What does the Silverhawk Plaque Excision System do?

It's a minimally invasive procedure - a catheter that's inserted into an artery, rotates around & shaves plaque off the artery walls. It sucks the plaque up too. Done to treat blockages & restore normal blood flow to the legs. It has helped alleviate severe leg pain for thousands of patients & saved many who were scheduled for amputation.

What patient might you see the Fox Hollow/Silverhawk used for?

Patients with Peripheral arterial disease. They're devices that open up clogged peripheral arteries.

Post-Op Coronary Artery Bypass: will se pt’s come back on ventilator in ICU with this. Just to show you that’s what that is. The pt will need their ________ pressures monitored very closely.

heart

Because of the need to monitor heart pressures very closely following coronary artery bypass, the SWAN GANZ CATHETER was developed to monitor:

pressure in the chambers ( pulmonary artery pressure, central venous pressure, & wedge pressure. It is inserted in the subclavian vein and it’s threaded through the right atria, right ventricle and pulmonary artery (it’s really long). )

If the Saw Ganz Catheter detects that pressure is too low or too high then what does this mean? What will the nurse do?

If pressure is too low: the patient needs more fluids. If pressure is too high: probably fluid overload. So, decrease fluids and give diuretics.

What's a radial arterial line used for?

it is an INVASIVE BLOOD PRESSURE measurement. A cannula is inserted into the radial artery on the wrist & it is used to continuously monitor the arterial BP.

What are chest tubes used for? Are they always used for pulmonary problems?

they drain blood from the lungs. No, it's not always a pulmonary problem. Know, that lungs collapse after surgeries that were done on the heart, etc.... so, it's not necessarily pulmonary when they have a chest tube.

What is a "temporary pulse generator"? Why is it on "stand by" after surgery?

This is a temporary pacemaker you will see on pt's after they come back from surgery. It's on stand by to provide temporary support if it is needed following a cardiac surgery. It's a dual chambered, external, battery powered, pulse generator.

Why do they call HTN a silent killer?

B/c you don't know usually until you are checked for something else. Suddenly you check their BP & the systolic & diastolic are sky high.

Are there symptoms in the early stages of HTN?

No there are no symptoms in the early stages of HTN.

HTN is caused by ______________.

atherosclerosis.

What is atherosclerosis?

It's arteries with cholesterol build-up. Really they are: atheromatous plaques containing cholesterol and lipids on the innermost layer of the walls of large and medium-sized arteries

What is a bruit?

the term for the unusual sound that blood makes when it rushes past an obstruction (called turbulent flow) in an artery

What are features that lead to atherosclerosis?

HTN, bruits, Labs: cholesterol >200 HDL <35 (good cholesterol is low) LDL>100 (bad cholesterol is high) Triglycerides >200 Homocysteine >15

Where are chest tubes inserted?

into the pleural space... that's the cavity that surrounds the lungs. The lungs are not within the pleural cavity. It's the space between the visceral & parietal layers of pleura. The parietal is the outer layer that connects to the chest wall & the visceral is the inner layer that covers the lungs.

What BP is considered atherosclerosis?

consistent SBP of greater then 140 & a consistent Diastolic BP of greater then 90. Doctor says: no caffeine, no smoking, decrease/restrict salts, better diet. Then come back in week. If BP is still significantly increased over 140/90 then they will put on medications.

Factors contributing to essential hypertension are...

There is NO KNOWN cause in 90% of cases. It is often age over 60, family hx, obesity, sedentary lifestyle, alcohol intake, high lipid levels, high salt intake, african-american ethnicity, smoking, etc...

While most forms of hypertension in humans have no known underlying cause (and are thus known as "essential hypertension" or "primary hypertension"), in about 10% of the cases, there is a known cause, and thus the hypertension is secondary hypertension. What causes secondary hypertension?

There is a known cause for secondary hypertension. It is a disease causing the HTN. Some causes are: Renal vascular disease, renal diseases like renal failure or kidney disease. Could have 2ndary HTN d/t endocrine disorders like: hyperaldosteronism Pheochromocytoma (tumor of the medulla) Cushings Disease, Acromegaly, Hyper/Hypothyroidism, Coarctation of aorta: narrow & more rigid, a genetic defect Brain tumors: impact serotonin Medication Renal carcinomas.

What's the difference between arteriosclerosis bs. atherosclerosis?

Arteriosclerosis is THICKENING/HARDENING OF THE ARTERIAL WALLS. While Atherosclerosis is FATTY PLAQUE IN THE ARTERIAL WALL.

What happens with arteriosclerosis?

it's a build up of fatty substances in the wall of the artery. Arteries become narrowed & blood flow decreases in arteriosclerosis.

What happens with atherosclerosis?

Get arteries with cholesterol build-up. Atherosclerosi is atheromatous plaques containing cholesterol and lipids on the innermost layer of the walls of large and medium-sized arteries

A patient with atherosclerosis might have what kind of labs? For cholesterol, HDLs, LDLs, Triglycerides, Homocysteine...

Cholesterol is greater then 200, HDLs (the good cholesterol) is less then 35, LDLs (the bad cholesterol) is greater then 100, Triglycerides are greater then 200, homocysteine is greater then 15.

What interventions are done for a patient with atherosclerosis?

Physician will recommend them to be on a diet low in fat. Need fat to be less then 30% of their total intake. Definitely low saturated fats. Stop smoking. Need to exercise. Need to reduce their weight. Given drugs.

What drugs are recommended for atherosclerosis patients?

Questran, Lipitor, Mevacor

What are BP regulatory mechanisms?

1. Baroreceptors 2. Renin-Angiotensin 3. Regulation of fluid volume 4. Vascular auto regulation

What is the etiology of essential HTN?

1. No known cause in 90% of cases 2. age over 60 3. family hx 4. obesity 5. Sedentary Lifestyle 6. increased alcohol 7. increased lipids 8. African-American 9. Smoking

What's the etiology of secondary HTN?

1. Renal Vascular Disease 2. Aldosteronism 3. Pheochromocytoma 4. Cushings 5. Coarctation of the Aorta 6. Brain Tumors 7. Medications 8. Renal Carcinoma

How high is the incidence of HTN in Americans?

1 in 4 Americans have HTN

HTN is 2 times greater in what ethnicity?

African-Americans

How many Americans have HTN?

50 million Americans

What are the symptoms of HTN? What's best to do?

1. None at first 2. Headache 3. Dizziness 4. Visual Disturbance 5. Confusion - Best to do? check their BP!

What diagnostic studies will reveal essential HTN?

increased BUN, increased Creatinine. The chest x-ray may show Left Ventricular Hypertrophy. and an EKG can show Left Ventricular Hypertrophy (LVH).

How do we treat essential HTN?

reduce or address all controllable risk factors. Next is the treatment essential for HTN.

The treatment essential to HTN is:

1. Diuretics (Lasix) 2. ACE inhibitors (all the 'prils') 3. Beta-Blockers (end in 'olol' ex/ metoprolol (Lopressor) 4. Calcium Channel Blockers (cause vasodilation & have neg tropic effects in all 3 categories) 5. Vasodialators (ex/ Apresoline... causes peripheral vasodilation & causes reduction in SVR, causing a hypotensive effect)

If they're in a hypertensive crisis what drug will you administer that acts really fast?

Nitroprusside (Nipride) drip works really fast....... or maybe a Nitroglycerine drip too

Peripheral Vascular Disease is:

get the intermittent claudication with reduced blood flow. They are pale.

Peripheral Arterial Disease (aka Peripheral Vascular Disease) is:

atherosclerosis of the extremities (virtually always lower) causing ischemia

What symptoms occur in mild to severe Peripheral Vascular Disease?

Mild PAD may be asymptomatic or cause intermittent claudication; severe PAD may cause rest pain with skin atrophy, hair loss, cyanosis, ischemic ulcers, and gangrene

If you have problems with your venous circulation then:

There is usually a clot, The Venous Return distal to the blockage will be impaired, Will be swelled & blue, Could have cellulites, Could have ulcers b/c of venous stasis

What does LEAD stand for?

lower extremity arterial disease. (it's peripheral arterial disease)

If there is inflow obstruction (Venous circulation), the common areas are:

distal end of the aorta, common internal and external iliac

if there is outflow obstructions (arterial circulation), the common areas are:

femoral, popliteal, and tibial (below the superficial femoral artery)

What is the main cause of Peripheral Arterial Disease?

Atherosclerosis

Who is most like to get Peripheral Vascular Disease?

There are 8 million in the US with PAD, 10% of them are over 70. Men over 45 & Post-Menopausal Women are at risk.

