MEDICAL-SURGICAL NURSING Respiration – primary stimulant is ↑ CO2 in the blood

JOHN RICAFORT, RN
Common manifestations of patient with respiratory
OXYGENATION problems:
1. RESPIRATORY SYSTEM 1. cough – cardinal sign
2. CARDIOVASCULAR SYSTEM 2. dyspnea – 3 types: (semi-fowler’s – 20 to 35
3. BLOOD / HEMATOPOIESIS (serves as degrees)
medium for transport – oxygen and nutrients) a. exertional dyspnea – thru physical
exertion
RESPIRATORY SYSTEM b. orthopnea dyspnea – related to
• Gas exchange positioning
• Blood pH regulation • supine – fluid in the blood
• Sense of smell will cause congestion
• best position – semi-fowler’s
Upper respiratory tract  sneezing reflex (nose to c. paroxysmal nocturnal dyspnea – at
epiglottis)
night
• Fibrissae (nostril hair); cilia (hair-like structure) 3. chest pain – causes:
• Snot (“kugang”) a. respiratory problem
b. cardiac problem
Lower respiratory tract (below glottis) c. musculoskeletal problem
• Coughing reflex • evaluate type of chest pain
Pertussis – characterized by 5-10 consecutive
• First nursing action for chest pain  start
coughs with a stridor or whoop at the end. giving supplemental oxygen
• ♥common problem associated  HERNIA 4. Hemoptysis
• tearing of tissue that will lead to hernia pH content Appearance
• put abdominal support Hemoptysis base w/o food
frothy
Noisy breathing – common presentation of airway hematemesis With
obstruction (partial airway obstruction) food Non-frothy

Loss of voice – complete airway obstruction • Contra-indicated – chest physiotherapy

(CPT)
Goblet cells – mucous production 5. Clubbing of fingers
///////////////// - cilia
• ♥present only during CHRONIC hypoxia
ooooooooo – goblet cells
• Schamroth method analysis – face nails
CARINA – serves as an anatomical landmark for the together and there should be a diamond
placement of the tip of endoctracheal tube (for equal formed in between (normal)
distribution of air as manifested by symmetrical lung • ♥ normal degree – 160 degrees
expansion) o >160 deg. – early clubbing
• ♥ chest Xray – to check placement o >180 deg. – advanced clubbing
• position two hands at the back (lowest rib) with o 0 to 3 months – closed fists
the thumbs toward the spinal and fingers o 3 to 6 months – holds a bottle
spread to lateral side of the ribs; tghen ask o 6 to 9 months – pincer grasp
patient to inhale deeply. o 9 to 12 months – picks objects
• Right bronchus – larger 6. fever
2 major cells in alveoli: 7. crackles
• Type 1 – needed to combat infections 8. activity intolerance
• Type 2 – producing surfactant (↑ tension in 9. seizures
alveoli) 10. skin flushing - ♥ due to ↑ CO2 retention
• ♥ atelectasis – collapsed alveoli (SIDS) (hypercapnea)  causes vasodilation
11. altered level of consciousness
HERING BREWER REFLEX – responsible for inflation
and deflation process of alveoli 3 Categories for respiratory problem:
Disturbances or disorders
Right lung  3 lobes a. Restrictive lung disease – atelectasis,
Left lung  2 lobes pneumonia, PTB or chest trauma
b. COPD (Chronic obstructive pulmonary
Beta 1 receptor – heart disease) or CAL (chronic airflow limitation) –
Beta 2 receptor – lungs emphysema and bronchitis, asthma
c. Pulmonary vascular disease – Cor pulmonale,
2 layers of lung: pulmonary embolism
1. visceral (inner)
2. parietal (outer) RESTRICTIVE LUNG DISEASE
• must not exceed to 100 ml or cc  will • Any process that limits to lung expansion
cause hydrothorax or pleural effusion (INSPIRATION – problem)

Diaphragm – major muscle for respiration COPD / CAL

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 • Opposite of restrictive lung disease o Put patient in a mechanical ventilation
(EXPIRATION – problem)  to correct atelectasis, hypoxia and
• ♥ what is the appropriate fluid?  1 to 2 liters acidosis
per minute o ♥ continuously monitor
• can cause respiratory depression if > 2 cardiopulmonary and neurostatus
l/min. (because of hypoxia)

