biologic crisis

BIOLOGIC CRISISBIOLOGIC CRISIS

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SHOCKSHOCK

ARRHYTHMIAS

HEART BLOCK/STROKE

DM/DKA

PULMONARY EMBOLISM

PULMONARY EDEMA

KIDNEY FAILURE (ERDS)

HEPATIC COMA/ENCEPHALOPATHY

BURNS

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What is Shock?What is Shock?

• A condition in which systemic BP is adequate to A condition in which systemic BP is adequate to deliver oxygen and nutrients to support vital deliver oxygen and nutrients to support vital organs and cellular functions.organs and cellular functions.

• Maintenance of tissue perfusion depends on Maintenance of tissue perfusion depends on adequate cardiac pump, effective vasculature or adequate cardiac pump, effective vasculature or circulating system and sufficient blood volume.circulating system and sufficient blood volume.

• Widespread serious reduction of tissue Widespread serious reduction of tissue perfusion ( lack of O2 )perfusion ( lack of O2 )

Classification of shockClassification of shock

A.A. HYPOVOLEMIC SHOCKHYPOVOLEMIC SHOCK

• Loss of circulating volume due to Loss of circulating volume due to excessive blood loss, loss of body fluids excessive blood loss, loss of body fluids and third spacing of fluids.and third spacing of fluids.

• Most common type of shock.Most common type of shock.

• Characterized by decreased intravascular Characterized by decreased intravascular volume of 15-25%.volume of 15-25%.

HYPOVOLEMIC SHOCK

Predisposing factors:Predisposing factors:

External:FluidLossExternal:FluidLoss Internal:FluidShift Internal:FluidShift – trauma a. hemorrhage trauma a. hemorrhage – surgery b. burns surgery b. burns – vomiting c. ascite vomiting c. ascite – diarrhea d. peritonitis diarrhea d. peritonitis – diuresis e. dehydration diuresis e. dehydration – diabetes insipidusdiabetes insipidus

Medical ManagementMedical ManagementGOALS:GOALS:• restore intravascular volume restore intravascular volume • redistribute fluid volume redistribute fluid volume • correct the underlying causecorrect the underlying cause

Fluid and Blood replacement:

• Lactated Ringer’s solution, colloid, and 0.9% NaCl (normal saline) to restore intravascular volume.

• Blood replacement for extensive and rapid blood loss; auto-transfusion methods may be considered for closed cavity hemorrhage.

Redistribution of Fluids

• Patients is positioned in trendelenburg to assist in fluid redistribution.

•Military antishock trousers (MAST) are used in extreme emergency situations when bleeding cannot be controlled

Pharmacologic ExamPharmacologic Exam

• DesmopressinDesmopressin

• Insulin Insulin

• Anti-emeticAnti-emetic

• Anti-diarrealAnti-diarreal

Nursing ManagementNursing Management• Closely monitor px at risk for fluid deficits(younger than Closely monitor px at risk for fluid deficits(younger than

1y/o or 65 years of age)1y/o or 65 years of age)

• Assist with fluid replacementAssist with fluid replacement

• Ensure safe administration of of prescribe fluids and Ensure safe administration of of prescribe fluids and medications, and document effectsmedications, and document effects

• Monitors and report signs of complications and effect of Monitors and report signs of complications and effect of treatment.treatment.

• Monitor for cardiovascular overload and pulmonary Monitor for cardiovascular overload and pulmonary edema: hemodynamic pressure, VS, ABG, and fluid IO.edema: hemodynamic pressure, VS, ABG, and fluid IO.

• Reduce fear and anxiety about the need for oxygen Reduce fear and anxiety about the need for oxygen mask by giving px explanations and frequent mask by giving px explanations and frequent reasurancereasurance

Cardiogenic ShockCardiogenic Shock

Cardiogenic ShockCardiogenic Shock

• The ability of the heart to pump blood is impaired The ability of the heart to pump blood is impaired that causes a decrease in cardiac output.that causes a decrease in cardiac output.

• Causes of cardiogenic shock are either coronary or Causes of cardiogenic shock are either coronary or noncoronarynoncoronary

• Coronary cardiogenic shock is more common and Coronary cardiogenic shock is more common and seen most often in px with myocardial infarction.seen most often in px with myocardial infarction.

• Noncoronary causes include tension pneumothorax, Noncoronary causes include tension pneumothorax, sever metabolic problem, cardiac tamponade, sever metabolic problem, cardiac tamponade, cardiomyopathy, valvular damage and cardiomyopathy, valvular damage and dysrhythmias.dysrhythmias.

Pathophysio of Cardiogenic Pathophysio of Cardiogenic ShockShock

Clinical Manifestation:Clinical Manifestation:

• Dysrhythmias are common and result from a decrease in Dysrhythmias are common and result from a decrease in oxygen to the myocardium.oxygen to the myocardium.

• Angina painAngina pain

• Hemodynamic instabilityHemodynamic instability

• Classic sign like low blood pressure, rapid and weak pulse.Classic sign like low blood pressure, rapid and weak pulse.

• Cerebral hypoxia and manifested by confusion and agitation.Cerebral hypoxia and manifested by confusion and agitation.

• Deceased urinary output and cold clammy skin.Deceased urinary output and cold clammy skin.

Medical ManagementMedical Management• correction of underlying cause correction of underlying cause • initiation of first line treatmentinitiation of first line treatment

Ø supplemental oxygenØ supplemental oxygenØ controlling chest painØ controlling chest painØ selected fluids supportØ selected fluids supportØ vasoactive medicationsØ vasoactive medicationsØ controlling heart rateØ controlling heart rateØ mechanical cardiac supportØ mechanical cardiac support

e.g intra-aortic balloon counterpulsation, e.g intra-aortic balloon counterpulsation, ventricular ventricular assist sysytem.assist sysytem.

• Coronary cardiogenic shock is treated with thrombolytic Coronary cardiogenic shock is treated with thrombolytic

theraphy, angioplasty, or CABGtheraphy, angioplasty, or CABG• Noncoronary cardiogenic shock is treated with cardiac Noncoronary cardiogenic shock is treated with cardiac

valve replacement or correction of dysrhythmias.valve replacement or correction of dysrhythmias.

PharmacologicPharmacologic

• DobutamineDobutamine

• DopamineDopamine

• Anti-arrythemic medsAnti-arrythemic meds

• NitroglycerineNitroglycerine

• Vasoactive medsVasoactive meds

Nursing ManagementNursing Management

• Preventing cardiogenic shock Preventing cardiogenic shock

• Administering meds and IV fluids Administering meds and IV fluids

• Maintaining mechanical devices Maintaining mechanical devices

• Enhancing safety and comfortEnhancing safety and comfort

Distributive Shock / Distributive Shock / Vasogenic Shock Vasogenic Shock ( Circulatory( Circulatory Shock ) Shock )

• Result from profound vasodilationResult from profound vasodilation

• Three classification of distributive Three classification of distributive shock: Septic shock, Anaphylactic shock: Septic shock, Anaphylactic shock and Neurologic shockshock and Neurologic shock

Septic ShockSeptic Shock


• The most common type of distributive The most common type of distributive shock, is caused by widespread infection.shock, is caused by widespread infection.

• Gram-negative bacteria are the most Gram-negative bacteria are the most common pathogens. common pathogens.

• Gram-positive bacteria and viruses and Gram-positive bacteria and viruses and fungi, can also cause septic shockfungi, can also cause septic shock

Risk factors:Risk factors:

• ImmunosuppressionImmunosuppression• Extremes of age ( younger than 1y/l and older than Extremes of age ( younger than 1y/l and older than

65y/o)65y/o)• AlcoholismAlcoholism• Extensive trauma of burnsExtensive trauma of burns• Malnutrition Malnutrition • DiabetesDiabetes• MalignancyMalignancy• Chronic illness Chronic illness • Invasive proceduresInvasive procedures

PathophysiologyPathophysiology

• Microorganism invasion causes immune Microorganism invasion causes immune response that activates biochemical mediators response that activates biochemical mediators associated with inflammatory response and associated with inflammatory response and produces a variety of effects leading to shock.produces a variety of effects leading to shock.

• There is an increase in the capillary permeability, There is an increase in the capillary permeability, with fluid loss from the capillaries and with fluid loss from the capillaries and vasodilatation, result in inadequate perfusion of vasodilatation, result in inadequate perfusion of oxygen and nutrients to the tissue and cell.oxygen and nutrients to the tissue and cell.

Clinical ManifestationClinical ManifestationFirst phase: Hyperdynamic or Progressive phaseFirst phase: Hyperdynamic or Progressive phase• High cardiac output with vasodilationHigh cardiac output with vasodilation• Hyperthermia (febrile) with warm, flushed skin, bounding pulsesHyperthermia (febrile) with warm, flushed skin, bounding pulses• Heart and respiratory rate elevatedHeart and respiratory rate elevated• Blood pressure may remain within normal limits, or subtle changes in Blood pressure may remain within normal limits, or subtle changes in

mental status.mental status.• Decreased urinary output or normalDecreased urinary output or normal• Gastrointestinal status compromised (eg, decreased bowel sounds, n/v Gastrointestinal status compromised (eg, decreased bowel sounds, n/v

or diarrhea)or diarrhea)

Late phase: Hypodynamic or Irreversible phaseLate phase: Hypodynamic or Irreversible phase• Low cardiac output with vasoconstrictionLow cardiac output with vasoconstriction• Decreased blood pressureDecreased blood pressure• Skin cool and paleSkin cool and pale• Temperature normal or below normalTemperature normal or below normal• Rapid respiratory and heart rateRapid respiratory and heart rate• Anuria and multiple organ dysfunctionAnuria and multiple organ dysfunction


Medical ManagementMedical Management

• Urine, blood, sputum, and wound drainage Urine, blood, sputum, and wound drainage specimens are collected to identify and specimens are collected to identify and eliminate the causes of infection.eliminate the causes of infection.

• Begins immediately a broad-spectrum antibiotic Begins immediately a broad-spectrum antibiotic therapytherapy

• Fluid replacement and aggressive nutritional Fluid replacement and aggressive nutritional supplement (high protein) is provided. Enteral supplement (high protein) is provided. Enteral feedings are preferred.feedings are preferred.


• Identify px at risk for sepsis and septic shockIdentify px at risk for sepsis and septic shock

• Monitor for sign of infection at intravenous lines, arterial and Monitor for sign of infection at intravenous lines, arterial and venous puncture sites, surgical incisions, trauma wounds, urinary venous puncture sites, surgical incisions, trauma wounds, urinary catheters and pressure ulcercatheters and pressure ulcer

• Reduce px temp. when ordered for temp above 104.8F (40.8C) Reduce px temp. when ordered for temp above 104.8F (40.8C) monitor closely for shiveringmonitor closely for shivering

• Administered prescribed intravenous fluids and medicationsAdministered prescribed intravenous fluids and medications

• Monitor and report blood levels (antibiotics, BUN, creatinine, WBC ) Monitor and report blood levels (antibiotics, BUN, creatinine, WBC ) and hemodynamic status, fluid IO and nutritional status.and hemodynamic status, fluid IO and nutritional status.

• Monitor daily wts. And serum albumin levels to determine daily Monitor daily wts. And serum albumin levels to determine daily protein requirementsprotein requirements

NEUROLOGIC SHOCK / NEUROLOGIC SHOCK / SPINAL SHOCKSPINAL SHOCK

• There is loss of vasomotor tone There is loss of vasomotor tone that includes arteriolar and that includes arteriolar and venous dilatation .venous dilatation .


– Spinal cord injury Spinal cord injury

– Spinal anesthesia Spinal anesthesia

– Depressant meds Depressant meds

– HypoglycemiaHypoglycemia


• Restoring sympathetic toneRestoring sympathetic tone

Nursing ManagementNursing Management• Elevate the head of the bed 30 degrees ( in spinal / epidural Elevate the head of the bed 30 degrees ( in spinal / epidural

anesthesia )anesthesia )

• Immobilize the patient ( in spinal cord injury ) Immobilize the patient ( in spinal cord injury )

• Elastic compression stockings Elastic compression stockings

• Feet elevation Feet elevation

• Heparin / low molecular weight heparin Heparin / low molecular weight heparin

• Pneumatic compression of the legs Pneumatic compression of the legs

• Passive ROMPassive ROM

Anaphylactic ShockAnaphylactic Shock

Anaphylactic ShockAnaphylactic Shock

• An antigen-antibody reaction brought about by An antigen-antibody reaction brought about by severe allergenic reaction provokes mast cell severe allergenic reaction provokes mast cell to release chemical mediators like histamine to release chemical mediators like histamine and bradykinin widespread vasodilatation and and bradykinin widespread vasodilatation and capillary permeability.capillary permeability.


• Drug sensitivity Drug sensitivity

• Transfusion reaction Transfusion reaction

• Bee sting allergy Bee sting allergy

• Latex sensitivityLatex sensitivity


• Rremoval of causative agent Rremoval of causative agent

• Restore vascular tone ( epinephrine ) Restore vascular tone ( epinephrine )

• Antihistamines and bronchodilatorsAntihistamines and bronchodilators


• Assess for previous hypersensitivity reactions Assess for previous hypersensitivity reactions

• Prevention of future exposure to antigens Prevention of future exposure to antigens

• Identification of new antigens Identification of new antigens

• Patient education Patient education

Stages of ShockStages of Shock

INITIAL STAGE / COMPENSATED / NONPROGRESSIVE INITIAL STAGE / COMPENSATED / NONPROGRESSIVE SHOCKSHOCK

• BP is maintained within normal limits due to the BP is maintained within normal limits due to the effect of normally functioning regulatory effect of normally functioning regulatory mechanismsmechanisms

• Blood loss less than 10%Blood loss less than 10%

Signs and SymptomsSigns and Symptoms

• Apprehension and restlessness ( 1st sign Apprehension and restlessness ( 1st sign of shock )of shock )

• Increase heart rateIncrease heart rate• Cool, pain skinCool, pain skin• Metabolic acidosisMetabolic acidosis• FatigueFatigue• TachypneaTachypnea• Mental status changeMental status change


• Identify the cause of shock Identify the cause of shock

• Correction of shock Correction of shock

• Support of the regulatory Support of the regulatory mechanismsmechanisms


– Monitoring tissue perfusionMonitoring tissue perfusion

Ø LOCØ LOC

Ø V/SØ V/S

Ø Urine outputØ Urine output

Ø SkinØ Skin

Ø Laboratory values Ø Laboratory values – Reducing anxiety Reducing anxiety – Promoting safetyPromoting safety

Progressive Stage / Progressive Stage / DecompensatedDecompensated

• Exhaustion of the compensatory mechanismExhaustion of the compensatory mechanism

• Myocardial depressionMyocardial depression

• Increased capillary permeabilityIncreased capillary permeability

Signs and SymptomsSigns and SymptomsA. Respiratory effectsA. Respiratory effectsØ hypoxemia and hypercarbiaØ hypoxemia and hypercarbiaØ intense inflammatory responseØ intense inflammatory responseØ decreased surfactant productionØ decreased surfactant productionØ acute respiratory distress syndrome ( acute lung injury, Ø acute respiratory distress syndrome ( acute lung injury, shock lungs, non cardiogenic pulmonary edema )shock lungs, non cardiogenic pulmonary edema )

B. Cardiovascular effectsB. Cardiovascular effectsØ dyshrythmiasØ dyshrythmiasØ myocardial infractionØ myocardial infractionØ cardiac depressionØ cardiac depression

C. Neurologic effectsC. Neurologic effectsØ decreased cerebral perfusionØ decreased cerebral perfusionØ mental status changeØ mental status changeØ behavioral changeØ behavioral changeØ papillary dilationØ papillary dilation

Signs and SymptomsSigns and Symptoms

D. Renal effectsD. Renal effectsØ MAP<80mmHgØ MAP<80mmHgØ Acute renal failureØ Acute renal failure

E. Hepatic effectsE. Hepatic effects

Ø Decreased blood flow Ø Decreased blood flow Ø Less ability to perform hepatic functionsØ Less ability to perform hepatic functions

F. gastrointestinal effectsF. gastrointestinal effects

Ø Decreased blood flowØ Decreased blood flowØ PUDØ PUDØ Bloody diarrheaØ Bloody diarrheaØ SepsisØ Sepsis


– Depends on the type of shock Depends on the type of shock

– Depends of the decompensation of Depends of the decompensation of the organ systemsthe organ systems

Irreversible StageIrreversible Stage

• Sever organ damage Sever organ damage

• Can no longer respond to treatmentCan no longer respond to treatment

• Survival is less likelySurvival is less likely


• Same with progressive stageSame with progressive stage


• Same with progressive shock Same with progressive shock

• Moral support to the family Moral support to the family

• Ethical issue ( living will )Ethical issue ( living will )

AssessmentsAssessmentsA. Early stagesA. Early stages

Ø Restlessness, confusionØ Restlessness, confusionØ Increase RR and PR, respiratory alkalosisØ Increase RR and PR, respiratory alkalosisØ Diaphoresis, cool clammy skin/warm, flushed skin in septic shockØ Diaphoresis, cool clammy skin/warm, flushed skin in septic shockØ Normal to decreased urine output, thirst, dry mucous membraneØ Normal to decreased urine output, thirst, dry mucous membraneØ HypokalemiaØ Hypokalemia

B. Late stagesB. Late stages

Ø Shallow respiration, decreased BP, increased PR, hypothermiaØ Shallow respiration, decreased BP, increased PR, hypothermiaØ Oliguria, AnuriaØ Oliguria, AnuriaØ HyperkalemiaØ HyperkalemiaØ Metabolic acidosisØ Metabolic acidosisØ EdemaØ EdemaØ Cool clammy skin- hypovolemic, cardiogenic and septic shockØ Cool clammy skin- hypovolemic, cardiogenic and septic shockØ Lethargy, dilated pupilsØ Lethargy, dilated pupilsØ Decreased bowel soundsØ Decreased bowel soundsØ CyanosisØ CyanosisØ DICØ DIC