What are the symptoms of PAD?

Pain d/t intermittent claudication, decreased or absent pedal pulses, decreased pain at rest or with feet in dependent position, foot ulcers, gangrene (great toe) painful.

What are symptoms specific to when there is an outflow obstruction (arterial)?

pain in legs, feet, calves

What are symptoms specific to when there is an inflow obstruction (venous)?

back pain, buttocks

Cyanosis of the first toe and dependent rubor of the foot (pronounced redness of the feet when they're held down) is characteristic of ____________ insufficiency.

arterial

If a patient is having arterial insufficiency, should the HC worker recommend walk or rest?

Encourage Walking. Regular walking of about 1 hour a day usually results in a significant increase in walking distace over time. This increase in walking distanche has been noted to range from 80% to more then 200%. Improvement comes from improved flow in the collateral pathways b/c of the walking..

A major factor contributing to progressive atherosclerotic disease is _________ __________.

Cigarette smoking. The HC workers will recommend to discontinue smoking. One study noted an 85% chance of improvement if smoking is stopped versus only a 20% chance of improvement if the patient continues smoking.

What are other risk factors that need to be controlled to help arterial insufficiency?

obesity, HTN, hyperlipidemia and diabetes

It is very important that patients with arterial insufficiency ensure good ______ ______. why?

foot care. b/c an ischemic foot is at risk for developing limb threatening ulceration from even minor trauma, good foot hygiene and appropriately fitting shoes are important. This is even more vital in patents with diabetes, who are at risk for neuropathic foot ulcers.

A pt. comes to see you with an Arterial Ulcer with necrotic tendon exposed. What kind of diagnostic tests will be run?

arteriogram (an x-ray of the blood vessels called arteries) & exercise tolerance testing.

Management for an Arterial Ulcer is both non-surgical and possible surgical. What non-surgical ways can this be improved?

Exercise (collateral circulation), positioning, keeping the extremities warm, no smoking, drugs (Trental, ASA, Plavix)

How do the drugs ASA, Plavix, Trental help with arterial circulation?

PLAVIX is proven to help keep platelets from sticking together and forming blood clots. This helps blood flow more easily, helping to reduce the risk of a future heart attack or stroke. Trental works to improve flow by decreasing bloods viscosity. ASA is acetylsalicylic acid or Aspirin!

Managing Arterial Ulcers surgically uses a number of different procedures. Some of them are:

PTA (percutaneous transluminal angioplasty) to treat peripheral ischemia. Laser-assisted angioplasty, Atherectomy, Aorta-femoral bypass graft, Ileo-femoral-popliteal bypass graft.

What is laser-assisted angioplasty?

A technique utilizing a laser coupled to a catheter which is used in the dilatation of occluded blood vessels.

What is Percutaneous transluminal angioplasty?

Peripheral angioplasty refers to the use of mechanical widening in opening blood vessels other than the coronary arteries. It is often called percutaneous transluminal angioplasty or PTA for short. PTA is most commonly done to treat narrowings in the leg arteries, especially the common iliac, external iliac, superficial femoral and popliteal arteries. IT USES AN INFLATED ANGIOPLASTY BALLOON.

What is an atherectomy?

removes plaque from the arteries supplying blood to the heart muscle. It uses a laser catheter, or a rotating shaver. The catheter is inserted into the body and advanced through an artery to the area of narrowing.

What is a bypass graft? How does it treat arterial insufficiency?

A peripheral vascular bypass, also called a lower extremity bypass, is the surgical rerouting of blood flow around an obstructed artery that supplies blood to the legs and feet. This surgery is performed when the buildup of fatty deposits (plaque) in an artery has blocked the normal flow of blood that carries oxygen and nutrients to the lower extremities. Bypass surgery reroutes blood from above the obstructed portion of an artery to another vessel below the obstruction. A bypass surgery is named for the artery that will be bypassed and the arteries that will receive the rerouted blood.

During post-op care following surgery for arterial insufficiency, the risk for occlusion is highest when?

in the first 24 hours

How often should you check the patients pulse during the first hour following surgery for arterial insufficiency/bypass graft? How often after the first hour?

Every 15 minutes for the first hour. Then every hour. Also be checking color and temperature of the extremity.

What other post-op care instructions are important for the patient following bypass surgery?

Keep the leg straight. The HC worker should Mark the location of pulses & assess the patient for pain.

What are the steps taken for Graft Occlusion?

1. Immediate Surgery 2. tPA therapy (tissue plasminogen activator) 3. ReoPro

ReoPro is a drug given following graft occlusion surgery. What does it do?

inhibits platelets aggregation. ReoPro reduces the chance that a harmful clot will form by preventing certain cells in the blood from clumping together. (ReoPro is similar to aspirin) ReoPro & tPA are both clot busting agents

What are discharge instructions for a patient following Graft Occlusion surgery?

1. go over Risk Reduction when the pt's ready to go home 2. continue the activity/exercise started in the hospital 3. POSITIONING: WANT EXTREMITY IN NEUTRAL OR DEPENDENT POSITION. NEUTRAL MEANING LEG WOULD BE KEPT OUT STRAIGHT, BUT NOT HIKED UP TOWARDS THE CEILING. This you want to help arterial outflow or blood supply to the extremities. (if the pt has a problem with venous return then elevation would be recommended then) 4. When to call the MD

What is the #1 thing you want to assess for following a Bypass Graft surgery?

CIRCULATION below that area. Check their pulses - want them to have good strong pulses… Make sure you verify with previous nurse the quality of their pulses, what color their extremity is, etc… Check “dorsalis pedis (top of foot)” and “posterior tibialis” (behind the ankle bone)

How will ANGINA feel? (need to be able to differentiate from MI symptoms)

Angina has SUBSTERNAL CHEST DISCOMFORT, it RADIATES, it is PRECIPITATED BY STRESS or EXERTION, it is RELIEVED BY Nintroglycerin or rest, it lasts less then 15 minutes and there are few other symptoms. What are the 5 E's of Angina? 5 E’s of Angina: Elimination, Exertion, Elevation in temperature, Eating heavy meal & Emotion or stress.

How will a MYOCARDIAL INFARCTION PAtiENT be? (Need to be able to differentiate this from angina).

an MI describes their substernal chest having pressure like an ELEPHANT on their chest. It radiates from their arms to their jaw. it OCCURS W/O a CAUSE. it is relieved only by opioids. Lasts 30 minutes or more. The patient has nausea, diaphoresis, dyspnea. They express fear of impending doom.

What are the MODIFIABLE risk factors for a myocardial infarction?

Weight, Activity, Diabetes, HTN, Smoking, Cholesterol (Risk factors are the same for all cardiac b/c of underlying atherosclerosis)

What are the NON-MODIFIABLE risk factors for myocardial infarction?

Age, Sex, Race & family History

What kind of labs would an MI patient have?

elevated TROPONIN, CPK, LDH, SGOT for detection of Myocardial Infarcation. The reason these levels are elevated is b/c the cells are damaged & they release these enzymes. They look at troponin first b/c that shoots right up. Normal troponin is 0.4 and so if it is 8,9, etc... then there has been a significant MI event. Also, myoglobin, CK, CK-MB shoots up.

What would an EKG reveal if there has been a MI? It is the ST segment, T wave and Q wave... what happens to them?

the ST SEGMENT IS ELEVATED. There can be T wave changes (these give picture of ventricular repolarization), and there is an abnormal Q wave that is a lot deeper. <--downward spike at the beginning of QRS complex.

______ ___________ lab is where they’re taken in less then an hour for an angioplasty.

Cardiac Catheterization

The acronym MONA explains the typical management of an MI. What does it stand for? What do you give for an MI?

M=morphine (for pain) O=oxygen N=Nitroglycerin (to dilate the arteries) A=Aspirin (given to reduce platelet aggregation)

What are the additional treatment measures HC workers do for an MI patient?

get IV access (need to have route ready when meds are required), Vital Signs (have them hooked up right away), EKG, Labs, and be ready to transport them to the cardiac catheterization lab

tPA therapy (Activase) is used for an MI. IF they’re in a rural lab & will not be at a cath lab for awhile then they’re given tPA (that’s like riopro or agrastat). Nurse wants to know if there is anything that contraindicates tPA? You’d be giving them a drug that precipitates bleeding. The tPA is going to cause them to bleed & they will have a big problem then. What are the contraindications for this though?

Like a stroke or a recent GI bleed or a recent eye surgery. any ACTIVE INTERNAL BLEEDING, a RECENT CVA (stroke) within 2 months, recent SPINAL OR CEREBRAL SURGERY, a CRANIAL NEOPLASM, Prolonged CPR, or recent eye surgery.