MEDULLA OBLONGATA – respiratory center

VENTURI MASK – most appropriate O2 device for 2. PNEUMONIA
COPD / CAL • refers to inflammation, infection of lung tissue
• most accurate O2 concentration • IP – 2 to 3 days
• next option  NASAL CANNULA • 2 types: (causative agents)
• ♥ most common complication  Cor o bacterial pneumonia
pulmonale (enlargement of Right ventricle)  streptococcus
 diplococcus
PULMONARY VASCULAR DISORDER o viral pneumonia
• disturbances in the vascular compartment of  H. influenzae
the pulmonary area • Pathognomonic signs:
o Strep./diplo. Pneu. – RUSTY
RESTRICTIVE LUNG DISORDERS – 3 conditions: PURULENT SPUTUM
1. ↓ lung capacity o Staphylococcal pneu. – YELLOW
2. ↓ elasticity or recoil BLOODY streak sputum
3. ↑ work of breathing o Microplasmal pneu.- NON-
PRODUCTIVE COUGH progressing to
1. ATELECTASIS mucoid
• collapsed of previously inflated lung tissue o Klebsiella pneu. – RED GELATINOUS
• 2 types: sputum
• Types of pneumonia:
1. Primary atelectasis  common to
newborn (premature) – common o LOBAR P. – site: either left or right
problem is surfactant lung
2. secondary atelectasis  due to o LOBULAR P. – entire lung; also called
compression and obstruction bronchopneumonia
• Classification of pneumonia – 4:
COMPRESSION OBSTRUCTION o Community acqd. Pneumonia (CAP)
Pneumothorax o Hospital acqd. Pneumonia (HAP) also
Hemothorax aspiration called nosocomial pneumonia
Pneumohemothorax o Aspiration pneumonia
hydrothorax o Pneumonia for immuno-compromise

• N. dx: Impaired Gas Exchange CAP – most common

• Manifestations: • Strepto / diplococcal
o Dyspnea • Rainy days
o Chest pain
o SOB HAP – staphylococcal
o Hypoxia • Acquired after 48 hours after admission or
discharge
o Asymmetrical lung expansion
o ↓ breath sound on affected lung Aspiration pneumonia – due to reflex of gastric
o signs of shock content into respiratory area
• Dx test: • Children and old people
o Chest Xray – confirmatory test • Neuro – problem, stroke, neuromuscular
o ABG – ↓ pH, ↑ PCO2, ↑ partial COs problem (myasthenia gravis)
and a ↓ O2 • Elevate HOB (20-35 deg.)
 Respiratory acidosis and
hypoxia Pneumonia for immuno-compromised
o Pulse oximetry - ↓ O2 saturation (N: • Patient with HIV, DM
95-100%) • Pneumocystic Carinii pneumonia (PCP) –
o ♥93% - O2 supplement (first nursing fungal or protozoal infection (cause)
action) • P.S. – Non-productive cough
• Management: • Drug of choice (DOC) – BACTRIM
o O2 supplement / therapy
(Trimethoprim-sulfamethorazole)  anti-
o Semi-fowler’s (to promote lung protozoal effect
expansion)
o Treat underlying cause (ex. Dx Test:
Hemathorax – chest tube insertion) • Chest Xray – confirmatory test (common
result: consolidation of lung tissue)
• Sputum exam

