| Balloon Valvuplasty Posted: 12 Oct 2010 09:53 PM PDT 
Balloon valvuplasty also called balloon valvutomy is an alternative management to valve replacement procedure. It is a less invasive procedure that opens or dilates a stenosed (narrowed) valve of the heart due to a congenital defect, rheumatic fever, calcification and aging. It uses a balloon-tipped catheter to dilate a narrowed area. There are four valves in the heart namely: tricuspid, pulmonic, mitral and aortic valves. These valves are essential for efficient blood flow in the heart. In some cases, a valve narrows causing an obstruction to blood flow. Balloon valvuplasty is used in the treatment of these cardiac disorders that blocks the blood flow. The procedure is done through a cardiac catheterization with an x-ray machine that has a special TV monitor or screen. Then a needle is inserted into the blood vessel and a contrast medium is injected. The dye is used to pinpoint the exact location of the blocked area as viewed on the screen. Once the narrowed valve has been identified, a thin wire is inserted into the catheter and guided to the blocked area. The wire serves as a guide for the balloon catheter by allowing the physician to position the deflated balloon precisely at the midpoint of the affected area. The balloon is then inflated and as it expands it increases the size of the orifice, improving the valve function and cardiac circulation. Pre-procedure - Emphasize the doctor's explanation of the procedure including the risks involved and other treatment alternatives.
- Inform the patient that he will be awake throughout the procedure and be given a sedative and/or local anesthetic before the procedure.
- Describe the expected sensation during local anesthesia administration and catheter insertion. With the injection of the contrast medium, a warm, flushed feeling will likely occur.
- Instruct the patient to abstain from eating and drinking 6 hours before the procedure or as prescribed. (Usually NPO post midnight)
- Tell the client that the procedure may last up to 4 hours.
- Assess for any allergy to shellfish, iodine or contrast medium.
- Check the informed consent for the client's signature, if over 18 years old or the parents if the patient is underage.
- Baseline vital signs must be taken including peripheral pulses in all extremities.
- Insert an intravenous line to provide entry for medications to be administered (Heparin).
- Shave insertion sites and cleanse it using an antiseptic.
- Check and collect the standard laboratory test results required by the doctor before the procedure such as ECG, chest x-rays and routine blood tests.
- Place ECG electrodes precisely upon patient's arrival in the cardiac catheterization laboratory and check the I.V. lines for patency.
During the procedure 
- Administer oxygen via nasal cannula.
- Under a local anesthesia the doctor will make a small cut in the femoral blood vessel in the upper part of the leg.
- A guide wire is carefully passed through the needle and is gently pushed into the vessel towards the chest. A catheter tube is threaded along the wire until it reaches the heart.
- The doctor then uses the catheter to inject the contrast medium to visualize the heart valves and assess the degree of the narrowed part.
- Heparin is also injected into the catheter to prevent it from clotting.
- The physician positions the deflated balloon precisely at the midpoint of the affected area. The balloon is then inflated using a low pressure for about 12-30 seconds. Time and pressure gradually increases and if desired outcome is not seen, a larger balloon may be used.
- A series of angiograms is obtained to evaluate the effectiveness of the treatment.
- The doctor then sutures the guide catheter in place and removes it after the effect of heparin wears off.
Post-procedure - Monitor insertion site frequently. Be alert for signs of hemorrhage.
- Keep the affected leg straight and instruct the patient to avoid prevent excessive hip flexion.
- Monitor vital signs with following order:
Every 15 minutes x 1hour Every 30 minutes x 2 hours Every hour x 5 hours Unstable vital signs: every 5 minutes - Assess the peripheral pulses, color, sensation, temperature and capillary refill of the affected leg.
- Closely observe the catheter site for bruising, hematoma and bleeding. If hematoma expands, mark the site for later evaluation and notify the physician immediately.
- Assess for signs of fluid overload (due to contrast medium injection) such as distended neck veins, dyspnea, pulmonary congestion, tachycardia, hypertension, hypoxemia, atrial and ventricular gallop.
- Monitor intake and output.
- Increase IV fluid rate for at least 100 ml/hour to aid kidneys in excreting the contrast medium.
- Encourage patient to do deep breathing exercises to prevent atelectasis.
- Frequent heart function evaluation should be done by auscultation. Murmurs indicate a worsening valve insufficiency.
- Be alert for signs and symptoms of cardiac tamponade such hypotension, decreased or absent peripheral pulses and pale or cyanotic skin. This condition requires immediate surgery.
- Removal of guide catheter is usually 6-12 hours after the procedure. Direct pressure should be applied for at least 10 minutes to prevent bleeding.
Images from my.clevelandclinic.org, familydoctor.co.uk Related posts: - Percutaneous Transluminal Coronary Angioplasty
- Cardiac Catheterization
- Aortic Dissection
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| Z-Track Method Posted: 12 Oct 2010 09:50 PM PDT 
Z-track method of intramuscular injection is used to administer drug in a large muscle that prevents the leakage of the medication into the layers of subcutaneous tissues. It is named Z-track because after the techniques of this medication administration are implemented a zigzag path is responsible for sealing the drug in the muscles. Irritating medications and those that cause discoloration such as Iron Dextran and Inferon preparations are administered intramuscularly using this method. Tissue irritation is minimized by the lateral displacement of the skin during injection that seals the drug into the muscle tissue, thereby, inhibiting the escape of drug injected into the subcutaneous layer of the skin. The procedure requires a thorough concentration to the technique because leakage of the injected drug causes permanent staining of some tissues and patient uneasiness. A large and deep muscle must be used in this procedure. Preferably, the ventrogluteal muscle is usually selected as the site of IM injection. Preparation - Verify doctor's order on the patient's chart.