What are the key indicators that blood flow has been reestablished to the myocardium? (the return of cardiovascular perfusion)

Chest pain abruptly subsides, there is a sudden onset of PVC's (premature ventricular contractions), The EKG returns to normal and there is a resolution of ST changes. Markers of myocardial damage peak at 12 hours.

What kind of drug therapy is given following an MI?

1. Aspirin 2. Beta Blockers 3. ACE inhibitors 4. Ca Channel Blockers

What does Aspirin do for therapy?

antiplatelet aggregation

what do beta blockers do as drug therapy?

reduce muscle damage

what do ACE inhibitors do for drug therapy following an MI?

Reduce CHF (congestive heart failure)

What does Ca Channel blockers do for drug therapy following an MI?

they ENHANCE MYOCARDIAL PERFUSION

They can pinpoint whether it is anterior, posterior based on whats happening with cardiogram. If it is anterior then:

PVC’S Third degree block BBB(bundle branch block)

They can pinpoint whether it is anterior, posterior based on whats happening with cardiogram. If it is inferior then:

Bradycardias (a slow HR) AV blocks (2° block) …. Like 1st degree, 2nd degree or complete heart block

What kind of interventional procedures are done for a patient after finding they had a MI?

PTCA (that’s the balloon angioplasty. stands for percutaneous transluminal coronary angioplasty), STENT (if they would do the balloon procedure, they may need to hold that artery open so they put a stent in there. Can be multiple stents in one artery), ATHERECTOMY (roto rooter: spin it through & suck…)

Another surgical intervention for an MI is a GRAFT of either the saphenous vein or the internal mammary artery, sometimes radial artery to bypass diseased part of coronary artery. Explain what a CABG & a MIDCAB is...

CABG (coronary artery bypass graft): one or more coronary arteries. MIDCAB (minimally invasive direct coronary artery bypass): right coronary artery ONLY. it will be a small incision.

The MIDCAB (minimally invasive direct coronary artery bypass) is less serious then a CABG. Explain about a MIDCAB...

it is practiced on a beating heart & doesn't require the heart lung machine or cardioplegia, it avoids splitting the sternum by using a small 10-12 cm incision through which the surgeon connects a graft to a diseased coronary artery. The MIDCAB's designed to bypass one or two coronary arteries.

Explain a bit about a CABG.

one or more coronary arteries are bypassed. There can be many grafts done (or just 1 or 2). Often take vein from leg or internal mammary artery. If they come back for a redo CABG then the grafted vessels have developed the same disease (atherosclerosis) b/c may be they’ve not reduced the risk factors. So, you’ll see they can use VEIN GRAFTS or ARTERIES. Bring from leg, must invert it b/c of valves otherwise couln’t get blood flow through it.

What are the post-op care concerns after a CABG (coronary artery bypass graft)?

1. Fluid & Electrolytes 2. Hypotension 3. Hemorrhage 4. Hypothermia: when on a heart lung machine they're cooled down

What Fluid & Electrolyes are of main concern?

K (potassium), MG (magnesium), Ca (calcium). Heart is very sensitive when too much or too little Potassium. When they come back from open heart surgery they want K+ at 4.0. <---remember that. If it is below 4.0 then the physician will order a round of Potassium Chloride. Mg & Ca are also imp, but K+ is the big one.

Hypotension & Hypertension are concerns after a CABG. It is a major cardiac surgery. Explain where they want the BP..

Want to keep SBP above 90, but less then 130. Do not want to stress the grafts.

We are obviously concerned with Hemorrhage following a CABG. How do we keep this under control & measure?

Chest tube drainage tells amt of hemorrhage. Mark the chest tube for baseline.

Following a CABG, we are concerned post-operatively with HYPOTHERMIA. Why? What do we do?

Because when they're on a heart lung machine they’re cooled down. Want to Rewarm their body temp to 98.6… overhead lights are warming the pt. Also have a bearhugger on them. Do it slowly over 4 hours.

Post-op CABG is concerned with the heart & patients will come back with a temporary ___________.

pacemaker, if it is needed. We should protect the wires.

Post-op CABG is concered with drainage from chest tubes (pleural & mediastinal)... what amt of drainage is normal? When should tell physician?

Less then 150 cc per hour. It should taper off. If more then 150 cc then tell the physician.

Patients following a CABG will likely be on a ventilator. When do they come off it, start weaning off it?

Usually will wean off evening of the surgery.

Post-op CABG we are concerned with Level of Consciousness. We should know the baseline prior & evaluate post-op. What are we looking for?

MAE, speaking, following commands... (No CVA/stroke)

What kind of hospital course does a CABG patient follow after surgery? What dept do they go to? how long??

CABG goes to ICU for the first 24 hours. Open heart surgery patients come into ICU looking like they got hit by train. But their wires start to come off. They’re usually transferred out of ICU within the first 24 hours if everything goes well. Typical open heart surg stay is 5-7 days (not much time to feel better).

What kind of care process is on the second day following open heart surgery?

1. Get them up in a chair for first time 2. remove mediastinal tubes 3. change chest and leg dressings 4. discontinue foley catheter 5. discontinue Swan-Ganz catheter 6. Hep. Lock IV’S going to put anti-emboli stockings, advance diet as tolerated, change to oral medications, discontinue morphine, will take Tylox for pain control, Lasix to diuresis them, start ASA once chest tubes are removed

Does it matter what order you do day 2 duties previously mentioned in?

Get pt up before you take mediastinal tubes. When you get pt upright then the rest of the fluid comes out. So, get pt up before you take the tubes out. Give them something for pain before you take those tubes out. Going to take radial arterial line out. You’ve left a large puncture area there. Might need to hold pressure on artery for 10 minutes even. Then put pressure dressing on. Take the Swan-Ganz out… there is a risk sitting up for an air embolism. Pt needs to be supine when you take the Swan Ganz catheter out. Also needs a pressure dressing on this site. You are going to disconnect the pacemaker wires before they go to step down. The wires may stay in a few days though. Foley Catheter is usually the last thing done before you transfer them. One of the reasons is Lasix for diuresis. Lasix is given early in the morning & then way later you can get an accurate catheter measurement. Then the aspirin - that started after the chest tubes were removed.. You don’t want bleeding when you take tubes out. So tubes out & then give aspirin.

On the second day post-op CABG (open heart surgery) the patient is transferred where? for what?

Transfer to step-down unit for increased ambulation

How long to do they stay in the step-down post open heart?

4-5 days

The patient will continue cardiac rehab on an _______________ basis.

out-patient

It is important to modify risk factors following a CABG/open heart surgery. Also address potential ________ once discharged at about 6 months.

depression

What other changes might occur following a CABG/open heart surgery that need to be assessed for? What might they be due to?

memory changes/memory loss might occur. This may be related to length of time on the pump/heart lung machine. Extended time on pump might mean more memory changes.

What are valvular heart diseases?

Mitral Stensis, Mitral Insufficiency, MVP, Aortic Stenosis, Aortic Insuficiency.

What valvular heart diseases often require surgery of valve replacements? Mitral __________ & Mitral ____________.

Mitral stenosis & insufficiency

What is MVP? Usually occurs in who?

Mitral Valve Prolapse, usually in tall thin people.

What are the symptoms of MVP? What will the physician put these patients on?

Tachycardia. Beta Blocker like Propanolol.

What are the nonsurgical valvular heart disease interventions?

treat symptoms of valvular heart disease with medications and rest.

If the pt is a 60 or 70 yo that can't carry out their ADLs though they will likely do a surgical intervention. What are the surgical interventions for valvular heart diseases?

1. Valve Replacements 2. Xenograft (A surgical graft of tissue from one species to an unlike species. A graft from a baboon to a human is a xenograft) or Autograft (Tissue transplanted from one part of the body to another in the same individual).

What medications are patients often on following surgery for valvular heart disease?

ANTICOAGULANTS once valves are implanted. PROPHYLACTIC ANTIBIOTICS (need to be taught to always tell their dentist for example about their valve replacement. They need to go on prophylactic antibiotics so they don't get a strep infection. Infection has an affinity for valves & so if they get infection they may have to have their valves removed.) There is also DIETARY RESTRICTIONS: RESTRICT FOODS WITH VITAMIN K. Spinach green leafy causes the blood to clot.

What is the Microbial Infection involving the endocardium that is seen in patients with valvular disease, but did not go on prophylactic antiobiotic therapy?

Infective Endocarditis. (the prosthetic valve is most commonly affected, but may occur in otherwise healthy person)

Is the heart muscle cut into in mitral valve replacement? What about CABG?