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 • Throat culture • tuberculin skin testing – if immuno-
compromised - > 4 months
Manifestations / SS of pneumonia:
1. productive cough Multi-drug therapy – prevention of emergence of drug
2. chest pain resistance
3. hemoptysis
4. dyspnea 4. Chest trauma
5. crackles 1. accident (common cause)
6. fever (infection) o nonpenetrating / blunt – flail chest
7. anorexia (chest is still intact)
8. ↑ fremitus  vibration – movement of o penetrating – break in the chest wall
air (ask patient to say 99 and feel for integrity (stab wound, gunshot)
the vibration – start up downwards –  hemothorax, pneumothorax,
diminishing fremitus) hemopneumothorax and
9. egophony – distortion of “e” sound to tension pneumothorax (cause
“a” sound (ask patient to say e, and mediastinal shift)
you will hear a sound during Flail chest  multiple rib fracture or rib fracture
auscultation) adjacent to each other
10. whispered pectoriloque – sound can Hemothorax  lower lobe
be heard clearly because sound Pneumothorax  upper lobe
travels faster in solid – (+) pneumonia tension pneumothorax  injury that resulted to
- an audible whispered 1-2-3 a one-way valve increasing tension in the
(instruct patient to whisper lungs.
123)
- normal: not clear Chest tube  purpose: to DRAIN (valsalva maneuver
not allowed)
Management: 2. for insertion or removal of chest tube (instruct
1. O2 supplement (dyspnea) patient to do valsalva maneuver)
2. semi-fowler’s position 3. DRAIN air (pneumothorax) – site: 2nd or 3rd
3. ↑ oral fluid intake (OFI) ICS
4. give nutritious food 4. Insertion – 7th or 8th ICS
5. adequate rest 5. After insertion: NR
6. give antibiotic – DOC: penicillin or erythromycin o Check site
7. turn patient to sides q 2 hours – prevent pulling of
o Check V/S
secretions on the lower lobe, which can cause dyspnea
(prevent hypostatic pneumonia) o Position: semi-fowler’s position
• ♥ position to promote ventilation: (promotes lung expansion)
o RIGHT LUNG pneumonia – unaffected  Unaffected side (to drain)
side (left)  ↓ pressure – affected side
o Ventilation – good lung down 6. check for tidalling or oscillation – refers to
fluctuation of fluid
3. TUBERCULOSIS o needle is out – it there is no tidalling
• Highly infectious respiratory infection caused o inspiration – fluid falls or goes down
by tubercle bacilli o expiration – fluid rises
• 3 common (most common – microbacterium 7. ♥nursing alerts
tuberculosis) o keep bottle below the heart
• 75 Filipinos die everyday (PTB) o clamp the tube as close to the
• 1993 – Global emergency (WHO declared PTB patient’s body
outbreak) o don’t clamp the tube for long period of
• manifestations: time – can cause tension
o fatigue, malaise, anorexia, weight loss pneumothorax
(early signs) o don’t milk the tube – will create suction
o chronic cough (productive) - > 2 weeks site and can cause trauma to the
o night sweats tissue
o hemoptysis (advanced state) o chest drainage – clamp or forceps
o low grade fever (afternoon) should be at the bedside (to clamp
tube incase bottle will break)
Best sputum specimen – contains bronchial o extra bottle with water should also be
secretions and mucous (not saliva) at the bedside  20 cms. High
o submerge tube to the water, which will
Best time for PPD  after 72 hours (exposure) act as seal
• induration of <4 mm – negative o interpretation:
• 5-9 mm – doubtful result (give INH for 6 to 12  intermittent bubbling –
months) indicates that the lungs have
o <35 y/o – INH – 6 to 12 mos re-expanded continuous
o >35 y/o – INH – 6 to 9 mos. (risk of bubbling – indicates leakage
drug induced hepatitis)
• 10 mm – (+) for exposure COPD / CAL  problem: EXPIRATION
