Flashcards.

WHAT IS IT?

Angina is chest pain caused by not enough blood flow to the heart muscle. If blood flow is not restored, it can lead to more heart damage. The most common cause is coronary artery disease (CAD), where atherosclerotic plaque (fatty buildup) ruptures and a clot forms. Other causes include anemia (low red blood cells), heart failure, stress or overexertion, and abnormal heart rhythms.

Quick Concept: The chest pain happens because the heart muscle is not getting enough oxygen for the work it is doing.

TYPES

• •Stable: comes with exertion (activity). Relieved by nitroglycerin.
• •Unstable: comes at rest. Lasts longer. NOT relieved by nitroglycerin.
• •Variant: unpredictable.

ASSESSMENT

• •Chest pain
• •Dyspnea on exertion (shortness of breath with activity)
• •Hypotension (low blood pressure) from decreased cardiac output (amount of blood the heart pumps)
• •Hypertension (high blood pressure) from increased stress on the heart
• •Bradycardia (slow heart rate) from decreased cardiac output
• •Supraventricular tachycardia (fast heart rate from above the ventricles) from increased stress on the heart
• •Atrial fibrillation (irregular heartbeat) from increased stress on the heart
• •Syncope (fainting)
• •Pale skin
• •Diaphoretic (sweaty)

MANAGEMENT

• •Goal: restore blood flow, decrease chest pain, and improve activity tolerance.

Medications (anticipated):

• •Thienopyridines (clopidogrel)
• •Heparin (blood thinner)
• •Renin-angiotensin blockade (ARBs or ACE inhibitors)
• •Oxygen
• •Morphine (only if indicated by facility)
• •Beta blockers
• •Nitroglycerin (per facility policy)

Monitoring and tests:

• •EKG (electrocardiogram, heart tracing) to rule out STEMI (a type of heart attack) and monitor arrhythmias (abnormal rhythms)
• •Monitor vital signs (HR, BP, SpO2) for changes
• •Cardiac enzymes to find heart muscle damage
• •Cardiac stress test to find the point of heart stress
• •Cluster care (group tasks together) so the client can rest and lower the heart's oxygen demand

WHAT IS IT?

The heart is a pump that moves blood through the body. Heart failure is pump failure. It happens when the heart cannot pump enough blood to meet the body's needs. If untreated, blood backs up (congestion) and tissues do not get enough blood (poor perfusion).

Quick Concept: Pump failure causes decreased perfusion moving forward and increased congestion backing up behind the heart.

CAUSES

• •Myocardial infarction (heart attack): dead muscle cannot pump
• •Hypertension (high blood pressure): raises afterload, which is the resistance the heart pumps against, adding stress to the heart muscle
• •Valve disorders: an inefficient pump means blood does not move in the right direction

DIAGNOSTICS

• •BNP (Brain Natriuretic Peptide): a hormone released by heart muscle cells when the ventricles stretch
• •Echocardiogram: detects ejection fraction and diagnoses valve disorders
• •Chest X-ray: detects cardiomegaly (enlarged heart) and pulmonary edema (fluid in the lungs)

COMPLICATIONS

• •Volume overload
• •Decreased perfusion

ASSESSMENT

Right-sided heart failure (decreased lung perfusion and increased body congestion):

• •Decreased oxygenation
• •Decreased activity tolerance
• •Peripheral edema (swelling in arms and legs)
• •Increased jugular venous distention (JVD, bulging neck veins)
• •Increased preload (volume returning to the heart)
• •Weight gain
• •Fatigue
• •Liver and GI congestion

Left-sided heart failure (decreased body perfusion and increased lung congestion):

• •Skin pale or dusky
• •Decreased peripheral pulses
• •Slow capillary refill
• •Decreased kidney perfusion (decreased urine output, kidney injury or failure)
• •Pulmonary edema: cough, pink or frothy sputum, crackles, wheezes, tachypnea (fast breathing), shortness of breath on exertion
• •Anxiety and restlessness

MANAGEMENT

The goal is to decrease the workload on the heart while still increasing cardiac output.

• •Decrease preload
• •Decrease afterload
• •Increase contractility

WHAT IS IT?

Heart failure means the heart cannot pump blood forward well. In left heart failure, the left ventricle (lower left pumping chamber) cannot push blood into the systemic circulation (the body). Blood backs up into the pulmonary circulation (the lungs). In right heart failure, the right ventricle cannot push blood into the lungs. Blood backs up into the venous circulation (the veins of the body).

Quick Concept: The side that fails causes a backup behind it, so left failure floods the lungs and right failure floods the body.

ASSESSMENT

Left heart failure (lung backup):

• •Shortness of breath
• •Dyspnea on exertion (trouble breathing with activity)
• •Crackles (abnormal lung sounds)
• •Pink, frothy sputum (foamy spit)
• •Cyanosis (bluish skin from low oxygen)
• •Fatigue
• •Orthopnea (trouble breathing while lying flat)
• •Tachycardia (fast heart rate)
• •Confusion
• •Restlessness

Right heart failure (body backup):

• •Jugular venous distention (bulging neck veins)
• •Fatigue
• •Ascites (fluid in the belly)
• •Anorexia (loss of appetite)
• •GI distress (stomach upset)
• •Weight gain
• •Dependent edema (swelling in the lower body)
• •Venous stasis (blood pooling in the veins)

WHAT IS IT?

Coronary artery disease is the buildup of plaque (fatty deposits) inside the main blood vessels of the heart. The main causes are high blood pressure and high cholesterol. The inner vessel walls get damaged, inflammation happens, plaque sticks to the walls, and clots form. This causes blockage and loss of blood supply to the heart. The main symptom is chest pain.

Quick Concept: When plaque and clots block a coronary artery, the heart muscle stops getting blood and starts to be damaged.

