- Provide small frequent feedings
- Low calorie, low cholesterol, low sodium diet
- Avoid stimulants, hot/cold beverages, gas forming foods
- Use bedpan, avoid straining at stool
CLDomocmat 8/9/2012 50
Potential for Dysrhythmias
related to myocardial ischemia, infarction,
electrolyte imbalances, medications
1. Continuous cardiac monitoring
2. Check electrolytes and replace as needed
3. Administer antiarrhythmic medications as
ordered
4. Teach client and family about warning signs
and symptoms of dysrhythmias
5. Report any changes in cardiac rhythm to
physician
continuous or intermittent monitoring of heart activity, generally by electrocardiography, with assessment of the patient's condition relative to their cardiac rhythm.
continuous or intermittent monitoring of heart activity, generally by electrocardiography, with assessment of the patient's condition relative to their cardiac rhythm.
A cardiac event monitor is a device that you control to record the electrical activity of your heart (ECG). This device is about the size of a pager. It records your heart rate and rhythm. Cardiac event monitors are used when you need long-term monitoring of symptoms that occur less than daily
The CVP catheter is an important tool used to assess right ventricular function and systemic fluid status. Normal CVP is 2-6 mm Hg. CVP is elevated by : overhydration which increases venous return.
A cardiac event monitor is a device that you control to record the electrical activity of your heart (ECG). This device is about the size of a pager. It records your heart rate and rhythm. Cardiac event monitors are used when you need long-term monitoring of symptoms that occur less than daily
The CVP catheter is an important tool used to assess right ventricular function and systemic fluid status. Normal CVP is 2-6 mm Hg. CVP is elevated by : overhydration which increases venous return.
Patent ductus arteriosus (PDA) is a congenital disorder in the heart wherein a neonate's ductus arteriosus fails to close after birth. Early symptoms are uncommon, but in the first year of life include increased work of breathing and poor weight gain. With age, the PDA may lead to congestive heart failure if left uncorrected. The ductus arteriosus is a normal fetal blood vessel that closes soon after birth. In a patent ductus arteriosus (PDA) the vessel does not close and remains "patent" (open) resulting in irregular transmission of blood between two of the most important arteries close to the heart, the aorta and the pulmonary artery. PDA is common in neonates with persistent respiratory problems such as hypoxia, and has a high occurrence in premature children. In hypoxic newborns, too little oxygen reaches the lungs to produce sufficient levels of bradykinin and subsequent closing of the DA. Premature children are more likely to be hypoxic and thus have PDA because of their underdeveloped heart and lungs.
A patent ductus arteriosus allows a portion of the oxygenated blood from the left heart to flow back to the lungs by flowing from the aorta (which has higher pressure) to the pulmonary artery. If this shunt is substantial, the neonate becomes short of breath: the additional fluid returning to the lungs increases lung pressure to the point that the neonate has greater difficulty inflating the lungs. This uses more calories than normal and often interferes with feeding in infancy. This condition, as a constellation of findings, is called congestive heart failure.
In some cases, such as in transposition of the great vessels (the pulmonary artery and the aorta), a PDA may need to remain open. In this cardiovascular condition, the PDA is the only way that oxygenated blood can mix with deoxygenated blood. In these cases, prostaglandins are used to keep the patent ductus arteriosus open
A study to assess the effectiveness of structured teaching program on knowledge regarding care of patients after cardiac surgery among staff nurses at Shree Narayana, Hospital, Raipur, chhattisgarh.
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Ischemic heart disease is a condition of recurring chest pain or discomfort that occurs when a part of the heart does not receive enough blood. This condition occurs most often during exertion or excitement, when the heart requires greater blood flow.
Abstract | In clinical guidelines, drugs for symptomatic angina are classified as being first choice
(β‑blockers, calcium-channel blockers, short-acting nitrates) or second choice (ivabradine,
nicorandil, ranolazine, trimetazidine), with the recommendation to reserve second-choice
medications for patients who have contraindications to first-choice agents, do not tolerate them,
or remain symptomatic. No direct comparisons between first-choice and second-choice
treatments have demonstrated the superiority of one group of drugs over the other.