1. EMPHYSEMA (irreversible) – PINK PUFFER
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 • Most appropriate device: VENTURI 1. Pon lobular emphysema – upper lobe (most
MASK common)
• 1 to 2 liters / min. 2. centro lobular emphysema – central lobe
• O2 saturation – 95 to 100% 3. paraseptal distal acinar emphysema – distal
• Loss of lung elasticity (alveoli wall) lower lobe
• Common cause: smoking (n. mgt.:
cessation of smoking) Management:
• Exposure to chemicals – asbestos 1. cessation of smoking
• Deficiency of anti-trypsin (protein that 2. O2 supplement – 1 to 2 liters/min.
will neutralize trypsin) 3. position: semi-fowler’s
4. antibiotics – affect coughing reflex, which
Pathologic changes in emphysema: makes a patient at risk to infection
1. Loss of lung elasticity 5. diuretics
2. Formation of bulla / bullae
(air sac) – because alveoli wall due to loss of Lobectomy – removal of a lobe
elasticity will not deflate properly causing air • position: (post) affected side
sac Pneumonectomy – removal of a lung (entire)
3. Hyperinflation of lung tissue • position: (post) semi-fowler’s
- 2˚ to loss of elasticity (affects inflation / BRONCHITIS (reversible) – BLUE BLOATERS
deflation) • inflammation of the bronchus
• Common result in Xray – “barrel chest” • termed as smoker’s coughs
(↑ anterior-posterior diameter than • N. Dx: Ineffective Airway Clearance
transverse diameter • Color: dusky to cyanotic
• There is air trapped inside – • Recurrent cough and ↑ sputum production
Hyperresonance during percussion • Hypoxia
4. small air trappings and collapse • Hypercapnea
• Hypercapnea - ↑ CO2 • Acidosis
• Edematous
PINK PUFFER – associated with smoking
• ↑ CO2 retention (pink) – loss of lung Management:
elasticity 1. avoidance of irritating substances
• no cyanosis 2. cessation of smoking
• dyspnea 3. ↓ physical stimuli ( to ↓ O2 demand)
• ineffective cough 4. Drugs:
• hyperresonance on chest percussion a. Anti-inflammatory (corticosteroids)
• orthopneic i. Don’t take corticos-teroids for
• barrel chest long period of time – cause
• exertional dyspnea immune suppression, Cushing
loss of lung elasticity  impaired gas exchange  ↑ syndrome
CO2 retention  vasodilation  blood will congest  ii. Watch for S/S of immune
resulting to pinkish discoloration suppression
iii. Don’t stop corticosteroids
Dx Test: CXR – reveals barrel chest abruptly
• history of smoking b. Bronchodilator – salbutamol,
theophylline, aminoptylline (N:
ABG – respiratory acidosis and hypoxia (↓ pH, ↑ theophylline level – 10 to 20)
PCO2, ↑ partial COs and a ↓ O2) i. Signs of theophylline toxicity
Pulmonary function test – INCENTIVE 1. tremors
SPIROMETER (measures total lung capacity) 2. palpitations
o done to enhance deep inspiration 3. nausea
4. headache
Incentive Spirometer: 5. dizziness
Tidal volume N: 500 ml c. antibiotics – prevent secondary
Residual vol. N: 1200 ml infection
Inspiratory reserve volume N: 3,000-3,300 ml
ASTHMA
Expiratory Reserve volume N: 1000-1200 ml
Tidal volume – amount of air that enters and leaves the • is a hypersensitivity reaction characterized by
lungs abnormal breath sounds secondary to
Residual volume – amount of air present inside the histamine release
lungs after a Normal expiration • effects of histamine:
Inspiratory Reserve volume – amount of air that can be o cause vasodilation
forcibly inspired after a normal inspiration (↓ o cause bronchoconstriction
IRV – emphysema) o ↑ mucous production
Expiratory Reserve volume – amount of air that can be o bronchospasm
expired (emphysema - ↓ ER) • N. Dx: Ineffective Airway Clearance
• Wheezes – expiration (expiratory wheezes –
3 types of emphysema: P.S.)
• Hypersensitivity

