Management Of Patients With Cardiovascular & Hematologic Problems Edited


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Management Of Patients With Cardiovascular & Hematologic Problems Edited

  3. 3. THE HEART <ul><li>Three layers of the heart: </li></ul><ul><ul><li>Endocardium </li></ul></ul><ul><ul><li>Myocardium </li></ul></ul><ul><ul><li>Epicardium </li></ul></ul><ul><li>Four chambers </li></ul><ul><li>Heart valves </li></ul><ul><li>Coronary arteries </li></ul><ul><li>Cardiac conduction system </li></ul><ul><li>Cardiac hemodynamics </li></ul>
  4. 5. HEART FACTS <ul><li>Your system of blood vessels - arteries, veins and capillaries - is over 60,000 miles long. That's long enough to go around the world more than twice! </li></ul><ul><li>The adult heart pumps about 5 quarts of blood each minute - approximately 2,000 gallons of blood each day - throughout the body. </li></ul><ul><li>When attempting to locate their heart, most people place their hand on their left chest. Actually, your heart is located in the center of your chest between your lungs. The bottom of the heart is tipped to the left, so you feel more of your heart on your left side of your chest. </li></ul>
  5. 6. HEART FACTS <ul><li>The heart beats about 100,000 times each day. </li></ul><ul><li>In a 70-year lifetime, the average human heart beats more than 2.5 billion times </li></ul><ul><li>An adult woman's heart weighs about 8 ounces, a man's about 10 ounces </li></ul><ul><li>A child's heart is about the size of a clenched fist; an adult's heart is about the size of two fists. </li></ul><ul><li>Blood is about 78 percent water. </li></ul>
  6. 7. HEART FACTS <ul><li>Blood takes about 20 seconds to circulate throughout the entire vascular system. </li></ul><ul><li>The structure of the heart was first described in 1706, by Raymond de Viessens, a French anatomy professor. </li></ul><ul><li>The electrocardiograph (ECG) was invented in 1902 by Dutch physiologist Willem Einthoven. This test is still used to evaluate the heart's rate and rhythm. </li></ul><ul><li>The first heart specialists emerged after World War I. </li></ul>
  7. 8. PULMONARY CIRCULATION <ul><li>the portion of the cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. The term is contrasted with systemic circulation. </li></ul>
  8. 9. SYSTEMIC CIRCULATION <ul><li>the portion of the cardiovascular system which carries oxygenated blood away from the heart, to the body, and returns deoxygenated blood back to the heart. The term is contrasted with pulmonary circulation. </li></ul>
  9. 10. CORONARY ARTERIES <ul><li>The heart’s own supply of blood </li></ul>
  11. 12. GENERAL CARDIAC ASSESSMENT <ul><li>Health history </li></ul><ul><ul><li>Demographic information </li></ul></ul><ul><ul><li>Family/genetic history </li></ul></ul><ul><ul><li>Cultural/social factors </li></ul></ul><ul><li>Risk factors </li></ul><ul><ul><li>Modifiable: High blood cholesterol, obesity, smoking, stress, hypertension, diabetes mellitus. </li></ul></ul><ul><ul><li>Nonmodifiable: Family history, increasing age, gender, race </li></ul></ul>
  13. 14. COMPARISON OF PHYSICAL CAUSES OF CHEST PAIN Characteristic M.I. Pericarditis G.I. Prob Angina Dis. Aneurysm P. Embolism Onset Gradual/ Sudden Sudden Gradual/ Sudden Gradual/ Sudden Abrupt Gradual/ Sudden Precipitating Factors At rest / after exercise or emotional stress Breathing deeply, rotating trunk, yawning Inflammation of GI parts; increased HCL; medications After exercise, emotional stress, eating, envt’l changes Hypertension Immobility, Prolonged bedrest Location Substernal, anterior chest, rarely back, radiates to jaw/neck Precordial; rotates to neck/ left shoulder & arm Xiphoid to umbilicus Substernal, anterior chest; poorly localized Site of rupture; anterior chest or back; between scapula Pleural area, retrosternal Quality Crushing, burning, stabbing, squeezing, vicelike Pleuritic, sharp Aching, burning, cramplike, gnawing Squeezing, feeling of heavy pressure; burning Sharp, tearing, ripping Sharp, stabbing
