Pages To Read (draft)..

Caring for a patient with a cardiac disorder

 Cardiac content:
Chapter 29: Cardiac disorders
JVD 838-839 (review from NUR 220)
Assessment (A PET MOUSE) 839-840
Heart sounds (review from NUR 220) 840-842
Murmur 842-845 (stop at health promo)
Monitoring VS (review norms, NUR 210, 220, 380)
Chapter 30: Cardiac conduction
Review anatomy 850-853
ECK/EKG 853-855 (skip bipolar/unipolar leads) (stop at signal averaged EKG)
Bedside monitoring 856-861
NSR 861
Dysrhythmias 862-869 (stop at AV node reentry tachycardia), 872-886
Cardioversion 886
Defibrillation 890
Pacemakers/ICD 890-899
Chapter 31: hemodynamic monitoring
Overview 901-903 (stop at equipment)
Normal pressures 905
Cardiac output 910-911
Invasive monitoring devices
Arterial lines 906
Central venous catheters 908-910
Pulmonary artery catheters (swan-ganz) 911-913 (skip ports, insertion, thermodilution cardiac output)
Chapter 32: Coronary artery disease (and clinical prep)
Cardiac cath & PCI 940-943 (stop at planning & intervention)
Acute coronary syndrome 945-958 (stop at infarct expansion
Nursing management ACS 959-960 (stop at health promo)
Surgical management ACS 964-966 (stop at health promo)
Chapter 34: Heart failure (and clinical prep)
Begin at renin-angiotensin-aldosterone 1029
Medications 1033-1039
Labs/diagnostics 1034-1035
Acute decompensated heart failure 1040-1041 & 1047 (stop at health promo)
Chart 34-9 1049
Chapter 35: Peripheral vascular disorders
Medications (all categories are common meds)
Aortic dissection 1080-1081 (stop at health promo)

Caring for a patient with a hepatic disorder

Osborn Chapter 38 Cirrhosis Acute Pancreatitis

Care of the woman with Dystocia related to Dysfunctional Uterine Contractions.

Dystocia - difficult labor.

Most common cause of dystocia is dysfunctional/uncoordinated uterine contractions, may result in prolonged labor.

Prolonged labor - lasting more than 24 hours

Normal uterine contractions pattern:  moderate or strong and regular
Early labor phase: 2-4 contractions in 10 minutes
Later phases: 4-5 contractions in 10 minutes

Tachysystolic Labor Patterns:  >5 contractions in 10 minutes, averaged over a 30-mins window.

Maternal Risks:

• increased discomfort due to uterine muscle anoxia (absence of oxygen)
• fatigue as patterns continue
• stress on coping abilities
• dehydration if labor is prolonged
• increased infection risks if labor is prologed

Fetal/Neonatal risks:

• nonreassuring fetal status because contractions and increased uterine tone interfere w/ the uteroplacental exchange of gases and nutrients.
• prolonged presurre on the fetal head, which may result in cephalohematoma, caput succedaneum, or excessive molding. 

Caput Succedaneum

Cephalohematoma

Clinical Therapy:

• bed rest and sedation to promote relaxation and reduced pain
• Often, pharmacologic intervention to promote sedation will stop tachysystolic contractions. 
• Pitocin and amniotomy (artificial rupture of membrane) may be considered if the pattern continues and developed into a prolonged latent phase. However, cephalopelvic disproportion (CPD) and fetal malpresentation need to be ruled out first. If CPD is present, labor is not stimulated because vaginal birth is not possible. Instead c/s will be performed. 
• CPD is said to be present if the maternal pelvic diameters are less than average, or if the fetus is particularly large or is in malpresentation or malposition.

Assessment and Diagnosis:

• Evaluate relationship between intensity of pain being experienced and the degree to which cervix is dilating and effacing.
• Note if anxiety is negatively affecting the labor progress
• Monitor for signs of nonreassuring fetal status.