RISK FACTORS

• •Smoking
• •High blood pressure
• •Obesity
• •Diabetes
• •Hyperlipidemia (high blood fats)
• •Family history

COMPLICATIONS

• •Acute coronary syndrome: plaque breaks off and blocks a coronary artery
• •STEMI (ST-segment elevation myocardial infarction): near or complete blockage, called the "widowmaker"
• •NSTEMI (non-ST-segment elevation myocardial infarction): partial blockage
• •Unstable angina
• •Concern for cardiac arrest

ASSESSMENT

• •Chest pain
• •Arrhythmia (irregular heartbeat)
• •Shortness of breath
• •Elevated blood pressure
• •Provider orders: electrocardiogram (EKG), cholesterol levels
• •CT scan to see vessel occlusion (blockage) and stenosis (narrowing)
• •Angiogram to view inside the vessels
• •Stress test to view blood flow

MANAGEMENT

Medications:

• •Statins (cholesterol medications) to decrease plaque in the blood
• •Anticoagulants to prevent blood clotting
• •Beta-blockers to decrease the workload of the heart
• •Calcium channel blockers to relax vessels and allow blood through
• •Nitroglycerin to open arteries, allow blood through, and decrease chest pain

Procedures:

• •Angioplasty: go in through a vein to open vessels
• •Stent placement to keep the vessel open
• •Coronary artery bypass surgery to make a new vessel pathway around the blockage

WHAT IS IT?

Hypertension is high blood pressure. It is called the "silent killer" because it has no symptoms until it has already damaged organs. Over time it can lead to stroke, heart attack (MI, myocardial infarction), kidney failure, and heart failure.

ASSESSMENT

• •Often no symptoms at first (asymptomatic until end-organ damage)
• •Vision changes
• •Frequent headaches
• •Dizziness
• •Chest pain or angina (chest pain from poor blood flow to the heart)

MANAGEMENT

• •Medications: ACE inhibitors (angiotensin-converting enzyme inhibitors), beta-blockers, calcium channel blockers, diuretics (water pills)
• •Diet and lifestyle changes

Nursing priorities (perfusion):

• •Check blood pressure and heart rate FIRST before giving blood pressure medications
• •Assess for end-organ damage: check kidney and neurological status
• •Strict intake and output (I&O)
• •Assess for cardiovascular changes

WHAT IS IT?

Cardiogenic shock is complete pump failure of the heart. The heart cannot move oxygen-rich blood to the body. Causes include myocardial infarction (MI, heart attack), end-stage cardiomyopathy (weak heart muscle), papillary muscle or valve rupture, cardiac tamponade (fluid pressing on the heart), and pulmonary embolism (PE, clot in the lung).

Quick Concept: When the pump fails, blood flow forward drops and blood backs up behind the heart.

ASSESSMENT

• •Sudden, severe, extreme heart failure

Decreased perfusion (poor blood flow):

• •Decreased cardiac output (CO, blood pumped) and decreased BP (blood pressure)
• •Increased HR (heart rate) as compensation
• •Increased SVR (systemic vascular resistance, vessel tightness) as compensation
• •Weak, thready pulses (the pump is not pumping strongly)
• •Cool, diaphoretic (sweaty) skin
• •Pale, dusky, cyanotic (bluish), or mottled skin
• •Decreased urine output
• •Decreased LOC (level of consciousness), anxiety

Volume overload (blood backs up because the pump cannot pump):

• •Increased CVP (central venous pressure)
• •JVD (jugular vein distention, neck vein bulging)
• •Pulmonary edema (fluid in the lungs): crackles, pink frothy sputum, sudden severe SOB (shortness of breath)

MANAGEMENT

Treat the cause of pump failure:

• •Revascularization for MI (PCI, percutaneous coronary intervention; or CABG, coronary artery bypass graft)
• •Thrombolytics (clot busters) or surgical removal for PE
• •Pericardiocentesis (draining fluid around the heart) for cardiac tamponade

Improve contractility (squeezing strength):

• •Dopamine (may increase HR)
• •Dobutamine

Decrease afterload (pressure the heart pumps against):

• •Dobutamine

Diuretics (water pills):

• •Furosemide for pulmonary edema
• •Caution: may decrease BP

WHAT IS IT?

A myocardial infarction (heart attack) is a sudden loss of blood supply to part of the heart. This causes ischemia (lack of oxygen) and death of the heart muscle tissue.

CAUSES

• •Coronary artery disease and thrombosis (clot)

ASSESSMENT

Subjective findings (what the patient reports):

• •Chest pain not relieved by rest
• •Pale, diaphoretic (sweaty), mottled skin
• •Nausea, anxiety, shortness of breath, and palpitations that worsen with activity

Objective findings (what you measure):

• •May be hypotensive (low blood pressure) or bradycardic (slow heart rate)
• •ST-elevation on a 12-lead EKG (called STEMI)
• •Elevated troponins (most sensitive), elevated CK-MB and CK

MANAGEMENT

Anticipated medications:

• •Thienopyridines (clopidogrel)
• •Heparin
• •Renin-angiotensin blockade (ARBs or ACE inhibitors)
• •Oxygen
• •Morphine (only if indicated by facility)
• •Beta blockers
• •Nitroglycerine (per facility policy)

Nursing actions:

• •Monitor EKG
• •Rest to decrease the oxygen demand of the heart

Anticipate provider orders:

• •12-lead EKG
• •Cardiac enzymes every 3 hours times 4
• •Thrombolytics unless contraindicated
• •Percutaneous transluminal coronary angioplasty (PTCA), which opens clogged arteries

WHAT IS IT?

This is the nursing care after cardiovascular (heart and vessel) procedures. Two common procedures are PCI (Percutaneous Coronary Intervention, a catheter that opens a blocked coronary artery) and CABG (Coronary Artery Bypass Graft, surgery that reroutes blood around a blocked artery).