- Hand washing.
- Use a proper needle. Rule of thumb in needle selection for IM injection are as follows:
200 lb (90.7 kg) – 2" needle 100 lb (45 kg) – 1 1/4" to 1 ½" needle - Aspirate the prescribed medication into the syringe. Draw 0.2-0.5 cc of air (depending on the hospital policy) to create an air lock. (Air-lock technique is used with this procedure.)
- Replace the needle with a new one after preparing the drug so that no drug remains outside the needle shaft. This prevents tracking the drug into the subcutaneous tissue during injection.
Essential Procedures - Identify the patient. Explain the procedure.
- Provide privacy by closing the doors and providing drapes.
- Position the client in either his abdomen (prone) or his side (lateral).
 ventrogluteal muscle - Expose the gluteal muscle. Ventrogluteal muscle is usually used.
- Prepare the site with an antiseptic swab. The principle of this method is to start from the inner to the outer surface.
- Don gloves.
- Perform the Z-track technique.
 Performing the Z-track method - Place gloved fingers on the skin surface and pull the overlying skin and subcutaneous tissue approximately 2.5-3.5 cm (1 to 1 ½ inches) laterally to the side. (See Figure A)
- Holding the skin taut with the nondominant hand, insert the needle at a 90 degree angle at the spot where the finger was initially placed before displacing the skin laterally. (See Figure B)
- Aspirate for blood return with the dominant hand only (practice of nurse makes this step easy). If there is no blood return on aspiration, inject the drug slowly, followed by the air. Air clears the clears the needle of the medication and prevents tracking of the medication through the subcutaneous layers upon needle withdrawal. (Air-lock technique)
- Wait for 10 seconds before withdrawing the needle to allow the medication to disperse evenly.
- Slowly remove the needle.
- Release the skin taut. A zigzag needle track is created (by sliding of the tissue planes across each other) preventing the escape of medication from the muscle tissue. (See Figure C)
- Instruct the patient never to wear tight or constricting clothing because it can force out the injected medication to the subcutaneous layers. Do not massage the site.
- Encourage the patient to mobilize (walk or move in bed) to facilitate the absorption of medication.
- Discard the needles and syringe in an appropriate sharps container. Always remember, never to recap the syringe to avoid needle-stick accidents.
- Remove gloves.
- Document medication, dosage, date, time and site of injection on the patient's chart.
Images from trainwiser.com, connectiondev.lww.com, wordsalads.blogspot.com
Related posts: - ADMINISTERING AN INTRAMUSCULAR INJECTION
- ADMINISTERING AN INTRADERMAL INJECTION
- ADDING A BOLUS INTRAVENOUS MEDICATION TO AN EXISTING INTRAVENOUS LINE
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| Mannitol – Drug Study Posted: 12 Oct 2010 09:46 PM PDT 
Brand Name: Osmitrol, Resectisol Classification: Osmotic Diuretic Action Summary | Half-life | Onset | Peak | Duration | | 100 minutes | 30-60 minutes | 1 hour | 6-8 hours | Indications - Acute oliguric renal failure
- Toxic overdose
- Edema
- Increased intracranial pressure (ICP)
- Intraocular pressure (IOP)
Action - In the oliguric phase of acute renal failure, Mannitol increases osmotic pressure (pressure needed to stop the absorption of something or osmosis) of the glumerular filtrate, thereby, promoting diuresis (treating the oliguric phase of renal failure) and excretes toxic materials (management for toxic overdose).
- It also elevates blood plasma osmolality thus, inhibiting the reabsorption of water and electrolytes (for relief of edema) and mobilizing fluids in the cerebral and ocular spaces (lowers intracranial or intraocular pressure).
Contraindications - Susceptibility
- Dehydration
Adverse reactions - Dehydration
- Anuria
- Intracranial bleeding
- Headache
- Blurred vision
- Nausea and vomiting
- Volume expansion
- Chest pain
- Pulmonary edema
- Thirst
- Tachycardia
- Hypokalemia (increases the risk of digoxin toxicity)
- Chronic renal failure
Dosage Adult Oliguria: 50-100 g as a 5-25% solution. Intracranial/Intraocular pressure: 0.25-2 g/kg as 15-25% solution administered for 30-60 minutes. Children Oliguria: 0.25-2 g/kg as a 15-20% solution for 2-6 hours Intracranial/Intraocular pressure: 1-2 g/kg as a 15-20% solution administered for 30-60 minutes. Nursing considerations Assessment – Monitor the following: - 1. Vital signs
- 2. Intake and output
- 3. Central venous pressure
- Pulmonary artery pressure
- Signs and symptoms of dehydration (e.g. poor skin turgor, dry skin, fever, thirst)
- Signs of electrolyte imbalance/deficit (e.g. muscular weakness, paresthesia, numbness, confusion, tingling sensation of extremity and excessive thirst)
- (for increase ICP) Neurologic status and intracranial pressure readings.
- (for increase IOP) Elevating eye pain or decreased visual acuity.
Laboratory Tests - Renal function (BUN and Creatinine)
- Serum Electrolyte (Sodium and Potassium)
Precaution Pregnancy and lactation (safe use during these conditions is not established) Interventions - Observe the IV site regularly for infiltration.
- Administration rate for oliguria should be titrated to produce a urine output. (about 30-50 ml/hr in adult and 2-6 hours in children)
image from mannitol.org Related posts: - Drug Study – Furosemide
- Drug Study – Gentamicin Sulfate
- Drug Study – Catopril
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