Meta-analyses show that all antianginal drugs have similar efficacy in reducing symptoms,
but provide no evidence for improvement in survival. The newer, second-choice drugs have more
evidence-based clinical data that are more contemporary than is available for traditional
first-choice drugs. Considering some drugs, but not others, to be first choice is, therefore,
difficult. Moreover, double or triple therapy is often needed to control angina. Patients with
angina can have several comorbidities, and symptoms can result from various underlying
pathophysiologies. Some agents, in addition to having antianginal effects, have properties that
could be useful depending on the comorbidities present and the mechanisms of angina, but the
guidelines do not provide recommendations on the optimal combinations of drugs. In this
Consensus Statement, we propose an individualized approach to angina treatment, which takes
into consideration the patient, their comorbidities, and the underlying mechanism of disease
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Surgical Site Infections, pathophysiology, and prevention.pptx
Nursing care of client with Coronary artery disease part 2 of 2
1. NURSING CARE OF CLIENT WITH
ACUTE CORONARY SYNDROME
NURSING DIAGNOSES AND COLLABORATIVE
INTERVENTIONS
Maria Carmela L. Domocmat, RN, MSN
Instructor
School of Nursing
Northern Luzon Adventist College
3. Management
Maria Carmela L.Domocmat, RN, MSN 8/9/2012 3
4. Door to needle time
Door to balloon time
CLDomocmat 8/9/2012 4
5. Goals of care
1. Treat the acute attack immediately
2. Determine location of myocardial infarction
3. Monitor for complications
Maria Carmela L.Domocmat, RN, MSN 8/9/2012 5
6. cells in ischemic area – are salvageable if
reperfusion therapies and inotropic support is
promptly instituted (Schumacher &
Chernecky, 2006)
within 10 min of arrival of suspected AMI –
ingest aspirin and obtain baseline cardiac
serum markers, 12-lead ECG
Maria Carmela L.Domocmat, RN, MSN 8/9/2012 6
7. Medical management
Reduce risk factors
Restore blood supply
Percutaneous transluminal coronary angioplasty
Directional coronary atherectomy
Laser ablation
Transmyocardial revascularization
Nursing management
Reduce risk factors
Restore blood supply
Surgical management
Cardiac surgery
Open heart surgery
Coronary artery bypass graft
Nursing management
before cardiac surgery
Phase I (In-hospital) Rehabilitation Programs
self-care
Phase 2 (Outpatient Exercise Training) Rehabilitation Programs
Phase 2 (Community) Rehabilitation Programs
Home exercise Rehabilitation Programs
CLDomocmat 8/9/2012 7
8. Medical mgmt
first-line and initial treatment
(Schumacher & Chernecky, 2006; Smetzer, 2010)
Semi folwer’s position
O2 (2-4 lpm)
IV access
obtain 12-lead EKG
VS and pulse oximetry
labs (serum cardiac markers)
ECG monitoring
conduct hx and PE
reduce pain
administer meds
Maria Carmela L.Domocmat, RN, MSN 8/9/2012 8
9. Medical mgmt
first-line and initial treatment cont.