MANAGEMENT

Perfusion (blood flow to tissues):

• •Pulse checks
• •Vital signs
• •Pain assessment
• •Skin assessment
• •Give blood pressure medications
• •Leg positioning

Clotting:

• •Give anticoagulant (blood thinner)
• •Monitor access site (where the catheter entered)
• •Monitor for bleeding
• •Check coagulation (clotting) studies
• •Check CBC (Complete Blood Count), including H/H (hemoglobin and hematocrit)
• •Assess for DVT (Deep Vein Thrombosis, a clot in a deep vein)

Patient education:

• •Incentive spirometer (a device for deep breathing)
• •Diet and lifestyle changes
• •Medication instructions
• •Activity restrictions
• •Bleeding precautions
• •When to notify the HCP (Health Care Provider)

WHAT IS IT?

Distributive shock is caused by an immune or inflammatory response that interferes with vascular tone (the tightness of blood vessels). This leads to massive peripheral vasodilation (widening of blood vessels throughout the body). Blood pressure drops because the vessels are too wide.

TYPES

• •Anaphylactic: from an allergic reaction and inflammatory cytokines (immune signaling proteins)
• •Neurogenic: from spinal cord injury and loss of SNS (sympathetic nervous system) activity
• •Septic: from a systemic (body-wide) infection and inflammatory cytokines

ASSESSMENT

Anaphylactic:

• •Hives, rash, swelling of arms, trunk, or face/mouth
• •Exposure to an allergen
• •Decreased SpO2 (oxygen level)
• •Decreased BP (blood pressure)
• •Increased HR (heart rate)
• •Increased RR (respiratory rate), wheezes
• •Warm, flushed skin

Neurogenic:

• •Spinal cord injury in the last 24 hours
• •Warm, flushed lower extremities
• •Decreased BP
• •Decreased HR (occasional)
• •Priapism (persistent erection) due to vasodilation

Septic:

• •Decreased LOC (level of consciousness)
• •Decreased BP
• •Increased HR
• •Warm, flushed skin
• •Increased temperature
• •Signs and symptoms of infection

Decompensated shock:

• •Refractory (does not respond to treatment) low BP
• •Decreased LOC
• •Decreased SpO2
• •Decreased HR

MANAGEMENT

Anaphylactic:

• •Epinephrine to relax airway muscles
• •Corticosteroids to decrease inflammation
• •Bronchodilators to protect the airway

Neurogenic:

• •Therapeutic hypothermia (controlled cooling) for neuroprotection

Septic:

• •IV antibiotics (draw blood cultures first)
• •IV fluids to increase preload (blood returning to the heart)
• •Corticosteroids only if vasopressors are ineffective

Decompensated shock:

• •Vasopressors (drugs that tighten blood vessels)
• •Intubation for airway protection

WHAT IS IT?

Cardiomyopathy is an abnormality of the heart muscle that changes how the heart works. It can be caused by long-term untreated high blood pressure, heart failure, or congenital disorders (present at birth). There is no cure, so care is supportive.

Types:

• •Dilated: all 4 chambers enlarge, walls thin and weaken, lower contractility and lower cardiac output (CO, amount of blood the heart pumps per minute)
• •Hypertrophic: thick, stiff ventricle muscle with less space to fill, lower preload (blood filling the heart) and lower CO
• •Restrictive: ventricles become rigid and cannot stretch to fill, lower stroke volume (SV, blood pumped per beat) and lower CO

ASSESSMENT

Signs of heart failure:

• •Fatigue
• •Shortness of breath (SOB)
• •Dysrhythmias (abnormal heart rhythms)
• •Extra heart sounds (S3/S4)
• •Poor perfusion (poor blood flow to tissues)
• •Volume overload: JVD (jugular venous distension, bulging neck veins) and pulmonary edema (fluid in the lungs)
• •Echocardiogram or chest X-ray shows an enlarged or thickened heart

MANAGEMENT

• •No cure, only supportive care
• •Encourage frequent rest
• •Minimize stress
• •Manage high blood pressure with DASH diet, ACE inhibitors (angiotensin-converting enzyme inhibitors), ARBs (angiotensin receptor blockers), and beta-blockers
• •Beta-blockers lower the force of contraction, lower workload, and lower oxygen demand
• •Ventricular assist devices help eject blood from the left ventricle to the aorta

WHAT IS IT?

Atrial fibrillation is when many disorganized cells in the atria (upper heart chambers) fire extra electrical impulses. This makes the atria quiver fast instead of contracting normally. Blood pools in the atria, which creates a HIGH risk for stroke. The AV node (atrioventricular node) blocks some impulses, so the ventricles contract in a rapid, irregular way.

Quick Concept: Because the atria only quiver and do not squeeze well, blood pools and can form clots that travel to the brain.

CHARACTERISTICS

• •Rhythm: irregular
• •Atrial rate: over 300 bpm, with a wavy baseline
• •Ventricular rate: 60-100 bpm; over 100 bpm is called Rapid Ventricular Rate (RVR)
• •P:QRS ratio: no obvious P waves
• •Wavy baseline that is not measurable
• •PR interval: not measurable
• •QRS complex: 0.06-0.12 seconds

ASSESSMENT

• •Palpitations (feeling the heartbeat)
• •Fatigue
• •Lightheadedness or syncope (fainting)
• •Decreased cardiac output (blood the heart pumps): syncope, hypotension (low BP)
• •PT/INR labs if taking Coumadin (a blood thinner)

MANAGEMENT

Nursing interventions:

• •12-lead EKG (heart tracing)
• •Restore NSR (normal sinus rhythm)
• •Assess for signs and symptoms of stroke

Control ventricular rate:

• •Antiarrhythmics
• •Beta-blockers
• •Calcium channel blockers
• •Transesophageal echocardiography / cardioversion (shock to reset rhythm)
• •Ablations (destroying the tissue causing the problem)

Decrease stroke risk:

• •Anticoagulants (blood thinners): Coumadin (Warfarin), Xarelto (Rivaroxaban), Eliquis (Apixaban)

WHAT IS IT?