  14. 15. COMPARISON OF PHYSICAL CAUSES OF CHEST PAIN Characteristic M.I. Pericarditis G.I. Prob Angina Dis. Aneurysm P. Embolism Intensity Asymptomatic to severe; increases with time Mild to severe Mild to severe Mild to moderate Severe, unbearable; maximal from onset Aggravated by breathing Duration 30 min to 1-2 hours; may wax and wane Continuous Periodic 2-10 min; ave: 3-5 min Continuous; does not abate once started Variable Relief Narcotics Sitting up, leaning forward Physical/ emotional rest, food, antacid Nitroglycerin, rest Large, repeated doses of narcotics 0 2 , sitting up; morphine Associated Symptoms Nausea, fatigue, heartburn, equal peripheral pulses Fever, dyspnea, nausea, anorexia, anxiety N/V, dysphagia, anorexia, weight loss Belching, indigestion, dizziness Syncope, loss of sensations / pulses, oliguria, BP discrepancies, decrease in pulses Dyspnea, tachypnea, diaphoresis, hemoptysis, cough, apprehension
  15. 16. CORONARY VASCULAR DISORDERS <ul><li>Also called occlusive disorders </li></ul><ul><ul><li>Arteriosclerosis </li></ul></ul><ul><ul><li>Angina Pectoris </li></ul></ul><ul><ul><li>Myocardial Infarction </li></ul></ul>
  16. 17. ARTERIOSCLEROSIS <ul><li>Narrowing and hardening of the arteries. </li></ul><ul><li>Three types: </li></ul><ul><ul><li>Atherosclerosis (fatty deposits called plaque on inner lining of vessel walls). </li></ul></ul><ul><ul><li>Calcific sclerosis (calcium deposits on the middle layer of the wall of the arteries). </li></ul></ul><ul><ul><li>Arteriolar sclerosis (a thickening of the arterioles caused by hypertension). </li></ul></ul>
  17. 18. RISK FACTORS <ul><li>Increased serum cholesterol (LDL ≥ 160 mg/dl) </li></ul><ul><li>Hypertension </li></ul><ul><li>Cigarette smoking </li></ul><ul><li>Diabetes Mellitus </li></ul><ul><li>Family history of premature CHD </li></ul>
  19. 20. PATHOPHYSIOLOGY <ul><li>Symptoms are due to myocardial ischemia. </li></ul><ul><li>Symptoms and complications are related to the location and degree of vessel obstruction. </li></ul><ul><ul><li>Angina pectoris </li></ul></ul><ul><ul><li>Myocardial infarction </li></ul></ul><ul><ul><li>Heart failure </li></ul></ul><ul><ul><li>Sudden cardiac death </li></ul></ul>
  20. 21. ANGINA PECTORIS <ul><li>A syndrome characterized by episodes of paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow </li></ul><ul><li>Physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand. </li></ul>
  22. 24. ASSESSMENT <ul><li>Subjective data: </li></ul><ul><ul><li>PAIN!!!! </li></ul></ul><ul><ul><ul><li>Type: squeezing, pressing, burning </li></ul></ul></ul><ul><ul><ul><li>Location: retrosternal, substernal, left of sternum, radiates to left arm </li></ul></ul></ul><ul><ul><ul><li>Duration: short; usually 3-5 mins, <30 mins </li></ul></ul></ul><ul><ul><ul><li>Cause: emotional stress, overeating, physical exertion, exposure to cold, may occur at rest </li></ul></ul></ul><ul><ul><ul><li>Relief: rest, nitroglycerin </li></ul></ul></ul><ul><ul><li>Women also complain jaw, upper back pain, & gastric upset </li></ul></ul>
  23. 25. ASSESSMENT <ul><li>Subjective data: </li></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Palpitations </li></ul></ul><ul><ul><li>Dizziness; faintness </li></ul></ul><ul><ul><li>Epigastric distress, indigestion </li></ul></ul><ul><li>Objective data: </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Pallor </li></ul></ul><ul><ul><li>Diaphoresis </li></ul></ul><ul><ul><li>ECG changes during attack </li></ul></ul>
  24. 26. ANALYSIS / NURSING DIAGNOSES <ul><li>Altered cardiopulmonary tissue perfusion related to insufficient blood flow </li></ul><ul><li>Pain related to myocardial ischemia </li></ul><ul><li>Activity intolerance related to onset of pain </li></ul>
  25. 27. NURSING CARE PLAN <ul><li>GOAL # 1: provide relief from pain </li></ul><ul><ul><li>Rest until pain subsides </li></ul></ul><ul><ul><li>Nitroglycerin (nitrites) </li></ul></ul><ul><ul><li>Identify precipitating factors: heavy meals, heavy exercise, stimulants, cold air </li></ul></ul><ul><ul><li>Vital signs: hypotension </li></ul></ul><ul><ul><li>Assist with ambulation: dizziness, flushing occurs with nitroglycerin </li></ul></ul>
  26. 28. NURSING CARE PLAN <ul><li>GOAL # 2: provide emotional support </li></ul><ul><ul><li>Encourage verbalization of feelings </li></ul></ul><ul><ul><li>Reassurance; positive self-concept </li></ul></ul><ul><ul><li>Acceptance of limitations </li></ul></ul>