admit to CCU
invasive line placement (arterial line, pulmo artery cath)
- to provide further data to monitor ventricular
dysfunction
IABP – intraaortic balloon pump
for severe L ventricular dysfunction
to assist ventricular ejection and promote CA perfusion
anticipate emergency PTCA or CABG
reperfusion procedures
if thrombolytics are either CI or unsuccessful
Maria Carmela L.Domocmat, RN, MSN 8/9/2012 9
10. Nursing mgmt: Goals
Recognize and treat cardiac ischemia
Admin thrombolytic therapy as ordered, or
ready client for PTCA and observe for
complications
Recognize and treat potentially life-
threatening dysrhythmias
Maria Carmela L.Domocmat, RN, MSN 8/9/2012 10
11. Nursing mgmt: Goals
Monitor for complications of reduced CO
Maintain a therapeutic critical care envt
Identify the psychosocial impact of AMI on
client and family
Educate the client in lifestyle changes and
rehabilitation
Maria Carmela L.Domocmat, RN, MSN 8/9/2012 11
12. Nursing Diagnoses
Acute Pain
Ineffective Tissue perfusion (Cardiopulmonary)
Activity Intolerance
Ineffective Coping
Potential or dysrhythmias
Potential for heart failure
Potential for recurrent symptoms and extension
of injury
CLDomocmat 8/9/2012 12
13. Acute Pain
related to imbalance between myocardial
oxygen supply and demand
CLDomocmat 8/9/2012 13
14. Acute Pain
1. Obtain description of chest discomfort
2. Vital signs and cardiac monitoring
3. Check vascular access
4. Place in semi fowler’s position
5. 12 lead ECG
6. O2 inhalation
CLDomocmat 8/9/2012 14
15. 7. Provide pain meds and aspirin
a. Nitroglycerine – increases collateral blood flow,
redistributes blood flow toward the subendocardium and
causes dilation of the coronary arteries
b. Morphine sulfate – relieves MI pain, decreases
sympathetic stimulation which decreases O2
demand and reduces circulating catecholamines
8. Assess the client’s VS and intensity of pain 5
minutes after administration of meds
9. Notify physician if patients condition deteriorates
CLDomocmat 8/9/2012 15
19. Let’s review: Acute Pain
1. Obtain description of chest discomfort
2. Vital signs and cardiac monitoring
3. Check vascular access
4. Place in semi fowler’s position
5. 12 lead ECG
6. O2 inhalation
7. Provide pain meds and aspirin
8. Assess the client’s VS and intensity of pain 5
minutes after administration of meds
9. Notify physician if patients condition deteriorates
CLDomocmat 8/9/2012 19
20. Ineffective Tissue perfusion
(Cardiopulmonary) related to
interruption of blood flow
• goal : to restore perfusion to the injured area
to reduce the size of the infarct and improve
left ventricular function
CLDomocmat 8/9/2012 20
21. Ineffective Tissue perfusion
Ineffective Tissue perfusion (Cardiopulmonary)
related to interruption of blood flow
CLDomocmat 8/9/2012 21
23. Ineffective Tissue perfusion
1. Thrombolytic therapy
- Tissue plasminogen activator,
streptokinase, reteplase
- Indicated for patients who have chest pain
of greater than 30 minutes, unrelieved by
nitroglycerin and transmural MI (Q wave
MI)
CLDomocmat 8/9/2012 23
26. Thrombolytic therapy
dissolves thrombus and promote
reperfusion
the golden period is 30 minutes from
“door to needle” or from onset of pain till
thrombolytic therapy within 30 minutes
or PTCA within 1 hour
Watch out for signs of bleeding and
hypersensitivity
hypersensitivity reaction ( Streptokinase )
IV infusion
CLDomocmat 8/9/2012 26
27. Ineffective Tissue perfusion
2. Glycoprotein IIB/IIIA Inhibitors
- targets the platelet component of the
thrombus to prevent fibrinogen from
attaching to activated platelets at the
site of the thrombus
- Examples: Abciximab, Eptifibatide,
Abciximab, Eptifibatide,
Tirofiban
- Administered through IV
CLDomocmat 8/9/2012 27
29. Aspirin
Swallow the tablets with a full glass of
water.
Taken as regular (not enteric-coated) low-
enteric- low-
dose aspirin.
Swallow the extended-release tablets whole with
a full glass of water. Do not break, crush, or chew
them.
Chewable aspirin tablets may be chewed, crushed,
or swallowed whole.
Drink a full glass of water, immediately after
taking these tablets.
