-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
1/88
CARE OF CLIENTS WITHPROBLEMS IN
OXYGENATION(P ART 2)
Jotham C. Marfil, RN
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
2/88
D IAGNOSTIC TESTS
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
3/88
CK-MB (CREATININE KINASE,MYOCAR D IAL MUSCLE)
An elevation in value indicates myocardialdamage
An elevation occurs within 4 to 6 hoursand peaks 18 to 24 hours following anacute ischemic attack
Normal value is 0% to 5% of total; totalCK is 26 to 174 units/L
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
4/88
L ACTATE D EHY D ROGENASE (L D H)
E levations in LDH levels occur 24 hoursfollowing myocardial infarction and peakin 48 to 72 hours
Normally, LDH1 is lower than LDH2;when the serum concentration of LDH1 ishigher than LDH2, the pattern is
indicated as flipped, signifyingmyocardial necrosis
140 to 280 IU/L
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
5/88
TROPONIN
Is composed of troponin C, cardiactroponin I, and cardiac troponin T
Has a high affinity for myocardial injury;it rises within 3 hours and persists for upto 7 days
Troponin I lower than 0.6ng/mLTroponin T 0 to 0.2ng/mL
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
6/88
C OMPLETE BLOO D COUNT
RBC decreases in rheumatic heart diseaseand infective endocarditis and increasesin conditions characterized by inadequatetissue oxygenation
The WBC increases in infectious andinflammatory diseases of the heart andafter MI to dispose necrotic tissueresulting from infarction
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
7/88
E levated hematocrit level can result from
vascular volume depletion
Decreases in hematocrit and hemoglobinlevels can indicate pneumonia
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
8/88
S ERUM LIPI D S
The lipid profile measures serumcholesterol, triglyceride, and lipoproteinlevels
Is used to assess the risk of developingcoronary artery disease
Serum cholesterol lower than 200mg/dLLDL lower than 130mg/dLHDL 30 to 70 mg/dL
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
9/88
B- TYPE NATRIURETIC PEPTI D E (BNP)
Is released in response to atrial andventricular stretch; it serves as a markerfor congestive heart failure
Should be lower than 100pg/mL
The higher the level, the more severe thecongestive heart failure
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
10/88
ELECTROCAR D IOGRAPHY
Noninvasive test that records theelectrical activity of the heart and isuseful for detecting cardiac dysrhythmias,location and extent of MI, and cardiachypertrophy and for evaluation of theeffectiveness of medications
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
11/88
INT E RV E NTIONS
Determine the clients ability to lie still;advise the client to lie still, breathenormally, and refrain from talking duringthe test
Reassure the client that an electrical shockwill not occur
Document any cardiac medications theclient is taking
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
12/88
E CHOCAR D IOGRAPHY
Noninvasive procedure based on theprinciples of ultrasound and evaluatesstructural and functional changes in theheart
Heart chamber size is measured, ejection
fraction is calculated, and flow gradientacross the valve is determined
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
13/88
E XERCISE TESTING (STRESS TEST )
Noninvasive test that studies the heartduring activity and detects and evaluatescoronary artery disease
Treadmill testing is the most commonlyused mode of stress testing
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
14/88
INT E RV E NTIONS
Obtain an informed consent if required
Provide adequate rest the night before theprocedure
Instruct the client to eat a light meal 1 to
2 hours before the procedure
Instruct the client to avoid smoking,alcohol and caffeine before the procedure
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
15/88
Instruct client to wear nonconstrictive,
comfortable clothing and supportiverubber-soled shoes for the exercise stresstest
Instruct the client to notify the physicianif any chest pain, dizziness, or shortnessof breath occurs during the procedure
Instruct client to avoid taking a hot bathor shower for at least 1 to 2 hours afterthe procedure
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
16/88
D IGITAL SUBTRACTION ANGIOGRAPHY
This test combines x-ray techniques and acomputerized subtraction technique withfluoroscopy for visualization of thecardiovascular system
A contrast media (dye) is injected
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
17/88
INT E RV E NTIONS
Assess for allergies to seafood, iodine, orradiopaque dyes. Premedicate client withantihistamines or corticosteroids to
prevent a reaction
Obtain informed consent
Monitor vital signs
Assess injection site for bleeding ordiscomfort
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
18/88
M AGNETIC RESONANCE IMAGING
Noninvasive diagnostic test that producesan image of the heart or great vesselsthrough interaction of magnetic fields,
radio waves, and atomic nuclei
Provides information on chamber size andthickness, valve and ventricular function,and blood flow through the great vesselsand coronary arteries
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
19/88
INT E RV E NTIONS
E valuate client for the presence of pacemaker or other implanted items thatpresent a contraindication to the test
E nsure client has removed all metallicobjects such as watch, jewelry, clothingwith metal fasteners, and metal hairfasteners
Inform client that she or he mayexperience claustrophobia while inscanner
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