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 • ↑ occurrence in males 2. dyspnea
• onset before 12 y/o 3. SOB
• retractions 4. tachycardia
• hypoxemia 5. signs of shock
o tachycardia
o ↑ restlessness Dx Test:
1. CXR
o tachypnea
2. ECG
• familial cough 3. ABG
• cough 4. Pulmonary angiography – confirmatory test
• ↑ mucus (invasive)
• SOB • N. priority – check peripheral pulses
• Expiratory wheezed (P.S.) (popliteal, dorsalis pedis, posterior
• ↑ CO2 retention pedialis)
• prolonged expiration • Damage of femoral line – diminish
peripheral pulses
2 major types of ASTHMA:
Management:
1. INTRINSIC ASTHMA – non-allergic (ex. 1. O2 supplement
Stress, infection, sudden change in weather) 2. Semi-fowler’s (20 to 35 degrees)
2. EXTRINSIC ASTHMA – allergic asthma attack 3. mechanical ventilation
a. IgE – mediated 4. ↓ physical stimuli
5. drugs:
b. Common cause: DUST a. analgesic – Morphine Sulfate
b. anti-coagulant – aspirin, heparin (PTT,
Management:
antidote: protamine sulfate),
1. O2 supplement
coumadin/warfarin (PT, antidote: Vit.
2. position: semi-fowler’s
K)
3. stay with patient
c. thrombolytics – dissolves clot
4. ↓ physical stimuli – to decrease oxygen
(streptokinase, TPA)
demand
5. Drugs: 6. Surgery – removal of clot (embolectomy)
a. Bronchodilators
b. Corticosteroids N. Dx for pulmonary embolism
c. Antii-histamine (♥ S/E – drowsiness  • Alteration in
discourage driving and avoid operating • Impaired Tissue Perfusion
machineries)
6. Avoidance of allergens
BLEEDING TENDENCIES
PULMONARY VASCULAR DISORDER 1. DISSEMINATED INTRAVASCULAR
1. Cor Pulmonale – refers to enlargement of Right COAGULATION
ventricle (R ventricle hypertrophy) • Common cause: SEPTICEMIA, ABRUPTIO
PLACENTA
• Common cause: COPD
• Management – blood transfusion (platelet
• COPD  narrowing of pulmonary vessels  ↑ concentrate)
resistance of blood flow to the lungs  ↑ 2. HEMOPHILIA
functional demand of heart (R ventricle) to • A bleeding disorder due to chromosomal
pump blood  compensation (hypertrophy) problem (male)
• Carrier – women
Manifestation of Cor Pulmonale  Right sided heart • Asymptomatic
failure • Earliest manifestation – bleeding of the umbilicus
or during circumcision
Management – treat respiratory problem
• Ratio and proportion
PULMONARY EMBOLISM
P.S. of hemophilia – HEMARTHROSIS (bleeding in the
• Refers to occlusion in one or more pulmonary joints)
veins
• Earliest manifestation – reluctance to move a
• Blood clot (♥ don’t forget – patients with oral body part
contraceptives - ↑ risk of clotting formation)
• (pediatric) – pad the joints and extremities
• Origin: LOWER extremities because there is bleeding
• Cholesterol • with active hemarthrosis – CBR
• Amniotic fluid • 2 types of hemophilia:
• Air (fatal: 10 cc) o A – CLOTTING FACTOR VIII (anti-
• Best position: (air embolism) head lower than the hemolytic factor)
body and on left side-lying (air normally goes up) o B – clotting factor IX (Christmas factor)
 left side lying so air bubbles won’t go on right – also called Christmas Disease
side • Dx Test – Partial Thromboplastin Time (PTT)
• Cryoprecipitate  administer plasma (to supply
Manifestations:
the needed clotting factors)
1. acute chest pain

