cardiology and hematology ppt

OXYGENATIONOXYGENATION

CARDIOVASCULAR CARDIOVASCULAR AND HEMATOLOGIC AND HEMATOLOGIC

SYSTEMSYSTEM

TERMINOLOGIESTERMINOLOGIES

VENTILATIONVENTILATION – MOVEMENT OF AIR IN & OUT OF THE – MOVEMENT OF AIR IN & OUT OF THE LUNGSLUNGS

RESPIRATIONRESPIRATION – EXCHANGE OF GASES : EXTERNAL & – EXCHANGE OF GASES : EXTERNAL & INTERNALINTERNAL

EXTERNAL EXTERNAL –– BET. ALVEOLI & PULMONARY CAPILLARIES BET. ALVEOLI & PULMONARY CAPILLARIES

INTERNAL INTERNAL – – BET. SYSTEMIC CAPILLARIESBET. SYSTEMIC CAPILLARIES

PERFUSION PERFUSION – AVAILABILITY & MOVEMENT OF – AVAILABILITY & MOVEMENT OF CAPILLARY BLOOD FOR EXCHANGE OF GASESCAPILLARY BLOOD FOR EXCHANGE OF GASES

CASE STUDYCASE STUDY

You are the Emergency Room nurseYou are the Emergency Room nurse

A patient came in, 48 y.o.,A patient came in, 48 y.o.,dyspneicdyspneic, , with the following vital signs : T= with the following vital signs : T= 38C, RR=50, CR=105, BP=160/110 38C, RR=50, CR=105, BP=160/110 mmHgmmHg


You noted that the patient is You noted that the patient is jaundiced, with bipedal edema, and jaundiced, with bipedal edema, and prefer to sit than lie down.prefer to sit than lie down.

What is your immediate nursing What is your immediate nursing action even without the doctor’s action even without the doctor’s order?order?


What nursing history would you ask ?What nursing history would you ask ?

What other nursing assessment What other nursing assessment would you do?would you do?

What is your plan for the patient?What is your plan for the patient?

CARDIOVASCULAR SYSTEM CARDIOVASCULAR SYSTEM

• Review of Anatomy & Physiology• Assessment : History and Physical

Assessment•Diagnostics•Planning

REVIEW OF ANATOMY AND REVIEW OF ANATOMY AND PHYSIOLOGY- PHYSIOLOGY- HeartHeart

StructuresStructures

Blood Supply – LCA, RCA, veinsBlood Supply – LCA, RCA, veins

Conductive System –Sino-atrial node Conductive System –Sino-atrial node AV node Bundle of His AV node Bundle of His Bundle branch Purkinje fibers Bundle branch Purkinje fibers

HEARTHEART

RA

RV

LUNGS

LA

LV

SYSTEMICCIRCULATION

SYSTEMICCIRCULATION

LUNGS

SYSTEMICCIRCULATION

CONDUCTION PATHWAYCONDUCTION PATHWAY

RA LA

RV LV

- SA NODE

AV NODE-

BUNDLE OF HIS

BUNDLEBRANCH

PURKINJE

PURKINJE


Nervous System ControlNervous System Control

– SYMPATHETICSYMPATHETIC

– PARASYMPATHETICPARASYMPATHETIC


Properties of the Heart:Properties of the Heart:– All or None PrincipleAll or None Principle– RhythmicityRhythmicity– ExcitabilityExcitability– RefractorinessRefractoriness– ConductivityConductivity– AutomaticityAutomaticity– ExtensibilityExtensibility


STROKE VOLUME (SV) - STROKE VOLUME (SV) - amount of blood amount of blood pumped out with each contractionpumped out with each contraction

HEART RATE (HR)HEART RATE (HR)CARDIAC OUTPUT (CO)– CARDIAC OUTPUT (CO)– volume of blood volume of blood

pumped out per minutepumped out per minute

=SV x HR =SV x HR

PRELOADPRELOAD

AFTERLOADAFTERLOAD

REVIEW OF ANATOMY AND REVIEW OF ANATOMY AND PHYSIOLOGY – Blood VesselsPHYSIOLOGY – Blood Vessels

ArteriesArteries MicrocirculationMicrocirculation VeinsVeins Flow RegulationFlow Regulation

– Pressure gradientPressure gradient– Flow resistanceFlow resistance

Role of Blood Role of Blood vesselsvessels

Layers of the Blood Layers of the Blood Vessels:Vessels:

IntimaIntima MediaMedia AdventitiaAdventitia

REVIEW OF ANATOMY AND REVIEW OF ANATOMY AND PHYSIOLOGYPHYSIOLOGY

CIRCULATIONCIRCULATION SYSTEMICSYSTEMIC

PULMONARYPULMONARY

PORTALPORTAL

PULMONARY CIRCULATIONPULMONARY CIRCULATION

RA

RV

LUNGS

LA

LV

SYSTEMICCIRCULATION

SYSTEMICCIRCULATION

LUNGS

SYSTEMICCIRCULATION

SYSTEMIC CIRCULATIONSYSTEMIC CIRCULATION

RA

RV

LUNGS

LA

LV

SYSTEMICCIRCULATION

SYSTEMICCIRCULATION

LUNGS

SYSTEMICCIRCULATION

HISTORY AND PHYSICAL HISTORY AND PHYSICAL EXAMEXAM

Check for: Check for: – dyspnea, dyspnea, – jaundice, jaundice, – edema, edema, – hemoptysis,hemoptysis,– fatigue,fatigue,– syncope and syncope and

fainting,fainting,– cyanosiscyanosis,,

– abdominal pain abdominal pain and discomfort, and discomfort,

– clubbing of clubbing of fingers, chest fingers, chest pain, pain,

– palpitationspalpitations


Heart –I P P A Heart –I P P A – aortic area,aortic area,– pulmonic area,pulmonic area,– tricuspid, tricuspid, – mitralmitral

Heart SoundsHeart Sounds S1- AV valve S1- AV valve

closure closure S2 semilunar S2 semilunar

v. closure v. closure S3 vent. S3 vent.

Gallop Gallop S4 atrial gallopS4 atrial gallop MurmursMurmurs rubsrubs


Blood vesselsBlood vessels– Inspection Inspection

color:pallor, rubor, cyanosiscolor:pallor, rubor, cyanosis circulation of extremitiescirculation of extremities

– Palpation Palpation edema, pulsesedema, pulses

– Auscultation Auscultation bruitbruit

Diagnostic AssessmentDiagnostic Assessment NonInvasive NonInvasive

ECGECG

Dynamic ECG Stress Dynamic ECG Stress Test Test

Treadmill VectorTreadmill Vector CardiogramCardiogram

Phonocardiogram Phonocardiogram

EchocardiogramEchocardiogram

Chest Xray Chest Xray

Radionuclide Radionuclide Studies Studies

Venography Venography

UTZ – DOPPLERUTZ – DOPPLER

PletysmographyPletysmography

Diagnostic AssessmentDiagnostic Assessment

InvasiveInvasive

Cardiac Cardiac CatheterizationCatheterization

ArteriogramArteriogram

AngiocardiogramAngiocardiogram

Venogram Venogram

Lymphogram Lymphogram

Bone Marrow Bone Marrow Aspiration:Aspiration:

– SternumSternum– iliac crestiliac crest– tibia (infantstibia (infants))

Diagnostic AssessmentDiagnostic Assessment Blood and Urine Blood and Urine

StudiesStudies– CBC CBC – Hematocrit Hematocrit – Clotting time Clotting time – PT PT – PTT PTT – APTT APTT – ESR ESR

– lipid profilelipid profile– serum enzymes: serum enzymes:

SGOT, SGPT, SGOT, SGPT, LDH, CPK LDH, CPK

– VMA VMA – Renin Test Renin Test – Schilling’s TestSchilling’s Test

HEMODYNAMICS HEMODYNAMICS MONITORINGMONITORING

CVP n= 6 -12 cm water CVP n= 6 -12 cm water – Measures:Measures:

cardiac efficiency,cardiac efficiency, bld volume,bld volume, peripheral resistance,peripheral resistance, right ventricular pressure right ventricular pressure

– 0-pt be at mid axillary line, 5 cm below 0-pt be at mid axillary line, 5 cm below the sternum the sternum

– dc ventilator with readingdc ventilator with reading– = fluid overload, = hypovolemia= fluid overload, = hypovolemia

HEMODYNAMICS HEMODYNAMICS MONITORING MONITORING

Pulmonary Artery and Pulmonary Pulmonary Artery and Pulmonary Wedge Pressure Wedge Pressure – Swan Ganz catheterSwan Ganz catheter : :– floated at the right heart, floated at the right heart, – measures left side of the heartmeasures left side of the heart

Intraarterial Blood PressureIntraarterial Blood Pressure : : – Radial Artery,Radial Artery,– Allen’s TestAllen’s Test

Planning for Health PromotionPlanning for Health Promotion

Modification of High Risk FactorsModification of High Risk Factors

Promotion of CirculationPromotion of Circulation

Prevention of Infection Prevention of Infection syphillis, syphillis, staph, strep, staph, strep, german measlesgerman measles