20/88
SICKLE CELL ANEMIA
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
21/88
Constitutes a group of diseases termedhemoglobinopathies, in which hemoglobin A is partly or completely replaced byabnormal sickle hemoglobin S
Caused by inheritance of a gene for astructurally abnormal portion of thehemoglobin chain
Hemoglobin S is sensitive to changes in theoxygen content of the RBC
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
22/88
Insufficient oxygen causes the cells to
assume a sickle cell shape and the cellsbecome rigid and clumped together,obstructing capillary blood flow
Situations that precipitate sickling includefever and emotional or physical stress; anycondition that increases the need for oxygenor alters the transport of oxygen can resultin sickle cell crisis
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
23/88
At risk are those having parents
heterozygous for hemoglobin S or being of African American descent
Sickle cell crises are acute exacerbations of the disease, which vary considerably inseverity and frequency ; these include vaso-occlusive crisis, splenic sequestration, andaplastic crisis
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
24/88
V ASO -O CCLUSIV E CRISIS
Caused by stasis of blood with lumping of the cells in the microcirculation, ischemia,and infarction
Fever, painful swelling of the hands, feet,and joints, and abdominal pain
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
25/88
S PL E NIC S EQ U E STRATION
Caused by the pooling and clumping of blood in the spleen (hypersplenism).
Profound anemia, hypovolemia, and shock
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
26/88
A PLASTIC CRISIS
Caused by the diminished production andincreased destruction of RBC, triggered byviral infection or the depletion of folic acid
Profound anemia and pallor
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
27/88
INT E RV E NTIONS
Maintain adequate hydration and bloodflow with IV administered NSS and withoral fluids
Administer oxygen and blood products asprescribed
Administer analgesics as prescribed(ATC)
Administration of meperidine (Demerol) isavoided
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
28/88
Assist the child to assume a comfortable
position so that the child keeps theextremities extended to promote venousreturn
E levate the bed of the head 30 degrees,avoid putting strain on painful joints, anddo not raise the knee gatch of the bed
E ncourage consumption of high-calorie,high protein diet, with folic acidsupplementation
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
29/88
Administer antibiotics as prescribed toprevent infection
Monitor for signs of complications,including increasing anemia, decreased
perfusion, and shock
Instruct the child and parents about theearly signs and symptoms of crisis and themeasures to prevent crisis
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
30/88
IRON D EFICIENCY ANEMIA
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
31/88
Iron stores are depleted, resulting in adecreased supply of iron for themanufacture of hemoglobin in RBC
Commonly results from blood loss,increased metabolic demands, syndromes of GI malabsorption and dietary inadequacy
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
32/88
S IGNS AND S YMPTOMS
Pallor
Weakness and fatigue
Irritability
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
33/88
INT E RV E NTIONS
Increase the oral intake of iron
Instruct the child and parents in foodchoices that are high in iron
Administer iron supplements as
prescribed
Give iron supplements between meals formaximum absorption
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
34/88
Give iron supplements with a multivitaminor fruit juice because vitamin C increases
absorption
Do not give iron supplements with milk orantacids because these items decrease
absorption
Teach the child and parents that a liquidiron preparation stains the teeth andshould be taken through a straw
Inform parents/client on side effects(constipation, black stools, foul aftertaste)
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
35/88
HEMOPHILIA
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
36/88
Refers to a group of bleeding disorders
resulting from a deficiency of specificcoagulation proteins
Factor VIII deficiency (hemophilia A orclassic hemophilia)
Factor IX deficiency (hemophilia B or
Christmas disease)
Result as an X-linked recessive disorder
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
37/88
Most frequently transmitted by the union
of an unaffected male with a trait-carrierfemale; however, it can result from theunion between an affected male and anormal or carrier female
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
38/88
S IGNS AND SYMPTOMS
Abnormal bleeding in response to trauma orsurgery (usually detected after circumcision)
E pistaxis
Joint bleeding causing pain, tenderness,swelling and limited ROM
Tendency to bruise easily
Platelet test is normal; clotting factorfunction may be abnormal
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
39/88
INT E RV E NTIONS
Monitor for bleeding and maintainbleeding precautions
Prepare to administer replacement factorsas prescribed
Monitor for joint pain; immobilize the
affected extremity if joint pain occurs
Assess neurological status (child is at riskfor intracranial hemorrhage)
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
40/88
Control joint bleeding by immobilization,elevation, and the application of ice; inaddition, apply pressure (15 minutes) forsuperficial bleeding
Instruct parents how to control bleeding