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 • Yellow discoloration of skin (pooling of plasma  T wave – ventricular repolarization
due to too much plasma)
DEPOLARIZATION – stimulated stage / phase
3. THROMBOCYTOPENIA REPOLARIZATION – resting stage / phase
• An ↑ in platelet (N: 150000-450000 mm3)
• Due to exposure to agents or drugs BASIC ECG INTERPRETATION
a. Alcohol Normal rate 60 – 100 bpm
b. Chemotherapy drugs – cause bone N P-R 0.12 – 0.20 seconds
marrow suppression N QRS 0.08 – 0.12 seconds
c. Radiation exposure
d. Viral exposure – ex. Dengue, ebola One small box = 1 mm
virus (ebola Zaire – causative agent) One big box = 5 mm
e. Thrombolytics – anti-coagulants
f. Chloramphenicol Normal sinus rhythm:
g. Corticosteroids – bone marrow  300, 150, 100, 75, 60, 50
suppression  look for R wave that falls in the dark line
h. Phenobarbital  R wave >100 –tachycardia
i. Penicillin  R wave < 100 – bradycardia
• Platelet count that can lead to bleeding  <
50,000 mm3 1. Standard ECG – composed of 12 leads
• Management – blood transfusion (platelet 2. Holter Test – also called ambulatory ECG
concentrate) 3. Stress Test
• Nursing alerts (for bleeding disorders)
12 leads – divided into 2 divisions, which shows
a. No invasive procedure
different angles of the heart:
b. Avoid astering, no anti-coagulant, no
1. chest
thrombolytics
a. V1 and V2 – Right side of heart
c. Avoid extreme temperatures
b. V3 and V4 – Septum
d. Observe safe administration /
c. V5 and V6 – left side
transfusion of blood
2. limb
e. No drugs that are psychophlegics
a. I
(drugs that can cause paralysis in the
ocular muscles) – can cause bleeding b. II – most important lead and most stable
of the eyes (where dysrhythmia is checked)
f. Pad extremities and joints of patients c. III
d. AVR
CARDIAC DISTURBANCES e. AVL
CARDIO-VASCULAR – a system that circulates blood f. AVE
around the body
Heart ♥Nursing alerts:
• 3 layers: 1. Can’t cause electrocution
 Pericardium (outermost) 2. No metals in the body
3. Breath normally and lie still
 Myocardium (thickest layer)
 Endocardium (innermost) 4. Holter test  report electrical activity of the heart
for 24 hours
 4 chambers – Right and left atrial and
ventricles a. ♥ Don’t forget to instruct patient to jot down
 valve – to prevent regurgitation or reflux the activities during reporting period
• AV valve b. ♥advise to do usual ADLS – No variations
c. ♥ Don’t moist / wet the apparatus
 Right tricuspid
d. ♥Don’t operate machineries / appliances –
 Left mitral will affect the result of the test
• SEMILUNAR valve
 Pulmonary SL valve STRESS TEST – evaluate cardiac function once the
 Aortic SL valve patient is subjected to physical exertion
• LUBB DUBB – sounds due to  ♥diet – light diet meal (crackers and soup)
valvular closure (Lubb – S1,  attire – proper footwear (rubber shoes)
closure of AV valve; Dubb – S2,  Don’t leave the patient alone
closure of SL valve)  Check the V/S before, during and after the test
 Stop the test when the patient complaints cardio-
Pacemaker – SA node (conductive system)
pulmonary manifestations (ex. Dyspnea)
– recorded in ECG
DISTURBANCES:
SA node – AV node – Bundle of His – Right and Left
1. INFECTION – RHEUMATIC HEART DISEASE
Branches – Purkinje Fiber
 RHD
ECG i. Complication or se sequelae of frequent
and untreated GABS infection (sore throat)
 electrical activities will be presented by waves
ii. Common: 5 to 15 y/o
 P wave – atrial depolarization iii. Auto-immune problem
 QRS wave – atrial repolarization & ventricular iv. Target: connective tissue (muscles, joints, bones
depolarization and blood)