Interventions Interventions A. Promoting fluids balanceA. Promoting fluids balance

Ø Blood transfusionsØ Blood transfusionsØ IV fluidsØ IV fluids

B. Assisting with cardiac supportB. Assisting with cardiac supportØ Intraaortic balloon pump ( IABP)Ø Intraaortic balloon pump ( IABP)Ø Medical anti-shock trousersØ Medical anti-shock trousersØ Modified trendelenburg positionØ Modified trendelenburg position

C. Assisting respiratory supportC. Assisting respiratory support

Ø O2 therapy Ø O2 therapy Ø Mechanical ventilatorØ Mechanical ventilatorØ Deep breathing, coughing excercisesØ Deep breathing, coughing excercisesØ Suction as necessaryØ Suction as necessary

InterventionsInterventions

D. Assisting with renal supportD. Assisting with renal supportØ Monitor I and O, BUN and creatinineØ Monitor I and O, BUN and creatinineØ DiureticsØ Diuretics

E. Assisting with GI supportE. Assisting with GI support

Ø NGTØ NGTØ H2 blockers and antacidsØ H2 blockers and antacids

F. Promoting safetyF. Promoting safety

Ø Soft restraints as neededØ Soft restraints as neededØ Practice strict asepsisØ Practice strict asepsisØ Prevent complications of immobilityØ Prevent complications of immobilityØ Protect from chillsØ Protect from chills

Drug TherapyDrug Therapy • Vasoconstrictors:Vasoconstrictors: Norepinephrine / epinephrine, Norepinephrine / epinephrine,

dopamine, dobutaminedopamine, dobutamine• Vasodilators:Vasodilators: Nitrates like nitroglycerine and Nitrates like nitroglycerine and

IsosorbideIsosorbide• Na+ bicarbonate to reverse acidosisNa+ bicarbonate to reverse acidosis• Antibiotics to control sepsisAntibiotics to control sepsis• Heparin to treat DICHeparin to treat DIC• Steroids to reduce inflammationSteroids to reduce inflammation• H2 antihistamines, Ranitidine, cimetidineH2 antihistamines, Ranitidine, cimetidine• Glucose 50% or glucagons to increased blood Glucose 50% or glucagons to increased blood

sugarsugar• Narcotics for painNarcotics for pain• Antidysrrhythamic drugsAntidysrrhythamic drugs

End of the slides

ArrhythmiasArrhythmias

Cardiac Arrhythmias Cardiac Arrhythmias

• It is an abnormal electrical It is an abnormal electrical conduction or automaticity conduction or automaticity causing changes in the heart causing changes in the heart rate and rhythm.rate and rhythm.


• CongenitalCongenital

• Myocardial IschemiaMyocardial Ischemia

• MIMI

• Organic heart diseaseOrganic heart disease

• Drug effect and toxicityDrug effect and toxicity

• Conductive tissue degenerationConductive tissue degeneration

• Electrolyte imbalanceElectrolyte imbalance

• Acid-base imbalanceAcid-base imbalance

• Cellular hypoxia Cellular hypoxia


• Result in the disturbance in the excitability, Result in the disturbance in the excitability, automaticity, or conductivityautomaticity, or conductivity

• Heart rate and rhythm are altered, reducing Heart rate and rhythm are altered, reducing cardiac outputcardiac output

Assessment Assessment

• AsymptomaticAsymptomatic

• Palpitation Palpitation

• Chest painChest pain

• DizzinessDizziness

• Weakness, fatigueWeakness, fatigue

• Feeling of impending Feeling of impending doomdoom

• Irregular heart rhythmIrregular heart rhythm

• Bradycardia or Bradycardia or tachycardiatachycardia

• hypotensionhypotension

• SyncopeSyncope

• LOCLOC

• DiaphoresisDiaphoresis

• PallorPallor

• N/VN/V

• Cold, clammy skinCold, clammy skin

• Life-threatening: Life-threatening: pulselessness, (-) pulselessness, (-) respiration, no respiration, no palpable blood palpable blood pressure pressure

DiagnosisDiagnosis

• ECG- change in heart rate, ECG- change in heart rate, rhythmrhythm

• Blood chemistry : electrolyte Blood chemistry : electrolyte imbalanceimbalance

Normal Sinus RhythmNormal Sinus Rhythm

Normal Sinus RhythmNormal Sinus Rhythm

Occurs when the electrical impulse starts at Occurs when the electrical impulse starts at the regular rate and rhythm n the sinus node and the regular rate and rhythm n the sinus node and travels at through the normal conduction pathwaytravels at through the normal conduction pathway

Characteristics:Characteristics:

• Ventricular and atrial rateVentricular and atrial rate: 60 to 100 in : 60 to 100 in adult adult

• Ventricular and atrial rhythmVentricular and atrial rhythm: Regular: Regular• QRS duration:QRS duration: Usually normal, but may Usually normal, but may

be regularly abnormalbe regularly abnormal• P waveP wave: Normal and consistent shape; : Normal and consistent shape;

always in front of QRSalways in front of QRS• PR interval:PR interval: Consistent interval between Consistent interval between

0.12 and 0.20 seconds0.12 and 0.20 seconds• P:P: QRS ratio 1:1 QRS ratio 1:1

Types of Sinus node Types of Sinus node DysrhythmiasDysrhythmias

A. Sinus BradycardiaA. Sinus Bradycardia

occurs when the sinus node creates an occurs when the sinus node creates an impulse at a slower rate than normal.impulse at a slower rate than normal.


• Ventricular and atrial rateVentricular and atrial rate: Less than : Less than 60 in adult60 in adult

• Ventricular and atrial rhythmVentricular and atrial rhythm: Regular: Regular

• QRS duration:QRS duration: Usually normal but may Usually normal but may be regularly abnormalbe regularly abnormal

• P wave:P wave: Normal and consistent Normal and consistent

interval between 0.12 and interval between 0.12 and

0.20 seconds0.20 seconds

• P:P: QRS ratio 1:1 QRS ratio 1:1

Sinus BradycardiaSinus Bradycardia

Management Management

• The urgency of treatment depend is on the effect The urgency of treatment depend is on the effect of the slow rate on maintenance of Cardiac of the slow rate on maintenance of Cardiac outputoutput

• Atropines, 0.5 to 1.0 mg given IV push block Atropines, 0.5 to 1.0 mg given IV push block vagal stimulation to the SA Node & therefore vagal stimulation to the SA Node & therefore accelerate heart rate.accelerate heart rate.

• If the bradycardia persists a pacemaker may be If the bradycardia persists a pacemaker may be required.required.

B. Sinus TachycardiaB. Sinus Tachycardia • Occur when the sinus node Occur when the sinus node

create an impulse at a faster create an impulse at a faster than normal rate. It may be than normal rate. It may be caused by acute blood loss, caused by acute blood loss, anemia, shock, hypervolemia, anemia, shock, hypervolemia, hypovolemia CHF, pain, hypovolemia CHF, pain, hypermetabolic states, fever, hypermetabolic states, fever, anxiety or sympathomimetic anxiety or sympathomimetic medication.medication.

Types of Sinus Node Types of Sinus Node DysrhythmiasDysrhythmias

• Ventricular and atrial rate: Ventricular and atrial rate: Greater Greater than 100 in the adultthan 100 in the adult

• Venticular and atrial rhythm: Venticular and atrial rhythm: RegularRegular

• QRS duration: QRS duration: Usually normal, but Usually normal, but may be regularly abnormalmay be regularly abnormal

• P wave:P wave: Normal and consistent shape, Normal and consistent shape, always in front of the QES, but may be always in front of the QES, but may be buried in the preceding T wave.buried in the preceding T wave.

• P:P: QRS ratio 1:1 QRS ratio 1:1

Characteristics:

As the heart rate increases, the diastolic falling time decreases, As the heart rate increases, the diastolic falling time decreases, result in reduced cardiac output and subsequent symptoms of result in reduced cardiac output and subsequent symptoms of syncope and low blood pressure. If the heart cannot compensate syncope and low blood pressure. If the heart cannot compensate for the decreased ventricular falling the px may develop acute for the decreased ventricular falling the px may develop acute pulmonary edemapulmonary edema

Sinus TachycardiaSinus Tachycardia

ManagementManagement

• It is usually directed at abolishing its It is usually directed at abolishing its causes.causes.

• Calcium channel blockers and Beta-Calcium channel blockers and Beta-blockers may be used to reduce the blockers may be used to reduce the heart rate quickly.heart rate quickly.

C. Sinus ArrhythmiasC. Sinus Arrhythmias

Occur when the sinus node create Occur when the sinus node create an impulse at an irregularly rhythm; the rate an impulse at an irregularly rhythm; the rate usually increase with inspiration and usually increase with inspiration and decrease with expiration. Non respiratory decrease with expiration. Non respiratory cause includes heart disease and valvular cause includes heart disease and valvular disease, but these are rarely seen.disease, but these are rarely seen.

Types of Sinus node Types of Sinus node DysrhythmiasDysrhythmias

• Ventricular and atrial rateVentricular and atrial rate: 60 to 100 in the adult : 60 to 100 in the adult • Ventricular and atrial rhythmVentricular and atrial rhythm: Irregular: Irregular• QRS duration:QRS duration: Usually normal, but may be Usually normal, but may be

regularly abnormalregularly abnormal• P waveP wave: Normal and consistent shape, always in : Normal and consistent shape, always in

front of the QRS.front of the QRS.• PR intervalPR interval: Consistent interval between 0.12 and : Consistent interval between 0.12 and

0.20 second 0.20 second • P:P: QRS ratio: 1:1 QRS ratio: 1:1

*Sinus Arrhythmia does not cause any significant hemodynamic *Sinus Arrhythmia does not cause any significant hemodynamic effect and usually is not treated.effect and usually is not treated.

Characteristics:

Atrial DysrhythmiasAtrial Dysrhythmias

A. Premature Atrial ComplexA. Premature Atrial Complex • Premature Atrial Complex Is a single ECG complex Premature Atrial Complex Is a single ECG complex

that occur when an electrical impulse start in the that occur when an electrical impulse start in the atrium before the next normal impulse of the sinus atrium before the next normal impulse of the sinus node.node.

• The PAC may be caused by caffeine, alcohol, The PAC may be caused by caffeine, alcohol, nicotine, stretched atrial myocardium, anxiety nicotine, stretched atrial myocardium, anxiety hypokalemia (low potassium level), hyper metabolic hypokalemia (low potassium level), hyper metabolic states or atrial ischemia, injury or infarction.states or atrial ischemia, injury or infarction.

Characteristics:Characteristics:• Ventricular and atrial rateVentricular and atrial rate: Depend on the : Depend on the

underlying rhythmunderlying rhythm• Ventricular and atrial rhythmVentricular and atrial rhythm: Irregular: Irregular• QRS duration:QRS duration: The QRS that follows the early P The QRS that follows the early P

wave is usually normal, but it may be abnormal.wave is usually normal, but it may be abnormal.• P waveP wave: An early and different P wave may be : An early and different P wave may be

seen or may be hidden in the T wave; seen or may be hidden in the T wave; • Other P wave in the strip is consistent.Other P wave in the strip is consistent.• PR interval:PR interval: The early P wave has a shorter than The early P wave has a shorter than

normal PR interval, but still between normal PR interval, but still between • 0.12 And 0.20 seconds 0.12 And 0.20 seconds • PP: QRS ratio: Usually 1:1: QRS ratio: Usually 1:1


• If PACs are in frequent, no treatment is If PACs are in frequent, no treatment is necessary. If they are frequent (more tan 6 per necessary. If they are frequent (more tan 6 per minute) this may herald a worsening diseases minute) this may herald a worsening diseases state or the onset of more serious state or the onset of more serious dysrhythmias, such as atrial fibrillation. dysrhythmias, such as atrial fibrillation. Treatment is directed toward the cause.Treatment is directed toward the cause.

• PAC’s should be monitored for increasing PAC’s should be monitored for increasing frequency frequency

Atrial FlutterAtrial Flutter


B. Atrial FlutterB. Atrial Flutter• Occur in the atrium and creates impulse at an Occur in the atrium and creates impulse at an

atrial rate between 250 and 400 time per atrial rate between 250 and 400 time per minute.minute.

• Because the atrial rate is faster than the AV Because the atrial rate is faster than the AV node can conduct, not all atrial impulse are node can conduct, not all atrial impulse are conducted into the ventricle causing a conducted into the ventricle causing a therapeutic block at the AV node.therapeutic block at the AV node.

Atrial FlutterAtrial Flutter


• Ventricular and atrial rate:Ventricular and atrial rate: Atrial range Atrial range between 250 and 400 ventricular rates between 250 and 400 ventricular rates usuallyusually

• Range between 75 and 150Range between 75 and 150• Ventricular and atrial rhythmVentricular and atrial rhythm: Usually : Usually

RegularRegular• P wave: P wave: Saw –toothed shape. These Saw –toothed shape. These

waves referred to as F wave waves referred to as F wave • PR interval; PR interval; Multiple F waves may make Multiple F waves may make

it difficult to determine the PR interval.it difficult to determine the PR interval.• PP: QRS ratio: 2:1, 3:1, or 4:1: QRS ratio: 2:1, 3:1, or 4:1

Sign and SymptomsSign and Symptoms

• Chest painChest pain

• Shortness of breathShortness of breath

• Low blood pressure.Low blood pressure.

ManagementManagement

• The urgency of treatment depend on the ventricular response The urgency of treatment depend on the ventricular response rate& resultant symptomsrate& resultant symptoms

• A Calcium channel blocker such as Diltiazem (cardizem) may be A Calcium channel blocker such as Diltiazem (cardizem) may be use to slow AV Nodal conduction used with caution in the use to slow AV Nodal conduction used with caution in the patient with CHF, hypotensionpatient with CHF, hypotension

• Digitalis & Quinidine preparation may be used.Digitalis & Quinidine preparation may be used.

• A beta –adrenergic block drug such as Esmolol may be used.A beta –adrenergic block drug such as Esmolol may be used.• If drug therapy is un successful, trial flutter will often respond to If drug therapy is un successful, trial flutter will often respond to

cardivertion.cardivertion.

• Small doses of electrical current are often successfulSmall doses of electrical current are often successful

Atrial FibrillationAtrial Fibrillation


C. Atrial FibrillationC. Atrial Fibrillation• May occur for a very short time (paroxysmal) or it may be chronicMay occur for a very short time (paroxysmal) or it may be chronic

• It is the most common dysrhythmias that cause patients seek It is the most common dysrhythmias that cause patients seek medical attentionmedical attention

• The shorter time in diastole reduce the time available for coronary The shorter time in diastole reduce the time available for coronary artery perfusion, there by increasing the risk for myocardial artery perfusion, there by increasing the risk for myocardial ischemia.ischemia.

• The erratic atrial contraction promotes the formation of a thrombus The erratic atrial contraction promotes the formation of a thrombus within the atria increasing the risk of stroke (brain attack).within the atria increasing the risk of stroke (brain attack).


• Ventricular and atrial rate:Ventricular and atrial rate: Atrial rate is Atrial rate is 300 and 600 in untreated atrial fibrilation300 and 600 in untreated atrial fibrilation

• Ventricular and atrial rhythmVentricular and atrial rhythm: Highly : Highly irregularirregular

• QRS shape and duration: QRS shape and duration: usually normal usually normal but may be abnormalbut may be abnormal

• P wave: P wave: No discernible P waves; irregular No discernible P waves; irregular undulating waves are seen and are referred undulating waves are seen and are referred to as fibrillatory or waves. to as fibrillatory or waves.

• PR interval: PR interval: Cannot be measuredCannot be measured• PP: QRS ratio: many:1: QRS ratio: many:1

Management Management • Cardiovertion may be indicated for atrial fibrillation that has been present Cardiovertion may be indicated for atrial fibrillation that has been present

for less than 48 hours, a condition termed acute onset of atrial fibrillationfor less than 48 hours, a condition termed acute onset of atrial fibrillation

• Acute onset, the medication quinidine, Acute onset, the medication quinidine,

• Ibutilide,flecanide, dofetilide, profafenon, procanamide, dysopyramide or Ibutilide,flecanide, dofetilide, profafenon, procanamide, dysopyramide or amiodirone may be given to achieve convertion to sinus rhythmamiodirone may be given to achieve convertion to sinus rhythm

• Intravenouse adenosine (adenocard,adenescan) has also been use for Intravenouse adenosine (adenocard,adenescan) has also been use for convertion, as well as to assist in the diagnosis.convertion, as well as to assist in the diagnosis.

• Calcium channel blocker and beta blocker are effective in controlling the Calcium channel blocker and beta blocker are effective in controlling the ventricular rate in atrial fibrillation ventricular rate in atrial fibrillation

• Use Digoxin is recommended to control the ventricular rate those patient Use Digoxin is recommended to control the ventricular rate those patient with poor cardiac function with poor cardiac function

• Aspirin may be substituted for warfarin.Aspirin may be substituted for warfarin.

Atrial FibrillationAtrial Fibrillation

Junctional DysrhythmiasJunctional Dysrhythmias

A.A.Premature Junction ComplexPremature Junction Complex

• Is an impulse that starts in the AV nodal before the next normal Is an impulse that starts in the AV nodal before the next normal sinus impulse reaches the AV node Premature junction complex are sinus impulse reaches the AV node Premature junction complex are less common than PAC’sless common than PAC’s

• The criteria for premature junction complex are the same as for The criteria for premature junction complex are the same as for PACs except for the Pwave and the PR interval. The Pwave may be PACs except for the Pwave and the PR interval. The Pwave may be absent QRS, or may occur before the QRS but with a PR interval of absent QRS, or may occur before the QRS but with a PR interval of less than 0.12 second less than 0.12 second

• Treatment for frequency premature junction complexes is the same Treatment for frequency premature junction complexes is the same as for frequent PACs.as for frequent PACs.