Instruct the parents on activities to beavoided by the child, emphasizing
avoidance of contact sports and the needfor protective devices while learning towalk
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
41/88
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
42/88
KAWASAKI D ISEASE
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
43/88
Is known as mucocutaneous lymph node
syndrome and is an acute systemicinflammatory illness
The cause is unknown but may be associatedwith an infection from an organism or toxin
Cardiac involvement is the most serious
complication; aneurysms can develop
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
44/88
S IGNS AND SYMPTOMS
Fever
Conjunctival hyperemia
Red throat acute stage
Swollen hands, rash,and enlargement of thecervical lymph nodes
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
45/88
Crackling lipsand fissures
Desquamation of theskin on the tips of thefingers and toes
subacute stageJoint pain
Cardiac manifestations
Thrombocytosis
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
46/88
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
47/88
Irritability may last up for up to 2 monthsafter the onset of symptoms
Peeling of the hands and feet may occur
Pain in the joints may persist for severalweeks
Stiffness in the morning, after naps, and incold temperatures may occur
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
48/88
INT E RV E NTIONS
Monitor temperatures frequently (refer if 101F or higher)
Assess heart sounds, rate, and rhythm
Assess extremities for edema, redness, anddesquamation
E xamine eyes for conjunctivitis
Monitor mucous membranes forinflammation
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
49/88
Monitor strict intake and output
Administer soft foods and liquids that areneither too hot nor too cold
Weigh the child daily
Provide passive range of motion exercises tofacilitate joint movement
Administer ASA as prescribed
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
50/88
Administer immune globulin intravenouslyas prescribed to reduce the duration of thefever and the incidence of coronary arterylesions and aneurysms
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
51/88
CORONARY ARTERYD ISEASE
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
52/88
Narrowing or obstruction of one or morecoronary arteries as a result of atherosclerosis, which is an accumulation of lipid-containing plaque in the arteries
Causes decreased perfusion of myocardialtissue and inadequate myocardial oxygensupply
Symptoms occur when the coronary arteryis occluded to the point that inadequateblood supply to the muscle occurs causingischemia
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
53/88
Coronary artery narrowing is significant if
the lumen diameter of the left main arteryis reduced at least 50%, or if any majorbranch is reduced at least 75%
The goal of treatment is to alteratherosclerotic progression
Cardiac catheterization provides the mostdefinitive source for diagnosis
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
54/88
S IGNS AND SYMPTOMS
Chest pain
Palpitations
Dyspnea
Syncope
Cough or hemoptysis
E xcess fatigue
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
55/88
When blood flow is reduced and ischemiaoccurs, ST segment depression, T waveinversion, or both is noted; ST segmentreturns to normal when the blood flowreturns
With infarction, cell injury results in STsegment elevation, followed by T waveinversion and an abnormal Q wave
Blood lipid levels may be elevated
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
56/88
INT E RV E NTIONS
Instruct the client regarding the purposeof diagnostic medical and surgicalprocedures and pre procedure and postprocedure expectations
Assist the client to identify risk factorsthat can be modified
Assist the client to set goals to promotelifestyle changes to reduce the impact of risk factors
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
57/88
Instruct the client regarding a low-calorie,low sodium, low cholesterol, and low fatdiet with an increase in dietary fiber
Stress to the client that dietary changes
are maintained for life
Provide community resources to the clientregarding exercise, smoking cessation,and stress reduction as prescribed
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
58/88
S URGICAL PROC E DUR E S
PTCA to compress the plaque against thewalls of the artery and dilate the vessel
Laser angioplasty to vaporize the plaque
Atherectomy to remove the plaque fromartery
Coronary artery bypass grafting toimprove blood flow to the myocardialtissue at risk for ischemia or infarction
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
59/88
ANGINA
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
60/88
Chest pain resulting from myocardial
ischemia caused by inadequatemyocardial blood and oxygen supply
Caused by an imbalance between oxygensupply and demand
Causes include obstruction of coronaryblood flow resulting from atherosclerosis,coronary artery spasm, or conditionsincreasing myocardial oxygenconsumption
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
61/88
P ATT E RNS OF ANGINA
Stable Anginay Also called exertional angina
y
Occurs with activities that involve exertionor emotional stress; relieved with rest ornitroglycerin
y
Usually has a stable pattern of onset,duration, severity and relieving factors
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
62/88
U nstable Anginay
Also called preinfarction angina
y Occurs with an unpredictable degree of exertion or emotion and increases in
occurrence, duration, and severity over time
y Pain may not be relieved with nitroglycerin