CLDomocmat 8/9/2012 29
31. Aspirin
If taking aspirin on a regular basis to prevent
heart attack or stroke, do not take ibuprofen
(Advil, Motrin) or other NSAIDs to treat pain
or fever (Ibuprofen can interfere with the anti-
platelet effect of low dose aspirin)
If need only a single dose of ibuprofen, take it
eight hours before or 30 minutes after taking
a regular (not enteric-coated) low-dose
aspirin.
CLDomocmat 8/9/2012 31
32. Aspirin
Ask a doctor before giving aspirin to child or
teenager.
Aspirin may cause Reye's syndrome (a serious
condition in which fat builds up on the brain, liver,
and other body organs) in children and teenagers,
especially if they have a virus such as chicken pox
or the flu.
CLDomocmat 8/9/2012 32
33. Clopidogrel
Plavix
when combined with
aspirin , more
effective in reducing
death, MI or stroke
when compared to
aspirin alone
CLDomocmat 8/9/2012 33
34. Nrg Considerations: Aspirin and
Plavix
teach: may bleed more if having surgery,
easily or for a longer including dental
time than usual while surgery, tell doctor or
you are taking dentist that taking
clopidogrel. Be careful aspirin or Plavix
not to cut or hurt
CLDomocmat 8/9/2012 34
35. Beta blockers – Metoprolol
reduces myocardial O2 requirement by
blocking beta receptors and slowing heart rate,
prolong diastole and increase myocardial
perfusion
aka: beta-adrenergic blocking agents
reduces myocardial O2 requirement by blocking
beta receptors and slowing heart rate, prolong
diastole and increase myocardial perfusion
Ex: Metoprolol, Acebutolol (Sectral), Atenolol
(Tenormin), Bisoprolol (Zebeta), Propranolol
(Inderal LA)
CLDomocmat 8/9/2012 35
38. Angiotensin-converting enzyme (ACE)
Inhibitors
given within 48 hours of
MI prevents ventricular Benazepril (Lotensin)
remodeling and Captopril
development of CHF
Enalapril (Vasotec)
help relax blood vessels Fosinopril
Lisinopril (Prinivil, Zestril)
Moexipril (Univasc)
Perindopril (Aceon)
Quinapril (Accupril)
Ramipril (Altace)
Trandolapril (Mavik)
CLDomocmat 8/9/2012 38
39. ACE Inhibitors
In some people the first dose can cause a drop in blood
pressure immediately. The following is advice for
starting ACE inhibitors:
If taking a diuretic (water tablet), may be advised not to take it
for a day or so before starting an ACE inhibitor.
After the very first dose, on the first day start an ACE inhibitor:
Stay indoors for about four hours, as occasionally some people
feel dizzy.
If you do feel dizzy, sit or lie down and it will usually ease off.
If you become very dizzy, contact your doctor immediately.
Thereafter, there is no need to take any special precautions.
http://www.patient.co.uk/health/ACE-Inhibitors.htm CLDomocmat 8/9/2012 39
43. Activity Intolerance
1. Bed rest with commode privilege for only 24-
24-
48 hours unless with complications.
2. Explain that the purpose of CCU confinement
is for continuous monitoring and safety during
the early recovery period.
3. Administer diazepam as ordered
4. Provide psychosocial support to the patient
and his family. Calmness and competency are
extremely reassuring.