Pt’s who have valve replacement surg they have to have an incision in to the muscle itself. Coronary Artery Bypass surgery does not require the incision into the muscle. Pt’s who have valve replacement surgery are more prone to cardiac arrhythmias post-op b/c heart muscle has been traumatized.

What disease often causes Valvular heart Diseases?

Rheumatic Fever --> rheumatic heart disease over years

What are the symptoms of Infective Endocarditis?

1. Fever, night sweats,malaise,fatigue 2. Anorexia,weight loss 3. Cardiac murmur 4. Heart failure 5. Systemic embolization 6. Petechiae (small red or purple spots on body caused by minor hemorrhage) 7. Osler’s nodes hands/feet tender lesions (painful bluish lesion on fingers or toes) 8. Janeway’s leisions non-tender hard lesions on hands and feet (painless nontender lesion that is pink on hands & feet) 9. Splinter hemorrhages: on fingernails (small area of bleeding under nailbeds, looks like red lines under nails)

What is pericarditis? Where is the pericardium?

Another condition that can occur following an MI or coronary artery bypass surgery. Essentially the pericardium gets inflamed & then there is a build up of fluid in pericardial space. The Pericardium is the 2 layered membrane that surrounds the heart.

What are the 2 things that are characteristic to Pericarditis diagnosis?

1. Pain: characteristic of pericarditis & can differentiate it. The pain is usually worse when they’re supine (laying down) with pericarditis. Comfortable position: sitting up & leaning over bedside table. Anything that keeps pericardium fwd & not compressing on chest wall really. 2. and an EKG. They will have ST ELEVATION with Pericarditis.

Infective Endocarditis can be treated non-surgically & surgically. How is it treated non-surgically?

With Antibiotics for 4-6 weeks and REST!

Infective Endocarditis can be treated non-surgically & surgically. How is it treated surgically?

Surgical replacement of the valve is done, draining of the abscess and repairing of the valve.

What are the different types of pericarditis?

Acute Pericarditis can be fibrous, serous, hemorrhagic, purulent, or neoplastic

Acute Pericarditis is most commonly associated with what causes?

Malignant Neoplasms, Idiopathic causes, Infective organisms (bacteria, viruses or fungi), Post-myocardial Infarction, Post Open Heart, Renal Failure and Systemic Connective Tissue Disease.

What are the symptoms of Pericarditis?

Pain radiating to left side of neck Grating and oppressive pain aggravated by breathing, coughing, swallowing Pain worse when supine Subsides when sitting and leaning forward. Things that aggravate pain: taking breath, coughing or swallowing.

What might you hear when ausculating a patient with pericarditis?

Precordial Friction Rub

What might you see when looking at an EKG of a patient with pericarditis?

ST-T wave elevation

What are the interventions for Pericarditis? What are they on?

ANTI-INFLAMMATORY AGENTS (tey're on for about 6 months). That controls the pain & inflammation. NO ANTICOAGULANTS for pericarditis patients! (No aspirin! If you anticoagulate then you have further build-up of fluid in pericardial sac). PERICARDIOCENTESIS: a procedure where fluid is aspirated from the pericardium (the sac enveloping the heart).

An Acute Peripheral Occlusion (PAOD) is an emergency. What do I do now? If limb is cool or a different color then the other, then do not wait. Needs help asap.

tPA (tissue plasminogen activator) or STREPTOKINASE INFUSION of occluded artery. These are options for peripheral occlusion. Surgical intervention may be indicated.

Common site for PAOD/Arterial is in the ______ _____.

lower limb. all the arteries all the way down the leg... (common iliac artery, external iliac artery, internal iliac artery, deep femoral artery, superficial femoral artery, popliteal artery, tibial artery)

What does Peripheral Arterial Occlusive Disease (PAOD) result from?

1. Atherosclerotic or inflammatory processes causing lumen narrowing (stenosis) 2. Thrombus formation (usually associated with underlying atherosclerotic disease)

So, how does a person KNOW they have an OCCLUSION?? Remember the 6 P's! What are they????

Pallor, Pain, Pulselessness, Paresthesia, Paralysis, Poikilothermia (Cold)

What is an aortic aneurysm?

Permanent dilation of an artery

(AAA)/______________ ________ ____________ account for 75% of aortic aneurysms.

abdominal aortic aneurysms

What is the other 25% of aneurysms?

Thoracic Aneurysms.

Rupture of an aneurysm is life-threatening. Aneurysms that are 6 cm or less then 50% rupture in how long?

1 year

How prevalent are AAAs (abdominal aortic aneurysms)? What's the mortality rate?

They're a real danger, AAAs are the 13th leading cause of death in the U.S. A ruptured AAA results in internal bleeding so severe that only 20% of victims survive.

What causes an aneurysm then?

ATHEROSCLEROSIS

What causes an aneurysm?

Being a man over 60 years old, having an immediate relative, such as a mother or brother, who has had an AAA, having high BP, Smoking

Aortic Aneurysms usually occurs in thoracic or abdomen. Usually long-term stress on aorta, a portion weakens & balloons out. It is a PERMANENT dilation of the aorta. If it is ___ cm or greater it needs to be repaired surg. If not, usually rupture.

6

There are different Surgical Interventions for aortic aneurysms (embolectomy, thrombectomy, by-pass graft occluded portion of peripheral artery). Post-op care includes careful monitoring of what?

Circulation to Extremity (pulses, temperature, color). Need to go in & do assessment between handoff shifts… to assess the limbs & body together.

What causes an Aneurysm?

May be caused by inflammation in the aorta, which may cause its wall to break down. Some researchers believe that this inflammation can be associated with atherosclerosis (also called hardening of the arteries) or risk factors that contribute to atherosclerosis, such as high blood pressure (hypertension).

Are males or females more likely to have an aneurysm?

Men are 4:1 to women

Aneurysms are typically in the ______, but also in the __________ area.

abdominal -- lower down from heart in abdomen are far more common (75%), but also occur in the thoracic area (25% do) -- right outside the heart.

Most Aneurysms are the result of ____________/

atherosclerosis

Is the mortality rate for thoracic aneurysms?

Yes, 50% mortality rate even with surgery (thoracic)

what are the SYMPTOMS of an aneurysm?

May be asymtomatic until rupture. Could have pulsation in upper abdomen or a bulge + pulsation might be an aneurysm. This is an area that you DO NOT want to palpate or percuss. You can listen, might hear blowy noise as the flow becomes more turbulent. Abdominal, flank, or back pain (steady, gnawing, unaffected by movement).

More Aneurysm Signs: (An ACUTE RUPTURE IS AN EMERGENCY!)

1. Hypotension 2. Diaphoresis 3. Cold clammy 4. Decreased level of consciousness 5. Oliguria 6. Abdominal distention 7. Hematoma of flank 8. Could have cardiac arrhythmias (usually d/t hemodynamic changes that are taking place) less nutrients to muscle & its getting more irritable...

an Aneurysm signs are:

Back pain Dyspnea Hoarseness Dysphagia (If in the Thoracic region they’ll additionally complain of hoarseness or difficulty swallowing) Rupture is also an emergency Acute and profound shock (1st sign of shock? restlessness) (

How is an aneurysm diagnosed?

1. Symptoms not so much, but if they come in w/ all the risk factors (atherosclerosis, HTN, smoker - then physician may look closely to see if disease is in aorta) and physical exam 2. Chest x-ray shows the aneurysm 3. CT scan determines size and location

When is a surgical intervention done for an aneurysm?

Elective surgery before rupture when aneurysm is 6cm or > (less), Goal is Surgery before it ruptures.

If they do have surgery on the aneurysm, what is it like?

what they do is cross clamp the aorta, open up the aorta, cut out the dilation area, sew a graft & bring flaps of aorta back together.

There is another procedure called an Endovascular Stent Graft, what is that?

Another procedure that can be done (depending on location & size of aneurysm) where they endovascularly deploy a stent - so person doesn’t have to have major abd or thoracic surgery.

What kind of conservative management is recommended for an aneurysm until surgery is performed?

Control Hypertension until elective surgery if able to do so. If pt is not a candidate for surgery. Then conservative management is implicated which is controlling their HTN. If they had carotid artery disease or a couple MI in past. Cornoary bypass in past. Maybe they’re just too frail… So they treat them conservatively.

The major thing you want to assess post-op aneurysm is ____________. What else?