Planning and Implementation:

• provide comfort and support to the laboring woman and her partner
• woman will be very uncomfortable due to increased force of contractions. Her anxiety and her partners anxiety will be very high. Work to reduce discomfort and promote more effective labor pattern
• Change of positions: left lateral side lying, high fowlers, on her knees with arms up, rocking in a rocking chair, sitting, walking.
• Soothing measures: quiet environment, back rub, therapeutic touch, music, visualization
• Comfort measures: mouth care, change of linens, effleurage, relaxation exercises
• Tub baths, warm shower can help promote comfort and uterine relaxation
• Provide information about the cause of tachysystolic labor pattern
• assure woman she's not overreacting
• patient education. She needs information about the dysfunctional labor pattern and the possible implications for her and her baby. This will relieve anxiety.
• Explain tx options
• offer opportunities to ask questions

Evaluation:

• Woman has increased comfort and decreased anxiety
• Woman and partner able to cope w/ the labor
• Woman experiences a more effective labor pattern

Hypotonic Labor Patterns:  fewer than 2-3 contractions in a 10-min period; develops in the active phase of labor; may occur when the uterus is overstretched from a twin gestation, or in the presence of a large fetus, hydramnios, or grand multiparity. Bladder or bowel distention and CPD may also be assoc. w/ this pattern.

Maternal Risks:

• exhaustion
• stress on coping abilities
• postpartum hemmorhage from insufficient uterine contractions ff birth
• intrauterine infection if labor is prolonged

Fetal/Neonatal Risks:

• nonreassuring fetal status due to prolonged labor pattern
• fetal sepsis from pathogen that ascend from the birth canal in the presence of ruptured membranes.

Clinical Therapy: The goal is to improve the quality of the uterine contractions and to ensure a safe outcome for mom and baby. 

• Stimulation of uterine contractions can be performed in several ways: Pitocin, amniotomy, and release of oxytocin due to nipples stimulation. 

• CPD, fetal malpresentation, and fetal immaturity need to be ruled out before Pitocin may be given to improve the quality of contractions. 

• IV fluids for hydration maintenance and prevention of maternal exhaustion. 

• Amniotomy may be used to stimulate labor process.  

• Electric breast pump can be applied or manual stimulation of nipples to help strengthen uterine contractions. Excellent starting point for women who wanted unmedicated birth. 

  • If labor pattern does not become effective or if other complications develop, c/s or other interventions may be necessary.  

 Assessment and Diagnosis:

• Assess ccontactions (frequency, intensity, duration), maternal VS and FHR.
• Assess s/s of infection and dehydration
• Observe coping mechanism
• Acute pain, ineffective coping, fatigue

 Planning and Implementation:

• promote maternal-fetal physical well being by frequent monitoring of contractions, maternal vs and fhr.
• Assess for presence of meconium if amniotic membranes were ruptured. Meconium indicates that the fetus is experiencing some form of stress w/c makes close observation of fetal status more critical.
• I/O record for maternal hydration or dehydration
• Encourage woman to void q2h, check bladder for distention.
• Monitor for s/s of infections (elevated temperature, chills, foul smelling amniotic fluid, fetal tachycardia)
• Keep vaginal examinations to a minimum to decrease risk for infections
• Emotional support
• Provide information about dysfunctional labor process and implications to mother and baby.
• Discuss disadvantages of and alternative tx

Evaluation:

• Woman maintains comfort during labor,
• Woman understand the type of labor pattern that is occurring and the tx plan.

•  

Anti-anginal Drugs

For treatment of angina pectoris (chest pain)
What causes angina? inadequate blood flow to the myocardium due to either plaque occlusions w/in or spasms of the coronary arteries. Decreased blood flow = decreased O2 to myocardium results in pain.
Anti-anginal drugs increase blood flow either by increasing oxygen supply or decreasing demand by the myocardium.
3 Types: Nitrates, Beta blockers, and Calcium Channel Blockers
Nitrates— major systemic effect is a reduction of venous tone, which decreases the workload of the heart and promotes vasodilation. Cause generalized vascular and coronary vasodilation, w/c increases blood flow through the coronary arteries to the myocardial cells. Reduces myocardial ischemia but can cause hypotension.