  27. 29. NURSING CARE PLAN <ul><li>GOAL # 3: health teaching </li></ul><ul><ul><li>Pain: alleviation, differentiation from M.I., precipitating factors </li></ul></ul><ul><ul><li>Medications: frequency, side effects, dosage, route.. </li></ul></ul><ul><ul><li>Diet: restricted calories if weight loss indicated; restricted fat, cholesterol, gas-forming food; small, frequent meals </li></ul></ul><ul><ul><li>Exercise: regular, graded, to promote coronary circulation </li></ul></ul><ul><ul><li>Behavior modification </li></ul></ul><ul><ul><li>Coronary bypass surgery if indicated </li></ul></ul>
  28. 30. EVALUATION/OUTCOME CRITERIA <ul><li>Relief from pain </li></ul><ul><li>Fewer attacks </li></ul><ul><li>No myocardial infarction </li></ul><ul><li>Alters lifestyle; complies with limitations </li></ul><ul><li>No smoking </li></ul>
  29. 31. MYOCARDIAL INFARCTION <ul><li>irreversible cardiac damage from occlusion of 1 or more coronary arteries </li></ul><ul><li>The term “acute coronary syndrome” includes unstable angina and myocardial infarction </li></ul>
  30. 32. CLINICAL MANIFESTATIONS AND DIAGNOSIS <ul><li>Chest pain, other symptoms </li></ul><ul><li>Laboratory tests—biomarkers </li></ul><ul><ul><li>WBC: 12000-15000/µL </li></ul></ul><ul><ul><li>CK-MB </li></ul></ul><ul><ul><li>Myoglobin </li></ul></ul><ul><ul><li>Troponin T or I </li></ul></ul><ul><li>ECG changes </li></ul>
  31. 33. EFFECTS OF M.I. ON E.C.G <ul><li>Recent M.I. </li></ul><ul><ul><li>ST elevation (injury) </li></ul></ul><ul><ul><li>T wave inversion (ischemia) </li></ul></ul><ul><li>Previous M.I. </li></ul><ul><ul><li>Q wave (necrosis / old infarct) </li></ul></ul>
  32. 34. ASSESSMENT <ul><li>Subjective data: </li></ul><ul><ul><li>PAIN!!! </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>SOB </li></ul></ul><ul><ul><li>Apprehension </li></ul></ul><ul><li>Objective data: </li></ul><ul><ul><li>VS </li></ul></ul><ul><ul><li>Diaphoresis </li></ul></ul><ul><ul><li>Emotional restlessness </li></ul></ul>
  33. 35. ANALYSIS / NURSING DIAGNOSES <ul><li>Decreased cardiac output related to myocardial damage </li></ul><ul><li>Impaired gas exchange related to poor perfusion, shock </li></ul><ul><li>Pain related to myocardial ischemia </li></ul><ul><li>Activity intolerance related to pain or inadequate oxygenation </li></ul><ul><li>Fear related to possibility of death </li></ul>
  34. 36. NURSING CARE PLAN <ul><li>Goal # 1: reduce pain / discomfort </li></ul><ul><ul><li>Narcotics – morphine; note response; Avoid IM </li></ul></ul><ul><ul><li>Humidified oxygen 2-4 L/min; mouth care – O 2 is drying </li></ul></ul><ul><ul><li>Position: semi-Fowler’s to improve ventilation </li></ul></ul>
  35. 37. NURSING CARE PLAN <ul><li>Goal # 2: maintain adequate circulation; stabilize heart rhythm </li></ul><ul><ul><li>Monitor VS/UO; observe for cardiogenic shock </li></ul></ul><ul><ul><li>Monitor ECG for arrhythmias </li></ul></ul><ul><ul><li>Medications: antiarrhythmics; anticoagulants; thrombolytics </li></ul></ul><ul><ul><li>Diagnostics: cardiac catheterizations, CAB surgery </li></ul></ul><ul><ul><li>Recognize heart failure: edema, cyanosis, dyspnea, crackles </li></ul></ul><ul><ul><li>Check labs: troponin, blood gases, electrolytes, clotting time </li></ul></ul><ul><ul><li>CVP: (5-15 cm H 2 O) increases with heart failure </li></ul></ul><ul><ul><li>ROM of lower extremities; antiembolic stockings </li></ul></ul>
  36. 38. NURSING CARE PLAN <ul><li>Goal # 3: decrease oxygen demand/promote oxygenation, reduce cardiac workload </li></ul><ul><ul><li>O 2 as ordered </li></ul></ul><ul><ul><li>Activity: bedrest (24-48 H) with bedside commode; planned rest periods; control visitors </li></ul></ul><ul><ul><li>Position: semi-Fowler’s to facilitate lung expansion and decrease venous return </li></ul></ul><ul><ul><li>Anticipate needs of client: call light, water / Reassurance </li></ul></ul><ul><ul><li>Assist with feeding, turning </li></ul></ul><ul><ul><li>Environment: quiet and comfortable </li></ul></ul><ul><ul><li>Medications: CCBs, vasodilators, cardiotonics </li></ul></ul>