Premature JunctionPremature Junction


B. Junctional RhythmB. Junctional Rhythm

Jucntional or idionodal rhythm occur when Jucntional or idionodal rhythm occur when the AV node, instead of the sinus node, become the AV node, instead of the sinus node, become the pacemaker of the heart.the pacemaker of the heart.

Characteristics: Characteristics:

• Ventricular and atrial rate:Ventricular and atrial rate: 40 to 60 40 to 60 • Ventricular rhythmVentricular rhythm: Regular : Regular • QRS duration:QRS duration: Usually normal but may be Usually normal but may be

abnormal abnormal • P wave:P wave: May be absent, after the QRS May be absent, after the QRS

complex, or before the QRS; may be complex, or before the QRS; may be invented, especially in lead IIinvented, especially in lead II

• PR interval:PR interval: If P wave is in front of the If P wave is in front of the QRS, PR interval is less than 0.12 secondQRS, PR interval is less than 0.12 second

• P:P: QRS ratio1:1 or 1:1 QRS ratio1:1 or 1:1


C. C. Atrioventicular Nodal Reentry Atrioventicular Nodal Reentry TachycardiaTachycardia

• Occurs when an impulse is conducted to an area in the AV Occurs when an impulse is conducted to an area in the AV node that causes the impulse to be rerouted back into the same node that causes the impulse to be rerouted back into the same area over and over again at a very fast rate.area over and over again at a very fast rate.

• It has an abrupt onset and an abrupt cessation with a QRS of It has an abrupt onset and an abrupt cessation with a QRS of normal duration had been called paroxysmal atrial tachycardia normal duration had been called paroxysmal atrial tachycardia (PAT)(PAT)


• Ventricular and atrial rate:Ventricular and atrial rate: atrial rate atrial rate 150-250; vent rate: 75-250150-250; vent rate: 75-250

• Ventricular and atrial rhythmVentricular and atrial rhythm: Regular; : Regular; sudden onset and termination of the sudden onset and termination of the tachycardia tachycardia

• QRS duration:QRS duration: Usually normal but may be Usually normal but may be abnormal abnormal

• P wave:P wave: usually very difficult to discern usually very difficult to discern• PR interval:PR interval: If P wave is in front of the QRS, If P wave is in front of the QRS,

PR interval is less than 0.12 secondPR interval is less than 0.12 second• P:P: QRS ratio1:1 or 2:1 QRS ratio1:1 or 2:1

Ventricular Ventricular DysrhythmiasDysrhythmiasA. Premature Ventricular ComplexA. Premature Ventricular Complex

• Caused by acute MI other form of heart disease, pulmonary Caused by acute MI other form of heart disease, pulmonary disease, electrolyte disturbance, metabolic instability and drug disease, electrolyte disturbance, metabolic instability and drug abuse abuse

• The wave of impulse originates from an ectopic Focus (Foci) within The wave of impulse originates from an ectopic Focus (Foci) within the ventricles at rate faster than the next normally occurring beat. the ventricles at rate faster than the next normally occurring beat.

• Because the normal conduction pathway is by passed Because the normal conduction pathway is by passed configuration of the PVC is wider than normal and is distorted in configuration of the PVC is wider than normal and is distorted in appearance.appearance.

• PVC’s may occur in regular sequence with normal rhythm.PVC’s may occur in regular sequence with normal rhythm.

Premature Ventricular Premature Ventricular ComplexComplex


• Ventricular and atrial rate:Ventricular and atrial rate: Depend on Depend on the underlying rhythm.the underlying rhythm.

• Ventricular and atrial rhythm: Ventricular and atrial rhythm: IrregularIrregular

• QRS duration:QRS duration: 0.12 second or longer 0.12 second or longer shape is bizarre and abnormalshape is bizarre and abnormal

• P waveP wave: none : none

• PP intervalPP interval: If the P wave is in front of the : If the P wave is in front of the QRS, the PR interval is less than 0.12 QRS, the PR interval is less than 0.12 second second

• PP: QRS ratio 0:1, 1:1: QRS ratio 0:1, 1:1


• The standard treatment is Lidocaine hydrochloride The standard treatment is Lidocaine hydrochloride (Xylocaine) by IV push(Xylocaine) by IV push

• Be alert to the development of confusion, slurring of speech Be alert to the development of confusion, slurring of speech and diminished mentation because lidocaine toxicity affects and diminished mentation because lidocaine toxicity affects the CNS.the CNS.

• If ventricular premature beats occur in conjunction with If ventricular premature beats occur in conjunction with bradysrhythmias, atropine may be chosen to accelerate the bradysrhythmias, atropine may be chosen to accelerate the heart rate and eliminate the need for etopic beat.heart rate and eliminate the need for etopic beat.

• Atropine should be used with caution in acute MI. the Atropine should be used with caution in acute MI. the injured myocardium may not be able to tolerate the injured myocardium may not be able to tolerate the accelerated rate.accelerated rate.

Ventricular Ventricular DysrhythmiasDysrhythmias

B. Ventricular TachycardiaB. Ventricular Tachycardia

• Ventricular tachycardia (VT) is designed as Ventricular tachycardia (VT) is designed as three or more PVCs in a row, occurring at a rate three or more PVCs in a row, occurring at a rate exceeding 100 beat per minute.exceeding 100 beat per minute.

• The causes are similar to those for PVCThe causes are similar to those for PVC

• VT is an emergency because the patient is VT is an emergency because the patient is usually unresponsive and pulse lessusually unresponsive and pulse less


• Ventricular and atrial rate:Ventricular and atrial rate: 100to200 beat per minute100to200 beat per minute

• Ventricular and atrial rhythmVentricular and atrial rhythm: : Usually RegularUsually Regular

• P wave:P wave: so atrial rate and rhythm so atrial rate and rhythm may be indeterminable.may be indeterminable.

• PR interval:PR interval: Very Irregular Very Irregular

• P:P: QRS ratio: difficult to determine QRS ratio: difficult to determine

Ventricular TachycardiaVentricular Tachycardia


• Cardiovertion may be the treatment of choice, Cardiovertion may be the treatment of choice, especially if the patient is unstable.especially if the patient is unstable.

• VT in a patient who is unconscious and VT in a patient who is unconscious and without a pulse treated in the same manner without a pulse treated in the same manner as ventricular fibrillation immediate as ventricular fibrillation immediate

defibrillation is the action of choicedefibrillation is the action of choice..


C. Ventricular FibrillationC. Ventricular Fibrillation

Is a rapid but disorganized ventricular rhythm Is a rapid but disorganized ventricular rhythm that cause of ventricular fibrillation are the that cause of ventricular fibrillation are the same as for VT, it may also result from same as for VT, it may also result from untreated or unsuccessfully treated VT. Other untreated or unsuccessfully treated VT. Other cause includes electrical shock and Brugada cause includes electrical shock and Brugada Syndrome.Syndrome.

Ventricular FibrillationVentricular Fibrillation


• Ventricular rate: Greater Ventricular rate: Greater thanthan 300 per minute 300 per minute

• Ventricular and atrial rhytm:Ventricular and atrial rhytm: Extremely irregularExtremely irregular

• QRS durationQRS duration Irregular Irregular

Management Management • Immediately fibrillation and activation of emergency serviceImmediately fibrillation and activation of emergency service

• The importance of defibrillation is evident in one of the recent The importance of defibrillation is evident in one of the recent change in basic life support.change in basic life support.

• Placing a call for emergency assistant and calling for a Placing a call for emergency assistant and calling for a defibrillator takes precedence over initiating Cardio defibrillator takes precedence over initiating Cardio pulmonary resuscitation in adult victim.pulmonary resuscitation in adult victim.

• Application of an automatic external defibrillator AED is Application of an automatic external defibrillator AED is included in basic life support classesincluded in basic life support classes

• Administering Vaso active and anti arrhythmia medication Administering Vaso active and anti arrhythmia medication alternating with defibrillation are treatment used to try alternating with defibrillation are treatment used to try convert the rhythm to normal sinus rhythm.convert the rhythm to normal sinus rhythm.


D. Idioventricular RhythmD. Idioventricular Rhythm

• Is also called ventricular escape rhythm, occur when the impulse Is also called ventricular escape rhythm, occur when the impulse starts in the conduction system below the AV node.starts in the conduction system below the AV node.

• Commonly cause the patient to lose consciousness and Commonly cause the patient to lose consciousness and experience other sign and symptoms of reduced cardiac out put . experience other sign and symptoms of reduced cardiac out put . Intervention may include identify the underlying cause, Intervention may include identify the underlying cause, administering administering

• Intravenous atropine and vasopressor medication. Initiating Intravenous atropine and vasopressor medication. Initiating emergency transcutaneous pacing.emergency transcutaneous pacing.

• Bed rest is prescribed so as not to increase the cardiac work load Bed rest is prescribed so as not to increase the cardiac work load


• Ventricular and atrial rateVentricular and atrial rate: : Between 20and 40 if the rate exceeds Between 20and 40 if the rate exceeds 40, is known (AIVR)40, is known (AIVR)

• Ventricular and atrial rhythm: Ventricular and atrial rhythm: RegularRegular

• QRS durationQRS duration: Bizarre, abnormal, : Bizarre, abnormal, duration is 0.12 second or more. duration is 0.12 second or more.


E. Ventricular AsystoleE. Ventricular Asystole

• Commonly called flat line, ventricular a systole Commonly called flat line, ventricular a systole characterized by QRS complexes, all though P wave characterized by QRS complexes, all though P wave may be apparent for a short duration is two different may be apparent for a short duration is two different leads. There is no heart beat, no palpable pulse and no leads. There is no heart beat, no palpable pulse and no respiration.respiration.

• Assessment to identify the possible cause which Assessment to identify the possible cause which may be hypoxia, acidosis, severe electrolyte imbalance, may be hypoxia, acidosis, severe electrolyte imbalance, drug overdose or hypothermia.drug overdose or hypothermia.

Ventricular AsystoleVentricular Asystole


• CPR and emergency service as necessary CPR and emergency service as necessary to keep the patient alive.to keep the patient alive.

• Transcutaneuos pacing may be Transcutaneuos pacing may be attempted. A bolus of intravenous attempted. A bolus of intravenous epinephrine should be ad minister and epinephrine should be ad minister and repeated 3to5 minutes interval repeated 3to5 minutes interval

End of the slides

HEART BLOCK

Conduction Conduction AbnormalitiesAbnormalities

• The nurse first to identify is the underlying rhythm.(eg, The nurse first to identify is the underlying rhythm.(eg, sinus rhythmia) then the PR interval is assessed for the sinus rhythmia) then the PR interval is assessed for the possibility of an AV block. possibility of an AV block.

• AV block occur when the conduction of impulse through AV block occur when the conduction of impulse through the AV nodal are is decreased or stopped. These block can the AV nodal are is decreased or stopped. These block can caused by medication (eg,digitalis, calcium channel caused by medication (eg,digitalis, calcium channel blockers, beta blocker).blockers, beta blocker).

• The Clinical sign and symptoms of a heart block vary with The Clinical sign and symptoms of a heart block vary with the resulting ventricular rate and the severity of any the resulting ventricular rate and the severity of any underlying disease processes.underlying disease processes.

• The treatment is based on the hemodynamic effect of the The treatment is based on the hemodynamic effect of the rhythm rhythm

Types of Types of Conduction Conduction AbnormalitiesAbnormalities

A. First Degree BlockA. First Degree Block

Occur when all the atrial Occur when all the atrial impulse are conducted through the impulse are conducted through the AV node into the ventricle at a rate AV node into the ventricle at a rate slower than normal slower than normal


• Ventricular and atrial rate:Ventricular and atrial rate: Depend on the underlying rhythm.Depend on the underlying rhythm.

• Ventricular and atrial rhythmVentricular and atrial rhythm: : Depend on the underlying rhythm.Depend on the underlying rhythm.

• QRS durationQRS duration; usually normal; usually normal

• P wave:P wave: In front of QRS complex; In front of QRS complex; shows sinus rhythm, regular shape.shows sinus rhythm, regular shape.

• P: QRSP: QRS ratio1:1 ratio1:1

First Degree AV BlockFirst Degree AV Block


B.1 Second Degree Atrioventricular Block Type IB.1 Second Degree Atrioventricular Block Type I

Second degree type I heart block occurs when all but Second degree type I heart block occurs when all but one of the atrial impulse are conducted. Through the AV node one of the atrial impulse are conducted. Through the AV node into the ventricles. Each atrial impulse a take longer time for into the ventricles. Each atrial impulse a take longer time for conduction than the one before, until one impulse is fully conduction than the one before, until one impulse is fully blocked.blocked.


• Ventricular and atrial rate:Ventricular and atrial rate: Depend on the Depend on the underlying rhythmunderlying rhythm

• Ventricular and atrial rhythm:Ventricular and atrial rhythm: The PP interval is The PP interval is regular if the patient has an underlying normal regular if the patient has an underlying normal sinus rhythm; the RR interval characteristically sinus rhythm; the RR interval characteristically reflect a pattern of change .reflect a pattern of change .

• QRS duration:QRS duration: Normal may be abnormal Normal may be abnormal• P wave:P wave: In front of the QRS complex; shape In front of the QRS complex; shape

depend on underlying rhythmdepend on underlying rhythm• PR interval:PR interval: PR interval become longer with each PR interval become longer with each

succeeding ECG complex until there is a P wave not succeeding ECG complex until there is a P wave not followed by a QRS.followed by a QRS.

• P:P: QRS ratio 3; 2, 4:3, 5:4, QRS ratio 3; 2, 4:3, 5:4,

Second Degree Second Degree Atrioventricular Block Type IAtrioventricular Block Type I


B.2 Second Degree Atrioventricular Block Type IIB.2 Second Degree Atrioventricular Block Type II

Occur when only some of the atrial impulses are Occur when only some of the atrial impulses are conducted through the AV node into the ventricles conducted through the AV node into the ventricles

Second Degree Atrioventricular Second Degree Atrioventricular Block Type IIBlock Type II


• Ventricular and atrial rate: Depend on Ventricular and atrial rate: Depend on the underlying rhythmthe underlying rhythm

• Ventricular and atrial rhythm. The PP Ventricular and atrial rhythm. The PP interval is regular if the patient has an interval is regular if the patient has an underlying normal sinus rhythm.underlying normal sinus rhythm.


C. Third Degree Atrioventricular C. Third Degree Atrioventricular BlockBlock

Occur when no atrial impulse is Occur when no atrial impulse is conducted through the AV node into the conducted through the AV node into the ventricle In the third degree heart block , ventricle In the third degree heart block , two impulse stimulate the heart :one two impulse stimulate the heart :one stimulate the ventricle ,represent by the stimulate the ventricle ,represent by the QRS complex, and one stimulate the atria . QRS complex, and one stimulate the atria .

Third Degree Third Degree Atrioventricular BlockAtrioventricular Block


• Ventricular and atrial rate: Ventricular and atrial rate: Depend on the Depend on the escape and underlying atrial rhythm.escape and underlying atrial rhythm.

• Ventricular and atrial rhythmVentricular and atrial rhythm:The PP interval :The PP interval is regular and the RR interval is regular; however is regular and the RR interval is regular; however the PP interval is not Equal to the RR interval.the PP interval is not Equal to the RR interval.

• QRS durationQRS duration: Depend on the escape of rhythm: Depend on the escape of rhythm

• P waveP wave: Depend on the underlying rhythm: Depend on the underlying rhythm

• P:P: QRS ratio: More P wave than QRS complexes QRS ratio: More P wave than QRS complexes


• IF the patient is short of breath, complains IF the patient is short of breath, complains of chest pain or lightheadedness, or has low of chest pain or lightheadedness, or has low BP: Intravenous bolus of Atropine is the BP: Intravenous bolus of Atropine is the initial treatment of choice.initial treatment of choice.

• If the patient does not respond to atropine If the patient does not respond to atropine or has acute MI, trascutaneous pacing or has acute MI, trascutaneous pacing should be started.should be started.

• A permanent pacemaker may be necessary A permanent pacemaker may be necessary if the block persist.if the block persist.

Nursing AssessmentNursing Assessment

• Major assessment include all possible cause of the Major assessment include all possible cause of the dysrhythmia and the dysrhythmia’s effect on the heart’s dysrhythmia and the dysrhythmia’s effect on the heart’s ability to pumped an adequate blood volume.ability to pumped an adequate blood volume.

• When cardiac output is reduced, the amount of O2 When cardiac output is reduced, the amount of O2 reaching the tissue and vital organ is diminished. This reaching the tissue and vital organ is diminished. This diminished oxygenation produces the s/sx associated with diminished oxygenation produces the s/sx associated with dysrhythmia.dysrhythmia.

• A health history is obtained to identify any previous A health history is obtained to identify any previous occurrence of decreased cardiac output such as syncope occurrence of decreased cardiac output such as syncope (fainting), lightheadedness , dizziness , fatigue, chest (fainting), lightheadedness , dizziness , fatigue, chest discomfort and palpitation discomfort and palpitation

• Coexisting condition that could be a possible cause of Coexisting condition that could be a possible cause of heart block or dysrhythmia (heart disease, chronic heart block or dysrhythmia (heart disease, chronic obstructive pulmonary disease ) may be also identified.obstructive pulmonary disease ) may be also identified.