CLDomocmat 8/9/2012 43
44. Cardiac Rehabilitation
actively assisting the client in achieving and
maintaining a vital and productive life while
remaining within the limits of the hearts ability to
respond to increases in activity and stress
begins the moment a client is admitted to the
hospital
3 Phases
1. From acute illness and ends with discharge from
the hospital
2. After discharge and continues through
convalescence at home
3. Long term conditioning
CLDomocmat 8/9/2012 44
45. Program of Physical Activity
1. Increase activities gradually after the first 24-
24-
48 hours
2. Early mobilization after an MI. May be allowed
to sit on a chair for increasing periods of time
and begins ambulation on the 4th or 5th day
3. Monitor V/S before activities.
4. An exercise session is terminated if any one of
the following occurs:cyanosis, cold sweats,
occurs:cyanosis,
faintness, extreme fatigue, severe dyspnea,
pallor, chest pain, PR > 100, dysrhythmias, Bp
> 160/90
CLDomocmat 8/9/2012 45
46. 5 Physical Activity: Sexual intercourse
4-6 weeks post MI or when
a patient with
uncomplicated MI is
capable of walking 2 flights
of stairs without difficulty
nitroglycerine before sex
avoid concomitant use with
Sildenafil
CLDomocmat 8/9/2012 46
47. Sexual intercourse
Perform sexual activity in a cool, familiar
environment
Refrain from sexual activity during a fatiguing
day, after eating a large meal, or after drinking
alcohol
If dyspnea, chest pain, dizziness or palpitations
occur, moderation should be observed. If
symptoms persist stop sexual activity.
CLDomocmat 8/9/2012 47
48. Sexual intercourse
assume position with less strain
Ex: woman on top, side lying
CLDomocmat 8/9/2012 48
49. Ineffective Coping
related to effects of acute illness, major
changes in lifestyle or loss of control
over a body part
1. Anxiolytics during the acute phase of illness
2. Provide opportunity for the patient and family
to explore their concerns
3. Identify clients coping mechanism
1. denial, anger and depression
CLDomocmat 8/9/2012 49
50. Promote Nutrition and
Elimination
Provide small frequent feedings
Low calorie, low cholesterol, low sodium
Avoid stimulants
Avoid taking very hot or very cold beverages and
gas forming foods to prevent vasovagal
stimulation
Use of bedpan and straining at stool should be
avoided. Avoid valsalva maneuver
Bedside commode
Administer stool softeners as ordered
CLDomocmat 8/9/2012 50
51. Potential for recurrent symptoms
& extension of injury
Goal: minimal angina while engaging in ADLs
and exercise program
Ix
Percutaneous Transluminal coronary angioplasty
(PTCA)
Coronary artery Bypass graft surgery (CABG)
Minimally invasive Direct coronary artery bypass
(MIDCAB)
Transmyocardial Laser Vascularization
Of-pump Coronary Artery Bypass (OPCAB)
Robotics
CLDomocmat 8/9/2012 51
53. Potential or dysrhythmias
Identify
Assess hemodynamic status
Monitor cardiac rhythm and CR
Evaluate for discomfort
CLDomocmat 8/9/2012 53
54. Dysrhythmias
most common complication and most major
cause of death among clients with MI
When Dysrhythmias develop the cardiac nurse
must:
1. Identify the Dysrhythmias
2. Assess the client’s hemodynamic status
3. Evaluate the client for chest
discomfort
4. attach to cardiac monitor
CLDomocmat 8/9/2012 54
55. Inferior Wall MI
- bradycardia – atropine
- second degree AV block – Pacemaker
Anterior Wall MI
- 3rd degree AV block – Pacemaker
- Ventricular irritability
- PVC’s – the most common dysrhythmia in MI
- notify physician if more than 6 PVC’s
occur per minute and client is
symptomatic (hypotensive, chest pain)
(hypotensive,
CLDomocmat 8/9/2012 55
56. Potential for heart failure
Goal: regain hemodynamic stability as
evidenced by:
BP and PR – within client’s acceptable range and
adequate for metabolic demands
Adequate UO
Mental alertness
Clear lungs o auscultation
Palpable peripheral pulses
CLDomocmat 8/9/2012 56
57. Potential for heart failure (HF)