Thrombophlebitis is the formation of a thrombus (clot) along with inflammation in an extremity. It can dislodge and travel, so it must be managed carefully.

RISK FACTORS

Virchow's Triad:

• •Venous stasis (slow or pooling blood flow)
• •Damage to the inner lining of the vessel
• •Hypercoagulability of the blood (blood clots too easily)

Medical history:

• •History of thrombophlebitis
• •Pelvic surgery
• •Obesity
• •Heart failure, MI (heart attack)
• •A-fib (atrial fibrillation)
• •Immobility
• •Pregnancy

ASSESSMENT

Unilateral findings on the affected side:

• •Pain
• •Warm skin
• •Redness
• •Tenderness
• •Febrile state (fever)

Diagnostics to confirm:

• •Ultrasound to visualize the clot
• •D-Dimer: a product of fibrin breakdown found in the blood after a clot is broken down (a positive result suggests a clot)

MANAGEMENT

If the client has a confirmed DVT (deep vein thrombosis):

• •No SCD/TED (compression devices), no massage, bedrest, because these could dislodge the clot

Anticoagulant therapy:

• •Heparin: monitor PTT every 6 hours
• •Coumadin (warfarin): monitor PT/INR

IVC filter (sits in the inferior vena cava and collects clots before they reach the heart and lungs):

• •Monitor for signs of emboli
• •Heart (MI): chest pain
• •Lungs (pulmonary embolism): anxiety, shortness of breath, increased heart rate, increased respiratory rate, chest pain
• •Brain (stroke): facial droop, arm weakness, speech difficulty
• •Monitor distal pulses

Clotting prevention and monitoring:

• •Monitor circumference of the limb twice daily
• •SCD/TED plus enoxaparin sodium (an anticoagulant), if ordered by the provider
• •Passive range of motion
• •Early ambulation

WHAT IS IT?

Hypovolemic shock is a loss of blood volume that lowers oxygen delivery to vital organs. The body tries to compensate, but when those mechanisms fail, organs begin to shut down. If not treated, organ failure occurs.

ASSESSMENT

• •Worsening hypotension (low blood pressure) from low volume
• •Tachycardia (fast heart rate) as the body works hard to pump the volume it has
• •Weakness
• •Tachypnea (fast breathing)
• •Decreased LOC (Level Of Consciousness)
• •Inadequate urinary output from low volume
• •Weak pulse

MANAGEMENT

Treat the cause:

• •OR (operating room) for repair
• •Medications for vomiting or diarrhea
• •Common causes include vomiting or diarrhea for days, severe burns, traumatic injury, and hemorrhage (surgical or obstetric)

Replace volume:

• •Crystalloid fluids: LR (Lactated Ringer's), NS (Normal Saline)
• •Colloid: blood products
• •Rapid infuser

Support perfusion (blood flow):

• •Hemodynamic monitoring (tracking blood pressure and circulation)
• •Vasopressors (drugs that raise blood pressure)

Life support:

• •Decreased LOC may need airway protection and ventilation

WHAT IS IT?

Sinus tachycardia is a heart rhythm that starts normally in the sinus node but is faster than normal. The heart rate is over 100 beats per minute. It is usually a response to another problem in the body.

RHYTHM CHARACTERISTICS

• •Rhythm: regular
• •Heart rate: greater than 100
• •P:QRS ratio: 1:1
• •PR interval: 0.12 to 0.20 seconds
• •QRS complex: 0.06 to 0.12 seconds

ASSESSMENT

• •Stable: no concerning symptoms
• •Unstable: rapid heartbeat, palpitations, lightheaded, decreased cardiac output
• •Causes: fever, dehydration, hypotension (low blood pressure), anemia, anxiety/fear, pain

MANAGEMENT

• •Find and treat the cause
• •Determine if the client is stable or unstable

Stable:

• •Vagal maneuvers, medications (beta-blockers, calcium channel blockers, adenosine)

Unstable:

• •Synchronized cardioversion (timed electric shock to reset the rhythm)

WHAT IS IT?

A cataract is a clouding of the lens in the eye. The cloudy lens distorts the image projected onto the retina, which lowers vision. If left untreated it can lead to blindness.

ASSESSMENT

Early findings:

• •Slightly blurred vision
• •Decreased color perception

Later findings:

• •Blurred vision
• •Double vision
• •Difficulty with activities of daily living (ADLs)
• •Vision loss is gradual
• •Pupil appears white

Diagnosis:

• •Visual acuity testing shows decreased vision
• •Eye exam shows a cloudy lens

MANAGEMENT

• •Surgery is the only curative method

Post-surgery care:

• •Eye drops several times a day for 2 to 4 weeks
• •Mild itching and slight swelling are normal
• •Pain control
• •Prevent increases in intraocular pressure (pressure inside the eye)

Report these complications:

• •Significant swelling
• •Bruising
• •Infection
• •Pain
• •Bleeding or increased discharge
• •Bloodshot sclera (white of the eye)
• •Decreased vision
• •Flashes of light or floating shapes

WHAT IS IT?

Cirrhosis is chronic, irreversible liver disease. Inflammation and fibrosis (scarring) of liver cells (hepatocytes) form scar tissue in the liver. This scar tissue blocks blood flow through the liver and stops the liver from working properly.

Quick Concept: Because the sick liver cannot do its jobs, toxins, fluid, and pressure build up throughout the body.