Genetic counsellingGenetic counselling

Role of nutritionRole of nutrition

Modification of High Risk Modification of High Risk FactorsFactors

dyslipedemiadyslipedemia

hypertension hypertension

smokingsmoking

sedentary sedentary lifestylelifestyle

obesityobesity

stress stress

glucose glucose intolerance,intolerance,

alcohol abusealcohol abuse

caffeinecaffeine pollutionpollution

Planning for Health Planning for Health Maintenance & Maintenance &

RestorationRestoration– Basic Life SupportBasic Life Support– Advanced Life SupportAdvanced Life Support

– Client With Client With Cardiac Surgery:Cardiac Surgery: Closed Heart surgeryClosed Heart surgery Open Heart SurgeryOpen Heart Surgery Heart TranspantHeart Transpant

Closed Heart Closed Heart surgerysurgery

– valvutomyvalvutomy

– mitral commisurotomymitral commisurotomy

Open Heart surgery (CABG)Open Heart surgery (CABG)

COMPLICATIONS COMPLICATIONS ::

DYSRHYTHMIASDYSRHYTHMIAS

THROMBOSIS THROMBOSIS AND PULMONARY AND PULMONARY EMBOLISMEMBOLISM

CARDIOGENIC CARDIOGENIC SHOCKSHOCK

BLEEDINGBLEEDING

WOUND INFECTIONWOUND INFECTION

RENAL FAILURERENAL FAILURE

ELECTROLYTE ELECTROLYTE IMBALANCEIMBALANCE

POST-OP POST-OP PSYCHOSISPSYCHOSIS

HEART TRANSPLANTHEART TRANSPLANTCRITERIACRITERIA

1. End Stage of Disease1. End Stage of Disease

2. Freedom from Chronic Disease2. Freedom from Chronic Disease

3. Family Support3. Family Support

4. Age < 50 yo4. Age < 50 yo

5. No psychological problem5. No psychological problem

IMPORTANTIMPORTANT1. Immunosuppressant & Steroids – 4 hrs prior1. Immunosuppressant & Steroids – 4 hrs prior

2. Donor-Recipient Compatibility – size, crossmatching2. Donor-Recipient Compatibility – size, crossmatching

3. Donor Heart – saline solution 4C up to 4 hrs3. Donor Heart – saline solution 4C up to 4 hrs

CARDIOVASCULAR CARDIOVASCULAR DISTURBANCESDISTURBANCES

CORONARY / ISCHEMIC HEART DISEASECORONARY / ISCHEMIC HEART DISEASE– Arteriosclerotic Heart DiseaseArteriosclerotic Heart Disease– Angina PectorisAngina Pectoris– Coronary InsufficiencyCoronary Insufficiency– Myocardial InfarctionMyocardial Infarction

CONGESTIVE HEART FAILURECONGESTIVE HEART FAILURE HYPERTENSIONHYPERTENSION PERIPHERAL VASCULAR DISEASEPERIPHERAL VASCULAR DISEASE DISORDERS OF THE BLOODDISORDERS OF THE BLOOD

ARTERIOSCLEROTIC HEART DISEASEARTERIOSCLEROTIC HEART DISEASE

Plaque formation and internal thickeningPlaque formation and internal thickening(intima)(intima)

Plaque formation and internal thickeningPlaque formation and internal thickening(intima)(intima)

Fibrosis and calcification (media)Fibrosis and calcification (media)Fibrosis and calcification (media)Fibrosis and calcification (media)

Narrowing and constriction of coronary arteriesNarrowing and constriction of coronary arteriesNarrowing and constriction of coronary arteriesNarrowing and constriction of coronary arteries

S/sx of ISCHEMIAS/sx of ISCHEMIAS/sx of ISCHEMIAS/sx of ISCHEMIA

ANGINA PECTORISANGINA PECTORIS

1. STABLE1. STABLE

2. UNSTABLE2. UNSTABLE

3. PRINZMETAL – coronary artery 3. PRINZMETAL – coronary artery spasm spasm

4. NOCTURNAL4. NOCTURNAL

5. DECUBITUS5. DECUBITUS

ISCHEMIA VS INFARCTIONISCHEMIA VS INFARCTION

ISCHEMIAISCHEMIA INFARCTIONINFARCTION

PAINPAIN SUBSTERNAL SUBSTERNAL PRESSURE/ PRESSURE/ HEAVINESSHEAVINESS

SQUEEZINGSQUEEZING

SUBSTERNALSUBSTERNAL

CONSTRICTIVE (+ SX CONSTRICTIVE (+ SX OF SHOCK)OF SHOCK)

DURATIONDURATION 3-5 MIN3-5 MIN > 5 MIN> 5 MIN

PRECIPITANTSPRECIPITANTS STRESS/ EXERTIONSTRESS/ EXERTION NONO

REST REST

NITROGLYCERINENITROGLYCERINERELIEVEDRELIEVED NOT RELIEVEDNOT RELIEVED

CARDIAC TISSUE CARDIAC TISSUE DAMAGEDAMAGE

NO PERMANENTNO PERMANENT PERMANENTPERMANENT

ANGINA PECTORISANGINA PECTORIS

DIAGNOSIS:DIAGNOSIS:Nitro Test 0.4mg Nitro Test 0.4mg

NURSING GOALS:NURSING GOALS:

1. 1. O2 to myocardiumO2 to myocardium

2. O2 demand2. O2 demand

3. Prevent future episodes of angina3. Prevent future episodes of angina

O2 to MyocardiumO2 to Myocardium::

AntiplateletsAntiplatelets

Calcium BlockersCalcium Blockers

Beta blockersBeta blockers

Whisky/BrandyWhisky/Brandy

Nitrates :Nitrates :RAPID-ACTING : RAPID-ACTING :

NitroglycerineNitroglycerine NitrostatNitrostat

AmylNitrateAmylNitrate

LONG-ACTING: LONG-ACTING: ISDN,ISMN,ISDN,ISMN,

Nitroglycerine Nitroglycerine ointment, ointment,

Transdermal, Transdermal, IVIV

O2 DemandO2 Demand

Limit activities – CBRLimit activities – CBR

Moderate ExerciseModerate Exercise

SedativesSedatives

WarmthWarmth

Prevent Future EpisodesPrevent Future Episodes DIET – low calorie, low saturated fatDIET – low calorie, low saturated fat

No tobaccoNo tobacco

Stress Reduction (Anger Stress Reduction (Anger Management)Management)

Coronary InsufficiencyCoronary Insufficiency

IMBALANCE BETWEEN :IMBALANCE BETWEEN :

OXYGEN SUPPLY OXYGEN SUPPLY

OXYGEN DEMANDOXYGEN DEMAND

MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTIONIRREVERSIBLE CARDIAC DAMAGE FROM OCCLUSION OF 1 OR IRREVERSIBLE CARDIAC DAMAGE FROM OCCLUSION OF 1 OR MORE CORONARY ARTERYMORE CORONARY ARTERY

REVIEW OF ANATOMY AND PHYSIOLOGYREVIEW OF ANATOMY AND PHYSIOLOGY

E.C.G.E.C.G.Recent M.I. – ST elevation (injury)Recent M.I. – ST elevation (injury)

T wave inversion (ischemia)T wave inversion (ischemia)Previous M.I. – Q wave (necrosis / old infarct)Previous M.I. – Q wave (necrosis / old infarct)

BLOOD STUDIESBLOOD STUDIESTroponin T & ITroponin T & ILDHLDHCPK MBCPK MB

P Q

R

S

T

E.C.G.

P Q

R

ST

E.C.G.

ST SEGMENTELEVATION

P Q

R

S

T

E.C.G.

INVERTEDT - WAVE

P

Q

R

S

T

E.C.G.

Q wave

MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTION

NURSING CARENURSING CARE1. Pain relief – 1. Pain relief –

Morphine ( + Morphine ( + preload & preload & afterload)afterload)

Demerol causes Demerol causes vomitingvomiting

2. Oxygen2. Oxygen

3. Inotropics3. Inotropics

4. Beta Blockers4. Beta Blockers

5. Antiarrhythmics5. Antiarrhythmics

6. No ice or very hot 6. No ice or very hot drinksdrinks

7. Anticoagulants7. Anticoagulants 8. ECG and CVP 8. ECG and CVP

monitoringmonitoring 9. Laxatives – 9. Laxatives –

LactuloseLactulose 10. PTCA10. PTCA 11. Thrombolytic 11. Thrombolytic

TherapyTherapyBEFORE CELLULAR BEFORE CELLULAR

DEATH, US. 6 HRS AFTER DEATH, US. 6 HRS AFTER THE ATTACKTHE ATTACK

CARDIAC ARRHYTHMIACARDIAC ARRHYTHMIA

Review Conduction PathwayReview Conduction Pathway

Review the Basics of Normal ECGReview the Basics of Normal ECG


RA LA

RV LV

- SA NODE

AV NODE-

BUNDLE OF HIS

BUNDLEBRANCH

PURKINJE

PURKINJE

P Q

R

S

T

E.C.G.


Sinus Tachycardia – Sinus Tachycardia – P wave precede each P wave precede each QRS >100 bpmQRS >100 bpm

Sinus Bradycardia – Sinus Bradycardia – P wave precede each P wave precede each QRS <60 bpmQRS <60 bpm

Atrial Fibrillation: Atrial Fibrillation: P wave = f waves; QRS = P wave = f waves; QRS = normalnormal

P Q

R

S

T

E.C.G.