  37. 39. NURSING CARE PLAN <ul><li>Goal # 4: maintain fluid electrolyte, nutritional status </li></ul><ul><ul><li>IV (KVO); CVP; vital signs </li></ul></ul><ul><ul><li>UO: 30 cc/hr </li></ul></ul><ul><ul><li>Labs: electrolytes (Na, K, Mg) </li></ul></ul><ul><ul><li>Monitor ECG </li></ul></ul><ul><ul><li>Diet : progressive low calorie, low sodium, low cholesterol, low fat, without caffeine </li></ul></ul>
  38. 40. NURSING CARE PLAN <ul><li>Goal # 5: facilitate fecal elimination </li></ul><ul><ul><li>Medications: stool softeners to prevent Valsalva maneuver; mouth breathing during bowel movement </li></ul></ul><ul><ul><li>Bedside commode </li></ul></ul>
  39. 41. NURSING CARE PLAN <ul><li>Goal # 6: provide emotional support </li></ul><ul><ul><li>Recognize fear of dying: denial, anger, withdrawal </li></ul></ul><ul><ul><li>Encourage expression of feelings, fears, concerns </li></ul></ul><ul><ul><li>Discuss rehabilitation, lifestyle changes: prevent cardiac-invalid syndrome by promoting self-care activities, independence </li></ul></ul>
  40. 42. NURSING CARE PLAN <ul><li>Goal # 7: promote sexual functioning </li></ul><ul><ul><li>Encourage verbalization of concerns regarding activity, inadequacy, limitations, expectations – include partner (usually resume activity 5-8 wks after uncomplicated MI or when client can climb 2 flights of stairs </li></ul></ul><ul><ul><li>Identify need for referral for sexual counselling </li></ul></ul>
  41. 43. NURSING CARE PLAN <ul><li>Goal # 8: health teaching </li></ul><ul><ul><li>Diagnosis and treatment regimen </li></ul></ul><ul><ul><li>Caution when to avoid sexual activity: after heavy meal, alcohol ingestion; when fatigued, stressed; with unfamiliar partners; in extreme temperatures </li></ul></ul><ul><ul><li>Information about sexual activity: less fatiguing positions </li></ul></ul><ul><ul><li>Support groups / Follow-up care </li></ul></ul><ul><ul><li>Medications: administration, importance, untoward effects; pulse taking </li></ul></ul><ul><ul><li>Control risk factors: rest, diet, exercise, no smoking, weight control, stress reduction </li></ul></ul>
  42. 44. EVALUATION <ul><li>No complications: stable vital signs; relief of pain </li></ul><ul><li>Adheres to medication regimen </li></ul><ul><li>Activity tolerance is increased </li></ul><ul><li>Reduction or modification of risk factors </li></ul>
  43. 45. CONGESTIVE HEART FAILURE <ul><li>inability of the heart to pump sufficient blood to meet the needs of the tissue for oxygen and nutrient. </li></ul>
  45. 47. ASSESSMENT <ul><li>Subjective data: </li></ul><ul><ul><li>Shortness of breath </li></ul></ul><ul><ul><ul><li>Orthopnea (sleeps on two or more pillows) </li></ul></ul></ul><ul><ul><ul><li>Paroxysmal nocturnal dyspnea (sudden breathlessness during sleep) </li></ul></ul></ul><ul><ul><ul><li>Dyspnea on exertion (climbing stairs) </li></ul></ul></ul><ul><ul><ul><li>Apprehension; anxiety; irritability </li></ul></ul></ul><ul><ul><ul><li>Fatigue; weakness </li></ul></ul></ul><ul><ul><ul><li>Reported weight gain; feeling of puffiness </li></ul></ul></ul>
  46. 48. ASSESSMENT <ul><li>Objective data: </li></ul><ul><ul><li>VS: </li></ul></ul><ul><ul><ul><li>BP : decreasing systolic; narrowing pulse pressure </li></ul></ul></ul><ul><ul><ul><li>Pulse : pulsus alternans (alternating strong-weak-strong cardiac contraction); increased. </li></ul></ul></ul><ul><ul><ul><li>Respirations : crackles; Cheyne-Stokes </li></ul></ul></ul><ul><ul><li>Edema: dependent, pitting (1+ to 4+ mm) </li></ul></ul><ul><ul><li>Liver: enlarged, tender </li></ul></ul><ul><ul><li>Distended neck veins </li></ul></ul><ul><ul><li>Chest X-ray: enlarged heart; dilated pulmonary vessels; lung edema </li></ul></ul>
  47. 49. Left Ventricular Compared with Right Ventricular Heart Failure LEFT VENTRICULAR FAILURE RIGHT VENTRICULAR FAILURE Pulmonary crackles Jugular venous distention Tachypnea Peripheral edema S 3 gallop Perioral and peripheral cyanosis Cardiac murmurs Congestive hepatomegaly Paradoxical splitting of S 2 Ascites Hepatojugular reflux