Impaired liver function:

• •Impaired protein metabolism
• •Increased drug toxicity (the liver cannot break down drugs)
• •Decreased clotting factors, increased ammonia levels, increased bilirubin levels
• •Increased LFTs (liver function tests): ALT, AST, ALP
• •Impaired blood sugar regulation

Complications:

• •Hepatic encephalopathy: increased ammonia causes brain tissue swelling
• •Bleeding risk: decreased clotting factors
• •Portal hypertension: blocked blood flow raises pressure in the portal vein and backs up into GI (gastrointestinal) circulation
• •Esophageal varices: dilated, thin veins in the esophagus from portal hypertension that can rupture and bleed (life-threatening emergency)

ASSESSMENT

• •Malaise (feeling unwell) and general fatigue
• •Anorexia (loss of appetite)
• •Increased bilirubin: jaundice (yellow skin) with scleral icterus (yellow eyes), dark urine, clay-colored stools
• •Impaired protein metabolism: edema (swelling), ascites (fluid in the belly), increased ammonia leading to hepatic encephalopathy (disorientation, altered LOC, asterixis or flapping hand tremor)
• •Pain in the RUQ (right upper quadrant of the abdomen)
• •Hepatomegaly (enlarged liver)
• •Splenomegaly (enlarged spleen)
• •Portal hypertension: hemorrhoids, varicose veins, esophageal varices that can cause massive GI bleed and vomiting blood
• •Impaired coagulation: anemia, bleeding, easy bruising

MANAGEMENT

Medications:

• •Analgesics (pain relievers)
• •Vitamin K for clotting factors
• •Antacids to decrease esophagus irritation
• •Lactulose to decrease ammonia levels
• •Blood products if bleeding
• •Diuretics (water pills) to remove fluid

Procedures and care:

• •Paracentesis to drain abdominal fluid
• •Dietary restrictions: fluid restriction, decreased protein intake, decreased sodium (Na) intake

Esophageal varices:

• •Endoscopy to cauterize, clip, or band varices to prevent bleeding
• •Sengstaken-Blakemore OR Minnesota tube: balloon inflated in the esophagus to put pressure on bleeding varices

WHAT IS IT?

Cirrhosis is a chronic, progressive disease of the liver. Liver cells are destroyed and replaced by scar tissue. Over time the liver can no longer do its jobs, which leads to many complications.

COMPLICATIONS

• •Hepatic encephalopathy: ammonia builds up because of liver failure and can cause neurologic decline
• •Hepatorenal syndrome: kidney failure linked to liver failure
• •Coagulation defects: the liver cannot make clotting factors, so the client bleeds easily
• •Ascites: fluid builds up in the peritoneal cavity (abdomen)
• •Portal hypertension: high pressure in the portal vein because blood flow through the liver is blocked
• •Esophageal variceal bleeding: blood shunts to weaker veins in the esophagus, and these fragile veins can rupture

ASSESSMENT

• •Neurological: encephalopathy, asterixis (hand-flapping tremor)
• •GI: ascites, esophageal varices, GI bleeding, hepatomegaly (enlarged liver), pain, nausea and vomiting, malnutrition
• •Cardiopulmonary: fatigue, spider angioma, edema, portal hypertension, dyspnea, hypoxemia, hyperventilation
• •Integumentary (skin): jaundice, spider angiomas, ecchymosis and petechiae (bruising and tiny red spots)
• •Fluid and electrolyte: ascites, hypokalemia (low potassium), water retention, edema
• •Hematologic: anemia, DIC, splenomegaly (enlarged spleen), thrombocytopenia (low platelets)

MANAGEMENT

Administer:

• •Supplemental vitamins
• •Enteral feedings
• •Diuretics
• •Blood products
• •Lactulose

Monitor:

• •Edema
• •I&O (intake and output), weight
• •Level of consciousness
• •Bleeding
• •Coagulation times
• •Abdominal girth

Prepare:

• •Patient for paracentesis
• •Patient for shunting

Other:

• •Restrict sodium (Na)
• •Elevate the head of the bed (HOB)
• •Gastric intubation if indicated
• •Avoid hepatotoxic medications

WHAT IS IT?

Peptic ulcer disease is an open sore in the lining of the stomach or the first part of the small intestine. Common causes are Helicobacter pylori (a stomach bacteria), frequent use of NSAIDs (Non-Steroidal Anti-Inflammatory Drugs like ibuprofen), smoking, and alcohol use. Diagnosis is done with an upper GI (gastrointestinal) series x-ray or an EGD (Esophagogastroduodenoscopy, a scope that looks inside the upper digestive tract).

ASSESSMENT

• •Nausea and vomiting
• •Abdominal pain, usually in the upper belly
• •Pain is often burning or sharp
• •Gastric ulcer: gnawing, sharp pain 30 to 60 minutes after a meal
• •Duodenal ulcer: pain 1.5 to 3 hours after eating, may be relieved by eating
• •Hematemesis (vomiting blood), seen with gastric ulcers
• •Melena (dark black tarry stool), seen with duodenal ulcers

MANAGEMENT

• •Avoid aspirin and NSAIDs because they increase bleeding risk
• •Monitor H&H (hemoglobin and hematocrit) and assess for bleeding
• •Medications: H2 receptor antagonists, proton pump inhibitors, antacids, and sucralfate (Carafate); take sucralfate 30 to 60 minutes before meals

Surgical options:

• •Vagotomy: cut the vagus nerves to lower the parasympathetic response, which lowers gastric acid secretion
• •Gastric resection or gastrectomy: remove all or part of the stomach to remove ulcerated tissue
• •Billroth I and Billroth II: remove a portion of the stomach and reattach it to the duodenum (I) or jejunum (II)

Post-op:

• •HOB (head of bed) at 45 degrees
• •Clear liquids for 3 to 7 days
• •Assess bowel sounds
• •To lower the risk of dumping syndrome (rapid influx of stomach contents into the small intestine), avoid sugar or fatty foods, eat smaller meals, and do not drink fluids with meals

WHAT IS IT?