RA LA

RV LV

- SA NODE

AV NODE-

BUNDLE OF HIS

BUNDLEBRANCH

PURKINJE

PURKINJE


Premature Ventricular Contraction: Premature Ventricular Contraction: P P wave normal: early QRSwave normal: early QRS

Ventricular Tachycardia : Ventricular Tachycardia : 3 or more PVCs3 or more PVCs

Asystole – Asystole – no cardiac activityno cardiac activity

P Q

R

S

T

E.C.G.


RA LA

RV LV

- SA NODE

AV NODE-

BUNDLE OF HIS

BUNDLEBRANCH

PURKINJE

PURKINJE


Nursing ManagementNursing Management– OxygenOxygen– Complete Bed RestComplete Bed Rest– Cardioversion/ defibrillationCardioversion/ defibrillation– Administer antiarrhythmics as prescribed:Administer antiarrhythmics as prescribed:

AtropineAtropine Beta blocker- propanololBeta blocker- propanolol LidocaineLidocaine Epinephrine Epinephrine

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE Review of Anatomy and PhysiologyReview of Anatomy and Physiology

Backward Failure Backward Failure Forward FailureForward Failure Left-SidedLeft-Sided Right SidedRight Sided Hypermetabolic FailureHypermetabolic Failure Clinical Manifestations according to:Clinical Manifestations according to:

– Tissue AnoxiaTissue Anoxia– Pulmonary HypertensionPulmonary Hypertension– Systemic congestionSystemic congestion

C.H.F.C.H.F.

RA

RV

LUNGS

LA

LV

SYSTEMICCIRCULATION

SYSTEMICCIRCULATION

LUNGS

SYSTEMICCIRCULATION

LV

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE Review of Anatomy and PhysiologyReview of Anatomy and Physiology

Backward Failure Backward Failure Forward FailureForward Failure Left-SidedLeft-Sided Right SidedRight Sided Hypermetabolic FailureHypermetabolic Failure Clinical Manifestations according to:Clinical Manifestations according to:

– Tissue AnoxiaTissue Anoxia– Pulmonary HypertensionPulmonary Hypertension– Systemic congestionSystemic congestion

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE DiagnosticsDiagnostics

Nursing Management Nursing Management – Goals :Goals :

1.1. CARDIAC LOADCARDIAC LOAD – REST AND SEDATIONREST AND SEDATION

2. 2. CARDIAC CONTRACTILITYCARDIAC CONTRACTILITY– CHRONOTROPICS – CHRONOTROPICS – DIGITALIS DIGITALIS

– Increase in force of contraction Increase in force of contraction – monitor serum K, monitor serum K, – C/I if HR </= 60 bpm,C/I if HR </= 60 bpm,– DIGITALIS TOXICITYDIGITALIS TOXICITY

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

3.3. SODIUM REABSORPTION AND FLUID SODIUM REABSORPTION AND FLUID RETENTION RETENTION

--DIURETICS ( Thiazide, Loop, K-sparing)DIURETICS ( Thiazide, Loop, K-sparing) -measure UO-measure UO

-weigh patient-weigh patient-watch for s/sx of electrolyte imbalance-watch for s/sx of electrolyte imbalance--DIET : DIET : Sodium Restricted (0.5gm/day)Sodium Restricted (0.5gm/day)

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

4.4. PREVENTION OF COMPLICATIONS:PREVENTION OF COMPLICATIONS:– Intractable HFIntractable HF– Pulmonary edemaPulmonary edema– Pulmonary InfarctionPulmonary Infarction– Myocardial InfarctionMyocardial Infarction– Digitalis ToxicityDigitalis Toxicity– Cardiac ArrhythmiaCardiac Arrhythmia– PneumoniaPneumonia

PULMONARY EDEMAPULMONARY EDEMA Emergency!Emergency! Fluid into the alveoli, bronchi & Fluid into the alveoli, bronchi &

bronchiolesbronchioles

S/SX:S/SX: ……of CHFof CHF DyspneaDyspnea Cough with pink frothy sputumCough with pink frothy sputum

PULMONARY EDEMAPULMONARY EDEMA MANAGEMENT:MANAGEMENT:

– OxygenationOxygenation

– Assist in Intubation Assist in Intubation

– Rotating tourniquetRotating tourniquet

– PhlebotomyPhlebotomy

– CVP monitoringCVP monitoring

HYPERTENSIONHYPERTENSION

IN SYSTOLIC PRESSURE >140IN SYSTOLIC PRESSURE >140 IN DIASTOLIC PRESSURE > 90IN DIASTOLIC PRESSURE > 90

CLASSIFICATION : CLASSIFICATION : – PRIMARY PRIMARY

BENIGN- GRADUAL BENIGN- GRADUAL MALIGNANT -ABRUPT ONSET ;SHORT COURSE MALIGNANT -ABRUPT ONSET ;SHORT COURSE

– SECONDARY: SECONDARY: Renal patho, Adrenal patho, Renal patho, Adrenal patho, GeneticsGenetics


CATEGORYCATEGORY SBP mmHgSBP mmHg DBP mmHgDBP mmHg

NormalNormal <120 and<120 and <180<180

PreHPNPreHPN 120-139 or120-139 or 80-8980-89

HPN, Stage 1HPN, Stage 1 140-159 or140-159 or 90-9990-99

HPN, Stage 2HPN, Stage 2 >=160 or>=160 or >=100>=100

HYPERTENSIONHYPERTENSION Assess for Major CVD Risk FactorsAssess for Major CVD Risk Factors Assess for Identifiable Causes of Assess for Identifiable Causes of

Hypertension:Hypertension:– Sleep apneaSleep apnea– Drug-Induced relatedDrug-Induced related– Chronic Kidney DiseaseChronic Kidney Disease– Primary AldosteronismPrimary Aldosteronism– Renovascular DiseaseRenovascular Disease– Cushing’s Syndrome/steroid TherapyCushing’s Syndrome/steroid Therapy– PheochromocytomaPheochromocytoma– Coarctation of the AortaCoarctation of the Aorta


DiagnosticsDiagnostics Nursing Care : Nursing Care :

– Teach about: modification of Lifestyle, Teach about: modification of Lifestyle, diet, avoidance of stimulants and coffeediet, avoidance of stimulants and coffee

– Administer meds as prescribed: Administer meds as prescribed: ANTIHYPERTENSIVES AND DIURETICSANTIHYPERTENSIVES AND DIURETICS

– Hypertensive Crisis : Hypertensive Crisis : DIAZOXIDE (Hyperstat), DIAZOXIDE (Hyperstat), NaNITROPRUSSIDE (Nipride)NaNITROPRUSSIDE (Nipride)

PERIPHERAL VASCULAR PERIPHERAL VASCULAR DISEASEDISEASE

ISCHEMIA OF THE PERIPHERAL VESSELSISCHEMIA OF THE PERIPHERAL VESSELS Review of Peripheral Vascular Review of Peripheral Vascular

StructuresStructures Signs and Symptoms of IschemiaSigns and Symptoms of Ischemia

– ColdnessColdness– PallorPallor– RuborRubor– CyanosisCyanosis– Pain ( Intermittent Claudication)Pain ( Intermittent Claudication)

ISCHEMIA OF THE PERIPHERAL ISCHEMIA OF THE PERIPHERAL VESSELSVESSELS

Nursing ManagementNursing Management1.1. Increase Arterial Blood Flow or Increase Arterial Blood Flow or

Venous returnVenous return

2.2. Promote VasodilationPromote Vasodilation

3.3. Prevent and Treat Vascular Prevent and Treat Vascular OcclusionOcclusion

Increase Arterial Blood Flow Increase Arterial Blood Flow or Venous returnor Venous return

Proper positioningProper positioning

ExerciseExercise Short walksShort walks Buerger Allen Routine Buerger Allen Routine Oscillating BedOscillating Bed Circoelectric BedCircoelectric Bed

Buerger Allen RoutineBuerger Allen Routine

1. FEET UP , 3 MIN 1. FEET UP , 3 MIN

2. SIT ON BED & DO FOOT EXERCISE,3 MIN2. SIT ON BED & DO FOOT EXERCISE,3 MIN

3. LIE DOWN 5 MIN3. LIE DOWN 5 MIN

Increase Arterial Blood Flow Increase Arterial Blood Flow or Venous returnor Venous return

Patient educationPatient education

Decrease wieghtDecrease wieght

Avoid prolonged standingAvoid prolonged standing

Never wear constricting garmentsNever wear constricting garments

Never cross legsNever cross legs

Promote VasodilationPromote Vasodilation

– WarmthWarmth

– No nicotineNo nicotine

– Vasodilators : papaverine HCl, vasodilanVasodilators : papaverine HCl, vasodilan

– Moderate alcoholModerate alcohol

– sympathectomysympathectomy

Prevent and Treat Vascular Prevent and Treat Vascular OcclusionOcclusion

- - avoid prolonged bedrestavoid prolonged bedrest

-increase fluids-increase fluids

-proper positions-proper positions

-anticoagulant therapy & fibrinolytics-anticoagulant therapy & fibrinolyticsHeparin - Heparin - APTT- Protamine SO4APTT- Protamine SO4