Nursing AssessmentNursing Assessment• All medications prescribed and over the counter All medications prescribed and over the counter

(supplements herbs and nutritional) may be reviewed.(supplements herbs and nutritional) may be reviewed.

• The nurse conducts physical assessment to the The nurse conducts physical assessment to the patient with diminished cardiac output especially the patient with diminished cardiac output especially the level of LOC . the nurse directs attention to the skin level of LOC . the nurse directs attention to the skin which may be pale and cool. Sign of fluid retention, which may be pale and cool. Sign of fluid retention, such as neck vein distention and crackles and such as neck vein distention and crackles and wheezes auscultated in the lungs.wheezes auscultated in the lungs.

• The nurse auscultates for extra heart sounds The nurse auscultates for extra heart sounds ( especially S3 and S4 ) and for heart murmur, ( especially S3 and S4 ) and for heart murmur, measure blood pressure indicates reduced cardiac measure blood pressure indicates reduced cardiac output.output.

Nursing DiagnosisNursing Diagnosis

• Decreased cardiac outputDecreased cardiac output

• Anxiety related to fear of the unknownAnxiety related to fear of the unknown

• Deficient knowledge about the dysrhythmias and its Deficient knowledge about the dysrhythmias and its related treatment. related treatment.

Collaborative Problems and Potential Collaborative Problems and Potential ComplicationComplication

• May developed over time a heart failureMay developed over time a heart failure

• ThromboembolicThromboembolic

Nursing InterventionNursing Intervention

1. Monitoring and managing the 1. Monitoring and managing the dysrhythmiasdysrhythmias

– Regularly evaluate the blood pressure, pulse rate and rhythm, Regularly evaluate the blood pressure, pulse rate and rhythm, rate and depth of respiration and breath sounds to determine rate and depth of respiration and breath sounds to determine the hemodynamic effects.the hemodynamic effects.

– Obtain a 12 lead ECG, continuously monitor the patient and Obtain a 12 lead ECG, continuously monitor the patient and analyze rhythm of the strips to track dysrhythmias.analyze rhythm of the strips to track dysrhythmias.

– Use an antiarrhythmias medications and the nurse assess and Use an antiarrhythmias medications and the nurse assess and observe for the beneficial and adverse effects of each observe for the beneficial and adverse effects of each medications ad prescribed.medications ad prescribed.

– Assist the patient in developing a plan to make a lifestyle Assist the patient in developing a plan to make a lifestyle change that eliminates or reduced the risk factors.change that eliminates or reduced the risk factors.


2. Minimize anxiety2. Minimize anxiety

– Maintain a calm and reassuring attitudeMaintain a calm and reassuring attitude

– Emphasized with the patient to promote a sense of confidence Emphasized with the patient to promote a sense of confidence in living the disease.in living the disease.

– Goal is to maximize the client’s controls and to make the Goal is to maximize the client’s controls and to make the unknown less threatening.unknown less threatening.

3. Promoting Home and Community Based 3. Promoting Home and Community Based CareCare

• Explain the importance of maintaining therapeutic serum levels of Explain the importance of maintaining therapeutic serum levels of the medications so that the patients understand why medications the medications so that the patients understand why medications should be taken regularly each day.should be taken regularly each day.

Adjunctive Modalities and Adjunctive Modalities and ManagementManagement

• Pacemaker therapyPacemaker therapy – is an electronic – is an electronic device that provide electrical stimulation device that provide electrical stimulation to the heart muscles. Used when the to the heart muscles. Used when the patient has a slower than normal impulse patient has a slower than normal impulse formation or conduction disturbance formation or conduction disturbance causing symptoms.causing symptoms.

– Permanent pacemaker- are used commonly Permanent pacemaker- are used commonly irreversible complete heart block.irreversible complete heart block.

– Temporary pacemaker- are used to support Temporary pacemaker- are used to support patients until they improve or receive a patients until they improve or receive a permanent pacemaker.permanent pacemaker.

Pacemaker Design and Pacemaker Design and typestypes

• Pacemaker consist of 2 components : an electronic pulse generator Pacemaker consist of 2 components : an electronic pulse generator and pacemaker electrodes, which are located on leads or wire. The and pacemaker electrodes, which are located on leads or wire. The generator contains the circuitry and batteries that generate the rate generator contains the circuitry and batteries that generate the rate and strength of the electrical impulse delivered to the heart.and strength of the electrical impulse delivered to the heart.

• The pacemaker electrodes convey the heart’s electrical activity The pacemaker electrodes convey the heart’s electrical activity through a lead to the generator ; the generator’s electrical response through a lead to the generator ; the generator’s electrical response to the information received is then transmitted to the heart.to the information received is then transmitted to the heart.

• Leads can be threaded through a major veins into the right Leads can be threaded through a major veins into the right ventricles (endocardial leads) or they can be lightly sutured onto ventricles (endocardial leads) or they can be lightly sutured onto the outside the heart and brought the chest wall during open heart the outside the heart and brought the chest wall during open heart surgery.surgery.

Pacemaker Design and Pacemaker Design and typestypes

• Epicardial wires are always temporary and are Epicardial wires are always temporary and are removed by a gentle tug within a few daysafter removed by a gentle tug within a few daysafter surgery.surgery.

• Endocardial leads may be temporarily placed with Endocardial leads may be temporarily placed with catheters through the femoral, antecubical, catheters through the femoral, antecubical, brachial or jugular veins, usually guided by brachial or jugular veins, usually guided by fluoroscopy.fluoroscopy.

• The energy source for permanent generators are: The energy source for permanent generators are: mercury-zinc batteries (which last 3 to 4 years), mercury-zinc batteries (which last 3 to 4 years), lithium cell units (up to 10 years), nuclear powered lithium cell units (up to 10 years), nuclear powered source such as plutonium (up to 20 years).source such as plutonium (up to 20 years).

Clinical ManifestationClinical Manifestation

• Block AV block usually 3 bundle Block AV block usually 3 bundle branch blockbranch block

• Symptomatic BradycardiaSymptomatic Bradycardia

• Arrhythmia during surgeryArrhythmia during surgery

• Sick sinus syndromeSick sinus syndrome


• Monitoring Pacemaker function-Monitoring Pacemaker function- observe observe the presence of the pacemaker spikes in the the presence of the pacemaker spikes in the ECG, monitor for the pacemaker ECG, monitor for the pacemaker malfunctions, weakness, dizziness, fainting, malfunctions, weakness, dizziness, fainting, hypotension, shortness of breath, chest pain, hypotension, shortness of breath, chest pain, ankle swelling.ankle swelling.

• Prevent infections-Prevent infections- changes the dressing changes the dressing regularly and inspects the insertion site for regularly and inspects the insertion site for redness, swelling, soreness or any unusual redness, swelling, soreness or any unusual drainage and increase the temperature drainage and increase the temperature should be noted. should be noted.


• Client teaching about pacemaker-Client teaching about pacemaker- instruct the patient how to check pulse at home, inform instruct the patient how to check pulse at home, inform

to report any changes in the heart rate, avoid contact to report any changes in the heart rate, avoid contact sports, carry ID, instruct to report sign of battery sports, carry ID, instruct to report sign of battery failure, wear loose fitting clothes, remind that most failure, wear loose fitting clothes, remind that most electrical appliances can be used without interference electrical appliances can be used without interference the functions of the pacemaker, avoid MRI, transmitter the functions of the pacemaker, avoid MRI, transmitter tower and anti theft device, move away from electrical tower and anti theft device, move away from electrical appliances that cause disturbances and emphasize appliances that cause disturbances and emphasize regular follow up check up.regular follow up check up.

End of the slides

STROKESTROKE

StrokeStrokeDisruption of cerebral circulation that results in motor and sensory deficitsDisruption of cerebral circulation that results in motor and sensory deficits

Causes:Causes:

• Cerebral arteriosclerosisCerebral arteriosclerosis

• SyphilisSyphilis

• TraumaTrauma

• HypertensionHypertension

• ThrombosisThrombosis

• EmbolismEmbolism

• HemorrhageHemorrhage

• VasospasmVasospasm

Types of StrokeTypes of Stroke

1. Ischemic Stroke1. Ischemic Stroke • Large Artery Thrombotic Strokes-Large Artery Thrombotic Strokes- are due to are due to

atherosclerotic plaques in the large blood vessel of the brain. atherosclerotic plaques in the large blood vessel of the brain. Thrombus formation and occlusion at the site of the Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infraction and occur in atherosclerosis result in ischemia and infraction and occur in older patients.older patients.

• Small Penetrating Artery Thrombotic Strokes-Small Penetrating Artery Thrombotic Strokes- affect one or more vessels are the most common type of affect one or more vessels are the most common type of ischemic stroke. Also called lacunar strokes. Occur in young ischemic stroke. Also called lacunar strokes. Occur in young ones.ones.

Types of StrokeTypes of Stroke

• Cardiogenic Embolic Strokes-Cardiogenic Embolic Strokes- are associated with cardiac dysrhythmias, usually atrial are associated with cardiac dysrhythmias, usually atrial fibrillation. Emboli originated from the heart and circulate to fibrillation. Emboli originated from the heart and circulate to the cerebral vasculature, most commonly in the left middle the cerebral vasculature, most commonly in the left middle cerebral artery, resulting in a stroke. Embolic strokes may be cerebral artery, resulting in a stroke. Embolic strokes may be prevented by the use of anticoagulant therapy in patients prevented by the use of anticoagulant therapy in patients with atrial fibrillation.with atrial fibrillation.

• Cryptogenic Stroke-Cryptogenic Stroke- which have no known cause which have no known cause and other stroke from cause of cocaine used, coagulopathies, and other stroke from cause of cocaine used, coagulopathies, migraine and spontaneous dissections of the carotid or migraine and spontaneous dissections of the carotid or vertebral arteries.vertebral arteries.

Clinical ManifestationClinical Manifestation• Numbness or weakness of the face, arm or leg especially on one Numbness or weakness of the face, arm or leg especially on one

side of the body.side of the body.

• Confusion or change in mental statusConfusion or change in mental status

• Trouble speaking or understanding speechTrouble speaking or understanding speech

• Visual disturbanceVisual disturbance

• Difficulty walking, dizziness or loss of balance or coordinationDifficulty walking, dizziness or loss of balance or coordination

• Sudden severe headacheSudden severe headache

Clinical ManifestationClinical ManifestationMotor lossMotor loss• A stroke is a lesion of the upper motor neurons and A stroke is a lesion of the upper motor neurons and

result in loss of voluntary control over motor result in loss of voluntary control over motor movements. Upper motor neuron decussate (cross) a movements. Upper motor neuron decussate (cross) a disturbance of voluntary motor control on one side of disturbance of voluntary motor control on one side of the body may reflect damage to the upper motor the body may reflect damage to the upper motor neuron on the opposite side of the brain.neuron on the opposite side of the brain.

• Most common motor dysfunction is Most common motor dysfunction is hemiplegia hemiplegia ((paralysis of one side of the body) due to the lesion of paralysis of one side of the body) due to the lesion of the opposite side of the brain.the opposite side of the brain.

• Hemiparesis Hemiparesis or weakness of one side of the body or weakness of one side of the body

• Flaccid paralysisFlaccid paralysis and loss or decrease of deep tendon and loss or decrease of deep tendon reflex.reflex.

Clinical ManifestationClinical ManifestationCommunication LossCommunication Loss

• Dysarthia Dysarthia ( difficulty in speaking), caused by paralysis of ( difficulty in speaking), caused by paralysis of the muscles responsible for producing speech.the muscles responsible for producing speech.

• Dysphasia or aphasiaDysphasia or aphasia (defective speech or loss of (defective speech or loss of speech) which can be speech) which can be expressive aphasia, receptive aphasia expressive aphasia, receptive aphasia or global (mixed) aphasiaor global (mixed) aphasia

• Apraxia Apraxia ( inability to perform a previously learned action) as ( inability to perform a previously learned action) as may be seen when a patient picks up a fork and attempts to comb.may be seen when a patient picks up a fork and attempts to comb.

Clinical ManifestationClinical ManifestationPerceptual DisturbancePerceptual Disturbance

• Perception is the ability to interpret sensationPerception is the ability to interpret sensation• Visual perceptual dysfunction are due to disturbance of the primary Visual perceptual dysfunction are due to disturbance of the primary

sensory pathways between the eye and visual cortex.sensory pathways between the eye and visual cortex.• Hemianopsia (loss of half of the visual fields) may be occur from the Hemianopsia (loss of half of the visual fields) may be occur from the

stroke and may be temporary or permanent.stroke and may be temporary or permanent.• Disturbance in visual spatial relation ( perceiving the relation of two or Disturbance in visual spatial relation ( perceiving the relation of two or

more objects in spatial areas) frequently seen in patient with right more objects in spatial areas) frequently seen in patient with right hemispheric damage. hemispheric damage. Sensory LossSensory Loss

• Sensory loss from stroke may take the form of slight Sensory loss from stroke may take the form of slight impairment of touch or may be more severe, with impairment of touch or may be more severe, with loss of proprioception ( ability to perceive the position loss of proprioception ( ability to perceive the position and motion of the body parts) as well as difficulty in and motion of the body parts) as well as difficulty in interpreting visual, tactile and auditory stimuli.interpreting visual, tactile and auditory stimuli.

Clinical ManifestationClinical ManifestationSensory LossSensory Loss

• Sensory loss from stroke may take the Sensory loss from stroke may take the form of slight impairment of touch or form of slight impairment of touch or may be more severe, with loss of may be more severe, with loss of proprioception ( ability to perceive the proprioception ( ability to perceive the position and motion of the body parts) position and motion of the body parts) as well as difficulty in interpreting as well as difficulty in interpreting visual, tactile and auditory stimuli.visual, tactile and auditory stimuli.


Cognitive ImpairmentCognitive Impairment

• Such dysfunction may be attention span, Such dysfunction may be attention span, difficulties in comprehension, forgetfulness difficulties in comprehension, forgetfulness and lack of motivation, which cause these and lack of motivation, which cause these patients to become frustrated in their patients to become frustrated in their rehabilitation program.rehabilitation program.

Nursing DiagnosisNursing Diagnosis• Impaired physical mobility related to Impaired physical mobility related to

hemiparesis. Loss of balance and coordination, hemiparesis. Loss of balance and coordination, spasticity and brain injury.spasticity and brain injury.

• Acute pain (painful shoulder) related to Acute pain (painful shoulder) related to hemiplegia and disuse hemiplegia and disuse

• Self care deficit ( hygiene, toileting, grooming Self care deficit ( hygiene, toileting, grooming and feeding) related to stroke sequelaeand feeding) related to stroke sequelae

• Disturbed sensory perception related to altered Disturbed sensory perception related to altered sensory reception, transmission and integration.sensory reception, transmission and integration.

• Impaired swallowingImpaired swallowing• Incontinence related to flaccid bladder, detrusor Incontinence related to flaccid bladder, detrusor

instability confusion or difficulty in instability confusion or difficulty in communicating.communicating.


• Disturbed thought process related to brain damage, confusion Disturbed thought process related to brain damage, confusion or inability to follow instruction.or inability to follow instruction.

• Impaired verbal communication related to brain damageImpaired verbal communication related to brain damage

• Risk for impaired skin integrity related to hemiparesis/ Risk for impaired skin integrity related to hemiparesis/ hemiplegia or decreased mobility.hemiplegia or decreased mobility.

• Interrupted family process related to catastrophic illness and Interrupted family process related to catastrophic illness and care giving burdenscare giving burdens

• Sexual dysfunction related to neurologic deficit or fear of failureSexual dysfunction related to neurologic deficit or fear of failure

Diagnosic Test FindingsDiagnosic Test Findings

• LP:LP: increase pressure, bloody CSFincrease pressure, bloody CSF

• CT scan:CT scan: intracranial bleeding, infarct, or intracranial bleeding, infarct, or shift of midline structuresshift of midline structures..

• EEG:EEG: focal slowing in area of lesionfocal slowing in area of lesion

• MRI:MRI: intracranial bleeding, infarct, or shift intracranial bleeding, infarct, or shift of midline structuresof midline structures

• Brain scan:Brain scan: decreased perfusiondecreased perfusion

• Digital subtraction Angiography:Digital subtraction Angiography: occlusion or narrowing of vesselocclusion or narrowing of vessel

Medical ManagementMedical Management• Platelet inhibiting medication decrease the incidence of Platelet inhibiting medication decrease the incidence of

cerebral infraction in patients who have experience TIA from cerebral infraction in patients who have experience TIA from embolic or thrombotic causeembolic or thrombotic cause

• Thrombolytic agents are used to treat ischemic by dissolving Thrombolytic agents are used to treat ischemic by dissolving the blood clot that is blocking blood flow to the brain. the blood clot that is blocking blood flow to the brain. Recombinant t-PA is genetically engineered form t-PA Recombinant t-PA is genetically engineered form t-PA thrombolytic substance made naturally by the body. It works thrombolytic substance made naturally by the body. It works by binding to fibrin and converting plasminogen to plasmin by binding to fibrin and converting plasminogen to plasmin which stimulate fibrinolysis of the atherosclerosis lesion.which stimulate fibrinolysis of the atherosclerosis lesion.

• The dose of t-PA minimum dose is 0.9mg/kg, the maximum The dose of t-PA minimum dose is 0.9mg/kg, the maximum dose is 90 mg. The loading dose is 10% of the calculated dose dose is 90 mg. The loading dose is 10% of the calculated dose and is administering over 1min. the remaining dose is and is administering over 1min. the remaining dose is administered over 1 hr via an infusion pump. Then flushed the administered over 1 hr via an infusion pump. Then flushed the line with 20 ml of normal saline solution.line with 20 ml of normal saline solution.