1. CIRCULATION distal to where the graft took place. So assess their peripheral pulses for graft patency. You're looking for changes in pulses, color, temperature, abdominal distention, severe pain). 2. Also need to check RENAL FUNCTION (once restored we need to check their output, measure urine hourly, if less then 30 cc's call physician). 3. check RESPIRATORY DISTRESS (check this if thoracic aneurysm, BIG surgery!) 4. PARALYTIC ILEUS (at risk for this d/t anesthesia & manipulation of abd organs... so assess GI SYSTEM & BOWEL SOUNDS

What are additional considerations of a thoracic aneurysm repair?

1. Assess for paralysis post-op 2. Cardiac arrhythmias 3. Hemorrhage 4. Respiratory Distress 5. When blood flow around thoracic aneurysm is clamped then circulation to spinal nerves may have been impaired. So that’s why you’re assessing for movement + sensation in all extremities. B/c they’re so close to myocardium, the heart muscle itself may become irritable so post-op they’re more prone to cardiac arrhythmias. Then again the respiratory distress.

What is thrombophlebitis? When does it occur?

it is a clot WITH inflammation. It's a clot & then the vein is enflamed. Caused by: Inflammation or injury to vessel, Infections, Lupus, Polycythemia, Oral contraceptives

What is Deep Vein Thrombosis? Who is at risk?

It is a CLOT ONLY. It is a clot without the inflammation. It is caused by birth control pills, bedrest (inactivity), pregnancy, post-op after surgery, if activity is limited post-op they're at greater risk. People on long term airplane rides are more prone.

Typical location of a DVT is the ____________ _________ in the leg... releases an embolus.

saphenous vein

For DVT & thrombophlebitis... remember BLUE, what's that mean?

they're in the venous return... veins

What are symptoms of venous disease?

Positive Homan's Sign (only 10% have this tho), Tenderness, Swelling of Extremity, Warmth over site

Diagnostic tests done to find venous disease are:

Venous Doppler Studies (more common) & also Venography (usually not done)-this is where a catheter is placed in the vein & contrast material is injected.

Therapy following venous disease involves take ANTICOAGULATION medications. What would they take???

Heparin (PTT) then Coumadin (PT & INR). Coumadin takes 72 hrs or 3 days to get to therapeutic level orally. So, start on Heparin IV first, then start tapering off & will be good on PO Coumadin from there.

What recommendations are made to Venous Disease patients?

Patient will be put on BEDREST, we Do NOT massage or compress over clot area!, Discharge instructions will include anticoagulant precautions. Likely tell the patient to select an alternative form of contraception if indicated, once they’ve had DVT - don’t take oral contraceptives anymore…

Patients with Venous Insufficiency have stasis ____ ________ b/c valves do not close properly. It is not caused by a clot.

leg ulcers

Venous Insufficiency/Stasis Leg Ulcer patients often have _____ in their extremities. These leg ulcers are a result of prolonged venous hypertension. They will require long-term care.

edema. (May have moddled appearance with some serous fluid coming out. Might feel tight or hard type of edema…)

What kind of compensatory mechanisms does the body have when heart failure is occuring??

Increased Heart Rate, Improved Stroke Volume, Arterial Vasoconstriction, Sodium & Water retention, Myocardial Hypertrophy (these eventually lead to decreased pump function)

what type of person usually gets congestive HF?

Usually heart attack before, HTN, smoker, salt intake, all the risk factors for atherosclerosis… they’re the ones that have had a LONG HISTORY OF HTN (Where you get hypertrophy of ventricle) & they’re at risk for heart failure.

Manifestations of HF depend on the type of failure. Left-sided ventricular HF has...

decreased CO & tissue perfusion. book said pulmonary congestion.. (pt is weak, dizzy, confused, pulmonary congested, decreased blood flow to extremities... especially urine output.)

Manifestations of HF depend on the type of failure. Right-sided ventricular HF has...

Systemic venous congestion. (examine the patient for edema. assess neck veins for distention)

Typically you just see the Left & Right sided HF, but what happens with systolic & diastolic HF?

Systolic = Ventricle unable to contract forcefully, Diastolic = Ventricle unable to relax fully

With ________ HF the heart does not manage to empty. With ______ HF the heart does not manage to fill up.

Systolic HF does not empty, it can't empty b/c it cannot contract fully. Diastolic HF does not fill up, it can't fill up because it can't relax fully.

What causes HF?

Myocardial Infarction is the most common cause. (Marty thought HTN was the longstanding diagnosis for HF though)

Do men or women have more HF?

Men

Left vs. Right Heart failure now. What are the symptoms of LEFT sided HF?

If left side is ineffective as a pump, then the syptoms you’ll have are of not pumping blood out & backing up into pulmonary. less CO, Fatigue, weakness, oliguria, angina, confusion, dizziness, tachycardia, cool extremities, weak pulses Pulmonary congestion, cough,dyspnea, crackles, pink frothy sputum and an S3-4 gallop rhythm. Classic is the dyspnea, crackles & frothy sputum.

Left vs. Right Heart failure now. What are the symptoms of RIGHT sided HF?

JVD - is the hallmark of R. sided HF. If Right side doesn’t pump, then doesn’t flow into pulmonary & backs up into systemic circulation… Will get enlarged liver, spleen, Anorexia, Dependent edema (maybe in sacral edema or even hands), Distended abdomen (result of liver & spleen enlargement + diminished blood flow, VR from abd organs), Polyuria at noc. Weight gain (happens b/c of fluid retention), BP changes

What lab tests are done for HF? These are ones that show impact of CHF, not to diagnose CHF.

hgb, hct, urinalysis, ABG’S (show the state of oxygenation) Chest x-ray (shows fluid build up from L. sided HF), EKG, ECHO, PAP (pulmonary artery pressure) measurements (wedge >10). If high it is indicative of HF. (need to know which side?). When you wedge it into a capillary bed, it reflects pressure from L side of heart. Can tell early on if dev. L sided HF.

What kind of interventions are called for in a patient with heart failure?

Breathing is a big problem. Ways to help breathing: HOB up to 45 degrees, Oxygen, Measures to reduce fluid overload (fluid restrictions may be ordered. Ex/ 1500 cc’s a day. You will calculate how much they’re allowed).

Drug to improve circulation/fluid overload?

a diuretic would be given.. (Lasix, Aldactone, Hydrochlorothiazide)

What drug is given to improve contractility?

Digoxin - given to improve cardiac contractility. Elevate feet and legs to improve venous return, put on Anti-emboli stockings, Reduce fluid volume overload with diuretic

What assessments & nursing responsibilities are done following the interventions for heart failure?

Need DAILY WEIGHTS, must MEASURE I & O, monitor ELECTROLYTES (Na, K+, Cl-. Esp, K+ if on Lasix), PULSES (tells how strong the Digonxin was in increasing contractilty & also reducing the fluid volume).

What's the best indicator of whether the diuretics were effective?

daily weights

What meds might your patient be on for Heart Failure?

VASOPRESSORS & VASODILATORS (may be on for BP control), DIGITALIS (know responsibilities. If K+ is too low: more prone to toxicity. Check pulse, if below 60 or above 100 hold the med & check with doctor. If elderly pt's been on it for awhile... they're not eating & very weak - then you would suspect Dig Toxicity)

What kind of energy management is done for HF patients?

They need rest periods alternated with activity. Nurse should guide them in conserving their energy.

Heart Failure Medications are:

Diuretics: Lasix, ACE inhibitors (Capoten), Digitalis (Digoxin), Nitrates, Beta-blockers

What diet therapy is enacted for HF patients?

2-3 Gm Sodium Diet, usually means no added salt. Should avoid processed meats & potato chips. They are on a FLUID RESTRICTION.

When is Digoxin taken? What are the S & S of toxicity?

Take at the same time each day, ONCE at 1:00. S & S of Dig toxicity are: Halos, Bradycardia, N/V. There is a LOW PULSE usually. Want to continue Potassium Supplements as instructed (they're at risk for hypokalemia when on Digoxin so give K+ supplements to avoid this)

You may see chronic congestive HF or an ACUTE occurence. If it is acute then it is referred to as:

FLASH PULMONARY EDEMA (left sided HF). This occurs in pt's that come in for a different reason, but they're at risk for developing. It would be an emergency - they're in bed, leaning fwd, dyspnes, SOB, respirations may sound wet & may have frothy sputum. They're taken to ICU & given diuretics to get fluid off immediately.

Peripheral arterial disease and exercise will __________ collateral circulation

increase

What is the first assessment finding indicating occlusion of an Aorto-femoral bypass graft?

No pulses below graft

What is the most desired treatment outcome for a client with congestive heart failure?

Respiratory status improves, edema reduction, breath sounds clearing

Assessment findings with Left-sided heart failure?