Cholecystitis is acute or chronic inflammation of the gallbladder. It is caused by cholelithiasis (gallstones), duct obstruction, and infection. The gallbladder stores and secretes bile into the duodenum (first part of the small intestine) to help digest fats. If not corrected, it can lead to liver damage.

ASSESSMENT

• •N/V (nausea and vomiting)
• •RUQ (right upper quadrant) pain that occurs 2 to 4 hours after high-fat meals and lasts 1 to 3 hours
• •Murphy's sign: the examiner places a hand below the costal margin on the right side at the midclavicular line. The client is asked to inspire (breathe in). If the client cannot breathe in due to pain, the test is positive.
• •Rebound tenderness over the RUQ

MANAGEMENT

• •Decrease gallbladder stimulation: NPO (nothing by mouth), nasogastric decompression, avoid gas-forming foods
• •Antiemetics (anti-nausea drugs), analgesics (pain drugs)

Cholecystectomy (removal of the gallbladder):

• •Abdominal splinting when coughing
• •Clear liquids post-op, advance as tolerated/ordered
• •T-tube drainage: maintain patency (keep the duct open), high Fowler's position, report drainage greater than 500 mL

WHAT IS IT?

Inflammatory bowel disease is a group of autoimmune inflammatory conditions that affect the GI (gastrointestinal, digestive) tract. The body attacks its own bowel. Symptoms come and go with periods of remission (calm) and exacerbation (flare-up).

Two main types:

• •Ulcerative colitis: affects the colon and rectum, poor nutrient absorption, edema (swelling) plus lesions plus ulcers, 10 to 20 stools per day with blood and mucus. Avoid foods that may worsen symptoms (raw vegetables and fruits, nuts, popcorn, whole grains, cereals, spicy foods).
• •Crohn's: affects the entire GI tract and may affect other body systems (especially skin and lymphatic system), causes thickening plus scarring plus abscesses, 5 to 6 stools per day with pus and mucus.

MANAGEMENT

Major medication classes:

• •Corticosteroids (for example methylprednisolone): decrease inflammation; chronic use raises the risk for Cushing's syndrome
• •Salicylates (for example sulfasalazine): block pro-inflammatory chemicals (prostaglandins, interleukin-I, tumor necrosis factor)
• •Immunomodulators (for example azathioprine or methotrexate): lower the immune and inflammatory response and reduce the need for corticosteroids
• •Antidiarrheals (for example loperamide): reduce loss of fluid and electrolytes

Surgical options:

• •Bowel resection or colectomy: curative for ulcerative colitis, palliative (symptom relief only) for Crohn's
• •Surgical removal of abscesses

WHAT IS IT?

These are two inflammatory bowel diseases. This card compares their key features side by side.

TABLE

Crohn's disease:

• •Progresses from rectum to cecum
• •Poor absorption of nutrients
• •Edema, lesions, and ulcers
• •10 to 20 stools per day

Ulcerative colitis:

• •Blood and mucus
• •Pus and mucus
• •Thickening, scarring, and abscesses
• •5 to 6 stools per day

• •[source fragment unclear, verify at source]

WHAT IS IT?

Appendicitis is inflammation of the appendix. The exact cause is unknown. The major risk is rupture, where pus and possibly fecal matter spill into the peritoneum (the lining of the belly), causing peritonitis (infection of that lining) and sepsis (a body-wide infection response).

ASSESSMENT

• •Abdominal pain at McBurney's point (a spot in the lower right belly)
• •Pain descends to the RLQ (Right Lower Quadrant)
• •Rebound tenderness (pain when pressure is released)
• •Increased WBC (White Blood Cell count)
• •Fever
• •Abdominal guarding (tensing the belly muscles)
• •SUDDEN RELIEF OF PAIN SIGNIFIES A RUPTURE: this is a medical emergency and requires immediate surgery

MANAGEMENT

• •Avoid heat application, which can lead to rupture
• •Avoid stimulating peristalsis (gut movement), so keep the client NPO (Nothing by Mouth)
• •May require an appendectomy (surgical removal of the appendix); keep NPO

Post-op:

• •NG (nasogastric) tube for decompression
• •Monitor vital signs
• •Assess for abdominal distention
• •Clear liquids, then advance diet as tolerated

WHAT IS IT?

Pancreatitis is inflammation of the pancreas. It happens when the pancreas digests itself (autodigestion) after long-term damage. Acute pancreatitis occurs suddenly, and most clients recover fully. Chronic pancreatitis is usually due to long-standing alcohol abuse with loss of pancreatic function.

CAUSES

• •Alcohol abuse
• •Gallbladder disease
• •Obstruction of the ducts
• •Hyperlipidemia (high blood fats)
• •Peptic ulcer disease (PUD)

ASSESSMENT

• •Abdominal pain with sudden onset, in the mid-epigastric area and left upper quadrant
• •N/V (nausea and vomiting)
• •Weight loss from malabsorption
• •Abdominal tenderness
• •Abnormal labs: increased WBC (white blood cells), bilirubin, ALP (alkaline phosphatase), amylase, lipase
• •Cullen's sign: bruising and edema (swelling) around the umbilicus (belly button)
• •Turner's sign: flank bruising, a sign of pancreatic autodigestion or retroperitoneal hemorrhage (bleeding behind the abdominal cavity)
• •Steatorrhea: fatty, foul-smelling stools

MANAGEMENT

• •Suppress pancreatic secretions with NPO (nothing by mouth) diet and NG (nasogastric) tube insertion to decompress the stomach
• •IV hydration
• •TPN (total parenteral nutrition, IV feeding) for prolonged exacerbations to provide adequate nutrition
• •ERCP (endoscopic retrograde cholangiopancreatography) to remove gallstones: a camera is inserted to visualize the common bile duct

Surgery:

• •Whipple: remove a portion of the pancreas (for a mass or tumor)
• •Pancreatectomy: remove the pancreas, which requires insulin, glucagon, and pancreatic enzyme supplementation
• •Cholecystectomy: if the source is gallbladder disease

Medications for pain and to control symptoms:

• •Analgesics, H2 blockers, proton pump inhibitors, insulin, and anticholinergics

WHAT IS IT?