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
63/88
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
64/88
I ntractable Angina is a chronic,incapacitating angina unresponsive tointerventions
P reinfarction Anginay
Associated with acute coronary insufficiency
y Lasts longer than 15 minutes
y Symptom of worsening cardiac ischemia
y Occurs after an MI, when residual ischemiamay cause episodes of angina
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
65/88
S IGNS AND SYMPTOMS
Pain
Dyspnea
Pallor
Sweating
Palpitations and tachycardia
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
66/88
Dizziness and faintness
Hypertension
Digestive disturbances
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
67/88
INT E RV E NTIONS
Assess pain
Provide bed rest
Administer oxygen at 3L/min by nasalcannula as prescribed
Administer nitroglycerin as prescribed
Obtain a 12-lead E CG
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
68/88
Provide a continuous cardiac monitoring
Assist the client in identifying angina-precipitating events
Instruct client to stop activity and rest if chest pain occurs and to take nitroglycerinas prescribed
Instruct client to seek medical attention if pain persists
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
69/88
Assist client to identify risk factors thatcan be modified
Provide dietary instructions
Provide community resources to the clientregarding exercise, smoking cessation,and stress reduction
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
70/88
MYOCAR D IAL INFARCTION
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
71/88
Occurs when myocardial tissue is abruptlyand severely deprived of oxygen
Ischemia can lead to necrosis of myocardial tissue if blood flow is notrestored
Infarction does not occur instantly butevolves over several hours
Obvious physical changes do not occur inthe heart until 6 hours after theinfarction, when the infarcted areasappears blue and swollen
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
72/88
Not all clients experience the classic
symptoms of an MI
Women may experience atypicaldiscomfort , shortness of breath, or fatigue
An older client may experience shortnessof breath, pulmonary edema, dizziness,altered mental status, or a dysrhythmia
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
73/88
S IGNS AND SYMPTOMS
Pain
Nausea and vomiting
Diaphoresis
Dyspnea
Dysrhythmias
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
74/88
Feelings of fear and anxiety
Pallor
Cyanosis
Coolness of extremities
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
75/88
INT E RV E NTIONS
Obtain a description of the chestdiscomfort
Assess vital signs
Assess cardiovascular status
Place client in a semi-Fowlers position
Administer oxygen at 2 to 4L/min by nasalcannula as prescribed
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
76/88
E stablish an IV access route
Administer nitroglycerin as prescribed
Administer morphine sulphate as
prescribed to relieve chest discomfort
Obtain a 12-lead E CG
Monitor thrombolytic therapy, which maybe prescribed for the first 6 hours of thecoronary event
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
77/88
Administer beta blockers as prescribed
Assess distal peripheral pulses and skintemperature
Monitor intake and output
Assess RR and breath sounds for signs of heartfailure
Monitor BP closely
Provide reassurance to the client and family
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
78/88
Maintain bed rest for the first 24 to 36hours as prescribed
Allow the client to stand to void or use a bedside commode if prescribed
Provide ROM exercises
E ncourage client to verbalize feelingregarding the MI
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
79/88
RAYNAU D S D ISEASE
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
80/88
Vasospasms of the arterioles and arteriesof the upper and lower extremities
Vasospasms cause constriction of thecutaneous vessels
Attacks are intermittent and occur withexposure to cold or stress
Affects primarily fingers, toes, ears, andcheeks
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
81/88
S IGNS AND SYMPTOMS
Blanching of the extremity, followed bycyanosis during constriction
Reddened tissue when the vasospasm isrelieved
Numbness, tingling, swelling, and a coldtemperature at the affected body part
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
82/88
INT E RV E NTIONS
Monitor pulses
Administer vasodilators as prescribed
Assist the client to identify and avoidprecipitating factors such as cold andstress
Instruct the client to avoid smoking
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
83/88
Instruct the client to wear warm clothing,
socks and gloves in cold weather
Advise client to avoid injuries to fingersand hands
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
84/88
BUERGER S D ISEASE
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
85/88
Thromboangiitis obliterans
An occlusive disease of the median andsmall arteries and veins
The distal upper and lower limbs areaffected most commonly
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
86/88
S IGNS AND SYMPTOMS
Intermittent claudication
Ischemic pain occurring in the digits whileat rest
Aching pain that is more severe at night
Cool, numb, or tingling sensation
Diminished distal pulses
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
87/88
-
8/8/2019 Care of Clients With Problems in Oxygenation (Part 2)
88/88
INT E RV E NTIONS
Instruct the client to stop smoking
Monitor pulses
Instruct the client to avoid injury to theupper and lower extremities
Administer vasodilators as prescribed