Dicumarol- Dicumarol- PT - Vit KPT - Vit K

ARTERIAL DISEASEARTERIAL DISEASE ARTERIOSCLEROSIS OBLITERANSARTERIOSCLEROSIS OBLITERANS

– – LATE STAGE OF ATHEROSCLEROSIS WITH PARTIAL OR LATE STAGE OF ATHEROSCLEROSIS WITH PARTIAL OR COMPLETE OCCLUSION BY ATHEROMA WITH THROMBOSISCOMPLETE OCCLUSION BY ATHEROMA WITH THROMBOSIS

RAYNAUD’S DISEASE – RAYNAUD’S DISEASE – PERIODIC SPASM OF PERIODIC SPASM OF THE ARTERIESTHE ARTERIES

ANEURYSMS – ANEURYSMS – LOCALIZED OR DIFFUSED ARTERIAL LOCALIZED OR DIFFUSED ARTERIAL DILATIONDILATION

EMBOLUS/THROMBUSEMBOLUS/THROMBUS

VENOUS DISEASEVENOUS DISEASE THROMBOPHLEBITISTHROMBOPHLEBITIS – –

– INFLAMMATION OF THE VEIN WITH CLOT FORMATIONINFLAMMATION OF THE VEIN WITH CLOT FORMATION– HOMAN’S SIGNHOMAN’S SIGN

PHLEBOTHROMBOSISPHLEBOTHROMBOSIS– CLOTS WITHOUT INFLAMMATIONCLOTS WITHOUT INFLAMMATION

VARICOSE VEINSVARICOSE VEINS– TRENDELENBERG’S TEST – NORMAL VEIN FILLS FROM BELOWTRENDELENBERG’S TEST – NORMAL VEIN FILLS FROM BELOW

DISEASE OF ARTERIES AND DISEASE OF ARTERIES AND VEINSVEINS

BUERGER’S DSE / Thromboangitis BUERGER’S DSE / Thromboangitis ObliteransObliterans– RECURRING INFLAMMATION OF ARTERIES & VEINSRECURRING INFLAMMATION OF ARTERIES & VEINS– SMOKINGSMOKING– INTERMITTENT CLAUDICATIONINTERMITTENT CLAUDICATION

A-V FISTULAA-V FISTULA– ABN COMMUNICATION BETWEEN A. & V.ABN COMMUNICATION BETWEEN A. & V.– TRAUMATIC/ CONGENITALTRAUMATIC/ CONGENITAL– BRUITBRUIT

NURSING CARE OF PATIENTS NURSING CARE OF PATIENTS WITH AMPUTATIONWITH AMPUTATION

1.1. Control Bleeding – BandageControl Bleeding – Bandage

2.2. Prevent Edema – elevate 1Prevent Edema – elevate 1stst 24 hrs 24 hrs

3.3. Relieving Phantom Limb Pain – Relieving Phantom Limb Pain – hypnosis, destructionhypnosis, destruction

4.4. Assume Body Alignment – Prone 30 Assume Body Alignment – Prone 30 min 2x a day to prevent flexion min 2x a day to prevent flexion contracture ; AKA –contracture ; AKA –HIP FLEXION AND HIP FLEXION AND

ABDUCTION, EXTERNAL ROTATION ABDUCTION, EXTERNAL ROTATION BKA – BKA – KNEE KNEE FLEXIONFLEXION

NURSING CARE OF PATIENTS NURSING CARE OF PATIENTS WITH AMPUTATIONWITH AMPUTATION

Trochanter roll against the hip along Trochanter roll against the hip along the outer side to prevent outward the outer side to prevent outward rotation rotation

5.5. Preparing for LocomotionPreparing for Locomotion– Stump care : wash with soap and water Stump care : wash with soap and water

onlyonly– Exercise : quad setting, isometricExercise : quad setting, isometric– Crutch walking : weight- palms, stairs : Crutch walking : weight- palms, stairs :

GOOD LEG FIRST TO HEAVEN; BAD LEG FIRST TO HELLGOOD LEG FIRST TO HEAVEN; BAD LEG FIRST TO HELL

The acute nursing management of a The acute nursing management of a client with CHF will include all of the client with CHF will include all of the following goals following goals except:except:

a.a. Increase in cardiac outputIncrease in cardiac output

b.b. Elevation in renal blood flowElevation in renal blood flow

c.c. Reduction in the heart’s workloadReduction in the heart’s workload

d.d. Decrease in myocardial contractilityDecrease in myocardial contractility

REVIEW OF ANATOMY AND REVIEW OF ANATOMY AND PHYSIOLOGY – Blood and PHYSIOLOGY – Blood and

LymphaticsLymphatics Composition of the bloodComposition of the blood

RBC, WBC, Platelets, PlasmaRBC, WBC, Platelets, Plasma RBC RBC

normal erythropoeisis requires : normal erythropoeisis requires : pyridoxine, Vit B12, pyridoxine, Vit B12, folic acid, protein, copper, cobalt;folic acid, protein, copper, cobalt;

HEMOBGLOBIN : HEMOBGLOBIN : Iron; Oxygen transport; Acid-base Iron; Oxygen transport; Acid-base bufferbuffer

WBC WBC granulocytes –neutrophils, eosinophils, basophilsgranulocytes –neutrophils, eosinophils, basophils agaranulocytes –lymphocytes (T,B), monocytesagaranulocytes –lymphocytes (T,B), monocytes

Plasma Plasma albumin, water, clotting factors, antibodiesalbumin, water, clotting factors, antibodies

REVIEW OF ANATOMY AND REVIEW OF ANATOMY AND PHYSIOLOGY – Blood and PHYSIOLOGY – Blood and

LymphaticsLymphatics Role of the Bone MarrowRole of the Bone Marrow

– Production of all blood componentsProduction of all blood components Major Roles of the Blood Major Roles of the Blood

– homeostasis homeostasis – transport of nutrients and electrolytes transport of nutrients and electrolytes – distribute hormones and electrolytesdistribute hormones and electrolytes

Major Role of Lymphatics Major Role of Lymphatics – brings back blood to the circulation brings back blood to the circulation – immune antibody productionimmune antibody production

HEMATOLOGIC HEMATOLOGIC DISTURBANCESDISTURBANCES

DISORDERS OF THE BLOODDISORDERS OF THE BLOOD– RBCRBC : : IDA, PERNICIOUS ANEMIA, APLASTIC ANEMIA, IDA, PERNICIOUS ANEMIA, APLASTIC ANEMIA,

HEMOLYTIC ANEMIA, POLYCYTHEMIA VERAHEMOLYTIC ANEMIA, POLYCYTHEMIA VERA

– WBC and Plasma CellWBC and Plasma Cell : LEUKEMIA, MULTIPLE : LEUKEMIA, MULTIPLE MYELOMAMYELOMA

– Lymph Nodes and SpleenLymph Nodes and Spleen : : LYMPHOMA, LYMPHOMA, INFECTIOUS MONONUCLEOSIS, SPLENIC RUPTURE, INFECTIOUS MONONUCLEOSIS, SPLENIC RUPTURE, HYPERSPLENISMHYPERSPLENISM

– Hemorrhagic DisordersHemorrhagic Disorders : : PURPURA PURPURA

– Altered CoagulationAltered Coagulation : : HEMOPHILIA, HEMOPHILIA, HYPOPROTHROMBINEMIA, D.I.C.HYPOPROTHROMBINEMIA, D.I.C.


RBCRBC : : IDAIDA PERNICIOUS ANEMIA PERNICIOUS ANEMIA APLASTIC ANEMIAAPLASTIC ANEMIA HEMOLYTIC ANEMIAHEMOLYTIC ANEMIA POLYCYTHEMIA VERAPOLYCYTHEMIA VERA

NUTRITIONAL ANEMIANUTRITIONAL ANEMIA

IRON DEFICIENCY ANEMIAIRON DEFICIENCY ANEMIA

PERNICIOUS ANEMIAPERNICIOUS ANEMIA


Composition of the bloodComposition of the blood RBC, WBC, Platelets, PlasmaRBC, WBC, Platelets, Plasma

RBC RBC normal erythropoeisis requires : normal erythropoeisis requires : pyridoxine, Vit B12, pyridoxine, Vit B12,

folic acid, protein, copper, cobalt;folic acid, protein, copper, cobalt;

HEMOBGLOBIN : HEMOBGLOBIN : IRONIRON; Oxygen transport; ; Oxygen transport; Acid-base bufferAcid-base buffer

WBC WBC granulocytes –neutrophils, eosinophils, basophilsgranulocytes –neutrophils, eosinophils, basophils agaranulocytes –lymphocytes (T,B), monocytesagaranulocytes –lymphocytes (T,B), monocytes


IRON DEFICIENCY ANEMIAIRON DEFICIENCY ANEMIA HEMOGLOBIN LEVEL FALLS BELOW NORMALHEMOGLOBIN LEVEL FALLS BELOW NORMAL

CAUSES:CAUSES:

1.1. Poor intake if iron rich foodsPoor intake if iron rich foods

2.2. Poor absorption & utilization of iron Poor absorption & utilization of iron from foodsfrom foods

3.3. Acute / chronic blood lossAcute / chronic blood loss

Poor intake if iron rich foodsPoor intake if iron rich foods

increased requirement : increased requirement : – infants after 6 mos, infants after 6 mos, – children & adolescents children & adolescents – women of reproductive age women of reproductive age – pregnant & nursing women pregnant & nursing women

Erroneous food practices Erroneous food practices Respiratory & GI conditions Respiratory & GI conditions Substandard living conditionSubstandard living condition


CAUSES:CAUSES:



3.3. Acute / chronic blood lossAcute / chronic blood loss

Poor absorption & utilization of Poor absorption & utilization of iron from foodsiron from foods

Form of Iron- Form of Iron- hemosiderin: from animal foodhemosiderin: from animal food

more readily absorbed more readily absorbed than than from plants from plants (nonheme iron)(nonheme iron)

Effects of other foods Effects of other foods – inhibit absorption of iron:inhibit absorption of iron:

tea, unpolished rice, veges: bulaklak ng tea, unpolished rice, veges: bulaklak ng kalabasa, sampalok, mustasakalabasa, sampalok, mustasa

Poor absorption & utilization of Poor absorption & utilization of iron from foodsiron from foods

Host factors : Host factors :

– poor iron absorption in:poor iron absorption in: severe protein-energy malnutrition & severe protein-energy malnutrition &

repeated diarrhea repeated diarrhea Infections Infections Delibitating diseaseDelibitating disease


CAUSES:CAUSES:



3.3. Acute / Chronic blood lossAcute / Chronic blood loss

Acute / Chronic blood lossAcute / Chronic blood loss

Acute hemorrhageAcute hemorrhage Chronic or repeated Blood loss:Chronic or repeated Blood loss:

– WHIPWORMWHIPWORM 0.005 ML OF BLOOD PER WORM PER DAY0.005 ML OF BLOOD PER WORM PER DAY

– HOOKWORMHOOKWORM 0.2 ML OF BLOOD PER WORM PER DAY0.2 ML OF BLOOD PER WORM PER DAY

– SCHISTOSOMIASISSCHISTOSOMIASIS– MALARIAMALARIA– PEPTIC ULCERPEPTIC ULCER– EXCESSIVE MENSTRUAL FLOWEXCESSIVE MENSTRUAL FLOW

IRON DEFICIENCY ANEMIAIRON DEFICIENCY ANEMIACLINICAL FEATURES:CLINICAL FEATURES: Asymptomatic Asymptomatic

– inability to respond to increased iron demandinability to respond to increased iron demand

Normal Hgb levels but with s/sx :Normal Hgb levels but with s/sx :– lack of energy, fatiguability, reduced power lack of energy, fatiguability, reduced power

and concentrationand concentration

Severe anemia : Severe anemia : – difficulty in breathing, difficulty in breathing, – palpitation, palpitation, – headache, headache, – faintness faintness – loss of appetiteloss of appetite


ASSESSMENT:ASSESSMENT: Lab: Lab:

DECREASED HEMOGLOBIN & HEMATOCRIT DECREASED HEMOGLOBIN & HEMATOCRIT LEVELLEVEL

MICROCYTIC, HYPOCHROMIC RBCMICROCYTIC, HYPOCHROMIC RBCDECREASED RETICULOCYTE COUNTDECREASED RETICULOCYTE COUNT

Clinical MethodClinical MethodHISTORYHISTORYCLINICAL EXAMINATION - PALLORCLINICAL EXAMINATION - PALLOR


TREATMENT:TREATMENT:

IRON ADMINISTRATION:IRON ADMINISTRATION: ORAL ORAL

– ADULT : 100-120 mg/day ADULT : 100-120 mg/day – INFANTS AND CHILDREN : 3mg/kg/dayINFANTS AND CHILDREN : 3mg/kg/day

PARENTERAL IRON DEXTRAN PARENTERAL IRON DEXTRAN – IM :IM :250 MG FOR EACH gm% LOWER THAN THE 250 MG FOR EACH gm% LOWER THAN THE

NORMAL VALUENORMAL VALUE

– IV: IV: 100-300 mg in 500ml SALINE SOLUTION100-300 mg in 500ml SALINE SOLUTION

ORAL IRON ORAL IRON ADMINISTRATIONADMINISTRATION

ABSORPTION :ABSORPTION : GREATEST DURING THE FIRST MONTH OF TX, GREATEST DURING THE FIRST MONTH OF TX,

AND DECREASES WHEN IRON STORES ARE INCREASINGAND DECREASES WHEN IRON STORES ARE INCREASING EMPTY STOMACH: EMPTY STOMACH: GOOD ABSORPTION, MORE G.I. S/EGOOD ABSORPTION, MORE G.I. S/E

ADMINISTER DURING OR PCADMINISTER DURING OR PC ASCORBIC ACID ASCORBIC ACID BETTER ABSORBED IN FERROUS BETTER ABSORBED IN FERROUS THAN IN FERRIC THAN IN FERRIC

FORMFORM FERROUS SULFATE FERROUS SULFATE IS THE CHEAPEST AND READILY IS THE CHEAPEST AND READILY

ABSORBABLE FORMABSORBABLE FORM DOSE: DOSE: CALCULATE THE ELEMENTAL IRONCALCULATE THE ELEMENTAL IRON

– FERROUS SULFATE HAS 36.74% ELEMENTAL IRONFERROUS SULFATE HAS 36.74% ELEMENTAL IRON

ORAL IRON ORAL IRON ADMINISTRATIONADMINISTRATION

DURATION:DURATION: 2 MOS, 2 MOS, ANEMIA IS ALREADY ALLEVIATEDANEMIA IS ALREADY ALLEVIATED

5 MOS, 5 MOS, FOR IRON STORESFOR IRON STORES

PREGNANT : PREGNANT : 2424THTH WK TO TERM WK TO TERM

SIDE EFFECTS:SIDE EFFECTS: CONSTIPATION/DIARRHEACONSTIPATION/DIARRHEA NAUSEANAUSEA EPIGASTRIC PAIN / HEART BURNEPIGASTRIC PAIN / HEART BURN

PARENTERAL IRON PARENTERAL IRON ADMINISTRATIONADMINISTRATION

INDICATIONS:INDICATIONS: SEVERE DEFICIENCYSEVERE DEFICIENCY ORAL PREPARATIONS FAILORAL PREPARATIONS FAIL CONDITION DO NOT PERMIT ORAL CONDITION DO NOT PERMIT ORAL

ADMINISTRATIONADMINISTRATION

ABSORPTION:ABSORPTION: RAPIDRAPID

THERAPEUTIC RESPONSETHERAPEUTIC RESPONSE SAME WITH ORALSAME WITH ORAL


ADVANTAGE:ADVANTAGE: S/E ARE AVOIDEDS/E ARE AVOIDED PROBLEMS WITH ABSORPTION IS PROBLEMS WITH ABSORPTION IS

AVOIDEDAVOIDED

DISADVANTAGE:DISADVANTAGE: COSTLYCOSTLY TOXICITY IS POSSIBLETOXICITY IS POSSIBLE ALLERGIC REACTIONALLERGIC REACTION


PRECAUTION:PRECAUTION: GIVEN UNDER CLOSE SUPERVISION GIVEN UNDER CLOSE SUPERVISION

BY PHYSICIANBY PHYSICIAN Z-TRACK METHOD Z-TRACK METHOD TISSUE STAINING & IRRITATIONTISSUE STAINING & IRRITATION

IRON TOXICITYIRON TOXICITY

VERY RARE IN ORALVERY RARE IN ORAL SIDEROSIS SIDEROSIS

– HEMOSIDERIN IN TISSUESHEMOSIDERIN IN TISSUES HEMOCHROMATOSIS HEMOCHROMATOSIS

– END POINT OF SIDEROSIS, END POINT OF SIDEROSIS, – DAMAGE TO LIVER AND PANCREASDAMAGE TO LIVER AND PANCREAS

PREVENTION: PREVENTION: – ADMIN IN DIVIDED DOSES ADMIN IN DIVIDED DOSES – KEEP OUT OF CHILDREN’S REACHKEEP OUT OF CHILDREN’S REACH

MEASURES TO MINIMIZE MEASURES TO MINIMIZE IRON REQUIREMENTSIRON REQUIREMENTS

PARASITE CONTROLPARASITE CONTROL– ADMINISTER MEDS FOR PARASITISMADMINISTER MEDS FOR PARASITISM– MINIMIZE RISK OF REINFESTATION:MINIMIZE RISK OF REINFESTATION:

REGULAR DEWORMING – EVERY 4-6 MOSREGULAR DEWORMING – EVERY 4-6 MOS FOOTWEARFOOTWEAR PROPER USE OF LATRINEPROPER USE OF LATRINE

FAMILY PLANNINGFAMILY PLANNING– DECREASE THE # OF PREGNANCIES AND DELIVERIESDECREASE THE # OF PREGNANCIES AND DELIVERIES– IUD – INCREASED MENSTRUAL LOSSESIUD – INCREASED MENSTRUAL LOSSES