• Vital sign monitored q 15min for the first 2 hrs,q30 min for the Vital sign monitored q 15min for the first 2 hrs,q30 min for the next 6 hrs.next 6 hrs.

• Bleeding is the most common side effects of t-PA Bleeding is the most common side effects of t-PA administration and the patient should be closely monitored.administration and the patient should be closely monitored.

• Other treatment are anticoagulant administration for Other treatment are anticoagulant administration for ischemic stroke and careful maintenace of cerebral ischemic stroke and careful maintenace of cerebral hemodynamics to maintain cerebral perfusion. Elevation of hemodynamics to maintain cerebral perfusion. Elevation of the head of the bed to promote venous drainage and to lower the head of the bed to promote venous drainage and to lower increased ICP.intubation with an endotracheal tube to increased ICP.intubation with an endotracheal tube to established a patent airway. established a patent airway.

• Endarterectomy for prevention of ischemic stroke is the Endarterectomy for prevention of ischemic stroke is the removal of an atherosclerotic plaques orthrombus from the removal of an atherosclerotic plaques orthrombus from the carotid artery to prevent stroke in patients with occlusive carotid artery to prevent stroke in patients with occlusive disease of the ectracranial cerebral arteries disease of the ectracranial cerebral arteries

Nursing InterventionNursing Intervention1.1. Improving mobility and preventing joint Improving mobility and preventing joint

deformitiesdeformities

– correct positioning is important to prevent contractures correct positioning is important to prevent contractures – Prevent adduction of the affected shoulder while the patients is in Prevent adduction of the affected shoulder while the patients is in

bed, a pillow is placed in the axilla when where is limited external bed, a pillow is placed in the axilla when where is limited external rotation; this keep the arm away from the chest.rotation; this keep the arm away from the chest.

– Positioning the finger so that they are flexed while the hand Positioning the finger so that they are flexed while the hand placed on slight supination which it is most functional position. placed on slight supination which it is most functional position.

– The patients position should be changed every 2 hrs. toplace a The patients position should be changed every 2 hrs. toplace a patient in a lateral position position, a pillow is placed between the patient in a lateral position position, a pillow is placed between the legs before the patients is turned. legs before the patients is turned.

– A full range of motion 4 to 5 times a day to maintain joint mobility A full range of motion 4 to 5 times a day to maintain joint mobility and regain motor control, prevent contractures, prevent further and regain motor control, prevent contractures, prevent further deterioration of the neurovascular systemdeterioration of the neurovascular system

– Preparing for ambulation, the patient is taught to maintain Preparing for ambulation, the patient is taught to maintain balance while sitting and then learn to balance while standing in a balance while sitting and then learn to balance while standing in a gradual manner until the patient can walk.gradual manner until the patient can walk.


22 Preventing Shoulder painPreventing Shoulder pain• To prevent shoulder pain, the nurse should never lift the To prevent shoulder pain, the nurse should never lift the

patient by the flaccid shoulder or pull on the affected arm patient by the flaccid shoulder or pull on the affected arm shoulder. If the arm is paralyzed, subluxation at the shoulder shoulder. If the arm is paralyzed, subluxation at the shoulder can occur from over stretching the joint capsule and can occur from over stretching the joint capsule and masculature by the force of gravity.masculature by the force of gravity.

• Amitriptyline hydrochloride used because of its sedating Amitriptyline hydrochloride used because of its sedating effects.effects.

• Some clinicians advocate the use of a properly worn sling Some clinicians advocate the use of a properly worn sling when the patients first becomes ambulatory to prevent upper when the patients first becomes ambulatory to prevent upper extremity from dangling without support.extremity from dangling without support.

• ROM is important in preventing painful shoulder ROM is important in preventing painful shoulder


3. Manage Dysphagia 3. Manage Dysphagia

• ETET is reduced the risk of aspiration while the patient is reduced the risk of aspiration while the patient

is in ET tube elevate the head of the bed at least 30 is in ET tube elevate the head of the bed at least 30 degree to prevent aspiration, check the proper degree to prevent aspiration, check the proper position of the ET tube before feeding the patients, position of the ET tube before feeding the patients, ensure the cuff of ET is inflated and give the formula ensure the cuff of ET is inflated and give the formula slowly.slowly.

• Intermittent catheterization is used with patient with Intermittent catheterization is used with patient with bladder distention. And increased high fiber diet and bladder distention. And increased high fiber diet and adequate fluid intake with patient with constipation adequate fluid intake with patient with constipation

STROKESTROKE

ISCHEMIC STROKE

HEMORRHAGIC STROKE

Hemorrhagic StrokeHemorrhagic Stroke• Primarily caused by an intracranial or Primarily caused by an intracranial or

subarachnoid hemorrhage, bleeding into the brain subarachnoid hemorrhage, bleeding into the brain tissue, the ventricles, or subarachnoid space.tissue, the ventricles, or subarachnoid space.

• Intracerebral hemorrhage from spontaneous Intracerebral hemorrhage from spontaneous rupture of small vessels account approximately rupture of small vessels account approximately 80% of hemorrhagic strokes and caused by 80% of hemorrhagic strokes and caused by uncontrolled hypertension.uncontrolled hypertension.

• Secondary intracerebral hemorhage is associated Secondary intracerebral hemorhage is associated with arteriovenous malformation, intracranial with arteriovenous malformation, intracranial aneurysm, or certain medications (anticoagulants aneurysm, or certain medications (anticoagulants and amphetamines)and amphetamines)

Hemorrhagic StrokeHemorrhagic Stroke

PathophysiologyPathophysiologyIntracerebral hemorrhage Intracerebral hemorrhage

• Bleeding into the brain substance, common in patients with hypertension Bleeding into the brain substance, common in patients with hypertension and cerebral atherosclerosis that causes rupture of the vesseland cerebral atherosclerosis that causes rupture of the vessel

• Brain tumor and the use of medicines( oral anticoagulants, amphetamines Brain tumor and the use of medicines( oral anticoagulants, amphetamines and illicit drugs such as crack and cocoaine).and illicit drugs such as crack and cocoaine).

• Bleeding occur mostly in the cerebral lobes, basal ganglia, thalamus, Bleeding occur mostly in the cerebral lobes, basal ganglia, thalamus, brain stem (mostly pons) and cerebellumbrain stem (mostly pons) and cerebellum

Intracranial (Cerebral) AneurysmIntracranial (Cerebral) Aneurysm

• Dilation of cerebral artery wall causes of weakness in the arterial walls.Dilation of cerebral artery wall causes of weakness in the arterial walls.

• An aneurysm due to atherosclerosis, vascular disease, head trauma or An aneurysm due to atherosclerosis, vascular disease, head trauma or advance aging.advance aging.

PathophysiologyPathophysiologyArteriovenous MalformationArteriovenous Malformation

• Due to an abnormality in embryonal development that leads to Due to an abnormality in embryonal development that leads to a tangle of arteries and viens in the brain without acapillary bed. a tangle of arteries and viens in the brain without acapillary bed. A cause of hemorrhagic in young peoples.A cause of hemorrhagic in young peoples.

Subarachnoid HemorrhageSubarachnoid Hemorrhage

• May occur as a result of an AVM, intracranial, aneurysm, trauma May occur as a result of an AVM, intracranial, aneurysm, trauma or hypertensionor hypertension

• There is a leaking aneurysm in the area of the circle of Willis or a There is a leaking aneurysm in the area of the circle of Willis or a congenital AVM of the brain.congenital AVM of the brain.

S

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Clinical manifestationsClinical manifestations

• Sudden, unusually severe headache and often loss Sudden, unusually severe headache and often loss of consciousness for a variable period.of consciousness for a variable period.

• Pain and rigidity at the bask of the neck (nuchal Pain and rigidity at the bask of the neck (nuchal rigidity) and spine due to meningeal irritation. rigidity) and spine due to meningeal irritation.

• Visual disturbance: loss of vision, diplopia, and Visual disturbance: loss of vision, diplopia, and ptosis occur when the aneurysm is adjacent to the ptosis occur when the aneurysm is adjacent to the oculomotor nerve.oculomotor nerve.

• Tinnitus, dizziness and hemiparesis may also occur.Tinnitus, dizziness and hemiparesis may also occur.

AssessmentAssessment• Altered level of consciousnessAltered level of consciousness

• Sluggish papillary reactionSluggish papillary reaction

• Motor and sensory dysfunctionMotor and sensory dysfunction

• Cranial nerve deficit (EOM, facial droop, presence of Cranial nerve deficit (EOM, facial droop, presence of ptosis)ptosis)

• Speech difficulties and visual disturbanceSpeech difficulties and visual disturbance

• Headache and nuchal rigidity or other neurologic deficit Headache and nuchal rigidity or other neurologic deficit


• Ineffective cerebral tissue perfusion related to Ineffective cerebral tissue perfusion related to bleedingbleeding

• Disturced sensory perception related to medically Disturced sensory perception related to medically imposed restrictions (aneurysm precautions)imposed restrictions (aneurysm precautions)

• Anxiety related to illness and / or medically Anxiety related to illness and / or medically imposed restrictions.imposed restrictions.

Medical ManagementMedical Management• Bed rest with sedation to prevent agitation and stress Bed rest with sedation to prevent agitation and stress

management of vasospasm and surgical and medical treatment management of vasospasm and surgical and medical treatment to prevent rebleedingto prevent rebleeding

• Analgesic prescribed for head and neck painAnalgesic prescribed for head and neck pain

• Elastic compression stockings to prevent DVT.Elastic compression stockings to prevent DVT.

• Adequate hydration must be ensured to reduced blood Adequate hydration must be ensured to reduced blood viscosity and improve cerebral blood flow.viscosity and improve cerebral blood flow.

• IV administration of calcium channel blockers, nimodipine which IV administration of calcium channel blockers, nimodipine which delay the ischemic deterioration.delay the ischemic deterioration.

• Mannitol is given to reduced ICP, it acts by pulling water out of Mannitol is given to reduced ICP, it acts by pulling water out of the brain tissue by osmosis as well as reducing total body water the brain tissue by osmosis as well as reducing total body water through diuresis.through diuresis.


Optimizing Cerebral Tissue Optimizing Cerebral Tissue PerfusionPerfusion

• Monitor blood pressure , pulse , level of Monitor blood pressure , pulse , level of responsiveness, papillary reaction and motor responsiveness, papillary reaction and motor functions hourly.functions hourly.

• Respiration status is monitored becaused reduction Respiration status is monitored becaused reduction of O2 in the areas of the brain with impaired of O2 in the areas of the brain with impaired autoregulation increased chances of cerebral autoregulation increased chances of cerebral infraction.infraction.


Implementing Aneurysm precautionImplementing Aneurysm precaution

• CBR with quite, non stressfull environment CBR with quite, non stressfull environment

• HOB elevated 15 to 30 degree to promote venous drainage and decrease ICP.HOB elevated 15 to 30 degree to promote venous drainage and decrease ICP.

• Avoid Valsalva maneuver, straining , forceful sneezing, pushing up to bed, acute Avoid Valsalva maneuver, straining , forceful sneezing, pushing up to bed, acute flexion or rotation of the head and neck.flexion or rotation of the head and neck.

• No enemas are permitted but stool softener and mild laxative is prescribed.No enemas are permitted but stool softener and mild laxative is prescribed.

• Dim light is helpful because of photophobiaDim light is helpful because of photophobia

• Coffee , tea, unless decaffeinated is usually eliminated.Coffee , tea, unless decaffeinated is usually eliminated.

• Wear antiemboic stocking to prevent DVTWear antiemboic stocking to prevent DVT

• Observed for the s/sx of deep vein thrombosis such as tenderness, swelling, Observed for the s/sx of deep vein thrombosis such as tenderness, swelling, warmth, discoloration, positive Homan’s sign report any abnormal findings warmth, discoloration, positive Homan’s sign report any abnormal findings End of the slides

BURNS

BurnsBurns

• Burns are caused by a transfer of energy from a source to the Burns are caused by a transfer of energy from a source to the body.body.

• Categorized as thermal, radiation or chemical burn.Categorized as thermal, radiation or chemical burn.

• There is a disruption in the skin that leads to increased fluid There is a disruption in the skin that leads to increased fluid loss, infection, hypothermia, scarring, compromised immunity loss, infection, hypothermia, scarring, compromised immunity and changes in function, appearance, and body image.and changes in function, appearance, and body image.

• Young children and older people are at high risk for burn injuryYoung children and older people are at high risk for burn injury

• Younger than 5 years and older than 40 y/o are at high risk for Younger than 5 years and older than 40 y/o are at high risk for death after burn trauma. death after burn trauma.


Four major goals relating to burn:Four major goals relating to burn:

• PreventionPrevention

• Institution of life saving measure Institution of life saving measure for the severely burned personfor the severely burned person

• Prevention of disability and Prevention of disability and disfigurementdisfigurement

• rehabilitationrehabilitation


Tissue destruction results from coagulation, protein denaturation, or ionization of cellular contents.

Skin and the mucosa of the upper airways are the sites of tissue destruction

Caused by transfer of energy form a heat source to the body

Thermal, radiation or chemical burn

Deep tissue can be damaged by electrical

burns or through prolonged contact with a

heat source

Disruption of the skin can lead increased fluid loss, infection,

hypothermia scarring compromised immunity, and

changes in function, appearance, and body image.

Depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent

Classifications of Burn Classifications of Burn According to Depth of Tissue According to Depth of Tissue DestructionDestruction

A.A. Superficial Partial-Thicknes Burn Superficial Partial-Thicknes Burn (first degree burn)(first degree burn)

• The epidermis and possibly a portion of the The epidermis and possibly a portion of the dermis are injureddermis are injured

• The damaged skin may be painful and The damaged skin may be painful and appear red and dry, as in sunburn, or it may appear red and dry, as in sunburn, or it may blister.blister.

First Degree BurnFirst Degree Burn

Classifications of Burn Classifications of Burn According to Depth of Tissue According to Depth of Tissue DestructionDestructionB. Deep Partial – ThicknessB. Deep Partial – Thickness

(second degree burn)(second degree burn)

• The epidermis and upper to uper deeper portion of the dermis are The epidermis and upper to uper deeper portion of the dermis are injured. eg, scaldinjured. eg, scald

• The wound is painful, appears red, and exudes fluid. Capillary The wound is painful, appears red, and exudes fluid. Capillary refill follows tissue blanching. refill follows tissue blanching.

• Hair follicles remain intact. Hair follicles remain intact.

• Deep partial-thickness burns take longer to heal and are more Deep partial-thickness burns take longer to heal and are more likely to result in hypertrophic scars.likely to result in hypertrophic scars.

Second Degree BurnSecond Degree Burn

Classifications of Burn Classifications of Burn According to Depth of Tissue According to Depth of Tissue DestructionDestructionC. Full – Thickness Burn C. Full – Thickness Burn

(third degree burn)(third degree burn)

• Burn from a flame or electric currentBurn from a flame or electric current

• The epidermis, entire dermis, and sometimes the underlying The epidermis, entire dermis, and sometimes the underlying tissue are injuredtissue are injured

• Wound color ranges widely from white to red, brown, or black. Wound color ranges widely from white to red, brown, or black.

• The burned area is painless because nerve fibers are destroyed. The burned area is painless because nerve fibers are destroyed. And the wound appears leathery; hair follicles and sweat glands And the wound appears leathery; hair follicles and sweat glands are destroyed are destroyed

Third Degree BurnThird Degree Burn

Extent of Body Surface Extent of Body Surface Area InjuredArea Injured

A. Inner zone A. Inner zone • known as the area of coagulation, where known as the area of coagulation, where

cellular death occurscellular death occurs• sustains the most damage. sustains the most damage.

B. Middle zone B. Middle zone • has a compromised blood supply, inflammation, has a compromised blood supply, inflammation,

and tissue injury. and tissue injury.

C. Outer zoneC. Outer zone• the zone of hyperemia which sustains the least the zone of hyperemia which sustains the least

damage.damage.

RULE OF NINERULE OF NINE

9

18 189 9

18 18

PARKLAND FORMULA Computation of fluids

Most commonly used in burned patient

Formula: TBSA x 4ml x kg body weight

1st 8hrs give 50% of the formula2nd 8hrs give 25% of the formula3rd 8hrs give 25% of the formula

An estimation of the TBSA involved in a burn is simplified by using the rule of nines. It is a quick way to calculate the extent of burns. The system assigns percentage in multiples of nine to major body surfaces.

1

Methods in Determining the Methods in Determining the Extent of Surface Area Extent of Surface Area BurnedBurned• Rule of NineRule of Nine: an estimation of the total body : an estimation of the total body

surface area (BSA) burned by dividing the body into surface area (BSA) burned by dividing the body into multiples of nine.multiples of nine.

• Lund and Browder MethodLund and Browder Method: a more precise : a more precise method of estimating the extent of the burn; the method of estimating the extent of the burn; the percentage of the surface area is represented by percentage of the surface area is represented by various anatomic parts (head and legs) changes various anatomic parts (head and legs) changes with growth. with growth.

• Palm MethodPalm Method: used to estimate percentage of the : used to estimate percentage of the scattered burns; using the size of the px palm (abt. scattered burns; using the size of the px palm (abt. 1% of body surface area) to assess the extent of 1% of body surface area) to assess the extent of burn injury.burn injury.

AssessmentAssessment• Review the initial assessment data obtained by prehospital providers. Assess Review the initial assessment data obtained by prehospital providers. Assess

the time of injury, mechanism of burn whether the burn happened in a closed the time of injury, mechanism of burn whether the burn happened in a closed space, the possibility of inhalation of noxious chemicals, and any related space, the possibility of inhalation of noxious chemicals, and any related trauma.trauma.

• Focus on the major priorities of any trauma patient: ABC, disability, exposure, Focus on the major priorities of any trauma patient: ABC, disability, exposure, and fluid resuscitation.and fluid resuscitation.