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v. Manifestations (Major symptoms – JONES 5. distended jugular veins
criteria) 6. anorexia and complaints of GI distress
1. carditis – inflammation of 3 layers of the heart 7. swelling in hands and fingers
2. valvular defect – mitral valve 8. dependent edema
3. chorea – St. Vitus dance
a. refers to LSHF – S/S;
abnormal jerking 1. paroxysmal nocturnal dyspnea
movement 2. elevated pulmonary capillary wedge pressure
b. upper extremities, (PCWP)
face – usually at night 3. cough
c. loud music – 4. crackles
aggravates 5. wheezes
d. self-limiting (3 6. blood-tinged sputum
mos.) 7. restlessness
4. Rashes on abdominal area going to peripheral 8. confusion
parts – erythema marginatum 9. orthopnea
5. subcutaneous nodules (self-limiting – requires 10. tachycardia
no treatment) 11. exertional dyspnea
6. Polyarthritis – inflammation of 2 or more joints 12. cyanosis
a. Put some bed
cradle Management:
 ↑ force of contraction without increasing HR
vi. Minor symptoms:
1. fever U – Upright position (prevent pulmonary congestion –
2. chest pain Cause dyspnea)
3. frequent sore throat N – Nitrates will be given – vasodilator of BVs
4. ↑ ASO titer (anti-streptolysin-O) L – Lasix – loop diuretics (remove congested fluids)
a. if >333 – indicates O – O2 (congestion – altered tissue perfusion)
GABS infection A – Aminophylline (bronchodilator– prevents dyspnea)
D – Digoxin (DOC) - ↑ force of contractions without
Diagnosing RHD criteria: Increasing HR
 1 major symptom (+) 2 minor symptoms F – Fluid restriction (1,000 – 1,300 ml/day)
 2 major symptoms (+) 1 minor symptom A – Afterload decrease (↓ O2 consumption) Beta-
Blocker, Ace inhibitors
Dx test – no specific test: S – Sodium restriction
 throat culture T – Test for ABG and K(+)
 serum / blood analysis - ↑ ASO titer
 ↑ ESR ↑ urine  fluid loss  K (+) excretion  Hypokalemia
 2 dimensional echocardiography  hydrogen (H+) elimination  ↑pH  alkalosis
o mitral valve
↑K(+) = H+ retention  acidosis (Hyperkalemia - ↓pH)
Management: ↓K(+) = H+ elimination  alkalosis (Hypokalemia-↑pH)
1. give aspirin
2. corticosteroids DIGOXIN – effective: ↑ urine output (↑GFR)
3. drug of choice (DOC)  penicillin drug  ♥check for HR and B/P
4. treatment for active RHD (3 to 6 years)   don’t give if HR <50bpm or <90/60(B/P)
compliance of patients to meds – problem  ♥check for digoxin level
 N: 0.5 – 2.0 g/dl
♥RHD i. 2.0 – digitalis toxicity – S/S
1. Take antibiotic prior to dental work-up or surgery – 1. bradycardia
prophylaxis 2. hypotension
2. Stress importance of good oral hygiene 3. dizziness
3. Compliance to treatment regimen 4. nausea and vomiting
4. Regular physical exam (annual 2D echo) 5. visual disturbances (yellow to yellow-green
5. provide comfort – put some bed cradle halos around the light
ii. antidote: DIGIBIND – or Digoxin Immune Fab
2. CONGESTIVE HEART FAILURE (CHF)
 Inability of the heart to pump properly 3. CORONARY ARTERY DISEASE (CAD)
 Types of CHF:  Affects normal perfusion of blood from heart
i. RSHF – systemic i. Atherosclerosis
ii. LSHF – pulmonary ii. Arteriosclerosis
iii. Angina pectoris
RSHF – blood will accumulate in systemic iv. MI
LSHF – pulmonary manifestations  Improve perfusion