Manage L ventricular failure
Assess and monitor
Classfication of Post MI HF (Killip I, II, III, IV)
Relieve pain
Decrease myocardial O2 reqt
Morphine
O2
Intra-aortic balloon pump
Immediate reperfusion (L sided heart cath; PTCA,
CABG)
CLDomocmat 8/9/2012 57
58. Potential for heart failure (HF)
Manage R ventricular failure
Enhance R ventricular preload
IFI – as much as 200 ml/hr
Monitor CO
Note: prevent dev L side HF :
Aucultate lungs
PAWP
CLDomocmat 8/9/2012 58
59. Decreased Cardiac output
Heart Failure is a relatively common
complication after an MI
results from left ventricular dysfunction,
rupture of the intra-ventricular septum,
intra-
papillary muscle rupture with valvular
dysfunction or cardiogenic shock
CLDomocmat 8/9/2012 59
60. Medical Management for Killip IV
Goal is to relieve pain and decrease myocardial O2
demand through preload and possibly after load reduction
1. IV morphine
2. O2 therapy – intubation and mechanical ventilation
3. Preload reduction – nitroglycerin, nitroprusside,
nitroprusside,
diuretics – monitor BP constantly
4. Vasopressor and Inotropes – dopamine, dobutamine –
used to maintain organ perfusion but can increase O2
consumption and can worsen ischemia
5. IABP
CLDomocmat 8/9/2012 60
61. Intra-
Intra-aortic Balloon Pump (IABP)
used when clients do not respond to drug
therapy
invasive intervention that is used to improve
myocardial perfusion during an acute MI,
reduce after load and facilitate left ventricular
emptying
inflation of balloon during diastole increases
diastolic pressure and improves coronary
perfusion
deflation of the balloon before diastole reduces
after load at the time of systolic contraction
CLDomocmat 8/9/2012 61
63. ☺ Let’s watch how it works!
Video animation of
IABP
YouTube - IABP Intraaortic Ballon Pump.flv
Video of IABP in
G:E CARMELA
OR
video downloadsvideos cardi
http://www.fda.gov/ucm/groups/fdagov-
public/documents/image/ucm064550.gif
CLDomocmat 8/9/2012 63
64. IABP:
IABP What precautions to take?
See handout
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/med
sun/news/printer.cfm?id=602
http://www.fda.gov/ucm/groups/fdagov-public/documents/image/ucm064550.gif CLDomocmat 8/9/2012 64
68. Collaborative Management
Anticoagulants
Thrombolytics
Move legs, avoid placing pressure under the knees,
elastic stockings
Early ambulation
Observe for signs and symptoms indicative of
pulmonary embolism
Sudden onset of dyspnea
Chest pain
Coughing
Hemoptysis
Rapid weak pulse
Pallor
CLDomocmat 8/9/2012 68
69. Pericarditis
28% of post MI patients
2-4 days post MI
inflamed areas of infarction rubs against the
pericardial surface causing it to lose
lubricating fluid
CLDomocmat 8/9/2012 69
70. Pericarditis
Dressler’s syndrome (Late Pericarditis)- 6
Pericarditis)
weeks to months after MI
The client presents with fever lasting 1 week or
longer, pericardial chest pain, pericardial friction
rub, and occasional pericardial effusion
self limiting
Bed rest, aspirin, prednisone, opioid analgesics
CLDomocmat 8/9/2012 70
71. Rupture of the myocardium
Mitral Regurgitation,
VSD and Ventricular
Aneurysm
CLDomocmat 8/9/2012 71
72. Mitral Regurgitation ,VSD and
Ventricular Aneurysm
MR due to rupture of papillary muscle
of LV
thinning , ballooning and hypokinesia of
the left ventricular wall after a
transmural MI
the dysfunctional area often becomes filled
with necrotic debris and clot
CLDomocmat 8/9/2012 72
73. Mitral Regurgitation ,VSD and
Ventricular Aneurysm
the aneurysm may rupture causing
cardiac tamponade and death
usually 7-10 days post MI
7-
report presence of new murmur
PVC’s-
PVC’s- due to irritability of necrotic
tissue
CLDomocmat 8/9/2012 73
74. Management
arteriolar vasodilation - to lower systemic
pressure
IABP
surgery-
surgery- 4-6 weeks post MI
excise ventricular aneurysm
replace mitral valve
repair VSD
pericardiocentesis for tamponade
CLDomocmat 8/9/2012 74
79. PTCA
an invasive procedure used to eliminate