• Assess respiratory status as first priority (airway patency and breathing Assess respiratory status as first priority (airway patency and breathing adequacy)adequacy)

• Note any increased hoarseness, stridor, abnormal respiratory rate, and depth, Note any increased hoarseness, stridor, abnormal respiratory rate, and depth, or mental changes from hypoxia.or mental changes from hypoxia.

• Evaluate circulation (apical, carotid, and femoral pulse) Evaluate circulation (apical, carotid, and femoral pulse)

• Check V/S frequently, using an ultrasound device if necessary.Check V/S frequently, using an ultrasound device if necessary.

• Check peripheral pulses on burned extremities hourly; use Doppler as neededCheck peripheral pulses on burned extremities hourly; use Doppler as needed

AssessmentAssessment• Review the initial assessment data obtained by perhospital Review the initial assessment data obtained by perhospital

providersproviders• Focus on the major priorities of any trauma patient (ABC)Focus on the major priorities of any trauma patient (ABC)• Assess respiratory status as first priorityAssess respiratory status as first priority• Note any increased hoarseness, stridor, abnormal respiratory Note any increased hoarseness, stridor, abnormal respiratory

rate and depth or mental changes from hypoxiarate and depth or mental changes from hypoxia• Evaluate circulation (apical, carotid and femoral pulses)Evaluate circulation (apical, carotid and femoral pulses)• Check V/S frequentlyCheck V/S frequently• Check pheripheral pulses on burned extremities hourlyCheck pheripheral pulses on burned extremities hourly• Monitor fluid intake and output measure hourlyMonitor fluid intake and output measure hourly• Arrange for patients with facial burns to be assessed for corneal Arrange for patients with facial burns to be assessed for corneal

injuryinjury• Assess body temperature, body weight, hx of preborn weight, Assess body temperature, body weight, hx of preborn weight,

allergies, tetanus immunization, past medical surgical allergies, tetanus immunization, past medical surgical problems, current illnesses and use of medicationproblems, current illnesses and use of medication

• Assess depth of wound and identify areas of full and partial Assess depth of wound and identify areas of full and partial thickness injurythickness injury

• Assess neurologic statusAssess neurologic status• Assess patient’s and family understanding of injury and Assess patient’s and family understanding of injury and

treatmenttreatment

Diagnosis Diagnosis

• Impaired gas exchange r/t carbon monoxide poisoning, smoke Impaired gas exchange r/t carbon monoxide poisoning, smoke inhalation, and upper airway obstructioninhalation, and upper airway obstruction

• Ineffective airway clearance r/t edema and effects of smoke Ineffective airway clearance r/t edema and effects of smoke inhalationinhalation

• Fluid volume deficit r/t increased capillary permeability and Fluid volume deficit r/t increased capillary permeability and evaporative fluid loss from burn wound.evaporative fluid loss from burn wound.

• Hypothermia r/t loss of skin microcirculation and open woundHypothermia r/t loss of skin microcirculation and open wound

• Pain r/t tissue and nerve injury and emotional impact of injury.Pain r/t tissue and nerve injury and emotional impact of injury.

• Anxiety r/t fear and emotional impact of injuryAnxiety r/t fear and emotional impact of injury

Nursing InterventionNursing Intervention1. 1. Promoting Gas Exchanage and Airway ClearancePromoting Gas Exchanage and Airway Clearance

– Provide humidified oxygen, and monitor arterial blood gas (ABGs), Provide humidified oxygen, and monitor arterial blood gas (ABGs), pulse oximetry, and carboxyhemoglobin levelspulse oximetry, and carboxyhemoglobin levels

– Assess breath sound, respiratory rate, rhythm, depth, and Assess breath sound, respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia.symmetry; monitor for hypoxia.

– Observed for sign of inhalation injury: blistering of lips or buccal Observed for sign of inhalation injury: blistering of lips or buccal mucosamucosa

– Report labored respiration, decreased depth of respirations; Report labored respiration, decreased depth of respirations; prepare to assist with intubations and escharotomiesprepare to assist with intubations and escharotomies

– Monitor patient with mechanical ventilation.Monitor patient with mechanical ventilation.– Institute aggressive pulmonary care measures; turning coughing, Institute aggressive pulmonary care measures; turning coughing,

deep breathing, using spirometry and deep breathing, using spirometry and tracheal suctioning.tracheal suctioning.

– Maintain proper positioning t promote removal of secretions and Maintain proper positioning t promote removal of secretions and patent airway, optimal chest expansion.patent airway, optimal chest expansion.

– Maintain asepsis to prevent contamination of the respiratory tract Maintain asepsis to prevent contamination of the respiratory tract and infection, which increase metabolic requirementsand infection, which increase metabolic requirements


2. Restoring Fluid and Electrolyte Balance2. Restoring Fluid and Electrolyte Balance– Insert large-bone IV catheter and indwelling urinary catheterInsert large-bone IV catheter and indwelling urinary catheter– Monitor V/S and urinary IO (hourly), note sign of hypovolimia or Monitor V/S and urinary IO (hourly), note sign of hypovolimia or

fluid overload.fluid overload.– Provide IV fluids as prescribe; document IO and daily weight.Provide IV fluids as prescribe; document IO and daily weight.– Elevate head of bed and burned extremitiesElevate head of bed and burned extremities– Monitor serum electrolyte levels (eg, sodium, potassium, calcium, Monitor serum electrolyte levels (eg, sodium, potassium, calcium,

phosphorus, bicarbonate); recognizing developing electrolyte phosphorus, bicarbonate); recognizing developing electrolyte imbalanceimbalance

3. Maintaining Normal Body Temperature3. Maintaining Normal Body Temperature– Provide warm environment; use heat shield, space blanket, and Provide warm environment; use heat shield, space blanket, and

heat lightsheat lights– Assess core body temp. frequentlyAssess core body temp. frequently– Work quikly when wounds must be exposed to minimize heat loss Work quikly when wounds must be exposed to minimize heat loss

from the wound from the wound

Nursing InterventionNursing Intervention4. Minimizing Pain and Anxiety4. Minimizing Pain and Anxiety

– Use pain sclae to asses painUse pain sclae to asses pain

– Perform respiratory assessment before giving analgesic agent to Perform respiratory assessment before giving analgesic agent to nonventilated px.nonventilated px.

– Admistered IV analgesic as prescribe and assess response to Admistered IV analgesic as prescribe and assess response to medicationmedication

– Assess px and family understanding of burn injury, coping strategies, Assess px and family understanding of burn injury, coping strategies, family dynamics, and anxiety levels.family dynamics, and anxiety levels.

– Provide emotional support, reassurance and simple explanation about Provide emotional support, reassurance and simple explanation about proceduresprocedures

– Provide pain releif, and give antianxiety med if px remain highly Provide pain releif, and give antianxiety med if px remain highly anxious and agitated.anxious and agitated.

Nursing InterventionNursing Intervention5. Monitor and Managing Potential Complications5. Monitor and Managing Potential Complications

– Acute Respiratory FailureAcute Respiratory Failure: assess for increasing dyspnea. : assess for increasing dyspnea. Stridor, changes in respiratory patterns; monitor arterial blood gas Stridor, changes in respiratory patterns; monitor arterial blood gas (ABGs), pulse oximetry to detect problematic oxygen saturation (ABGs), pulse oximetry to detect problematic oxygen saturation and increasing carbon monoxide; monitor chest x-rays for cerebral and increasing carbon monoxide; monitor chest x-rays for cerebral hypoxiahypoxia

– Distributive ShockDistributive Shock: monitor for early signs of shock or progressive : monitor for early signs of shock or progressive edema. Administered fluid resuscitation as ordered in response to edema. Administered fluid resuscitation as ordered in response to physical findings; continue monitoring fluid statusphysical findings; continue monitoring fluid status

– Acute Renal FailureAcute Renal Failure: monitor and report abnormal urine output : monitor and report abnormal urine output and qualityand quality

– Compartment SyndromeCompartment Syndrome: assess nuerovascular status of : assess nuerovascular status of extremities hourly; report any extremity pain, loss of peripheral extremities hourly; report any extremity pain, loss of peripheral pulse or sensationpulse or sensation

– Paralytic Ileus:Paralytic Ileus: NGT and maintain in low intermittent suction until NGT and maintain in low intermittent suction until bowel sound resumebowel sound resume

– Curling’s Ulcer:Curling’s Ulcer: assess gastric aspirate for blood and pH; assess assess gastric aspirate for blood and pH; assess stools for occult blood; administerd antacids and histamine blockers stools for occult blood; administerd antacids and histamine blockers (eg, ranitidine, (zantac)) as prescribed.(eg, ranitidine, (zantac)) as prescribed.

Acute and Intermediate Acute and Intermediate PhasePhase• It begins 42 to 72 hours after the burn injury. Burn wound care It begins 42 to 72 hours after the burn injury. Burn wound care

and pain control are the priorities in this stageand pain control are the priorities in this stage

AssessmentAssessment - Focus on hemodynamic changes- Focus on hemodynamic changes

- Measure V/S frequently- Measure V/S frequently - Assess peripheral pulses frequently- Assess peripheral pulses frequently - Observe electrocardiogram for dysrhythmias resulting from - Observe electrocardiogram for dysrhythmias resulting from potassium imbalancepotassium imbalance - Assess residual gastric volume and pH in px with NGT- Assess residual gastric volume and pH in px with NGT - Note and report blood in gastric fluid or stool.- Note and report blood in gastric fluid or stool. - Assess wound: size, color, eschar, exudate, abscess formation - Assess wound: size, color, eschar, exudate, abscess formation under the eschar, epithelial buds, bleeding granulation tissue under the eschar, epithelial buds, bleeding granulation tissue appearanceappearance - Focus on pain and psychosocial response- Focus on pain and psychosocial response - Assess for excessive bleeding adjacent to areas of surgical - Assess for excessive bleeding adjacent to areas of surgical exploration and debridement exploration and debridement

Diagnosis Diagnosis

• Excessive fluid volume related to resumption of capillary Excessive fluid volume related to resumption of capillary integrityintegrity

• Risk for infection related to loss of skin barrier and impaired Risk for infection related to loss of skin barrier and impaired immune responseimmune response

• Impaired skin integrity related to open burn woundsImpaired skin integrity related to open burn wounds

• Imbalance nutrition: Less than body requirementsImbalance nutrition: Less than body requirements

• Impaired physical mobility r/t burn wound edema, pain, and joint Impaired physical mobility r/t burn wound edema, pain, and joint contracturescontractures

• Ineffective coping r/t fear and anxietyIneffective coping r/t fear and anxiety

• Deficit knowledge about the burn treatmentDeficit knowledge about the burn treatment

Nursing InterventionNursing Intervention1. Restoring Fluid Balance1. Restoring Fluid Balance• Monitor IV and oral fluid intakeMonitor IV and oral fluid intake• Measure IO and daily weightMeasure IO and daily weight• Report in changes in hemodynamicReport in changes in hemodynamic• Administered low dose of dopamine as prescribe to increase perfusion and Administered low dose of dopamine as prescribe to increase perfusion and

diuretics to promote increased urine output diuretics to promote increased urine output

2. Preventing infection2. Preventing infection • Provide a clean and safe environmentProvide a clean and safe environment• Caution px to avoid touching wounds or dressings, bathed unburned areas Caution px to avoid touching wounds or dressings, bathed unburned areas

and change linens regularlyand change linens regularly• Closely scrutinized wound t detect early sign of infectionClosely scrutinized wound t detect early sign of infection

3. Maintain Adequate Nutrition3. Maintain Adequate Nutrition• Initiate oral fluid slowly when bowel sound resumeInitiate oral fluid slowly when bowel sound resume• Collaborate with dietitian Collaborate with dietitian • Document caloric intakeDocument caloric intake• Weight px daily and graph weightsWeight px daily and graph weights• Encourage px with anorexia to increase food intake, provide pleasant Encourage px with anorexia to increase food intake, provide pleasant

surroundings surroundings


4. Promote Skin Integrity4. Promote Skin Integrity

• Asses wound statusAsses wound status

• Support px during distressing and painful wound careSupport px during distressing and painful wound care

• Coordinate complex aspects of wound careCoordinate complex aspects of wound care

• Assess and record any changes and progress in wound healingAssess and record any changes and progress in wound healing

• Assist, instruct, support, and encourage px and family to take part in Assist, instruct, support, and encourage px and family to take part in dressing changes and wound care.dressing changes and wound care.

5. Relieving Pain and Discomfort5. Relieving Pain and Discomfort

• Teach px relaxation techniqueTeach px relaxation technique

• Use guided imagery to alter px perception and responses to painUse guided imagery to alter px perception and responses to pain

• Administer minor antianxiety med and analgesic agent before becomes Administer minor antianxiety med and analgesic agent before becomes too severetoo severe

• Promote comfort during healing phasePromote comfort during healing phase


6. Promoting Mobility6. Promoting Mobility• Prevent complications for immobilityPrevent complications for immobility• Modify intervention to meets patient’s needModify intervention to meets patient’s need• Make aggressive effort to prevent contractures and hypertrophic scaring of Make aggressive effort to prevent contractures and hypertrophic scaring of

the wound area after wound closure for a year or morethe wound area after wound closure for a year or more• Initiate passive ROMInitiate passive ROM• Apply splits or functional devices to extremities for contracture controlApply splits or functional devices to extremities for contracture control

7. Monitoring and Managing Potential Complication7. Monitoring and Managing Potential Complication• Heart failure: assess for decreased cardiac output. Oliguria,edema, or Heart failure: assess for decreased cardiac output. Oliguria,edema, or

onset of S3 or S4 heart soundonset of S3 or S4 heart sound• Pulmonary edema: assess fro increasing central venous pressure (CVP)Pulmonary edema: assess fro increasing central venous pressure (CVP)• SepsisSepsis• ARDSARDS• Visceral damage (frm electrical burns)Visceral damage (frm electrical burns)

Rehabilitation and Long-Rehabilitation and Long-Term PhaseTerm PhaseRehabilitation phase should begin immediately after the burn has Rehabilitation phase should begin immediately after the burn has

occurredoccurred..

AssessmentAssessment

• Obtain information about patient’s educational level, occupation, Obtain information about patient’s educational level, occupation, leisure activities, cultural background, religion and family interactionsleisure activities, cultural background, religion and family interactions

• Assess self-concept, mental status , emotional response to injury and Assess self-concept, mental status , emotional response to injury and • hospitalization, level of intellectual functioning, previous hospitalization, hospitalization, level of intellectual functioning, previous hospitalization,

response to pain and pain relief measures and sleep patternresponse to pain and pain relief measures and sleep pattern

• Perform ongoing assessments relative to rehabilitation goalPerform ongoing assessments relative to rehabilitation goal

• Document participation and self care abilities in wound care and Document participation and self care abilities in wound care and ambulationambulation

• Maintain comprehensive and continuous assessment for detection of Maintain comprehensive and continuous assessment for detection of early complicationearly complication

Diagnosis Diagnosis

• Activity intolerance r/t to pain on exercise, muscle Activity intolerance r/t to pain on exercise, muscle wasting, and limited endurancewasting, and limited endurance

• Disturbed body image r/t altered appearance and Disturbed body image r/t altered appearance and self-conceptself-concept

• Deficient knowledge of postdischarge home care and Deficient knowledge of postdischarge home care and follow-up needsfollow-up needs


1.Promoting Activity Tolerance1.Promoting Activity Tolerance• Schedule care to allow periods of uninterrupted sleepSchedule care to allow periods of uninterrupted sleep

• Administer hypnotic agents as prescribedAdminister hypnotic agents as prescribed

• Communicate plan of care to family and other caregiversCommunicate plan of care to family and other caregivers

• Reduce metabolic stress by relieving pain, preventing chilling Reduce metabolic stress by relieving pain, preventing chilling or fever and promoting integrity of all body systems to help or fever and promoting integrity of all body systems to help conserve energyconserve energy

• Incorporate physical therapy exercises to prevent muscular Incorporate physical therapy exercises to prevent muscular atrophy and maintain mobility required for daily activitiesatrophy and maintain mobility required for daily activities

• Support positive outlook and increase tolerance for activity by Support positive outlook and increase tolerance for activity by scheduling diversion activities in periods of increasing scheduling diversion activities in periods of increasing durationduration

Nursing InterventionNursing Intervention2. Improving Body Image and Self-Concept2. Improving Body Image and Self-Concept• Refer patient to support group to develop coping strategiesRefer patient to support group to develop coping strategies• Assess patient’s psychosocial reactionsAssess patient’s psychosocial reactions• Support patient through small gesturesSupport patient through small gestures• Teach patient ways to direct attention away from a disfigured Teach patient ways to direct attention away from a disfigured

body to the self withinbody to the self within• Coordinate communications of consultantsCoordinate communications of consultants

3. Monitoring and managing potential 3. Monitoring and managing potential complicationcomplication

ContracturesContractures• Provide early and aggressive physical and occupational therapyProvide early and aggressive physical and occupational therapy• Support patient if surgery is needed to achieve full ROMSupport patient if surgery is needed to achieve full ROM

Impaired psychological adaptation to the burn injuryImpaired psychological adaptation to the burn injury• Obtain psychological or psychiatric referral as soon as evidence Obtain psychological or psychiatric referral as soon as evidence

of major coping problems appearsof major coping problems appears

Diabetes Mellitus Diabetes Mellitus

• -Diabetes Mellitus is a group of metabolic disorders characterized by -Diabetes Mellitus is a group of metabolic disorders characterized by elevated blood glucose hyperglycemia) resulting from defects in elevated blood glucose hyperglycemia) resulting from defects in insulin production and secretion, decreased cellular response to insulin production and secretion, decreased cellular response to insulin, or both.insulin, or both.