  48. 50. ANALYSIS / NURSING DIAGNOSE S <ul><li>Decreased cardiac output related to decreased myocardial contractility </li></ul><ul><li>Activity intolerance related to generalized body weakness and inadequate oxygenation </li></ul><ul><li>Fatigue related to edema and poor oxygenation </li></ul><ul><li>Fluid volume excess related to compensatory mechanisms </li></ul><ul><li>Impaired gas exchange related to pulmonary congestion </li></ul><ul><li>Anxiety related to shortness of breath </li></ul><ul><li>Sleep pattern disturbance related to paroxysmal nocturnal disturbance </li></ul>
  49. 51. NURSING CARE PLAN <ul><li>Goal # 1: provide physical rest/ reduce emotional stimuli </li></ul><ul><ul><li>Position: sitting or semi-Fowler’s until tachycardia, dyspnea, edema resolved; change position frequently; pillows for support </li></ul></ul><ul><ul><li>Rest: planned periods; limit visitors, activity, noise. Chair and commode privileges </li></ul></ul><ul><ul><li>Support: stay with client who is anxious; have family member who is supportive present; administer sedatives/tranquilizers as ordered </li></ul></ul><ul><ul><li>Warm fluids if appropriate </li></ul></ul>
  50. 52. NURSING CARE PLAN <ul><li>Goal # 2: provide for relief of respiratory distress; reduce cardiac workload </li></ul><ul><ul><li>Oxygen: low flow rate; encourage deep breathing (5-10 min q 2H); auscultate breath sounds for congestion, pulmonary edema. </li></ul></ul><ul><ul><li>Position : elevating head of bed 20-25 cm (8-10 in) alleviates pulmonary congestion </li></ul></ul><ul><ul><li>Medications – digitalis, ACE inhibitors, inotropic agents, diuretics, tranquilizers, vasodilators </li></ul></ul>
  51. 53. NURSING CARE PLAN <ul><li>Goal # 3: provide for special safety needs </li></ul><ul><ul><li>Skin care: </li></ul></ul><ul><ul><ul><li>Inspect, massage, lubricate bony prominences </li></ul></ul></ul><ul><ul><ul><li>Use foot cradle, heel protectors; sheepskin </li></ul></ul></ul><ul><ul><li>Side rails up if hypoxic (disoriented) </li></ul></ul><ul><ul><li>Vital signs: monitor for signs of fatigue, pulmonary emboli </li></ul></ul><ul><ul><li>ROM: active, passive; elastic stockings </li></ul></ul>
  52. 54. NURSING CARE PLAN <ul><li>Goal # 4: maintain fluid and electrolyte balance, nutritional status </li></ul><ul><ul><li>Urine output: 30 cc/hr minimum; estimate insensible loss in client who s diaphoretic. Monitor BUN, serum creatinine, and electrolytes. </li></ul></ul><ul><ul><li>Daily weight; same time, clothes, scale </li></ul></ul><ul><ul><li>IV: IV infusion pump to avoid circulatory overload; strict I/O </li></ul></ul><ul><ul><li>Diet </li></ul></ul><ul><ul><ul><li>Low sodium </li></ul></ul></ul><ul><ul><ul><li>Small, frequent feedings </li></ul></ul></ul><ul><ul><ul><li>Discuss food preferences with client. </li></ul></ul></ul>
  53. 55. NURSING CARE PLAN <ul><li>Goal # 5: health teaching </li></ul><ul><ul><li>Diet restrictions; meal preparation </li></ul></ul><ul><ul><li>Activity restrictions; planned rest periods </li></ul></ul><ul><ul><li>Medications: schedule (e.g. diuretics in early morning); purpose; dosage; side effects (pulse taking, daily weights, intake of potassium-containing foods) </li></ul></ul><ul><ul><li>Refer to available community resources for dietary assistance, weight reduction, exercise program. </li></ul></ul>
  54. 56. EVALUATION <ul><li>Increase in activity level tolerance – fatigue decreased </li></ul><ul><li>No complications – pulmonary edema, respiratory distress </li></ul><ul><li>Reduction in dependent edema </li></ul>
  56. 58. THE BLOOD <ul><li>Composition of the blood </li></ul><ul><ul><ul><li>RBC, WBC, Platelets, Plasma </li></ul></ul></ul><ul><li>RBC </li></ul><ul><ul><ul><li>normal erythropoeisis requires : pyridoxine, Vit B12, folic acid, protein, copper, cobalt; </li></ul></ul></ul><ul><ul><ul><li>HEMOBGLOBIN : Iron; Oxygen transport; Acid-base buffer </li></ul></ul></ul><ul><li>WBC </li></ul><ul><ul><ul><li>granulocytes –neutrophils, eosinophils, basophils </li></ul></ul></ul><ul><ul><ul><li>agaranulocytes –lymphocytes (T,B), monocytes </li></ul></ul></ul><ul><li>Plasma </li></ul><ul><ul><ul><li>albumin, water, clotting factors, antibodies </li></ul></ul></ul>