• Prototype drug: Nitroglcerin (Nitrostat, Nitrobid) - vasodilator; sublingual, the effects of SL last for 10minutes; client can use a maximum of 3 tablets, if pain is not relieve call 911.
• client may experience dizziness, faintness or headache as a result of peripheral vasodilation.
• causes relaxation and dilation, reduces cardiac preload and afterload and reduces myocardial 02 demand.
• ONSET: SL and IV, rapid 1-3mins; Trandermal 30-60minutes, patch should be removed nightly to avoid tolerance, 8-12 hour nitrate free interval. TD should be tapered.
• HA, hypotension, dizziness, weakness, faintness

Beta blockers—Why are they effective for angina? because by decreasing the heart rate and myocardial contractility, they reduced the need for oxygen consumption and consequently reduce anginal pain.

• decrease the workload of the heart and decrease oxygen demand.
• blocks beta-1 and beta-2
• decrease the effects of SNS by blocking the action of cathecolamines (epinephrine, norepinephrine), thereby reducing heart rate and BP
• used as antianginal, antidysrhythmic, and antihypertensive drugs
• should be tapered of to avoid reflex tachycardia and recurrence of anginal pain

Review side effects, contraindications:

• Contraindicated: pts who have low HR and BP; clients who have 2nd or 3rd degree AV block  

Calcium channel blockers—Why are they effective for angina?

• decrease workload of the heart, which decreases oxygen demand.
• Blocks influx of calcium into cardiac cells
• relax coronary artery spasm
• relax peripheral arterioles
• decrease cardiac contractility
• decrease afterload
• decrease peripheral resistance

Common side effects: Headache, peripheral edema, bradycardia, flushing, constipation, dizziness, hypotension

Nitrates and calcium channel blocker - effective in treating variant angina pectoris.
Beta blockers- for stable angina
Unstable angina, immediate medical care. Nitrates are usually given SQ and IV as needed. If cardiac pain continues, a beta blocker is given intravenously, if bblocker is not tolerated, calcium channel blocker can be used as substitute.

Cardiac Glycosides: Digoxin

Use: Increases contractility of cardiac muscle fibers
Indications: heart failure; heart rate control in atrial fibrillation
Desired results: Slows heart rate; decreases rate of cardiac electrical conduction; increases strength of cardiac muscle contraction. Improves heart failure symptoms by improving peripheral circulation, which increases fluid excretion.

Prototype drug: Digoxin (Lanoxin)—long half-life

• Narrow Therapeutic Window: therapeutic range = 0.5 (to treat HF) - 2.0 (best for atrial flutter or fibrillation) ng/ml
• Low serum potassium level (<3.5) can result in drug toxicity
• Bradycardia, N/V, visual “halos”, confusion
• Antidote: Digoxin immune Fab (Digibind)

Maintenance dose: 0.125 - 0.5 mg/dl. For older adults, dose is usually 0.125 mg/dl
Pulse rate should be above 60 beats/min.
Does not convert atrial fibrillation to normal heart rhythm. For mngmt. of atrial fibrillation, a calcium channel blocker, such as Calan may be prescribed. To prevent thromboemboli resulting from atrial fibrillation, Warfarin is prescribed concurrently w/ other drugs.
In clients w/ failing heart, cardiac glycosides increases myocardial contraction, w/c increases cardiac output and improves circulation and tissue perfusion. Because it decrease conduction through the AV node, the heart rate decreases.
Phenytoin and lidocaine are effective in treating digoxin induced ventricular dyshrythmias.
Lasix, HCTZ and systemic cortisone can cause hypokalemia. Patient should consume potassium rich foods or take potassium supplements.
Antacid can reduce Digoxin absorption so avoid taking it on the same time.

PHOSPHODIESTERASE INHIBITORS - Positive inotropic drug used for acute heart failure treatment
Promotes increase in cardiac muscle contraction, vasodilation

• IV drugs: inamrinone (Inocor), milrinone (Primacor) - increase stroke volume and cardiac output and promote vasodilation. Administered for no longer than 48-72 hours.

Used for short-term acute management of heart failure, requires cardiac monitoring during therapy for severe dysrhythmias can occur.

ATRIAL NATIURETIC PEPTIDE HORMONE
Nesiritide (Natrecor)— diuresis for heart failure treatment
Inhibits  ADH by increasing urine sodium loss. Promote vasodilation, diuresis and natriuresis. Useful for treating clients who have acute decompensated HF w/ dyspnea at rest or who have dyspnea w/ little exertion.