• -This leads to hyperglycemia, which may lead to acute metabolic -This leads to hyperglycemia, which may lead to acute metabolic complications, such as diabetic ketoacidosis (DKA),and complications, such as diabetic ketoacidosis (DKA),and hyperglycemic hyperosmolar nonketonic syndrome (HHNS)hyperglycemic hyperosmolar nonketonic syndrome (HHNS)

• -Long term hyperglycemia may contribute to chronic microvascular -Long term hyperglycemia may contribute to chronic microvascular complications (kidney and eye disease) and neuropathic complications (kidney and eye disease) and neuropathic complicationscomplications

• -Diabetic is also associated with an increased occurrence of CAD, CVA, -Diabetic is also associated with an increased occurrence of CAD, CVA, and peripheral diseaseand peripheral disease

Types of DiabetesTypes of Diabetes1. Type 1 (Formerly Insulin-Dependent Diabetes Mellitus)1. Type 1 (Formerly Insulin-Dependent Diabetes Mellitus)• About 5%-10% of diabetic patient have type 1 diabetes. Beta cells of the About 5%-10% of diabetic patient have type 1 diabetes. Beta cells of the

pancreas that normally produce insulin are destroyed by an autoimmune pancreas that normally produce insulin are destroyed by an autoimmune process. Insulin injections are needed to control the blood glucoseprocess. Insulin injections are needed to control the blood glucose

• Type 1 diabetes has a sudden onset, usually before the age of 30 yearsType 1 diabetes has a sudden onset, usually before the age of 30 years

2. Type 2 (Formerly Non-Insulin-Dependent Diabetes Mellitus)2. Type 2 (Formerly Non-Insulin-Dependent Diabetes Mellitus)• About 90%-95% of diabetes has type 2 diabetes. Results from a About 90%-95% of diabetes has type 2 diabetes. Results from a

decreased sensitivity to insulin (insulin resistance) or from a decreased decreased sensitivity to insulin (insulin resistance) or from a decreased amount of insulin productionamount of insulin production

• First treated with diet and exercise, then oral hypoglycemic agents as First treated with diet and exercise, then oral hypoglycemic agents as neededneeded

• Occurs most frequently in patients older than 30 years of age and in Occurs most frequently in patients older than 30 years of age and in obese patientsobese patients

3.Gestational Diabetes3.Gestational Diabetes• Characterized by an degree of glucose intolerance with onset during Characterized by an degree of glucose intolerance with onset during

pregnancy (second or third trimester)pregnancy (second or third trimester)• It occurs in women 25 years of age or older, women younger than 25 It occurs in women 25 years of age or older, women younger than 25

years of age who are obese, women with a family history of diabetesyears of age who are obese, women with a family history of diabetes


• Polyuria, polydipsia and polyphagiaPolyuria, polydipsia and polyphagia

• Fatigue and weakness, sudden vision changes, tingling or Fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, sores that heal slowly and numbness in hands or feet, dry skin, sores that heal slowly and recurrent infectionsrecurrent infections

• Onset of the type 1 diabetes may be associated with the nausea, Onset of the type 1 diabetes may be associated with the nausea, vomiting, or stomach painsvomiting, or stomach pains

• Type 2 diabetes results from slow, progressive glucose Type 2 diabetes results from slow, progressive glucose intolerance and results in long-term complications if diabetes intolerance and results in long-term complications if diabetes goes undetected for many years. Complications may have goes undetected for many years. Complications may have developed before the actual diagnosis is madedeveloped before the actual diagnosis is made

• Signs and symptoms of DKA include abdominal pain, nausea, Signs and symptoms of DKA include abdominal pain, nausea, vomiting, hyperventilation, and fruity breath odor.vomiting, hyperventilation, and fruity breath odor.

Assessment and Diagnostic Assessment and Diagnostic MethodsMethods

• High blood glucose levels: fasting plasma glucose levels 126 mg/dL High blood glucose levels: fasting plasma glucose levels 126 mg/dL or more, or random plasma glucose levels more than 200 mg/dL on or more, or random plasma glucose levels more than 200 mg/dL on more than one occasionmore than one occasion

• Evaluation for complicationsEvaluation for complications

PreventionPrevention• For obese patients(especially those with type 2 diabetes): weight loss For obese patients(especially those with type 2 diabetes): weight loss

is the key to treatment and the major preventive factor for the is the key to treatment and the major preventive factor for the

development of diabetesdevelopment of diabetes


• Primary treatment of type 1 diabetes is insulin.Primary treatment of type 1 diabetes is insulin.

• Primary treatment of type 2 diabetes is weight lossPrimary treatment of type 2 diabetes is weight loss

• Exercise is important in enhancing the effectiveness of insulinExercise is important in enhancing the effectiveness of insulin

• Use of oral hypoglycemic agents if diet and exercise are not Use of oral hypoglycemic agents if diet and exercise are not successful in controlling blood glucose levels. Insulin injections successful in controlling blood glucose levels. Insulin injections may be used in acute situationsmay be used in acute situations

• Because treatment varies throughout course because of Because treatment varies throughout course because of changes in lifestyle and physical and emotional status as well changes in lifestyle and physical and emotional status as well as advances in therapy.as advances in therapy.


• Maintain fluid and electrolytes balance.Maintain fluid and electrolytes balance.

• Improve nutritional intakeImprove nutritional intake

• Reduce anxietyReduce anxiety

• Monitor and Manage potential complicationsMonitor and Manage potential complications

• Teaching patient about self care Teaching patient about self care

Diabetic KetoacidosisDiabetic Ketoacidosis• Caused by an absence of inadequate amout of insulin. This Caused by an absence of inadequate amout of insulin. This

results in disorders in the metabolism of carbohydrates, results in disorders in the metabolism of carbohydrates, protein, and fat.protein, and fat.

The three main clinical features of DKA :The three main clinical features of DKA :

(1)(1)Hyperglycemia, due to decreased use of glucose by the cells and Hyperglycemia, due to decreased use of glucose by the cells and increased production of glucose by the liver; increased production of glucose by the liver;

(2)(2)Dehydration and electrolyte loss, resulting from polyuria, with a Dehydration and electrolyte loss, resulting from polyuria, with a loss of up to 6.5 liters of water and up to 400 to 500 mEq each of loss of up to 6.5 liters of water and up to 400 to 500 mEq each of sodium, potassium, and chloride over 24 hours; and sodium, potassium, and chloride over 24 hours; and

(3)(3)Acidosis, due to an excess breakdown of fatty acids and production Acidosis, due to an excess breakdown of fatty acids and production of ketone bodies, which are also acids. Three main causes of DKA of ketone bodies, which are also acids. Three main causes of DKA are decreased or missed dose of insulin, illness or infection, and are decreased or missed dose of insulin, illness or infection, and initial manifestation of undiagnosed or untreated diabetes. initial manifestation of undiagnosed or untreated diabetes.

Clinical ManifestationsClinical Manifestations • Polyuria, polydipsia (increased thirst)Polyuria, polydipsia (increased thirst)

• Blurred vision, weakness, and headacheBlurred vision, weakness, and headache

• Orthostatic hypotension in patient with the volume depletionOrthostatic hypotension in patient with the volume depletion

• Weak rapid pulseWeak rapid pulse

• GI symptoms, such as anorexia, nausea/vomiting, and GI symptoms, such as anorexia, nausea/vomiting, and abdominal painabdominal pain

• Acetone breathAcetone breath

• Kaussmauls respirationKaussmauls respiration

• Mental status changesMental status changes

Assessment and Diagnostic Assessment and Diagnostic FindingsFindings

• Blood glucose level:300-800mg/dLBlood glucose level:300-800mg/dL

• Lower serum bicarbonate level: 0-15mEq/LLower serum bicarbonate level: 0-15mEq/L

• Low pH: 6.8-7.3Low pH: 6.8-7.3

• Low pCO2: 10-30 mmHgLow pCO2: 10-30 mmHg

• Low sodium and potassiumLow sodium and potassium

• Elevated creatinine, BUN, hemoglobin, and hematocritElevated creatinine, BUN, hemoglobin, and hematocrit

Nursing ManagementNursing Management • Administer fluid as orderedAdminister fluid as ordered

• Monitor fluid volume statusMonitor fluid volume status

• Monitor for sign of fluid overloadMonitor for sign of fluid overload

• *Monitor carefully for hypokalemia due to rehydration and insulin *Monitor carefully for hypokalemia due to rehydration and insulin treatment.treatment.

• Promote electrolyte and acid-base balancePromote electrolyte and acid-base balance

• -Observe frequently for signs of hyperkalemia (ie, tall, peaked T waves -Observe frequently for signs of hyperkalemia (ie, tall, peaked T waves on the ECG) and obtain frequent (every 2-4 hours) potassium values on the ECG) and obtain frequent (every 2-4 hours) potassium values during first 8 hours of treatment.during first 8 hours of treatment.

• Teach the patient about “sick-day rules” which are strategies Teach the patient about “sick-day rules” which are strategies to help prevent diabetic complications.to help prevent diabetic complications.– Do not eliminate insulin doses when nausea and vomiting occurDo not eliminate insulin doses when nausea and vomiting occur– Take usual insulin dose or previously prescribed sick-day doses and Take usual insulin dose or previously prescribed sick-day doses and

attempt to consume frequent small portions of carbohydratesattempt to consume frequent small portions of carbohydrates– Drink fluids every hour to avoid dehydrationsDrink fluids every hour to avoid dehydrations– Check blood glucose level every 3-4 hoursCheck blood glucose level every 3-4 hours End of the slides

Hepatic EncephalopathyHepatic Encephalopathy

• ammonia (cerebral toxin)ammonia (cerebral toxin)

• It is a potentially reversible neuropsychiatic abnormality It is a potentially reversible neuropsychiatic abnormality in the setting of liver failure.in the setting of liver failure.

• It can be diagnosed only after exclusion of other It can be diagnosed only after exclusion of other neurological, psychiatric, infectious and metabolic neurological, psychiatric, infectious and metabolic etiologies etiologies

Clinical ManifestationClinical ManifestationEarly signs:Early signs:• minor mental changes and motor disturbanceminor mental changes and motor disturbance• Slight confusion and mood alterationSlight confusion and mood alteration• Patient is unkemptPatient is unkempt• Disturbance in sleep pattern (sleeps during the day)Disturbance in sleep pattern (sleeps during the day)• Restlessness and insomnia at nightRestlessness and insomnia at night

As coma progresses the px may be difficult to awaken. As coma progresses the px may be difficult to awaken. • asterisxis (flapping tremor of the hand) asterisxis (flapping tremor of the hand) • Reflexes are hyperactive; with worsening encephalopathy Reflexes are hyperactive; with worsening encephalopathy

reflexes disappear and extremities become flaccidreflexes disappear and extremities become flaccid• Slowing and increase in amptitude of brain waves (EEG)Slowing and increase in amptitude of brain waves (EEG)• Fetor hepaticus: breath odor like freshly mowed grass, acetone Fetor hepaticus: breath odor like freshly mowed grass, acetone

or old wineor old wine• Gross disturbances of consciousness and complete disorientationGross disturbances of consciousness and complete disorientation• With further progression, frank coma and seizure occursWith further progression, frank coma and seizure occurs

Diagnosis Diagnosis • Liver enzymes- All increaseLiver enzymes- All increase

• SGPT (ALT)SGPT (ALT)

• SGOT (AST)SGOT (AST)

• Serum cholesterol & ammonia increaseSerum cholesterol & ammonia increase

• Indirect bilirubin increaseIndirect bilirubin increase

• CBC – pancytopeniaCBC – pancytopenia

• PTT – prolongedPTT – prolonged

• Hepatic ultrasonogram – fat necrosis of liver lobulesHepatic ultrasonogram – fat necrosis of liver lobules


• Administer lactulose (cephulac) to reduce serum ammonia levelAdminister lactulose (cephulac) to reduce serum ammonia level

• Reduce protein intake Reduce protein intake

• Give enema as prescribed to reduce ammonia absorption from GITGive enema as prescribed to reduce ammonia absorption from GIT

• Administer nonabsorbable antibiotics (neomycin) as an intestinal Administer nonabsorbable antibiotics (neomycin) as an intestinal antisepticantiseptic

• Monitor serum ammonia level daily; monitor electrolyte status and correct Monitor serum ammonia level daily; monitor electrolyte status and correct if abnormalif abnormal

• Discontinue medications that may precipitate encephalopathy (eg, Discontinue medications that may precipitate encephalopathy (eg, sedative medication, tranquilizers, analgesic agents)sedative medication, tranquilizers, analgesic agents)

• Other treatment include administration of IV glucose, vitamins and oxygenOther treatment include administration of IV glucose, vitamins and oxygen


• Assess neurologic status frequently. Keep daily record of Assess neurologic status frequently. Keep daily record of handwriting and performance in arithmetic to monitor handwriting and performance in arithmetic to monitor mental statusmental status

• Monitor fluid IO and body weight dailyMonitor fluid IO and body weight daily

• Monitor for peritoneal, pulmonary, or other infectionMonitor for peritoneal, pulmonary, or other infection

• Instruct family to observe subtle sign of recurrent Instruct family to observe subtle sign of recurrent encephalopathyencephalopathy

• Maintain low protein, high calorie dietMaintain low protein, high calorie diet

End of the slides

End- Stage Renal End- Stage Renal DiseaseDisease

Chronic renal failure or ESRD is a progressive irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails,

resulting in uremia and azotemia

CAUSESCAUSES• Diabetes mellitusDiabetes mellitus

• HypertensionHypertension

• Chronic glomerulonephritisChronic glomerulonephritis

• PyelonephritisPyelonephritis

• Obstruction of the urinary tractObstruction of the urinary tract

• Hereditary lesions (eg. Polycystic kidney disease)Hereditary lesions (eg. Polycystic kidney disease)

• Vascular disorderVascular disorder

• InfectionsInfections

• Medications / toxic agentsMedications / toxic agents

• Environmental and occupational agents (eg. Lead, cadmium, mercury, Environmental and occupational agents (eg. Lead, cadmium, mercury, chromium)chromium)


Renal function declines

End product of CHON metabolism accumulates in the blood

Uremia develops

Affects every system in the body

Stages of Kidney FailureStages of Kidney FailureStage I - (Reduced renal reserve)Stage I - (Reduced renal reserve)• Loss of nephron function (40% - 70%)Loss of nephron function (40% - 70%)• Px usually does not have sx because the remaining nephrons are able Px usually does not have sx because the remaining nephrons are able

to carry out the normal function of the kidneyto carry out the normal function of the kidney

Stage II - (Renal insufficiency)Stage II - (Renal insufficiency)• Nephron function is lost (75% - 90%)Nephron function is lost (75% - 90%)• Serum creatinine and blood urea nitrogen riseSerum creatinine and blood urea nitrogen rise• Kidney loses it’s ability to concentrate urine and anemia developsKidney loses it’s ability to concentrate urine and anemia develops• Px may report polyuria and nocturiaPx may report polyuria and nocturia

Stage III - (ESRD)Stage III - (ESRD)• Final stage of chronic renal failureFinal stage of chronic renal failure• Loss of nephron function (10%)Loss of nephron function (10%)• All of the normal regulatory, excretory and hormonal function of the All of the normal regulatory, excretory and hormonal function of the

kidney are severely impairedkidney are severely impaired• Elevated creatinine and BUN levels as well as electrolyte imbalancesElevated creatinine and BUN levels as well as electrolyte imbalances• Dialysis is indicatedDialysis is indicated

Clinical ManifestationClinical Manifestation• CardivascularCardivascular: : hypertension, pitting and periorbital edema, pericardial friction hypertension, pitting and periorbital edema, pericardial friction

rub, pericardial tamponade, hyperkalimiarub, pericardial tamponade, hyperkalimia

• Integumentary:Integumentary: ecchymosis, purpura, thin brittle nails, coarse thinning hair, ecchymosis, purpura, thin brittle nails, coarse thinning hair, gray-bronze skin color, dry flaky skingray-bronze skin color, dry flaky skin

• Pulmonary:Pulmonary: crackles, thick tenacious sputum, depressed cough reflex, crackles, thick tenacious sputum, depressed cough reflex, shortness of breath, tachypnea, kussmaul type of respiration, uremic pneumonitisshortness of breath, tachypnea, kussmaul type of respiration, uremic pneumonitis

• Gastrointestinal:Gastrointestinal: ammonia odor of breath, metallic taste, mouth ulceration ammonia odor of breath, metallic taste, mouth ulceration and bleeding,N/V, constipation or diarrhea, bleeding in GITand bleeding,N/V, constipation or diarrhea, bleeding in GIT

• Nuerologic:Nuerologic: weakness, fatigue, confusion, disorientation, tremors, seizure, weakness, fatigue, confusion, disorientation, tremors, seizure, burning of sole of feet, behavioral changeburning of sole of feet, behavioral change

• Musculoskeletal:Musculoskeletal: muscle craps, loss of muscle strength, renal muscle craps, loss of muscle strength, renal osteodystrophy, bone pain, fracture, foot droposteodystrophy, bone pain, fracture, foot drop

• Reproductive:Reproductive: amenorrhea, testicular atrophy, infertility, decrease libidoamenorrhea, testicular atrophy, infertility, decrease libido

• Hematologic:Hematologic: anemia,thrombocytopeniaanemia,thrombocytopenia

Assessment and Diagnostic Assessment and Diagnostic FindingsFindings

1. Glomerular filtration rate 1. Glomerular filtration rate • 24ᵒ urinalysis for creatinine clearance = decrease GFR24ᵒ urinalysis for creatinine clearance = decrease GFR• Increase BUN levelIncrease BUN level• Serum creatinine (most sensitive indicator of renal function Serum creatinine (most sensitive indicator of renal function