A urinary tract infection (UTI) is an infection anywhere in the urinary tract (kidneys, ureters, bladder, urethra) that causes inflammation. Pathogens (germs) enter through the perineal area or through the bloodstream. Indwelling catheters can cause a catheter-associated UTI (CAUTI). Older males are more prone due to urinary stasis (urine not draining) from an enlarged prostate.

ASSESSMENT

• •Cloudy urine with a strong odor (pyuria)
• •Burning with urination
• •Increased urinary frequency
• •Confusion (altered mental status) and lethargy, especially in the elderly
• •Increased temperature, increased WBCs (white blood cells)
• •Urine cultures reveal bacteria

MANAGEMENT

• •Get urine and blood cultures BEFORE starting antimicrobials
• •Antimicrobials
• •Antispasmodic for bladder pain: Oxybutynin
• •Analgesic: Pyridium specifically relieves pain and burning with urination

WHAT IS IT?

Acute kidney injury is a sudden onset of kidney damage. Kidney function is lost because of poor circulation or damage to kidney cells. It is usually reversible and may resolve on its own, but it can cause permanent damage if not reversed quickly.

CAUSES

• •Prerenal: decreased blood flow to the kidneys, which accounts for most cases (hypotension, hypovolemia, decreased cardiac output such as heart failure or shock)
• •Intrarenal: damage within the kidney itself (tubular necrosis, infection, obstruction, contrast dye, nephrotoxic medications)
• •Postrenal: a backup between the kidney and the urethral meatus that damages the kidneys (infection, calculi, or obstruction)

PHASES

• •Onset: a decrease from baseline urine output
• •Oliguric: decreased urine output under 400 mL/day; the sickest phase, with increased BUN/creatinine and decreased glomerular filtration rate (GFR)
• •Diuretic: beginning to recover, with a gradual increase in urine output followed by diuresis
• •Recovery: decreased edema, electrolytes normalize, and GFR increases

ASSESSMENT

• •Signs and symptoms come from the kidneys' inability to regulate fluid and electrolytes
• •Azotemia (retention of nitrogen wastes in the blood): increased BUN/creatinine
• •Decreased glomerular filtration rate (GFR)
• •Decreased urine output in the oliguric phase, which should increase in the diuretic phase
• •Signs of volume overload (hypertension, peripheral edema, pulmonary edema)
• •Signs of infection if that was the source
• •Metabolic acidosis: kidneys are not holding HCO3 (bicarbonate)
• •Electrolyte abnormalities: increased potassium, decreased sodium, increased phosphate, decreased calcium

MANAGEMENT

Oliguric phase:

• •Restrict fluid intake because of volume overload, give diuretics for volume overload, and identify and treat the cause

Diuretic phase:

• •Replace fluids and electrolytes, and watch potassium and sodium levels closely

If not recovering:

• •May need dialysis

WHAT IS IT?

Chronic kidney disease is a progressive, irreversible loss of kidney function. It comes with a decline in GFR (Glomerular Filtration Rate, how fast the kidneys filter blood) below 60 mL/min. All body systems are affected, and dialysis is required. ESRD (End-Stage Renal Disease) is a GFR below 15 mL/min. Common causes are DM (Diabetes Mellitus), HTN (Hypertension, high blood pressure), an acute kidney injury that did not reverse, glomerulonephritis (kidney filter inflammation), and autoimmune disorders.

Quick Concept: As the kidneys fail, waste, fluid, and electrolytes build up and harm every body system.

ASSESSMENT

Diagnostics:

• •GFR in mL/min, normal is above 90 mL/min
• •Ultrasound shows scarring or damage
• •Decreased urine output (could be anuric, meaning no urine)
• •Increased BUN (Blood Urea Nitrogen) and creatinine (waste products)

Body system signs (CKD affects every body system):

• •Azotemia (buildup of nitrogen waste in the blood as urea), shown by increased BUN, creatinine, and uremia
• •Cardiac (from RAAS effects): volume overload, HTN, and CHF (Congestive Heart Failure)
• •Respiratory: pulmonary edema (lung fluid) from volume overload
• •Hematologic: low erythropoietin causes anemia and thrombocytopenia (low platelets)
• •Gastrointestinal: anorexia (from azotemia) and nausea and vomiting (from metabolic acidosis)
• •Neurological (cerebral edema and uremic encephalopathy): lethargy, confusion, and coma
• •Urinary: decreased urine output and proteinuria (protein leaking into urine because the kidney is not filtering properly)
• •Skeletal: osteoporosis from an imbalance of calcium and phosphorus needed for healthy bones, because the kidneys are not filtering properly

MANAGEMENT

• •Epoetin alfa (synthetic erythropoietin)
• •Avoid aspirin or NSAIDs (risk for interstitial nephritis)

Monitor potassium levels:

• •Hyperkalemia (high potassium) causes EKG changes: peaked T waves, flat P, wide QRS, blocks, asystole
• •Continuous cardiac monitoring
• •Low potassium diet
• •Potassium lowering medications: Kayexalate, insulin with dextrose, calcium gluconate

Other:

• •Phosphate binders to lower phosphorus, given BEFORE meals
• •Calcium supplements to treat hypocalcemia (low calcium)
• •Hemodialysis or peritoneal dialysis

WHAT IS IT?