Crackles & frothy Sputum

Signs of DVT?

Pain in calf

What physical finding does a client with chronic venous disease exhibit?

Edema, Venous Stasis Ulcers

Emergency procedure for Ventricular Fibrillation is...

Defibrillation, synchronize button off; ↑ charge (200); stops and restarts heart

The Cardio version emergency is:

Scheduled procedure for A-fib→conscious sedation; synchronize button on; ↓charge (50); restores normal rhythm

What is the best indicator that diuretics are working?

Daily Weights

When Digoxin and diuretics are administered to your client with CHF, what lab test would you check and why?

K+ (Potassium)

Hypertension detection and when should it be treated?

140/90 3X but drug therapy is initiated much earlier

Measures to facilitate patency of a graft following surgical repair of an aneurysm.

Maintain systolic BP between 90-130; if ↑ 130 too much pressure and graft will tear. Maintain extremities in neutral position.

How would you verify that the graft is patent through your assessment?

check pulses distal to the graft

what are signs of a ruptured aneurysm?

Abd. Pain, flank pain, pulsating mass, hypotension, shock

Following an abdominal aneurysm repair the patient complains of severe flank pain and decreased urinary output. Why?

Renal Artery Embolism

How do you ensure that the graft site does not leak or rupture??

Keep BP under control

Most common initial response for those experiencing chest pains due to a myocardial infarction?

Denial → there is a typical 3 hr delay between onset of pain and going to the hospital

Following a cardiac catheterization what would be the signs of retroperitoneal bleeding?

Bruising, pressure on kidneys, back pain

What is normal post-op chest tube drainage following a CABG? for 1 hour, 8 hours and sitting up?

1 hr post-op→300 cc normal 8 hr post-op→300 cc abnormal Sit-up→300 cc normal

Significance of continued chest pain with tPA therapy???

tPA therapy not working; Don’t give tPA therapy if recent trauma

PTCA does what???

Balloon→pushes plaque away

Stent does what???

Holds artery open

____________ is the most significant cardiac monitor for MI

Troponin

is best used when right coronary or only 1 coronary is involved.

MIDCAB

Safety precautions with a TEMPORARY pacemaker include wearing ______.

gloves

Pink frothy sputum= pulmonary edema = _____ sided heart failure

Left

Pain w/ ______ is typically relieved w/ rest and brought on w/ exertion.

angina

What should you give for chest pain? Then check what?

Chest pain→ give Nitro sublingually→ √ BP

What is the goal with preload & afterload?

Goal is to increase preload & you want to get that moving. Goal is to decrease afterload.

Treatment for symptomatic bradycardia following an MI is...

Atropine, IV drip or a pacemaker

What is the Most common cause of sudden cardiac death?

Cardiac arrhythmia

Most common arrhythmia following MI:

PVT premature ventricular contraction, treated with Lidocaine.

Care of patient following cardiac catheterization: care until sheets are removed.

They need to be supine, keep leg straight (no bending) assess q hr for any bleeding around insertion site

Removal of femoral sheaths following cardiac catheterization: once removals done then ________ dressing is put on, told to stay in bed following removal of sheets.

pressure

Complications following cardiac catheterization are:

1. Can dev a hemotoma & bleed at insertion site 2. Following discharge they’ll have a bulge in groin, & they’ve developed a femoral aneurysm.. Have to have it repaired.

Problems in the hormonal systems of the endocrine system, are usually either a __________ in production or an ________ in production. Often there are problems at the _________ site.

deficieny or an excess in production of the hormones. RECEPTOR

Where is the pituitary?

at the base of the brain (it's at the core), under the hypothalamus, it is about the size of a dime.

What are the anterior pituitary hormones?

TSH (thyroid stimulating hormone), ACTH (adrenocorticotropic hormone or corticotropin), LH (luteinizing hormone), FSH (follicle-stimulating hormone), PRL (prolactin), GH (growth hormone), MSH (melanocyte stimulating hormone)

What are the posterior pituitary hormones?

Vasopressin or ADH (antidiuretic hormone): that promotes water reabsorption, and OXYTOCIN (stimulates uterine contractions and ejection of breast milk)

In HYPOPITUITARISM are all the hormones decreased?

No, it is USUALLY ONE HORMONE MARKEDLY DECREASED AND THE OTHERS ARE SOMEWHAT DECREASED.

Deficiencies of ___ and ____ hormones are the most life threatening.

ACTH (adrenocorticotropic hormone) & TSH (thyroid stimulating hormone)

Hypopituitarism is often caused by what?

often it's Prolactinoma: accounts for 25-30% of pituitary adenomas. They enlarge & take over space for others to work well (the pituitaries getting squished). Hypopituitarism can also be a brain tumor, radiation, surgery, stroke, infection, etc...

So how do we know the pituitary is getting squished? What are the signs of hypopituitarism?

Problem is it's insidious & the S/S are slow... The S/S depend on the hormone affected. There is fatigue, weakness, sensitivity to the cold, low blood pressure, headaches, visual disturbances, In women: cessation of menstrual periods, infertility. In men: decreased libido, loss of body or facial hair.

How is hypopituitarism diagnosed?

cranial CT scan or cranial MRI (might show a tumor), Blood levels of SERUM LUTEINIZING HORMONE (LH), SERUM FOLLICLE STIMULATING HORMONE (FSH), or SERUM THYROID STIMULATING HORMONE (TSH), decreased or abnormal. SERUM TESTOSTERONE SERUM ESTRADIOL (estrogen), SERUM CORISOL, SERUM ACTH levels decreased. T4 (thyroid hormone) is decreased. SERUM GROWTH HORMONE (GH) decreased.

Hypopituitarism is often tested by injecting agents that are known to stimulate secretion of specific pituitary hormones & then measuring the response. This is called __________ testing.

injection

How do we treat hypopituitarism tumors? then what?

To treat hypopituitarism there is surgery to remove the tumor (in through nose/upper lip to the base of his brain) & then we REPLACE THE DEFICIENT HORMONES. (we never abruptly start or stop or could have a rebound effect)

Hyperpituitarism is OVER SECRETION of hormones d/t pituitary tumors or hyperplasia. ________ __________ are the most common.

benign adenomas

If the tumor gets large enough what happens?

it PRESSES ON BRAIN TISSUE! causing visual changes, headaches & signs of increased intracranial pressure.

GH HYPERSECRETION is usually caused by a pituitary tumor, it leads to giantism if ....

it occurs before puberty. This is really rare.

GH HYPERSECRETION in adulthood is way more common. If it happens in adulthood it causes _______. ONSET is ________.

Acromegaly, insidious (VERY SLow oNSET!! remember that)

For people with acromegaly, the mortality rate is 2-3 times that of the general population. What about with successful treatment... can they expect to return to a normal life expectancy if they normalize their GH levels?

Yes, if GH levels are normalized - they return to a normal life expectancy. The most common cause of death is cardiovascular and pulmonary complications.

What are the S/S of acromegaly?

CHANGES IN APPEARANCE: thick oily skin, increased lip and nose size, protrusion of the lower jaw, increased head size, and increase head, hands and feet. JOINT ENLARGEMENT with pain, kyphosis, and barrel chest. EXCESSIVE SWEATING, HYPERGLYCEMIA. IRWAY NARROWING, ENLARGED HEART & LIVER.

Pt's tested for acromegaly is done with an ORAL GLUCOSE TOLERANCE TEST, testing their Serum GH levels. What would these tests show if patient is + ?

Inability to suppress serum GH

What kind of medical treatment is done for acromegaly patients then?

Somatostatin Analogs & Dopamine Agonists

What is the surg treatment for acromegaly? What should the nurse monitor? what should the nurse teach the patient following this surgery?

They would surgically remove the tumor. Nurse should monitor vitals, vision, mental status, LOC. Needs to watch for a HALO sign b/c worried about CNS fluid leakage. Nurse needs to teach pt to report POST NASAL DRIP, also to AVOID COUGHING, SNEEZING OR BLOWING THE NOSE right after surg. They can INCREASE PRESSURE and CSF LEAKAGE. We don't do anything to increase ICP!!! (stool softener)

Posterior Pituitary HYPOFUNCTION causes Diabetes _______.

Insipidus

What is Diabetes Insipidus? What's it caused by?

A water metabolism problem. caused by either an ADH DEFICIENCY (not making enough) or the KIDNEYS ARE NOT RESPONDING TO ADH.

The key features of DI are what happens to the concentration of urine? Leads to what?