  57. 62. IRON DEFICIENCY ANEMIA <ul><li>Composition of the blood </li></ul><ul><ul><ul><li>RBC, WBC, Platelets, Plasma </li></ul></ul></ul><ul><li>RBC </li></ul><ul><ul><ul><li>normal erythropoeisis requires : pyridoxine, Vit B12, folic acid, protein, copper, cobalt; </li></ul></ul></ul><ul><ul><ul><li>HEMOGLOBIN : IRON ; Oxygen transport; Acid-base buffer </li></ul></ul></ul><ul><li>WBC </li></ul><ul><ul><ul><li>granulocytes –neutrophils, eosinophils, basophils </li></ul></ul></ul><ul><ul><ul><li>agranulocytes –lymphocytes (T,B), monocytes </li></ul></ul></ul><ul><li>Plasma </li></ul><ul><ul><ul><li>albumin, water, clotting factors, antibodies </li></ul></ul></ul>
  59. 64. CAUSES &EFFECTS <ul><li>Poor intake if iron rich foods </li></ul><ul><li>Poor absorption & utilization of iron from foods </li></ul><ul><li>Acute / chronic blood loss </li></ul>
  60. 65. ANALYSIS / NURSING DIAGNOSES <ul><li>Altered nutrition, less than body requirements, related to inadequate iron absorption </li></ul><ul><li>Altered tissue perfusion related to reduction in red cells </li></ul><ul><li>Risk for activity intolerance related to profound weakness </li></ul><ul><li>Impaired gas exchange related to decreased oxygen-carrying capacity </li></ul>
  61. 66. NURSING CARE PLANS <ul><li>Goal # 1: promote physical and mental equilibrium </li></ul><ul><ul><li>Position: optimal for respiratory excursion; deep breathing; turn frequently to prevent skin breakdown </li></ul></ul><ul><ul><li>Rest: balance with activity, as tolerated; assist with ambulation </li></ul></ul><ul><ul><li>Keep warm: no hot water bottles, heating pads, due to increased sensitivity </li></ul></ul><ul><ul><li>Diet: high in protein, iron, vitamins </li></ul></ul>
  62. 67. NURSING CARE PLANS <ul><li>Goal # 1: promote physical and mental equilibrium </li></ul><ul><ul><li>Medication (hematinics) </li></ul></ul><ul><ul><ul><li>oral iron therapy (FeSO 4 ) – give with meals </li></ul></ul></ul><ul><ul><ul><li>IM therapy (iron dextran) </li></ul></ul></ul><ul><ul><ul><ul><li>use second needle for injection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Z-track </li></ul></ul></ul></ul><ul><ul><ul><ul><li>inject 0.5 mL of air before </li></ul></ul></ul></ul><ul><ul><ul><ul><li>withdrawing needle to </li></ul></ul></ul></ul><ul><ul><ul><ul><li>prevent tissue necrosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rotate sites </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Do not rub site or allow wearing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>of constricting garments after injection </li></ul></ul></ul></ul>
  63. 68. NURSING CARE PLANS <ul><li>Goal # 2: health teaching </li></ul><ul><ul><li>Dietary regimen </li></ul></ul><ul><ul><li>Iron therapy: explain purpose, dosage, side effects (black/green stools, constipation, diarrhea); take with meals </li></ul></ul><ul><ul><li>Activity: exercise to tolerance, with planned rest periods </li></ul></ul>
  64. 69. EVALUATION <ul><li>Hemoglobin and hematocrit level return to normal range </li></ul><ul><li>Tolerates activity without fatigue </li></ul><ul><li>Selects foods appropriate for dietary regimen </li></ul>
  65. 70. LEUKEMIA <ul><li>Fatal neoplastic disease that involves the blood forming tissues of the: </li></ul><ul><ul><li>Bone marrow </li></ul></ul><ul><ul><li>Spleen </li></ul></ul><ul><ul><li>Lymph nodes </li></ul></ul><ul><li>Uncontrolled & destructive proliferation of one type of WBC & its precursors </li></ul>
  66. 71. LEUKEMIA <ul><li>Types: </li></ul><ul><ul><li>Acute nonlymphocytic (ANLL) – also known as acute myelogenous leukemia (AML); seen generally in older age (>60 yr). </li></ul></ul><ul><ul><li>Acute lymphoblastic (ALL) – common in children 2-10y/o </li></ul></ul><ul><ul><li>Chronic lymphocytic (CLL) – generally affects the elderly </li></ul></ul><ul><ul><li>Chronic myelogenous (CML) – also known as chronic granulocytic leukemia (CGL); more likely to occur between 25-60 years old. </li></ul></ul>
  67. 72. LEUKEMIA <ul><li>Risk Factors </li></ul><ul><ul><li>Viruses </li></ul></ul><ul><ul><li>Genetic abnormalities </li></ul></ul><ul><ul><li>Exposure to chemicals </li></ul></ul><ul><ul><li>Radiation </li></ul></ul><ul><ul><li>Treatment for other types of cancer (e.g. alkylating agents) </li></ul></ul>