POST-DELIVERY MEASURESPOST-DELIVERY MEASURES– LATCH ON – OXYTOCIN RELEASELATCH ON – OXYTOCIN RELEASE– CUT THE CORD AFTER PULSATION STOPSCUT THE CORD AFTER PULSATION STOPS

MEASURES TO DIRECTLY MEASURES TO DIRECTLY AUGMENT IRON STORESAUGMENT IRON STORES

SUPLEMENTATIONSUPLEMENTATION– PREGNANT 24 WKS TO TERMPREGNANT 24 WKS TO TERM– NURSING MOTHERSNURSING MOTHERS– MALNOURISHED INFANTS & MALNOURISHED INFANTS &

PRESCHOOLERSPRESCHOOLERS– PRETERM INFANTSPRETERM INFANTS

FORTIFICATIONFORTIFICATION

EDUCATIONEDUCATION

Burger King guest

PERNICIOUS ANEMIAPERNICIOUS ANEMIAREVIEW OF ANATOMY & PHYSIOLOGY : REVIEW OF ANATOMY & PHYSIOLOGY :

STOMACHSTOMACH Stores and mixes food with gastric juices & Stores and mixes food with gastric juices &

mucus producing chemical & mechanical mucus producing chemical & mechanical changes in the bolus of foodchanges in the bolus of food

Sphincters: cardiac and pyloricSphincters: cardiac and pyloric Divisions: fundus, body, antrumDivisions: fundus, body, antrum Secretions:Secretions:

– Pepsinogen : by chief cellsPepsinogen : by chief cells– HCl:HCl: by parietal cells by parietal cells

– Intrinsic factor : by parietal Intrinsic factor : by parietal cellscells

– mucoidmucoid

PERNICIOUS ANEMIAPERNICIOUS ANEMIA Composition of the bloodComposition of the blood

RBC, WBC, Platelets, PlasmaRBC, WBC, Platelets, Plasma

RBC RBC normal erythropoeisis requiresnormal erythropoeisis requires : : pyridoxine, pyridoxine,

Vitamin B12Vitamin B12, , folic acid, protein, copper, cobalt; folic acid, protein, copper, cobalt; HEMOBGLOBIN : Iron; Oxygen transport; Acid-base HEMOBGLOBIN : Iron; Oxygen transport; Acid-base

bufferbuffer WBC WBC

granulocytes –neutrophils, eosinophils, basophilsgranulocytes –neutrophils, eosinophils, basophils agaranulocytes –lymphocytes (T,B), monocytesagaranulocytes –lymphocytes (T,B), monocytes


PERNICIOUS ANEMIAPERNICIOUS ANEMIANo INTRINSIC FACTORNo INTRINSIC FACTOR

VIT B 12 cannot be absorbedVIT B 12 cannot be absorbed

Alteration in DNA synthesis Alteration in DNA synthesis needed for cell divisionneeded for cell division

Delayed cellular division, altered nuclear pattern Delayed cellular division, altered nuclear pattern

MEGALOBLASTMEGALOBLAST

Ineffective erythropoeisisIneffective erythropoeisis : increased : increased serum bilirubin & urobilinogen excretionserum bilirubin & urobilinogen excretion


OTHER TISSUES AFFECTED BY VIT B12 OTHER TISSUES AFFECTED BY VIT B12 DEFICIENCY:DEFICIENCY:

MOUTHMOUTH STOMACHSTOMACH VAGINAVAGINA MYELIN SHEATHMYELIN SHEATH

PERNICIOUS ANEMIAPERNICIOUS ANEMIAS/SX:S/SX: WEAKNESS, FATIGUE, PALLOR, WEAKNESS, FATIGUE, PALLOR,

JAUNDICEJAUNDICE SORE MOUTH, SMOOTH BEEFY SORE MOUTH, SMOOTH BEEFY

TONGUETONGUE ATROPHY OF THE GASTRIC MUCOSAATROPHY OF THE GASTRIC MUCOSA PERIPHERAL NERVE DEGENERATION : PERIPHERAL NERVE DEGENERATION :

TINGLING, NUMBNESS OF HANDS AND TINGLING, NUMBNESS OF HANDS AND FEETFEET

LOSS OF COORDINATION, LOSS OF COORDINATION, +ROMBERG’S+ROMBERG’S


DIAGNOSIS:DIAGNOSIS:

PERIPHERAL SMEAR : PERIPHERAL SMEAR : MACROCYTIC MACROCYTIC CELLSCELLS

(+) ROMBERG’S(+) ROMBERG’S GASTRIC ANALYSIS GASTRIC ANALYSIS

– (diagnex blue test) – (diagnex blue test) – ACHLORHYDRIA from ACHLORHYDRIA from thinning of mucosa – HCl is also produced by thinning of mucosa – HCl is also produced by parietal cells of the stomachparietal cells of the stomach

SCHILLING’S TESTSCHILLING’S TEST – – B12 IN 24 HRS B12 IN 24 HRS URINE SPECURINE SPEC

SCHILLING’S TESTSCHILLING’S TEST DEFINITIVE TEST DEFINITIVE TEST FOR PERNICIOUS ANEMIAFOR PERNICIOUS ANEMIA

DETECT DETECT LACK OFLACK OF INTRINSIC FACTOR INTRINSIC FACTOR

MEASURES ABSORPTION MEASURES ABSORPTION OF OF RADIOACTIVE RADIOACTIVE VIT B12 VIT B12 BOTH BEFORE & AFTER PARENTERAL BOTH BEFORE & AFTER PARENTERAL

ADMINISTRATION OFADMINISTRATION OF INTRINSIC FACTOR INTRINSIC FACTOR

FASTINGFASTING CLIENT IS GIVEN CLIENT IS GIVEN RADIOACTIVE VIT RADIOACTIVE VIT B12 BY MOUTH AND NONRADIOACTIVE VIT B12 BY MOUTH AND NONRADIOACTIVE VIT B12 IMB12 IM

SCHILLING’S TESTSCHILLING’S TEST

24-48 HR URINE 24-48 HR URINE OBTAINED & TESTED FOROBTAINED & TESTED FOR VIT B 12VIT B 12

AFTERAFTER 1 WK, FASTING CLIENT IS GIVEN 1 WK, FASTING CLIENT IS GIVEN RADIOACTIVE VIT B 12 RADIOACTIVE VIT B 12 ORALLY WITH ORALLY WITH

PARENTERALPARENTERAL HUMAN INTRINSIC FACTOR HUMAN INTRINSIC FACTOR

URINE TEST URINE TEST IS REPEATEDIS REPEATED

PERNICIOUS ANEMIAPERNICIOUS ANEMIAMANAGEMENT:MANAGEMENT: NO CURE; NO CURE; VIT B12 IM FOR LIFEVIT B12 IM FOR LIFE

DIET: DIET: MEAT & DAIRYMEAT & DAIRY

HCL : HCL : – 11STST WK; WK; – DILUTE WITH WATER; DILUTE WITH WATER; – ADMINISTER WITH STRAWADMINISTER WITH STRAW

AVOID SEASONED FOODSAVOID SEASONED FOODS


MANAGEMENT:MANAGEMENT:

MOUTH CARE: MOUTH CARE: SOFT TOOTHBRUSHSOFT TOOTHBRUSH

AVOID HEATING PADS – AVOID HEATING PADS – DECREASE IN DECREASE IN SENSATIONSENSATION

AFTER 2-3 DAYS TX, AFTER 2-3 DAYS TX, INCREASE IN INCREASE IN RETICULOCYTE COUNTRETICULOCYTE COUNT

REHAB & PT FOR NEURODEFICITSREHAB & PT FOR NEURODEFICITS

APLASTIC ANEMIAAPLASTIC ANEMIA

DEPRESSION OF ALL BLOOD FORMING ELEMENTS DEPRESSION OF ALL BLOOD FORMING ELEMENTS FROM BONE MARROW DESTRUCTIONFROM BONE MARROW DESTRUCTION

IDIOPATHIC IDIOPATHIC

SECONDARYSECONDARY


CAUSE:CAUSE:

ANTINEOPLASTIC DRUGS & RADIATIONANTINEOPLASTIC DRUGS & RADIATION IMMUNOSUPPRESIVE DRUGSIMMUNOSUPPRESIVE DRUGS CHLORAMPHENICOLCHLORAMPHENICOL SULFONAMIDESSULFONAMIDES TOXIC SUBSTANCES: TOXIC SUBSTANCES: BENZENE ,DDT, THIAZIDE, BENZENE ,DDT, THIAZIDE,

DIURETICS GOLDDIURETICS GOLD


ASSESSMENTASSESSMENT::

S/SX OF ANEMIAS/SX OF ANEMIA INCREASED SUSCEPTIBILITY TO INCREASED SUSCEPTIBILITY TO

INFECTIONINFECTION BLEEDING TENDENCIES & BLEEDING TENDENCIES &

HEMORRHAGEHEMORRHAGE


LAB:LAB: NORMOCYTIC ANEMIANORMOCYTIC ANEMIA GRANULOCYTOPENIAGRANULOCYTOPENIA THROMBOCYTOPENIATHROMBOCYTOPENIA

BONE MARROW BIOPSY:BONE MARROW BIOPSY: FATTYFATTY VERY FEW DEVELOPING CELLSVERY FEW DEVELOPING CELLS

HEMOLYTIC ANEMIAHEMOLYTIC ANEMIA EXCESSIVE RBC DESTRUCTIONEXCESSIVE RBC DESTRUCTION

CAUSES:CAUSES:

ACQUIREDACQUIRED– SNAKE VENOMSNAKE VENOM– BURNSBURNS– BT BT

INCOMPATIBILITYINCOMPATIBILITY– MALARIAMALARIA– TOXOPLASMOSISTOXOPLASMOSIS

CONGENITALCONGENITAL– HEREDITARY HEREDITARY

SPHEROCYTOSISSPHEROCYTOSIS– G6PD G6PD

DEFICIENCYDEFICIENCY– THALASSEMIATHALASSEMIA– SICKLE CELLSICKLE CELL

POLYCYTHEMIA POLYCYTHEMIA

INCREASE IN CIRCULATING BLOOD CELLS IN THE INCREASE IN CIRCULATING BLOOD CELLS IN THE BLOOD DUE TOBLOOD DUE TO BONE MARROW BONE MARROW OVERGROWTHOVERGROWTH

FORMS: FORMS: POLYCYTHEMIA VERA POLYCYTHEMIA VERA SECONDARY POLYCYTHEMIA SECONDARY POLYCYTHEMIA RELATIVE POLYCYTHEMIARELATIVE POLYCYTHEMIA

POLYCYTHEMIAPOLYCYTHEMIA

ASSESSMENTASSESSMENT:: RUDDY COMPLEXIONRUDDY COMPLEXION HYPERTENSIONHYPERTENSION SYMPTOMS OF CHFSYMPTOMS OF CHF THROMBUS FORMATIONTHROMBUS FORMATION BLEEDINGBLEEDING HEPATOSPLENOMEGALYHEPATOSPLENOMEGALY GOUTGOUT

PHLEBOTOMYPHLEBOTOMY

CLINICAL CARE OF PATIENTS CLINICAL CARE OF PATIENTS WITH ANEMIAWITH ANEMIA

RESTREST SKIN CARE SKIN CARE

– DECUBITUS ULCER FROM CELL HYPOXIADECUBITUS ULCER FROM CELL HYPOXIA DIET DIET

– 6 SMALL EASILY DIGESTIBLE MEALS6 SMALL EASILY DIGESTIBLE MEALS– NO HOT & SPICY FOODSNO HOT & SPICY FOODS

MOUTH CAREMOUTH CARE TRANSFUSION NOT A ROUTINETRANSFUSION NOT A ROUTINE OXYGENOXYGEN

CLINICAL CARE OF PATIENTS CLINICAL CARE OF PATIENTS WITH ANEMIAWITH ANEMIA

PROTECTION FROM INJURYPROTECTION FROM INJURY– BURNS and CHILLINGBURNS and CHILLING

ISLOLATION BY:ISLOLATION BY:– REVERSE ISOLATIONREVERSE ISOLATION– LIFE ISLAND- BED ENCLOSED IN PLASTIC LIFE ISLAND- BED ENCLOSED IN PLASTIC

CANOPYCANOPY– LAMIANR AIRFLOW LIMIT – UNIT WITH LAMIANR AIRFLOW LIMIT – UNIT WITH

MICROFILTERMICROFILTER

Don’t look at me…


WBC and Plasma CellWBC and Plasma Cell ::

LEUKEMIALEUKEMIA

MULTIPLE MYELOMAMULTIPLE MYELOMA

LEUKEMIALEUKEMIA

FATAL NEOPLASTIC DISEASE THAT INVOLVES THEFATAL NEOPLASTIC DISEASE THAT INVOLVES THE BLOOD FORMING TISSUESBLOOD FORMING TISSUES OF THE: OF THE: – BONE MARROWBONE MARROW– SPLEEN SPLEEN – LYMPH NODESLYMPH NODES

UNCONTROLLED & DESTRUCTIVEUNCONTROLLED & DESTRUCTIVE PROLIFERATION PROLIFERATION OF ONE TYPE OF OF ONE TYPE OF WBCWBC & & ITS PRECURSORSITS PRECURSORS

LEUKEMIALEUKEMIA

INFILTRATE:INFILTRATE:– LIVERLIVER

– SKINSKIN

– KIDNEYS KIDNEYS

– LYMPH TISSUESLYMPH TISSUES

TYPES:TYPES:

MYELOGENOUSMYELOGENOUS

LYMPHOCYTICLYMPHOCYTIC

LEUKEMIALEUKEMIA

S/SX:S/SX:– ANEMIAANEMIA– THROMBOCYTOPENIATHROMBOCYTOPENIA– INFECTIONINFECTION– PETECHIAEPETECHIAE– HEPATOSPLENOMEGALY & LYMPH NODE HEPATOSPLENOMEGALY & LYMPH NODE

ENLARGEMENTENLARGEMENT– ARTHRALGIA & BONE PAIN ARTHRALGIA & BONE PAIN FROM FROM

EXPANSION OF BMEXPANSION OF BM

LEUKEMIALEUKEMIA

LAB:LAB: INCREASED WBCINCREASED WBC ANEMIAANEMIA THROMBOCYTOPENIATHROMBOCYTOPENIA INCREASE ALKALINE PHOSPHATASEINCREASE ALKALINE PHOSPHATASE

– OSTEOBLASTIC ACTIVITYOSTEOBLASTIC ACTIVITY

BONE MARROW BIOPSYBONE MARROW BIOPSY

LEUKEMIA – NURSING CARELEUKEMIA – NURSING CARE

PROVIDE ADEQUATE REST PROVIDE ADEQUATE REST INCREASED METABOLIC RATE FROM INCREASED METABOLIC RATE FROM OVERPRODUCTION OF LEUKOCYTESOVERPRODUCTION OF LEUKOCYTES

PAIN CONTROL PAIN CONTROL ASA, CODEINE, DEMEROLASA, CODEINE, DEMEROL

ADEQUATE FOOD & FLUID ADEQUATE FOOD & FLUID INTAKEINTAKE HIGH CALORIE DIET VITAMIN HIGH CALORIE DIET VITAMIN SUPPLEMENTS 3-4 L OF FLUID PER DAYSUPPLEMENTS 3-4 L OF FLUID PER DAY

LEUKEMIA – NURSING CARELEUKEMIA – NURSING CARE

MOUTH CARE MOUTH CARE H2O2 LEMON & GLYCERINEH2O2 LEMON & GLYCERINE

PREVENT INFECTION PREVENT INFECTION PROTECT PATIENT PROTECT PATIENT FROM HIS OWN FLORA – NEOMYCINFROM HIS OWN FLORA – NEOMYCIN

CHEMOTHERAPY CHEMOTHERAPY GOAL- INDUCTION OF COMPLETE REMISSION GOAL- INDUCTION OF COMPLETE REMISSION

TOLERABLE LEVEL OF TOXICITY – CRITERION FOR TOLERABLE LEVEL OF TOXICITY – CRITERION FOR LIMITATION OF INDUCTION PHASELIMITATION OF INDUCTION PHASE

MULTIPLE MYELOMAMULTIPLE MYELOMA MOST COMMON NEOPLASTIC DISORDER OF THE MOST COMMON NEOPLASTIC DISORDER OF THE

PLASMA CELLPLASMA CELL BONE MARROW MALIGNANCYBONE MARROW MALIGNANCY

REVIEW OF PLASMA CELL AND ITS REVIEW OF PLASMA CELL AND ITS PRODUCTSPRODUCTS

S/SX:S/SX:– BACK PAIN, BACK PAIN, – FATIGUE, WEIGHT LOSS,FATIGUE, WEIGHT LOSS,– OSTEOPOROSISOSTEOPOROSIS– HYPERCALCEMIAHYPERCALCEMIA

MULTIPLE MYELOMAMULTIPLE MYELOMA

LABS:LABS:– BLOOD: DECREASED WBC, HGB & PLATELET; BLOOD: DECREASED WBC, HGB & PLATELET;