DI has an inability to concentrate urine. This leads to polyuria (excessive urinating) with excessive fluid loss. Remember DEHYDRATION is what happens from DI. Pt has increased thirst, hypotension, tachycardia, is irritable, decreased LOC, and lethargy.

To assess for DI we get a 24 I & O on the pt. Urine output must exceed __ _______ to diagnose. Also, do a "Water Deprivation" or "Dehydration Test" that measures urine output, specific gravity, osmolality and weight hourly.

4 liters

How do we treat Diabetes Insipidus?

Vasopressin (ADH) Nasal Sprays. Also, give Diabinese (antihyperglycemic), daily weights, drink fluids equal to urine output, wear a med alert bracelet.

SIADH: causes Posterior Pituitary Hyperfunction. SIADH: syndrome of inappropriate antidiuretic hormone does it put out too much or too little ADH?

too much vasopressin (ADH) is put out even when plasma osmolarity is low.

Some of the causes of SIADH are:

Causes: Malignancies, Pulmonary: pneumonia/pneumothorax, CNS: trauma, infection, strokes Drugs: opioids, general anesthesia

SIADH causes GI disturbances like N/V & loss of appetite. What does SIADH do to water & sodium?

Water Retention & HYPONATREMIA. (especially if Na fall below 115 mEq/L) and fluid shifts leads to lethargy, headaches delirium, decreased LOC, seizures and coma. Decreased tendon reflexes, tachycardia and hypothermia.

What is done for the treatment & monitoring of SIADH?

FLUID RESTRICTION- As low as 500 mL/24 hr I & O, DAILY WEiGHTS- weight gain of 2 lbs per day troubling, 1 Kg wt. = 1 L fluid. diuretics- may cause more Na loss Use SALINE IN ALL IVs- hypertonic saline is rarely used because it can cause fluid shifts and heart failure Demeclyocycline (Declomycin)-rarely used

What hormones does the adrenal medulla put out?

norepinephrine & epinephrine

What hormones does the adrenal cortex put out?

Cortisol, Aldosterone & Androgens

Adrenal Hypofunction is called __________ disease: also called adrenal insufficiency, or hypocortisolism.

Addison's

What is the most common cause of primary adrenal insufficiency?

Autoimmune Disease (Tuberculosis, AIDS or other drugs & toxins)

What is the most common cause of secondary adrenal insufficiency?

pituitary tumors, high dose pituitary radiation, or abrupt stop of long term glucocorticoid therapy

Does the onset of adrenal hypofunction happen fast or slow? What are some symptoms?

BEGINS GRADUALLY. there is fatigue, muscle weakness, joint pain, loss of appetite, wt. loss, N/V, diarrhea, salt cravings, irritability, depression, anemia, orthostatic hypotension, hypoglycemia, hyponatremia, hypercalcemia, and hyperkalemia.

What is an Addisonian Crisis?

a life threatening event. Usually when someone with ADRENAL INSUFFICIENCY experiences a STRESSOR such as surgery, severe infection or surgery.

What does an Addisonian Crisis lead to?

SEVERE HYPOTENSION, HYPONATREMIA & HYPERKALEMIA.

LAB TESTS for Adrenal Hypofunction reveal ____ Serum _________.

low cortisol! also, low blood glucose, hyponatremia, hyperkalemia, increased BUN, (elevated eosinophils & ACTH in primary disease). Secondary disease also has low serum ACTH, ACTH stimulation test results in increased cortisol levels.

Other Adrenal Testing includes:

CT, MRI, skull x-rays or angiography to detect tumors or atrophy. Urinary testing for glucocorticoid etablite 17-hydroxycorticosteroid. (Tylenol, Vit. C, Digoxin can all interfere)

What kind of nursing interventions are imp for adrenal hypofunction?

MAINTAIN FLUID BALANCE (Daily weights, I & O), MONITOR FOR CARDIAC PROBLEMS, manage ELECtroLYTE IMBALANCES, monitor & manage for HYPOGLYCEMIA, ADMINISTER GLUCOCORTICOIDS & ALDOSTERONE AS ORDERED, teach the patient to wear a MEDIC ALERT BRACELET. HORMONAL REPLACEMENT IS LIFE LONG & WHAT TO DO IN CASE OF SICK DAYS OR STRESSORS.

HYPERSECRETION of the ADRENAL GLAND results in hyperCORTICALISM or ___________ Disease/Syndrome, hyperADLDOSTERONISM & Excesive ANDROGEN production.

Cushing's

What is the difference between Cushing Disease & Cushing's Syndrome?

Cushing's Disease is if the body is doing it to themselves, then it's the disease. It's caused by endogenous cortisol secretion by pituitary or adrenal adenomas or lung, GI or pancreatic malignancies. Cushing's SYNDROME is caused by administration of glucocorticoids or ACTH as an antiinflammatory of asthma, transplants, autoimmune diseases or allergic responses. (IF ASKED IF they're ON GLUCOCORTICOIDS, if WE'VE GIVEN THEM A MED.. THEN IT IS THE 'SYNDROME')

What are the physical signs of Cushing's? (Hypercorticolism)

fat redistribution (usually to the trunk of the body), MOON FACE, BUFFALO HUMP, OBESITY (Wt gain). MUSCULAR ATROPHY, THIN (paperlike) SKIN, STRIAE, INCREASED RISK FOR INFECTION.

manifestations of Cushing's are:

increased risk for infection, no inflammation, OSTEOPOROSIS with spontaneous fracture, HTN, increased risk for DVT, edema, bruising.

Cushing's pt's often have _____ disturbances, decreased _______, weakness, fatigue, increased glucose & possibly DM, changes in menstrual periods, libido & secondary sex characteristics.

sleep, memory

Assessing for Cushing's Disease looks for elevated plasma ______ levels, what time of day? Also you will see increased glucose & sodium, but decreased calcium, potassium & lymphocyte counts.

cortisol, same time each day b/c it normally fluctuates.

Urine is also tested for free cortisol & metabolites for Cushing's assessment. It is done as a 24 hour assessment. What else is elevated in urine?

Ca+, K+, and glucose will be elevated.

What is the nonsurgical way of managing Cushing's?

We want to treat the CLINICAL MANIFESTATIONS (all the hypernatremia, hypokalemia, hyperglycemia & HTN) and PROTECT FROM INJURY (falls, fractures & skin tears), prevent INFECTION, provide EDUCATION.

Surgical management of Cushing's Disease involves REMOVING THE ________ __________. This is the most common cause of Cushing's Disease. Surg cure rate is 85-90%, will need replacement steroids.

PITUITARY ADENOMA

Another Surgical Management for Cushing's is an _____________, usually done laproscopically.

Adrenalectomy

Following Surgical removal of the pituitary adenoma or an adrenalectomy, what will the patient need for LIFELONG???

Steroid Replacement

Pre-operatively we want to correct:

electrolyte imbalances

post-operatively we may need immediate ____________ replacement therapy.

glucocorticoid

_______________ is excessive secretion of aldosterone.

Hyperaldosteronism

Hyperaldosteronism is usually caused by an ________ ________.

adrenal adenoma

What does the excess aldosterone lead to?

Sodium retention and potassium and Hydrogen ion loss.

High levels of _____________ kills lymphocytes and thus decreases the inflammatory response to illness or infection. You may not see a fever or peri-wound redness in people receiving steroids.

corticosteroids (Cushings)

What symptoms will HYPERALDOSTERONISM have??

HIGH BLOOD PRESSURE!!!, headaches, muscle weakness, fatigue, numbness

What tests reveal hyperaldosteronism?

Low Serum Potassium levels, Abdominal CT scan (shows adrenal mass), elevated PLASMA & URINE ALDOSTERONE levels, Low plasma RENIN ACTIVITY, ECG shows abnormalities associated with low K+ levels

_______________ is the name of the tumor of the adrenal gland. It causes excess release of _________________ & ______________.

Pheochromocytoma. Epinephrine & noripinephrine

What are the S&S of Pheochromocytoma?

RAPID HEART RATE, INCREASED APPETITE. also headaches, palpitations, irritability, etc...

Pheochromocytoma's are found by adrenal biopsy. An MRI or CT of abdomen that shows the adrenal mass. Also a 24 hr urine collection looking ____ , which is what? also a _________ suppression test.

VMA (vanilylmandelic acid), metanephrine & catecholamines are elevated with pheochromocytoma. CLONIDINE suppression test. (clonidine normally decreases catecholamine levels, but with pheochromocytoma the clonidine tests won't change.)

What is the main treatment for Pheochrmocytoma?