  68. 73. ASSESSMENT <ul><li>Subjective data: </li></ul><ul><ul><li>Fatigue, weakness </li></ul></ul><ul><ul><li>Anorexia, nausea </li></ul></ul><ul><ul><li>Pain: joints, bone (acute leukemia) </li></ul></ul><ul><ul><li>Night sweats, weight loss, malaise </li></ul></ul>
  69. 74. ASSESSMENT <ul><li>Objective data: </li></ul><ul><ul><li>Skin: pallor due to anemia; jaundice </li></ul></ul><ul><ul><li>Fever: frequent infections; mouth ulcers </li></ul></ul><ul><ul><li>Bleeding: petechiae, purpura, ecchymosis, epistaxis, gingiva </li></ul></ul><ul><ul><li>Organ enlargement: spleen, liver </li></ul></ul><ul><ul><li>Enlarged lymph nodes; tenderness </li></ul></ul><ul><ul><li>Bone marrow aspiration: increased presence of blasts </li></ul></ul>
  70. 75. ASSESSMENT <ul><li>Lab data: </li></ul><ul><ul><li>WBC – abnormally low (<1000/mm 3 ) or extremely high (>200,000/mm 3 ); differential is important </li></ul></ul><ul><ul><li>RBC – normal to severely decreased </li></ul></ul><ul><ul><li>Hgb – low or normal </li></ul></ul><ul><ul><li>Platelets – usually low </li></ul></ul>
  71. 76. ANALYSIS / NURSING DIAGNOSES <ul><li>Risk for infection related to immature or abnormal leukocytes </li></ul><ul><li>Activity intolerance related to hypoxia and weakness </li></ul><ul><li>Fatigue related to anemia </li></ul><ul><li>Altered tissue perfusion related to anemia </li></ul><ul><li>Anxiety related to diagnosis and treatment </li></ul><ul><li>Altered oral mucous membrane related to susceptibility to infection </li></ul><ul><li>Fear related to diagnosis </li></ul><ul><li>Ineffective individual or family coping related to potentially fatal disease </li></ul>
  72. 77. NURSING CARE PLAN <ul><li>Goal # 1: prevent, control, and treat infection </li></ul><ul><ul><li>Protective isolation if indicated </li></ul></ul><ul><ul><li>Observe for early signs of infection: </li></ul></ul><ul><ul><ul><li>Inflammation at injection sites </li></ul></ul></ul><ul><ul><ul><li>Vital signs changes </li></ul></ul></ul><ul><ul><ul><li>Cough </li></ul></ul></ul><ul><ul><ul><li>Obtain cultures </li></ul></ul></ul><ul><ul><li>Give antibiotics as ordered </li></ul></ul><ul><ul><li>Mouth care: clean q2h, examine for new lesions, avoid trauma </li></ul></ul>
  73. 78. NURSING CARE PLAN <ul><li>Goal # 2: assess and control bleeding, anemia </li></ul><ul><ul><li>Activity: restrict ; to prevent trauma </li></ul></ul><ul><ul><li>Observe for hemorrhage: vital signs; body orifices, stool, urine </li></ul></ul><ul><ul><li>Control localized bleeding: ice, pressure at least 3-4 min after needle sticks, positioning </li></ul></ul><ul><ul><li>Use soft-bristle or foam-rubber toothbrush to prevent gingival bleeding </li></ul></ul><ul><ul><li>Give blood/blood components as ordered; observe for transfusion reactions </li></ul></ul>
  74. 79. NURSING CARE PLAN <ul><li>Goal # 3: provide rest comfort, nutrition </li></ul><ul><ul><li>Activity: 8 hr sleep or rest; daily nap </li></ul></ul><ul><ul><li>Comfort measures: flotation mattress, bed cradle, sheepskin </li></ul></ul><ul><ul><li>Analgesics : without delay </li></ul></ul><ul><ul><ul><li>Mild pain (Acetaminophen; without aspirin) </li></ul></ul></ul><ul><ul><ul><li>Severe pain (codeine, meperidine HCl) </li></ul></ul></ul><ul><ul><li>Diet: bland </li></ul></ul><ul><ul><ul><li>High in protein, minerals, vitamins </li></ul></ul></ul><ul><ul><ul><li>Low roughage </li></ul></ul></ul><ul><ul><ul><li>Small, frequent feedings </li></ul></ul></ul><ul><ul><ul><li>Favorite foods </li></ul></ul></ul><ul><ul><li>Fluids: 3000 – 4000 mL/day </li></ul></ul>
  75. 80. NURSING CARE PLAN <ul><li>Goal # 4: reduce side effects from therapeutic regimen </li></ul><ul><ul><li>Nausea: antiemetics , usually half-hour before chemotherapy </li></ul></ul><ul><ul><li>Increased uric acid level: force fluids </li></ul></ul><ul><ul><li>Stomatitis: antiseptic anesthetic mouthwashes </li></ul></ul><ul><ul><li>Rectal irritation: meticulous toileting, sitz bath, topical relief </li></ul></ul>
  76. 81. NURSING CARE PLAN <ul><li>Goal # 5: provide emotional / spiritual support </li></ul><ul><ul><li>Contact clergy if client desires </li></ul></ul><ul><ul><li>Allow, encourage client-initiated discussion of death (developmentally appropriate) </li></ul></ul><ul><ul><li>Allow family to be involved with care </li></ul></ul><ul><ul><li>If death occurs, provide privacy for family, listening, sharing of grief </li></ul></ul>