stenosis in the coronary arteries by
insertion a catheter through the skin and
moving forward through the veins. At the
last stage,a balloon catheter is inserted in
the coronary arterial lesion and the balloon
is inflated at the level of occlusion to open
the lumen
CLDomocmat 8/9/2012 79
80. PTCA: types
1. Percutaneous Coronary Laser
Angioplasty or Laser with balloon
angioplasty
2. Placement of Percutaneous
Coronary Stent
3. Percutaneous Coronary
Atherectomy
4. Brachytherapy
CLDomocmat 8/9/2012 80
86. Nursing Management: Post-op
VS, monitor for complications
(AMI,Spasm)
Assess for development of crackles,
wheezes, tachypnea, frothy sputum, S3
heart sound
Administer medications as ordered
Anti-coagulation with aspirin/heparin
SL Nifedipine – to prevent coronary spasm
Glycoprotein IIb/IIIA – prevent restenosis
CLDomocmat 8/9/2012 86
87. Nursing Management: Post-op
Monitor for signs of poor organ perfusion
Change in LOC
Oliguria
Cool, clammy extremities with decreased pulses
Unusual fatigue
Recurrent chest pain
Monitor right atrial pressure , pulmonary
artery wedge pressure (measure of preload)
by using the Swan Ganz catheter
if < 18mmHg do volume infusion or administer
inotropes
CLDomocmat 8/9/2012 87
90. CABG
bypass of a blockage in artery
use of saphenous vein or internal
mammary artery (graft of choice because it
has a 90% patency rate after the procedure)
reduces 80-90% of symptoms
80-
indicated when clients do not respond to
medical management of CAD or when
disease progression is evident
cardiopulmonary bypass needed
CLDomocmat 8/9/2012 90
91. CABG
G:E CARMELA G:E CARMELA
video downloadsvideos cardi video downloadsvideos cardi
Let us watch! Let us watch!
Animation of Heart Bypass CABG in the OR
Surgery (CABG)
http://video.about.com/heartdisease/OPCAB.htm CLDomocmat 8/9/2012 91
103. Minimally invasive Direct
coronary artery bypass
(MIDCAB)
indicated for clients with a lesion of the left
anterior descending artery
left thoracotomy incision with removal of 4th rib
dissection of the left IMA and attached to the
still beating heart below the level of the lesion in
the LAD
no cardiopulmonary bypass needed
CLDomocmat 8/9/2012 103
106. TECAB
Totally Endoscopic,
Minimally Invasive
Coronary Bypass
Surgery : High-
Precision Robotic
Surgery Without any
Opening of the Chest
The da Vinci robot's
"wristed"
instruments provide
a greater range of
motion than the
human hand while
eliminating
physician tremor.
CLDomocmat 8/9/2012 106
109. TMLR
a procedure used to relieve severe angina or chest pain in
very ill patients who aren't candidates for bypass surgery or
angioplasty.
Procedure
a surgeon makes an incision on the left breast to expose the
heart.
Then, using a laser, the surgeon drills a series of holes from the
outside of the heart into the heart's pumping chamber.
From 20 to 40 mm laser channels are placed during the
procedure.
Bleeding from the laser channels on the outside of the heart
stops after a few minutes of pressure from the surgeon's finger.
In some patients TMR is combined with bypass surgery. In
those cases an incision through the breastbone is used.
http://www.americanheart.org/presenter.jhtml?identifier=4782 109
CLDomocmat 8/9/2012
110. TMLR
How does it work?
How TMR reduces angina still isn't fully understood.
The laser may stimulate new blood vessels to grow,
called angiogenesis
It may destroy nerve fibers to the heart, making
patients unable to feel their chest pain.
http://www.americanheart.org/presenter.jhtml?identifier=4782
The heart feeds itself by taking blood from within its
chambers, just like in reptiles, whose hearts have no
coronary arteries. http://www.texheartsurgeons.com/TMLR.htm
CLDomocmat 8/9/2012 110
111. Indications
people who are high-risk candidates for a second
bypass or angioplasty.
people whose blockages are too diffuse to be
treated with bypass alone.
some patients with heart transplants who develop
atherosclerosis after their transplant.