2. Na and H2O retention2. Na and H2O retention• Kidney cannot concentrate or dilute urine normallyKidney cannot concentrate or dilute urine normally• Retain Na and H2O = increase risk for edem, heart failure and HPNRetain Na and H2O = increase risk for edem, heart failure and HPN• Other px tends to lose salt and develop hypotension and hypovolemiaOther px tends to lose salt and develop hypotension and hypovolemia• Vomiting and diarrhea may produce Na and H2O depletion which worsen the Vomiting and diarrhea may produce Na and H2O depletion which worsen the

uremic stateuremic state

3. Anemia3. Anemia• Inadequate erythropoietin productionInadequate erythropoietin production• Producing fatigue, angina and shortness of breathProducing fatigue, angina and shortness of breath

4. Ca and Phosporous imbalance4. Ca and Phosporous imbalance• Body does not normally respond to the increased secretion of parathormoneBody does not normally respond to the increased secretion of parathormone• Active metabolite of vitaminD normally manufactured by the kidney decreasesActive metabolite of vitaminD normally manufactured by the kidney decreases• Uremic bone disease develops from the complex changes in Ca, PO4 and Uremic bone disease develops from the complex changes in Ca, PO4 and

parathormone balanceparathormone balance

Medical ManagementMedical Management1. Medications1. Medications• Antihypertensive -Antihypertensive - to manage HPNto manage HPN

• Antiseisure agentsAntiseisure agents - ( - (Diazepam, Phenytoin)Diazepam, Phenytoin)

• Erythropoietin (EpogenErythropoietin (Epogen)) - - tto manage anemiao manage anemiaAdminister via IV or SubQ tidAdminister via IV or SubQ tidA/E: HPN, increased clotting of vascular A/E: HPN, increased clotting of vascular

access access sites, seizure and depletion of iron storessites, seizure and depletion of iron stores• Iron supplementIron supplement

• PO4 binding PO4 binding agents - agents - suitable for or select not to participate in dialysis suitable for or select not to participate in dialysis or or transplantationtransplantation

• Antacids Antacids • Hyperphosphatemia and hypocalemia are treated with aluminium based Hyperphosphatemia and hypocalemia are treated with aluminium based

antacidantacid• Magnesium based antacid should be avoided to prevent magnesium Magnesium based antacid should be avoided to prevent magnesium

toxicittoxicit

Medical ManagementMedical Management2. 2. Diet therapyDiet therapy• Vitamin supplementationVitamin supplementation

• CHON restrictionCHON restriction

• Potassium restrictionPotassium restriction

• Adequate caloric intakeAdequate caloric intake

• Fluid intake to balance fluid losesFluid intake to balance fluid loses

• Na intake to balance Na losesNa intake to balance Na loses

3. Dialysis3. Dialysis• Used to remove fluid and uremic waste products from the body when the kidney Used to remove fluid and uremic waste products from the body when the kidney

cannot do so.cannot do so.

• Used to treat px with edema that does not respond to tx, hepatic coma, Used to treat px with edema that does not respond to tx, hepatic coma, hyperkalemiam hypercalcemiam HPN and uremiahyperkalemiam hypercalcemiam HPN and uremia

Types of Dialysis Types of Dialysis

Medical ManagementMedical Management• Methods of TherapyMethods of Therapy

1. 1. HemodialysisHemodialysis• Commonly used method of Commonly used method of

dialysisdialysis• Used for acutely ill and Used for acutely ill and

require short term dialysis require short term dialysis (days to weeks)(days to weeks)

• Used for ESRD who require Used for ESRD who require long term or permanent long term or permanent therapy to prevent deaththerapy to prevent death

• Uses Uses dialyzerdialyzer (synthetic (synthetic semipermeable membrane semipermeable membrane replacing the renal glomeruli replacing the renal glomeruli and tubules as the filter for and tubules as the filter for the impaired kidneys)the impaired kidneys)

Dialysis disequilibriumDialysis disequilibrium

Complication includes:Complication includes:

• HypertriglyceridemiaHypertriglyceridemia• Heart failureHeart failure• Coronary heart diseaseCoronary heart disease• Angina painAngina pain• StokeStoke• Peripheral vascular Peripheral vascular

insufficiencyinsufficiency• HypotensionHypotension• Painful muscle crampingPainful muscle cramping• ExsanguinationsExsanguinations• DysrhythmiasDysrhythmias• Air embolismAir embolism• Dialysis disequilibriumDialysis disequilibrium

Hemodialysis Hemodialysis


• Excess fluid volume r/t decreased urine output, dietary Excess fluid volume r/t decreased urine output, dietary excesses and retention of Na and H2Oexcesses and retention of Na and H2O

• Imbalance nutrition: less than body requirements r/t anorexia, Imbalance nutrition: less than body requirements r/t anorexia, N/V, dietary restriction and altered oral mucous membranesN/V, dietary restriction and altered oral mucous membranes

• Deficient knowledge regarding condition and tx regimenDeficient knowledge regarding condition and tx regimen• Activity intolerance r/t fatigue, anemia, retention of waste Activity intolerance r/t fatigue, anemia, retention of waste

product and dialysis procedureproduct and dialysis procedure

• Low self-esteem r/t dependency, role changes, change in Low self-esteem r/t dependency, role changes, change in body image and sexual dysfunctionbody image and sexual dysfunction

Nursing ManagementNursing Management• Assessing fluid status and identifying potential source of Assessing fluid status and identifying potential source of

imbalanceimbalance

• Implementing dietary program to ensure proper nutritional intakeImplementing dietary program to ensure proper nutritional intake

• Promoting positive feelings by encouraging increase self-care and Promoting positive feelings by encouraging increase self-care and greater independencegreater independence

• Report the health care provider the s/sx of decreased renal fxnReport the health care provider the s/sx of decreased renal fxn

– Worsening s/sx of renal failure (N/v, change in usual output, ammonia Worsening s/sx of renal failure (N/v, change in usual output, ammonia odor or breathodor or breath

– s/sx of hyperkalemias/sx of hyperkalemia– s/sx of access problem (clotted fistula or graft and infection)s/sx of access problem (clotted fistula or graft and infection)

• Multiple dietary restrictions is required, including fluid intake, NA, Multiple dietary restrictions is required, including fluid intake, NA, K and CHON restrictionK and CHON restriction

End of the slides

PULMONARY EDEMA

Pulmonary EdemaPulmonary Edema

• Defined as abnormal accumulation of fluid in the lung Defined as abnormal accumulation of fluid in the lung tissue and alveolar spacetissue and alveolar space

• Fluid may accumulate in the interstitial spaces.Fluid may accumulate in the interstitial spaces.

• It is a severe life threatening condition.It is a severe life threatening condition.

CAUSES:• Hypovolemia• Sudden increased in intravascular pressure in the

lung• Inadequate liver function


pulmonary edema most commonly occurs as a result of increased microvascular pressure from abnormal cardiac function

an acute event that results from HF, It can occur acutely, such as with MI, or it can occur as an exacerbation of chronic HF

The backup of blood into the pulmonary vasculature resulting from inadequate

left ventricular function causes an increased microvascular pressure and fluid begins to

leak into the interstitial space and the alveoli.

Clinical ManifestationClinical Manifestation– Decreased cerebral oxygenationDecreased cerebral oxygenation

– Sudden onset of breathlessnessSudden onset of breathlessness

– Patient hands become cold and moist the nailbeds are Patient hands become cold and moist the nailbeds are cyanoticcyanotic

– Neck veins are distendedNeck veins are distended

– Very anxious and often agitatedVery anxious and often agitated

– Confused and stuporousConfused and stuporous

– Pink foamy or frothy secretions by blood tingedPink foamy or frothy secretions by blood tinged


AssessmentAssessment

• Auscultation reveals crackles in the lung bases that rapidly Auscultation reveals crackles in the lung bases that rapidly progress toward the apices of the lungs.progress toward the apices of the lungs.

• Crackles are due to the movement of air through the alveolar Crackles are due to the movement of air through the alveolar fluidfluid

• Chest x-ray reveals increased interstitial markingChest x-ray reveals increased interstitial marking

• Tachycardia, the pulse oximetry values begins to fall and arterial Tachycardia, the pulse oximetry values begins to fall and arterial blood gads analyzing demonstrates increased hypoxemiablood gads analyzing demonstrates increased hypoxemia

Medical managementMedical management

• Improving ventricular function and Improving ventricular function and increased respiratory exchangedincreased respiratory exchanged

• Goal mgt. Accomplish through a Goal mgt. Accomplish through a combination of oxygen medical therapies combination of oxygen medical therapies and nursing support.and nursing support.


Pharmacologic Pharmacologic ManagementManagement

1.Oxygen therapy1.Oxygen therapy• oxygen administered in concentration adequate to relieve oxygen administered in concentration adequate to relieve

hypocemia and dyspneahypocemia and dyspnea2. Morphine2. Morphine• administered intravenously in small doses(2-5mg) to reduce administered intravenously in small doses(2-5mg) to reduce

peripheral resistance and venous return so that blood can be peripheral resistance and venous return so that blood can be redistributed from the pulmonary circulatiuon to the parts of body.redistributed from the pulmonary circulatiuon to the parts of body.

3. Diuretics3. Diuretics• promote the excretion of sodium and water by the kidneyspromote the excretion of sodium and water by the kidneys4. Dobutamine4. Dobutamine• intravenous medication given to patient with significant left intravenous medication given to patient with significant left

ventricular dysfunction.ventricular dysfunction.5. Milrinone5. Milrinone• a phospodieterase inhibitor that delays the released of calcium a phospodieterase inhibitor that delays the released of calcium

from intracellular reservoir and prevents the uptake of extracellular from intracellular reservoir and prevents the uptake of extracellular calcium by the cells.calcium by the cells.

6. Nesiritide6. Nesiritide• indicate for acutely decompensate HF indicate for acutely decompensate HF

Nursing managementsNursing managements

• Administration of oxygen and intubation and mechanical Administration of oxygen and intubation and mechanical ventilation if respiratory failure occurs.ventilation if respiratory failure occurs.

• Positioning the patient to promote circulationPositioning the patient to promote circulation

• Monitor I and OMonitor I and O

• Monitoring pulse rate and blood pressureMonitoring pulse rate and blood pressure

• Examining skin turgor and mucous membranes for signs of Examining skin turgor and mucous membranes for signs of DHN.DHN.

• Assessment symptoms of fluid overload.Assessment symptoms of fluid overload.

End of the slides

PULMONARY EMBOLISM

Pulmonary EmbolismPulmonary Embolism

• Pulmonary Embolism refers to the obstruction of the base or one or Pulmonary Embolism refers to the obstruction of the base or one or more branches of the pulmonary arteries by the thrombus (or more branches of the pulmonary arteries by the thrombus (or thrombi) that originates somewhere in the venous system or in the thrombi) that originates somewhere in the venous system or in the right side of the heart.right side of the heart.

• Gas exchange is impaired in the lung mass supplied by the Gas exchange is impaired in the lung mass supplied by the obstructed vessel. obstructed vessel.

• Massive pulmonary embolism is life threatening and can cause Massive pulmonary embolism is life threatening and can cause death within the first 1 to 2 hours after the embolic event. death within the first 1 to 2 hours after the embolic event.

• It is a common disorder associated with trauma, surgery It is a common disorder associated with trauma, surgery (orthopedic, major abdominal, pelvic, gynecologic), pregnancy, oral (orthopedic, major abdominal, pelvic, gynecologic), pregnancy, oral contraceptive use, congestive heart failure, age older that 50 contraceptive use, congestive heart failure, age older that 50 years, hypercoagulable states, and prolonged immobility. Most years, hypercoagulable states, and prolonged immobility. Most thrombi originates in the deep veins of the legs.thrombi originates in the deep veins of the legs.

Clinical ManifestationsClinical Manifestations

• Symptoms depend on the size of the thrombus and the area of the Symptoms depend on the size of the thrombus and the area of the pulmonary artery occlusion.pulmonary artery occlusion.

• Dyspnea is the most common symptom. Tachypnea is the most Dyspnea is the most common symptom. Tachypnea is the most frequent signfrequent sign

• Chest pain is common, usually sudden in onset and pleuritic in Chest pain is common, usually sudden in onset and pleuritic in nature; it can be substernal and may mimic angina pectorisnature; it can be substernal and may mimic angina pectoris

• Fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, Fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, syncope, shock, and sudden death may occursyncope, shock, and sudden death may occur

• Multiple small emboli in the terminal pulmonary arterioles stimulate Multiple small emboli in the terminal pulmonary arterioles stimulate symptoms of bronchopneumonia or heart failuresymptoms of bronchopneumonia or heart failure

Assessment and Diagnostic Assessment and Diagnostic MethodsMethods

• Ventilation-perfusion scan, pulmonary Ventilation-perfusion scan, pulmonary angiography, chest radiographangiography, chest radiograph

• Electrocardiogram (ECG), tachycardia, PR Electrocardiogram (ECG), tachycardia, PR interval and T-wave changes, peripheral interval and T-wave changes, peripheral vascular studies, impedance vascular studies, impedance plethysmography, and arterial blood gas plethysmography, and arterial blood gas (ABG) analysis (for hypoxemia)(ABG) analysis (for hypoxemia)

PreventionPrevention

• Ambulation or leg exercises in patients on bed restAmbulation or leg exercises in patients on bed rest

• Anticoagulant therapy before abdominothoracic Anticoagulant therapy before abdominothoracic surgery and every 8 to 12 hours until discharge surgery and every 8 to 12 hours until discharge from hospitalfrom hospital

• Application of intermittent pneumatic leg Application of intermittent pneumatic leg compression devicescompression devices

Medical ManagementMedical Management• Stabilize the cardiorespiratory systemStabilize the cardiorespiratory system

• Nasal oxygen is administered immediately to relieve hypoxemia, respiratory Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and cyanosisdistress, and cyanosis

• An infusion is started to establish an intravenous route for drugs or fluidsAn infusion is started to establish an intravenous route for drugs or fluids

• Pulmonary angiography, spiral CT, perfusion lung scans, hemodynamic Pulmonary angiography, spiral CT, perfusion lung scans, hemodynamic measurements, and ABGs are performedmeasurements, and ABGs are performed

• An indwelling urethral catheter is inserted to monitor urinary outputAn indwelling urethral catheter is inserted to monitor urinary output

• Infusion of dobutamine or dopamineECG is monitored continuously for Infusion of dobutamine or dopamineECG is monitored continuously for dysrhythmias and right ventricular failuredysrhythmias and right ventricular failure

• Administration of digitalis glycosides, intravenous diuretic, and antiarrythmic Administration of digitalis glycosides, intravenous diuretic, and antiarrythmic agentsagents

• Administer small doses of intravenous morphine are given to relieve anxiety, Administer small doses of intravenous morphine are given to relieve anxiety,

Medical ManagementMedical ManagementAnticoagulation TherapyAnticoagulation Therapy• The partial thromboplastin time (PTT) is maintained at 1.5 to 2.5 times The partial thromboplastin time (PTT) is maintained at 1.5 to 2.5 times

normal, prothrombin time (PT) 1.5 to 2.5 time normal, or an ANR of 2.0 normal, prothrombin time (PT) 1.5 to 2.5 time normal, or an ANR of 2.0 to 3.0to 3.0

• Heparin id administered for 5 to 7 daysHeparin id administered for 5 to 7 days• Warfarin (Coumadin) is begun within 24 hours following the start of Warfarin (Coumadin) is begun within 24 hours following the start of

heparin therapy and continued for 3 to 6 monthsheparin therapy and continued for 3 to 6 months

Thrombolytic TherapyThrombolytic Therapy• Thrombolytic therapy may include urokinase alteplase, anistreplase and Thrombolytic therapy may include urokinase alteplase, anistreplase and

streptokinase (tissue plasminogen activator). It is reserved for streptokinase (tissue plasminogen activator). It is reserved for pulmonary embolism affecting a significant area and causing pulmonary embolism affecting a significant area and causing hemodynamic instabilityhemodynamic instability

• Bleeding is a significant side effect; nonessential invasive procedures Bleeding is a significant side effect; nonessential invasive procedures are voidedare voided

Surgical ManagementSurgical Management• Embolectomy by means of thoracotomy with cardiopulmonary bypass Embolectomy by means of thoracotomy with cardiopulmonary bypass

techniquetechnique• Transvenous catheter embolectomy with or without insertion of an Transvenous catheter embolectomy with or without insertion of an

inferior vena caval filter (eg. Greenfield)inferior vena caval filter (eg. Greenfield)

Nursing InterventionsNursing Interventions• Providing general care.. Encourage deep-brathing exercisesProviding general care.. Encourage deep-brathing exercises

• Preventing thrombus formation. Encourage ambulationPreventing thrombus formation. Encourage ambulation

• Monitoring anticoagulant and thrombolytic therapy. Advise bed Monitoring anticoagulant and thrombolytic therapy. Advise bed rest, monitor VS every 2 hours, limit invasive proceduresrest, monitor VS every 2 hours, limit invasive procedures

• Minimizing chest pain, pleuritic. Administer analgesics as Minimizing chest pain, pleuritic. Administer analgesics as prescribed for severe painprescribed for severe pain

• Alleviating anxiety. Encourage patient to express feeling and Alleviating anxiety. Encourage patient to express feeling and concernsconcerns

• Managing oxygen therapy. Assess for hypoxiaManaging oxygen therapy. Assess for hypoxia

• Providing postoperative nursing care. Measure pulmonary arterial Providing postoperative nursing care. Measure pulmonary arterial pressure and urinary outputpressure and urinary output

END OF THE SLIDEEND OF THE SLIDE

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