Pelvic inflammatory disease is an infection of the female reproductive tract. The infection moves into the pelvis and the bacteria move into the uterine cavity, leading to inflammation and scarring. It can be fatal if untreated.

CAUSES

• •STDs (sexually transmitted diseases), the most common cause
• •Vaginal flora overgrowth
• •Infection of pelvic structures

RISK FACTORS

• •Risky sexual practice
• •Multiple sexual partners
• •Recent IUD (intrauterine device) placement, which acts as a foreign body
• •History of STD

COMPLICATIONS

• •Infertility
• •Ectopic pregnancy (pregnancy outside the uterus)
• •Sepsis/death

ASSESSMENT

• •Abdominal pain
• •Abnormal vaginal bleeding/discharge: spotting, yellow or green discharge
• •Pain with urination and intercourse
• •Fever, chills, malaise (general feeling of being unwell)
• •Diagnosis is based on clinical history, physical exam, and lab tests including a gram stain to identify the organism and a culture and sensitivity to choose the right antibiotic

MANAGEMENT

• •Antibiotics
• •Pain control with mild analgesics: NSAIDs
• •Positioning: semi-Fowler's to help drainage of the infection

WHAT IS IT?

Dialysis filters the blood when the kidneys cannot. It clears waste and toxins (urea, creatinine, uric acid) and regulates electrolytes. The two main types are hemodialysis (filtering blood through a machine) and peritoneal dialysis (using the lining of the abdomen as a filter).

HEMODIALYSIS

Complications:

• •Hypotension or hypovolemic shock (pulling off 1 to 4 L of fluid in 2 to 4 hours)
• •Air embolus (air bubble in the blood)
• •Electrolyte imbalance
• •Sepsis (blood infection)
• •Hemorrhage from the site

Medication precautions:

• •HOLD antihypertensives and medications that might drop blood pressure (verify with the provider)
• •HOLD medications that will be removed by dialysis (contact pharmacy with questions, verify with the provider)

Nursing priorities:

• •Monitor vital signs and EKG closely throughout (risk for hypotension or EKG changes)
• •Monitor lab values closely
• •Weigh the client before and after dialysis to estimate fluid loss (1 kg = 1 L)
• •Assess for bleeding from the site

Vascular access (the connection used for hemodialysis):

• •Types: graft (artificial vessel loop), fistula (allows higher velocity or volume in veins), external dialysis catheter (usually temporary)
• •Do NOT insert IVs or take a blood pressure (NIBP, noninvasive blood pressure) on the extremity with an active fistula or graft
• •Assess pulses and capillary refill in the affected extremity
• •Monitor fistulas and grafts closely for clots: listen for a bruit (swooshing sound), feel for a thrill (vibration)
• •If bruit and thrill are absent, notify the provider
• •Protect vascular access, it is their LIFELINE

PERITONEAL DIALYSIS

• •The peritoneum (lining of the abdomen) acts as a semipermeable membrane for dialysis
• •Contraindications: peritonitis and abdominal surgery
• •Can be continuous (24/7) or intermittent and can be done at home
• •The client is at risk for peritonitis (infection of the peritoneum), which is prevented with strict sterile technique and shows as cloudy outflow

WHAT IS IT?

The source content for this card covers contrast dye and cystoscopy precautions related to genitourinary procedures.

NURSING CONSIDERATIONS

Contrast dye:

• •The dye is damaging to the kidneys, so increase fluids to flush it out after the procedure unless contraindicated.
• •Contrast dye plus glucophage (Metformin) can cause lactic acidosis, so hold Metformin before a CT scan and for 48 hours after the scan.

Cystoscopy:

• •A camera is inserted to examine the bladder and take a biopsy.
• •Assess coagulation studies (clotting labs) first.
• •After the procedure, assess the site for bleeding and apply pressure to the site.
• •[source fragment unclear, verify at source]

WHAT IS IT?

A blood transfusion gives a client blood products through an IV. There are four types of products: packed red blood cells (PRBCs), cryoprecipitate, fresh frozen plasma, and platelets. The product must match the donor type by ABO type, Rh status, and special antibodies.

PRODUCT TYPES

• •PRBCs (also called a "unit of blood"): given for anemia
• •FFP (fresh frozen plasma): contains clotting factors
• •Platelets: given for thrombocytopenia (low platelets) and often before a procedure for clients with platelets less than 50. Re-check 1 hour post-transfusion.
• •Cryoprecipitate: contains fibrinogen, commonly used for hemorrhage and DIC (disseminated intravascular coagulation)

PROCEDURE

Prepare to transfuse:

• •Type and crossmatch/screen
• •Pre-transfusion vitals
• •Materials: special blood IV tubing, 0.9% normal saline, access to emergency medications

Begin transfusion:

• •Independent double-check completed by two RNs
• •Start the infusion at a slow rate for the first 10 to 15 minutes
• •Monitor for reaction

ASSESSMENT

• •Transfusion reactions most commonly occur in the first 10 to 15 minutes
• •Symptoms: pruritus (itching), rash, fever, chills, low back pain, anxiety
• •Reactions present similarly to anaphylaxis and can occur up to 24 hours after transfusion
• •Delayed reactions: caused by antibody mismatch, can be potentially fatal, occur in clients who have had transfusions before or have undetectable antibodies below the screening threshold
• •Post-transfusion: redraw CBC (complete blood count)

MANAGEMENT

For a transfusion reaction:

• •Immediately STOP the transfusion and SAVE the blood product for the lab
• •Treatment is similar to anaphylaxis: notify provider, give antihistamines (diphenhydramine), give acetaminophen
• •Consider furosemide for fluid overload and to maintain kidney function
• •Monitor airway patency
• •Maintain IV access
• •Report to the blood bank