S/S of RSHF: 1) Atherosclerosis (fatty deposition) – form of

1. fatigue arteriosclerosis
2. ↑ peripheral venous pressure  ↑ cholesterol level
3. ascites
4. enlarged liver and spleen

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 an abnormal accumulation of lipid, or fatty  Drugs – decongestants (can cause constriction
substances and fibrous tissues in the vessel wall of the blood vessels
o cholesterol: o Types of AP:
 HDL – good cholesterol  Stable angina
 LCL – bad cholesterol (Hard to metabolize –  Unstable angina
most abundant)  Variant angina
 Triglycerides  Intractable or refractory angina
 Silent angina
LDL (low density level) – deposited in the tunica intima  Ludwig’s angina
(inner lining of the BV)
 WBC and macrophages will modify LDL, so HDL Stable angina – when under stress (tired) –
can remove it (might cause injury – fibrous formation) arteriosclerosis (common cause)
o Thick capsule – can impede circulation of the Unstable angina – may lead to MI (also called
blood preinfarction angina) – even at rest (atheroscle-
o Thin capsule – can result to rupture (aneurysm) rosis – cause)
or emboli to be released to the blood stream (injured Variant angina – or nocturnal angina (at night only) or
tunica intima) – releases fibrous tissue Prinzmetal angina (vasospasm – cause)
Intractable or Refractory angina – will not respond to
2) Arteriosclerosis – hardening of the blood vessel Drug (severe pain); vasocompression – cause
wall (secondary to aging process) Silent angina – asymptomatic (ECG – inverted T wave
But no pain)
Risk factors for CAD: Ludwig’s angina – drug-induced AP
1. NON-MODIFIABLE:
 Family history of CAD Manifestations of AP:
 Increasing age 1. chest pain - <15 mins. To 30 mins.
2. nitroglycerin or rest – pain will disappear
 Gender (male)
3. radiating pain – chest to left arm
 Race (African American)
4. Levine sign – grasping outer chest
2. MODIFIABLE:
Classifi- Activity Evoking Limits to
 High B/P (↑s chances of atherosclerosis)
cations Activity
 Cigarette smoking (nicotine will promote I Prolonged exertion None
accelerated atherosclerosis)
II Walking more than 2 Slight
 High blood cholesterol level blocks
 DM III Walking < 2 blocks Marked
 Lack of estrogen in women IV Minimal activity or at severe
 Physical inactivity rest
 Obesity
Management for AP:
Normal cholesterol: 1. Supplemental O2
N total serum cholesterol – 150 to 240 mg/dl 2. Position: semi-fowler’s (lung expansion promotion
N HDL – 29 to 77 mg/dl – improve perfusion)
N LDL – 60 to 160 mg/dl 3. ↓ physical stimuli (↓ O2 demand)
Triglycerides – 10 to 190 mg/dl 4. drugs:
a. aspirin – anti-coagulant (prevents formation of
Desired level of LDL: new clot)
 If one (1) risk factor or no risk factors – 160 b. nitroglycerin or nitrates – vasodilation to improve
mg/dl flow and perfusion
 2 or more risk factors - <130 mg/dl o comes in several packages:
 Dx: CAD  <100 mg/dl o tablet – must be stored in a dark, dry place and
o If not corrected – result to angina pectoris (AP) tightly cupped container
 ♥If not corrected – result to Angina Pectoris (AP)  must be taken
 AP  refers to chest pain/discomfort sublingually (burning
sensation – effective)
o Cause: Myocardial ischemia (inability of the
 light-headedness and
coronary arteries to supply blood to the heart)
nausea are expected
 Inverted T wave – ischemia
 taken 1 tablet at a
normal time at 5 mins. Interval for
3 tablets
 ♥ same with spray (3
abnormal
doses at 5 mins. Interval)
 discard nitroglycerin
o Factors that affect AP (which will lead to after 6 months - potency
(4th month – patency
myocardial ischemia)
starts to ↓)
 Atherosclerosis
 Arteriosclerosis o spray
 Vasospasm o patch
 Vasocompression  Nursing alerts:

8
 Don’t touch medicated surface – cause
hypotension
 Place the patch on a non-hairy spot (shaved
site) – shave along the hair growth to prevent skin
breakdown
 Anterior chest (site of patch) – intermittent R & L
o Parenteral – don’t give rapid infusion

MYOCARDIAL INFARCTION (MI)

o Coronary occlusion or “heart attack”
o Causes: same with AP
o Chest pain is >15 – 30 mins.
o Levine sign
o Radiating pain
o Manifestations:
o D – dyspnea
o A – anxiety
o N – N/V
o C – crushing substernal pain
o E – elevated temperature
o P – pallor
o A – arrhythmia
o D – diaphoresis
o Lactic acid can cause chest pain
o Cardiac enzymes ↑ (activation of pyrogenes - ↑s
temperature) – due to injury
o LDH
o CPK
 Rises 4 to 8 hours after attack
 Peak of CPK – ½ to 1 ½ days
 Normalizes 3 to 4 days after
o Troponin T & I – most reliable
 (-) Normal
 rises: immediately
 peak: 4 to 24 hours
 normalizes: 1-3 weeks after
o Lactic dehydrogenase
 100 to 190 in/liter
 rises: 12 to 24 hours after
 peak: 2 to 6 days after

Management of MI:
M – Morphine sulfate (narcotic analgesic)
O – O2 (improve tissue perfusion)
A – Aspirin and Ace inhibitors (anti-coagulant;
↓ afterload)
N – Nitroglycerin/nitrates (vasodilator)
S – streptokinase (thrombolytic – dissolves a
clot)
best time: within 3 hours after the attack

o pathological Q wave or very large Q wave

N. Dx (MI) – alteration in comfort and pain

Ace inhibitors – “pril” captopril

Streptokinase – substance derived (bacteria)

N. alerts:♥
o best given within 3 hours after attack
o don’t give to active streptococcal infection
patients
o don’t give to immunocompromise – cause septic
shock
o don’t give to patients with thrombocytopenia - ↓
platelet can cause bleeding