Surgical Removal of tumor

We need to monitor & stabilize BP before & after the surgery. We start with ______ blockers & then _______ blockers for meds. We do NOT palpate the abdomen, provide adequate hydration & nutrition.

alpha, then beta

_____________ is an imbalance of metabolism caused by overproduction of thyroid hormones.

HYPERTHYROIDISM

"_______________" is the term for the manifestations of hyperthyroidism.

Thyrotoxicosis

Hyperthyroidism causes hyper__________, affecting protein, lipid and carbohydrate metabolism.

metabolism

Hyperthyroidism causes increased __________ nerve stimulation (more epinephrine & noripinephrine).

sympathetic

_____________ Disease causes hyperthyroidism

Graves (because of the goiter)

What does Hyperthyroidism cause?

Heat intolerance, diaphoresis, thinning hair, pretibial myxedema, SOA (shortness of air), rapid shallow breathing, muscle weakness & wasting.

Patients with ____________ will have a goiter (thyroid enlargement), exopthalmos, lid lag (eyes don't open/close completely), photophobia, irritability + restlessness, emotional lability

What are the key features of hyperthyroidism? What happens to BP, HR, body weight, periods?

Hypertension, Rapid HR, Chest pain, dysrhythmias, weight loss, sleep disturbance, amenorrhea

Hyperthyroid lab tests will reveal what?

High levels of T3 & T4, TSH, T3RU, TSH antibodies

Diagnostic Testing for hyperthyroidism is a THYROID SCAN, explain...

radioactive iodine is given by mouth or IV & reuptake by the thyroid is monitored.

What size needle is used for a Fine Needle Aspiration Biopsy of hyperthyroidism?

a fine needle (25 or 27 gauge) is inserted 4-7 times to obtain cells for examination.

What drugs are given to hyperthyroid patients?

ANTI THYROID AGENTS (Proplthiouracil (PTU), Methimazole (Tapazole), Cabimazole) or IODINE PREPARATIONS (strong iodine (Lugol's solution), Saturated solution of Potassium Iodide (SSK), Potassium iodide tablets, solution or syrup)

Surgical Management of hyperthyroidism is done b/c it presses on esophagus. It is important for the surgeon to avoid what?

superficial laryngeal nerve (effects voice permanently)

Thyroidectomy: post-op care includes...

patient has difficulty swallowing & a stiff neck. CHECK BLOOD LEVELS FOR PTH & CALCIUM. Educate on S/S of LOW CALCIUM (muscle twitches, increased HR), watch for RESPIRATORY DISTRESS. slight swelling below incision is normal, keep incision COVERED TO AVOID SUN, can shower once drain is out, but don't soak the area. numbness in the area is usually permanent. Supplementation is LIFE LONG when thyroid is taken out.

Parathyroid glands regulate ______ so you need to have a good surgeon work around them.

calcium, watch for muscle twitching & tingles so you don't advance

What is Thyroid Storm?

Rare, LIFE THREATENING (20-25% mortality even with treatment). It's an exaggerated maximum of hyperthyroidism. Signs are: fever, systolic HTN, HI distress, anxiety, tremors, confusion, psychosis, seizures & coma

What triggers a thyroid storm?

Trauma (post surgery), uncontrolled diabetes/ketoacidosis, pregnancy (during labor), severe drug reaction, MI, acute infections, radioactive iodine therapy with iodine load, vigorous palpation of goiter

What do you do about a patients infiltrative ophthalmopathy (bulging eyes)?

elevate the HOB, use artificial tears, tape eyes shut at night, have them wear dark galasses for photophobia, surgery

______________ is absent or insufficient production of thyroid hormone resulting in decreased metabolism.

Hypothyroidism

What are the risk factors for a thyroid to fail?

family hx of thyroid disease, radiation treatment to head, neck or chest are big ones. Also other autoimmune diseases. Medications like Lithium , amiodarone (Cordarone), iodine, older age

What causes Thyroid Failure???

1. Chronic autoimmune thyroiditis (Hashimoto's thyroiditis) 2. Treated Grave's Disease (the radioactive iodine therapy, thyroidectomy, antithyroid drugs all can go from hyperthyroidism to failed/hypothyroidism)

Some S/S of Hypothyroidism are:

weakness, dry skin, coarse hair, brittle nails, thick tongue, hoarse voice, COLD INTOLERANCE, constipation, weight gain, MENTAL IMPAIRMENT, DEPRESSION (blank expression), muscle cramps, bradycardia. If they're cold all the time & can't get warm??? Hypthyroidism. They are THICK, SWOLLEN & SLOW = hypothyroidism

S/S of hypothyroidism are:

nonpitting edema of eyelids, face, legs, hearing loss, menorrhagia, slowing of return phase of reflexes (eg. knee jerk), goiter

___________ Come is a LIFE THREATENING EMERGENCY! It is a complication of long-standing or poorly treated hypothyroidism.

Myxedema Coma. can be triggered by illness, surg, trauma, anesthesia, hypothermia, CNS depressants, rapid thyroid med w/drawal.

What happens in a Myxedema Coma?

Coma, resp failure, hypotension, HYPOTHERMIA (body temo is like 74 degrees), hyponatremia, hypoglycemia, shock, organ failure & death.

How are meds given for hypothyroidism?

START SLOW & build up dose, Need Patient education b/c treatment will be lifelong, same brand, same dose, same time every day. Take 1-2 hrs before other meds. NO double dosing

______ is inflammation of the thyroid gland.

Thyroiditis

Chronic Thyroiditis is Hashimoto's or Autoimmune thyroiditis, this is the ______ _________.

most common is chronic..

Other kind is sub-acute thyroiditis. when's this occur?

granulomatous or painful thyroiditis after a viral infection. d/t bacterial.

Hashimoto's Thyroiditis is:

autoimmue destruction of the thyroid leadig to scarring & hypothyroidism.

What does Hashimoto's Thyroiditis do to the thyroid? How is it diagnosed?

causes enlargement of one or both lobes of the thyroid. Diagnosed by testing TSH, thyroid hormone & anti-thyroid antibodies.

Subacute thyroiditis is the most common cause of a ___________ _________.

painful thyroid. Usually follows a viral infection. Noted for REFERRED PAIN to the throat or jaw.

Thyroid Cancer is usually identified as a..

single, PAINLESS lump. It is a nodule FIXED to the location and does not move with swallowing.

What's the cure rate for thyroid cancer? What's the treatment of choice?

95% cure rate. Usually surgery followed by RADIOACTIVE IODINE.

Radioactive Iodine Therapy is never used in _________ ________. What procedure is followed for these patients?

pregnant women. A private room is required, radiation precautions: label room, limit time in room, flush twice. Avoid close contact with pg women, children & pets for 5-11 days.

In Hyperparathyroidism... the PTH (parathyroid hormone) does what to the kidneys?

INCREASES REABSORPTION OF CALCIUM & INCREASES PHOSPHATE EXCRETION.

What causes hyperparathyroidism?

96% d/t benign adenoma of the gland, parathyroid carcinoma, congenital hyperplasia, neck trauma or radiation, Vitamin D deficiency, chronic renal failure with hypercalcemia, parathyroid hormone secreting tumors of other organ. (know in general, nothing highlighted on this slide)

S/S of Hyperparathyroidism are:

'MOANS, GROANS, STONES & BONES". Meaning: you get kidney stones, osteoporosis, bone pain, fractures, peptic ulcers, constipation, depression, anxiety, leep disturbances... 1/2 are aymptomatic though.

Diagnosis hyperparathyroidism includes labs that show HIGH levels of ____, ________ and low __________.

high PTH, hypercalcemia. low phosphate. Also, bone density studies.

Hyperparathyroidism is treated by surgically removing the affected gland. Drug therapy is done to lower serum _________ levels.

Calcium

Post-op patients who had surgery to remove their hyperparathyroidism is called parathyroidectomy. What is the nurse watching for?

Respiratory distress (from compression of trachea by hemorrhage or swelling) and Hypocalcemic Crisis (d/t atrophy of of remaining glands we monitor calcium every 4 hours) Do Trousseau's & Chvostek's signs, watch for hoarseness & voice changes.

How prevalent is hypoparathyroidism? Why's it occur usually?

It's extremely rare, usually d/t surgical removal of the glands. Get problems with too little magnesia (hypomagnesiemia)

symptoms related to Hypoparathyroidism are related to hypo__________. So were worried about...

calcemia. tingling, muscle cramps, tetany & convulsions.

How do we treat Hypoparathyroidism?

Vit. D & Calcium supplements, Mg supplement if needed. SUPPLEMENTATION IS LIFE LONG. Want them to WEAR A MED ALERT BRACELET. There isn't really a parathyroid hormone replacement really, just above supplements.