risk factors

Instruct the client regarding a low-calorie, low sodium, low cholesterol, and low fat diet with an increase in dietary fiber

Stress to the client that dietary changes are maintained for life

Provide community resources to the client regarding exercise, smoking cessation, and stress reduction as prescribed

SURGICAL PROCEDURES

PTCA to compress the plaque against the walls of the artery and dilate the vessel

Laser angioplasty to vaporize the plaque

Atherectomy to remove the plaque from artery

Coronary artery bypass grafting to improve blood flow to the myocardial tissue at risk for ischemia or infarction

ANGINA

Chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and oxygen supply

Caused by an imbalance between oxygen supply and demand

Causes include obstruction of coronary blood flow resulting from atherosclerosis, coronary artery spasm, or conditions increasing myocardial oxygen consumption

PATTERNS OF ANGINA

Stable AnginaAlso called exertional angina

Occurs with activities that involve exertion or emotional stress; relieved with rest or nitroglycerin

Usually has a stable pattern of onset, duration, severity and relieving factors

Unstable AnginaAlso called preinfarction angina

Occurs with an unpredictable degree of exertion or emotion and increases in occurrence, duration, and severity over time

Pain may not be relieved with nitroglycerin

Variant AnginaAlso called Prinzmetal’s or vasospastic

angina

Results from coronary artery spasm

May occur at rest

Attacks may be associated with ST segment elevation noted on the ECG

Intractable Angina – is a chronic, incapacitating angina unresponsive to interventions

Preinfarction AnginaAssociated with acute coronary

insufficiency

Lasts longer than 15 minutes

Symptom of worsening cardiac ischemia

Occurs after an MI, when residual ischemia may cause episodes of angina

SIGNS AND SYMPTOMS

Pain

Dyspnea

Pallor

Sweating

Palpitations and tachycardia

Dizziness and faintness

Hypertension

Digestive disturbances

INTERVENTIONS

Assess pain

Provide bed rest

Administer oxygen at 3L/min by nasal cannula as prescribed

Administer nitroglycerin as prescribed

Obtain a 12-lead ECG

Provide a continuous cardiac monitoring

Assist the client in identifying angina-precipitating events

Instruct client to stop activity and rest if chest pain occurs and to take nitroglycerin as prescribed

Instruct client to seek medical attention if pain persists

Assist client to identify risk factors that can be modified

Provide dietary instructions

Provide community resources to the client regarding exercise, smoking cessation, and stress reduction

MYOCARDIAL INFARCTION

Occurs when myocardial tissue is abruptly and severely deprived of oxygen

Ischemia can lead to necrosis of myocardial tissue if blood flow is not restored

Infarction does not occur instantly but evolves over several hours

Obvious physical changes do not occur in the heart until 6 hours after the infarction, when the infarcted areas appears blue and swollen

Not all clients experience the classic symptoms of an MI

Women may experience atypical discomfort , shortness of breath, or fatigue

An older client may experience shortness of breath, pulmonary edema, dizziness, altered mental status, or a dysrhythmia

SIGNS AND SYMPTOMS

Pain

Nausea and vomiting

Diaphoresis

Dyspnea

Dysrhythmias

Feelings of fear and anxiety

Pallor

Cyanosis

Coolness of extremities

INTERVENTIONS

Obtain a description of the chest discomfort

Assess vital signs

Assess cardiovascular status

Place client in a semi-Fowler’s position

Administer oxygen at 2 to 4L/min by nasal cannula as prescribed

Establish an IV access route

Administer nitroglycerin as prescribed

Administer morphine sulphate as prescribed to relieve chest discomfort

Obtain a 12-lead ECG

Monitor thrombolytic therapy, which may be prescribed for the first 6 hours of the coronary event

Administer beta blockers as prescribed

Assess distal peripheral pulses and skin temperature

Monitor intake and output

Assess RR and breath sounds for signs of heart failure

Monitor BP closely

Provide reassurance to the client and family

Maintain bed rest for the first 24 to 36 hours as prescribed

Allow the client to stand to void or use a bed side commode if prescribed

Provide ROM exercises

Encourage client to verbalize feeling regarding the MI

RAYNAUD’S DISEASE

Vasospasms of the arterioles and arteries of the upper and lower extremities

Vasospasms cause constriction of the cutaneous vessels

Attacks are intermittent and occur with exposure to cold or stress

Affects primarily fingers, toes, ears, and cheeks

SIGNS AND SYMPTOMS

Blanching of the extremity, followed by cyanosis during constriction

Reddened tissue when the vasospasm is relieved

Numbness, tingling, swelling, and a cold temperature at the affected body part

INTERVENTIONS

Monitor pulses

Administer vasodilators as prescribed

Assist the client to identify and avoid precipitating factors such as cold and stress

Instruct the client to avoid smoking

Instruct the client to wear warm clothing, socks and gloves in cold weather

Advise client to avoid injuries to fingers and hands

BUERGER’S DISEASE

Thromboangiitis obliterans

An occlusive disease of the median and small arteries and veins

The distal upper and lower limbs are affected most commonly

SIGNS AND SYMPTOMS

Intermittent claudication

Ischemic pain occurring in the digits while at rest

Aching pain that is more severe at night

Cool, numb, or tingling sensation

Diminished distal pulses

Extremities that are cool and red in the dependent position

Development of ulcerations in the extremities

INTERVENTIONS

Instruct the client to stop smoking

Monitor pulses

Instruct the client to avoid injury to the upper and lower extremities

Administer vasodilators as prescribed