  77. 82. NURSING CARE PLAN <ul><li>Goal # 6: health teaching </li></ul><ul><ul><li>Prevent infection. </li></ul></ul><ul><ul><li>Limit activity. </li></ul></ul><ul><ul><li>Control bleeding. </li></ul></ul><ul><ul><li>Reduce nausea. </li></ul></ul><ul><ul><li>Mouth care. </li></ul></ul><ul><ul><li>Chemotherapy: regimen; side effects. </li></ul></ul>
  78. 83. EVALUATION <ul><li>Alleviate symptoms; obtain remission. </li></ul><ul><li>Prevent complications (e.g. infection). </li></ul><ul><li>Ventilates emotion – accepts and deals with anger. </li></ul><ul><li>Experiences peaceful death (e.g. pain free). </li></ul>
  79. 84. IDIOPATHIC THROMBOCYTIC PURPURA <ul><li>Potentially fatal disorder characterized by spontaneous increase in platelet destruction </li></ul><ul><li>Possible autoimmune response </li></ul><ul><li>Predominant in 2 – 4-year-olds and girls/women ≥10 years old </li></ul><ul><li>Secondary thrombocytopenia – viral infections, drug hypersensitivity (i.e. quinidine, sulfonamides), lupus, or bone marrow failure </li></ul><ul><ul><li>Treat cause </li></ul></ul>
  80. 86. ASSESSMENT <ul><li>Subjective data: </li></ul><ul><ul><li>Spontaneous skin hemorrhages – lower extremities </li></ul></ul><ul><ul><li>Menorrhagia </li></ul></ul><ul><ul><li>Epistaxis </li></ul></ul>
  81. 87. ASSESSMENT <ul><li>Objective data: </li></ul><ul><ul><li>Bleeding: GI, urinary, nasal; following minor trauma, dental extractions. </li></ul></ul><ul><ul><li>Petechiae; ecchymosis </li></ul></ul><ul><ul><li>Tourniquet test – positive, demonstrating increased capillary fragility </li></ul></ul><ul><ul><li>Lab data </li></ul></ul><ul><ul><ul><li>Decreased platelets (100,000/µL). </li></ul></ul></ul><ul><ul><ul><li>Increased bleeding time </li></ul></ul></ul>
  82. 88. ANALYSIS / NURSING DIAGNOSES <ul><li>Risk for injury related to hemorrhage </li></ul><ul><li>Altered tissue perfusion related to fragile capillaries </li></ul><ul><li>Impaired skin integrity related to skin hemorrhages </li></ul>
  83. 89. NURSING CARE PLAN <ul><li>Goal # 1: prevent complication from bleeding tendencies </li></ul><ul><ul><li>Precautions: </li></ul></ul><ul><ul><ul><li>Injections – use small-bore needles; rotate sites; apply direct pressure </li></ul></ul></ul><ul><ul><ul><li>Avoid bumping, trauma. </li></ul></ul></ul><ul><ul><ul><li>Use swabs for mouth care </li></ul></ul></ul><ul><ul><li>Observe for signs of bleeding, petechiae, following blood pressure reading, ecchymosis, purpura. </li></ul></ul><ul><ul><li>Administer steroids to increase platelet count in ITP; give platelets <20,000-30,000/µL with STP; high-dose immunoglobulins. </li></ul></ul>
  84. 90. NURSING CARE PLAN <ul><li>Goal # 2: health teaching </li></ul><ul><ul><li>Avoid traumatic activities: </li></ul></ul><ul><ul><ul><li>Contact sports </li></ul></ul></ul><ul><ul><ul><li>Violent sneezing, coughing, nose blowing. </li></ul></ul></ul><ul><ul><ul><li>Straining at stool </li></ul></ul></ul><ul><ul><ul><li>Heavy lifting </li></ul></ul></ul><ul><ul><li>Signs of decreased platelets – petechiae, ecchymosis, gingival bleeding, hematuria, menorrhagia </li></ul></ul><ul><ul><li>Use MedicAlert tag/card </li></ul></ul><ul><ul><li>Precautions: self-medication; particularly avoid aspirin-containing drugs </li></ul></ul><ul><ul><li>Prepare for splenectomy if drug therapy is unsuccessful </li></ul></ul>
  85. 91. EVALUATION <ul><li>Returns for follow-up. </li></ul><ul><li>No complications (e.g. intracranial hemorrhage). </li></ul><ul><li>Platelet count > 200,000/µL. </li></ul><ul><li>Skin remains intact. </li></ul><ul><li>Resumes self-care activities. </li></ul>
  86. 92. REFERENCES <ul><li>Donofrio, J. Haworth, K. Schaeffer, L. Thompson, G. (Eds.). (2005). Cardiovascular care made incredibly easy. Philadelphia: Lipincott Williams & Wilkins. </li></ul><ul><li>Lagerquist, S.L. (Ed.) (2005). Davis’s nclex-rn success. (2 nd ed.). Philadelphia: F.A. Davis Company. </li></ul><ul><li>Topol EJ (Ed.). (2000). Cleveland clinic heart book. New York: Hyperion. </li></ul>