CLDomocmat 8/9/2012 111
115. Transmyocardial
revascularization
G:E CARMELA
video downloadsvideos cardi
An animation of the transmyocardial
revascularization procedure
CLDomocmat 8/9/2012 115
118. Cardiac tamponade
is pressure on the heart that occurs when blood or fluid
builds up in the space between the heart muscle
(myocardium) and the outer covering sac of the heart
(pericardium).
Cardiac tamponade is a condition involving compression of
the heart caused by blood or fluid accumulation in the
space between the myocardium (the muscle of the heart)
and the pericardium (the outer covering sac of the heart).
Blood or fluid collects within the pericardium. This prevents
the ventricles from expanding fully, so they cannot
adequately fill or pump blood. Cardiac tamponade is an
emergency condition that requires hospitalization.
CLDomocmat 8/9/2012 118
120. pulsus paradoxus
an abnormal inspiratory decrease in arterial
blood pressure, seen in cardiac tamponade
and caused by a decreased pulmonary venous
return.
http://medical-dictionary.thefreedictionary.com/pulsus+paradoxus
CLDomocmat 8/9/2012 120
121. inotropic agent
any of a class of agents affecting the force of
muscle contraction, particularly a drug
affecting the force of cardiac contraction;
positive inotropic agents increase, and
negative inotropic agents decrease the force
of cardiac muscle contraction.
CLDomocmat 8/9/2012 121
122. Drugs affect the function of the heart in three
main ways. They can affect the force of
contraction of the heart muscle (inotropic
effects); they can affect the frequency of the
heartbeat, or heart rate (chronotropic
effects); or they can affect the regularity of
the heartbeat (rhythmic effects).
http://www.britannica.com/EBchecked/topic/171942/drug/233954/Drug
s-affecting-the-heart?anchor=ref295300
CLDomocmat 8/9/2012 122
123. Inotropic agents
A drug may be classified by the chemical type of the active ingredient or
by the way it is used to treat a particular condition. Each drug can be
classified into one or more drug classes.
Inotropic agents affect the contraction of the heart muscle. Positive
inotropes stimulate and increase the strength of heart muscle
contraction causing the heart rate to increase. Negative inotropic
agents weaken the force of muscular contractions.
Inotropic state depends on the amount of calcium in the cytoplasm of
the heart muscle wall, as contractility of the heart depends on control of
intracellular calcium i.e. control of calcium entry into the cell membrane
and calcium storage in the sarcoplasmic reticulum. The main factors
controlling calcium entry are activity of voltage gated calcium channels
and sodium ions, which affects calcium/sodium ion exchange.
Positive inotropes usually increase the level of intracellular calcium and
negative inotropes decrease it.
CLDomocmat 8/9/2012 123
125. pulsus paradoxus
also paradoxic pulse or paradoxical pulse, is defined as an
abnormally large decrease in systolic blood pressure and
pulse wave amplitude during inspiration.
The normal fall in pressure is less than 10 mmHg or 10 torr.
When the drop is more than 10mm Hg, it is referred to as
pulsus paradoxus.
has nothing to do with pulse rate or heart rate. The normal
variation of blood pressure during breathing/respiration is a
decline in blood pressure during inhalation/inspiration and
an increase during exhalation/expiration.
is a sign that is indicative of several conditions, including
cardiac tamponade, pericarditis, chronic sleep apnea,
croup, and obstructive lung disease (e.g. asthma, COPD).
http://en.wikipedia.org/wiki/Pulsus_paradox
us
CLDomocmat 8/9/2012 125
129. Pleur-evacⓇ
Adult/Pediatric Chest
Drainage Model A-
6000. The Pleur-evac
Chest Drainage
Systems have been the
world's most popular
units since their
inception in 1967.
(Courtesy of Deknatel,
Inc., Fall River, MA.)
CLDomocmat 8/9/2012 129