INCREASED SERUM INMMUNEGLOBULINSINCREASED SERUM INMMUNEGLOBULINS

RADIOLOGYRADIOLOGY– DIFFUSE BONE LESIONSDIFFUSE BONE LESIONS

DIAGNOSIS: DIAGNOSIS: BENCE-JONES PROTEINBENCE-JONES PROTEIN GLOBULIN IN THE URINEGLOBULIN IN THE URINE


Lymph Nodes and SpleenLymph Nodes and Spleen : :– LYMPHOMALYMPHOMA

– INFECTIOUS MONONUCLEOSISINFECTIOUS MONONUCLEOSIS

– SPLENIC RUPTURESPLENIC RUPTURE

– HYPERSPLENISMHYPERSPLENISM

LYMPHOMALYMPHOMA

HODGKIN’S & NON HODGKIN’S HODGKIN’S & NON HODGKIN’S DISEASE DISEASE

LYMPHOSARCOMALYMPHOSARCOMA

BURKITT’S LYMPHOMABURKITT’S LYMPHOMA

HODGKIN’S DISEASEHODGKIN’S DISEASE

MALIGNANT NEOPLASM OF THE LYMPHOID TISSUEMALIGNANT NEOPLASM OF THE LYMPHOID TISSUE

ENLARGEMENT OF THE LYMPH NODESENLARGEMENT OF THE LYMPH NODES

NIGHT SWEATSNIGHT SWEATS

BODY MALAISEBODY MALAISE

WEIGHT LOSSWEIGHT LOSS

REED-STERNBERG CELLS IN LYMPHNODE BIOPSYREED-STERNBERG CELLS IN LYMPHNODE BIOPSY

NONHODGKIN’S DISEASENONHODGKIN’S DISEASE

MALIGNANT NEOPLASM OF THE LYMPHOID TISSUEMALIGNANT NEOPLASM OF THE LYMPHOID TISSUE

ENLARGEMENT OF THE LYMPH NODESENLARGEMENT OF THE LYMPH NODES

MORE FATAL & DIFFICULT TO CONTROLMORE FATAL & DIFFICULT TO CONTROL

UNDIFFERENTIATED CELLS IN LYMPH NODE UNDIFFERENTIATED CELLS IN LYMPH NODE BIOPSYBIOPSY

INFECTIOUS INFECTIOUS MONONUCLEOSISMONONUCLEOSIS

AKAAKA: GLANDULAR / KISSING DSE: GLANDULAR / KISSING DSE

S/SX:S/SX: PAINFUL ENLARGEMENT - LYMPHNODESPAINFUL ENLARGEMENT - LYMPHNODES

LYMPHOCYTOSISLYMPHOCYTOSIS

FEVERFEVER

INFECTIOUS INFECTIOUS MONONUCLEOSISMONONUCLEOSIS

CAUSE:CAUSE: EPSTEIN-BARR VIRUS EPSTEIN-BARR VIRUS

CONTACT:CONTACT: KISSING KISSING

DIAGNOSISDIAGNOSIS: PAUL-BUNNEL : PAUL-BUNNEL HETEROPHIL HETEROPHIL TEST TEST

COMPLICATIONCOMPLICATION: SPLENIC RUPTURE: SPLENIC RUPTURE

SPLENECTOMYSPLENECTOMYINDICATIONS:INDICATIONS:

RUPTURERUPTURE OF THE SPLEEN OF THE SPLEEN FROM FROM TRAUMA, INFECTIOUS MONONUCLEOSISTRAUMA, INFECTIOUS MONONUCLEOSIS

HYPERSPLENISMHYPERSPLENISM – – EXCESSIVE SPLENIC EXCESSIVE SPLENIC DAMAGE OF CELLULAR BLOOD COMPONENTSDAMAGE OF CELLULAR BLOOD COMPONENTS

SPLENECTOMYSPLENECTOMY

NURSING CARE:NURSING CARE:

PREOP PREOP PNEUMOCOCCAL VACCINEPNEUMOCOCCAL VACCINE

POSTOPPOSTOP MONITOR FOR BLEEDING & SHOCKMONITOR FOR BLEEDING & SHOCK FEVER WITHOUT INFECTION IS COMMONFEVER WITHOUT INFECTION IS COMMON PROPHYLACTIC ANTIBIOTICPROPHYLACTIC ANTIBIOTIC

Hemorrhagic Disorders : Hemorrhagic Disorders : PURPURAPURPURA

EXTRAVASATION OF SMALL AMTS OF BLOOD INTO THE EXTRAVASATION OF SMALL AMTS OF BLOOD INTO THE TISSUES AND MUCUS MEMBRANETISSUES AND MUCUS MEMBRANE

VASCULAR PURPURAVASCULAR PURPURACAUSES : CAUSES :

1.1. HEREDITYHEREDITY2.2. ALLERGY (HENOCH-SCHONLEIN)ALLERGY (HENOCH-SCHONLEIN)3.3. DRUGS (TOXIC PURPURA)DRUGS (TOXIC PURPURA)4.4. POOR NUTRITIONPOOR NUTRITION5.5. INFECTIONINFECTION6.6. HPNHPN

THROMBOCYTOPENIC PURPURATHROMBOCYTOPENIC PURPURA

Disorders of Altered Disorders of Altered CoagulationCoagulation

– HEMOPHILIAHEMOPHILIA

– HYPOPROTHROMBINEMIAHYPOPROTHROMBINEMIA

– D.I.C.D.I.C.

HEMOPHILIAHEMOPHILIA

Deficit in one of the clotting factorsDeficit in one of the clotting factors

A A – Factor VIII – Factor VIII

BB- Factor IX - Factor IX

C-C- Factor XI Factor XI

HEMOPHILIAHEMOPHILIAS/SX:S/SX:– PROLONGED BLEEDING AFTER MINOR INJURY:PROLONGED BLEEDING AFTER MINOR INJURY:

CUTTING OF CORD CUTTING OF CORD CIRCUMCISION CIRCUMCISION IMMUNIZATIONIMMUNIZATION

– HEMARTHROSISHEMARTHROSIS– PERIPHERAL NEUROPATHY – PERIPHERAL NEUROPATHY – BLEEDING NEAR BLEEDING NEAR

PERIPHERAL PERIPHERAL NERVESNERVES

LAB:LAB:PROLONGED PTTPROLONGED PTTNORMAL PLT CTNORMAL PLT CTANEMIAANEMIA

HYPOPROTHROMBINEMIAHYPOPROTHROMBINEMIA

LIVER FAILURELIVER FAILURE

BLEEDING EPISODESBLEEDING EPISODES

VITAMIN KVITAMIN K

D.I.C.D.I.C.2 CONFLICTING SETS OF 2 CONFLICTING SETS OF

MANIFESTATIONS:MANIFESTATIONS:

DIFFUSE FIBRIN DEPOSITIONDIFFUSE FIBRIN DEPOSITION WITHIN WITHIN ARTERIOLES AND CAPILLARIES ARTERIOLES AND CAPILLARIES THROUGHOUT THE BODYTHROUGHOUT THE BODY

BLEEDINGBLEEDING INTO THE KIDNEYS, BRAIN, INTO THE KIDNEYS, BRAIN, ADRENAL, HEART AND OTHER ORGANSADRENAL, HEART AND OTHER ORGANS

D.I.C.D.I.C.

DIFFUSE FIBRIN DEPOSITION WIHIN DIFFUSE FIBRIN DEPOSITION WIHIN ARTERIOLES AND CAPILLARIESARTERIOLES AND CAPILLARIES

DIFFUSE FIBRIN DEPOSITION WIHIN DIFFUSE FIBRIN DEPOSITION WIHIN ARTERIOLES AND CAPILLARIESARTERIOLES AND CAPILLARIES

WIDESPREAD CLOTTINGWIDESPREAD CLOTTINGWIDESPREAD CLOTTINGWIDESPREAD CLOTTING

DEPLETION OF CLOTTING FACTORSDEPLETION OF CLOTTING FACTORSDEPLETION OF CLOTTING FACTORSDEPLETION OF CLOTTING FACTORS

D.I.C.D.I.C.

CAUSE:CAUSE: UNKNOWNUNKNOWN CRITICAL ILLNESS:CRITICAL ILLNESS:

– TOXEMIA OF TOXEMIA OF PREGNANCYPREGNANCY

– CANCERCANCER– SURGICAL SURGICAL

PROBLEMSPROBLEMS– HEMOLYTIC DSEHEMOLYTIC DSE

ASSESMENT:ASSESMENT: PETECHIAE, PETECHIAE,

ECCHYMOSISECCHYMOSIS PROLONGED BLEEDINGPROLONGED BLEEDING ARFARF CONVULSIONSCONVULSIONS COMACOMA

LAB:LAB: FIBRIN SPLIT FIBRIN SPLIT

PRODUCTSPRODUCTS

A.I.D.S.A.I.D.S.

Severe deficit in cellular immune functionsSevere deficit in cellular immune functions HIV virus- infects T helper cellsHIV virus- infects T helper cells Transmission Transmission Antiretroviral drugsAntiretroviral drugs Assessment:Assessment:

– Flulike s/sxFlulike s/sx– Hypoxemia from pulm infectionHypoxemia from pulm infection– Progressive weight loss Progressive weight loss – Temp elevations; night sweatsTemp elevations; night sweats– Neurologic dyfxnNeurologic dyfxn– Opportunistic infectionsOpportunistic infections

•Laboratory :

•ELISA•Western Blot•Anemia•Leukopenia•thrombocytopenia

A.I.D.S.A.I.D.S.

NURSING INTERVENTION:NURSING INTERVENTION: Administer medsAdminister meds Monitor resp, neurologic, F & E balanceMonitor resp, neurologic, F & E balance Monitor nutritional intakeMonitor nutritional intake Inspect oral cavity for ulcerationsInspect oral cavity for ulcerations Observe s/sx of infectionObserve s/sx of infection Severe leukopenia – neutropenic Severe leukopenia – neutropenic

precautionprecaution Blood & body fluid precautionBlood & body fluid precaution Emotional supportEmotional support

The nurse should understand that a The nurse should understand that a heparin order for a client with DIC is heparin order for a client with DIC is given to:given to:

a.a. Prevent clot formationPrevent clot formation

b.b. Increase blood flow to target organsIncrease blood flow to target organs

c.c. Increase clot formationIncrease clot formation

d.d. Decrease blood flow to target Decrease blood flow to target organsorgans

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