| Pericarditis Posted: 20 Sep 2010 11:17 PM PDT 
 Pericarditis is an inflammation and/ or infectious process of the pericardium, the sac that contains the heart. It may be an acute or chronic (constrictive) condition that can lead to pericardial effusion or tamponade. It can lead to arterial and ventricular dysrhythmias, limit the cardiac chamber's ability to fill, and effect to cardiac output. Risk factors include bacterial and viral infections, vaasculitis – connective tissue disease, MI, uremia, neoplasms, and trauma; or can be iatrogenic (after cardiac surgery, drugs, and cardiac resuscitation) or idiopathic.
Signs And Symptoms - Chest pain and fever are the most common manifestation.
- Pericardial friction rub is a clinical hall mark.
- Pain begins suddenly, is severe and sharp, and is aggravated by inspiration and deep breathing.
- Pain is usually anterior to the precordium, radiates to the left shoulder, and is generally relieved by sitting up and leaning forward.
Physical Examination Appearance - Restlessness
- Irritability
- Weakness
- Pallor
Vital signs - HR: increased
- Temp: normal to increased
- RR: increased
Cardiovascular - Friction rub
- Pulsus paradoxus
- Jugular vein distention
Acute Care Patient Management Nursing Diagnosis: Ineffective breathing pattern related to acute pain secondary to inflammation and aggravated by position and inspiration. Outcome Criteria - Patient communicates pain relief
- Patient breathes with comfort
- O2 sat ? 92%
- RR 12 to 20 breaths/min, eupnea
Patient Monitoring - Assess pain using patients self-report when possible. A self-report rating scale assesses intensity of pain.
- Auscultate the anterior chest to determine the quality of the friction rub.
- Assess respiratory status because the patient may hypoventilate as a result of pain.
Diagnostic Assessment - Review the ABGs to evaluate oxygenation and acid-base status.
- Review results of echocardiogram and chest X-ray if available.
- Review serial ECGs for changes.
- Review CBC, leukocyte counts, and culture if possible.
Patient Management - Administer pharmacologic agents such as ibuprofen and indomethacin, as ordered to reduce inflammation and pain.
- Stay with the patient, providing a calm, quiet environment.
- Assist the patient to maintain a position of comfort.
- Ensure activity restrictions while the patient is asymptomatic, febrile, or if friction rubs is present.
- Promote pulmonary hygiene to prevent risk of atelectasis.
Related posts: - Cardiac Tamponade
- Cardiogenic Shock
- Pulmonary Embolus
  |
| Hypertensive Crisis Posted: 20 Sep 2010 11:04 PM PDT 
 Hypertensive crisis is an emergent situation in which a marked elevation in diastolic blood pressure can cause end-organ damage. Severe hypertension, usually a diastolic reading >120 mm Hg can cause irreversible injury to the brain, heart, and kidneys that can rapidly lead to death. Hypertensive crisis can occur in patients with either essential hypertension (unknown) or secondary hypertension which can be a result of renal or endocrine disease. Emergencies include hypertension in association with acute central nervous system events, acute aortic dissection, pulmonary edema, pheochromocytoma crisis, eclampsia, and nonadherence to medical therapy.
Signs And Symptoms - Headache
- Nausea
- Dizziness
- Visual disturbances
- Altered level of consciousness
Physical Examination Acute Care Patient Management Nursing Diagnosis: Ineffective tissue perfusion related to compromised blood flow secondary to severe hypertension resulting in end-organ damage. Outcome Criteria - Patient alert and oriented
- Skin warm and dry
- Pulses strong and equally bilaterally
- Capillary refill <3 sec
- BP <140 mm Hg
- BP < 90 mm Hg
- Mean arterial pressure 70 to 120 mm Hg
- HR 60 to 100 beats/min
- Absence of life-threatening dysrhythmias
- Urine output 30 mL/hr or 0.5 to 1 ml/kg/hr
- BUN <20 mg/dL, creatinine <1.5 mg/dL
Patient Monitoring - Monitor arterial BP continuously and note sudden increases or decrease in readings. A precipitous drop in BP can cause reflex ischemia to the heart, brain, kidneys, and/or GI tract. Note trends in mean arterial pressure and the patient's response to therapy.
- Monitor hourly urine output and note any presence of blood in the urine.
- Continuously monitor the ECG fir dysrhythmias or ST segment and T-wave changes associated with ischemia or injury.
Patient Assessment - Assess the patient for laboratories indicated.
Diagnostic Assessment - Review BUN and creatinine to evaluate the effect of BP on kidneys. BUN>20 mg/dL and creatinine >1.5 mg/dL suggest renal impairment.
- Review serial chest radiography for pulmonary congestion.
- Review serial 12-lead ECGs for patterns of injury, ischemia, and infarction
Patient Management - Provide oxygen at 2 to 4 liters/min to maintain or improve oxygenation.
- Minimize oxygen demand by maintaining the patient at bed rest.
- Help the patient decrease anxiety, and keep the patient NPO or provide a liquid diet in the acute phase.
- Administer nitrates as ordered to reduce preload and afterload.
- Administer ?-blockers as ordered. Labetalol may be given as 20 to 80 mg bolus every 10 to 15 minutes to rapidly lower the blood pressure.
- Prepare the patient and family for surgical intervention to correct the underlying cause, if this is indicated.
Related posts: - Aortic Dissection
- Hypovolemic Shock
- Acute Peritonitis
  |
| Hypovolemic Shock Posted: 20 Sep 2010 10:44 PM PDT 
Hemorrhage is a major cause of hypovolemic shock. However, plasma loss/ dehydration and interstitial fluid accumulation (third spacing) adversely reduce circulating volume by decreasing tissue perfusion. The primary defect is decreased preload. Four classifications of hypovolemic shock based on the amount of fluid and blood loss: - Class I: <750 ml, or ? 15% total circulating volume.
- Class II: 750 to 1000 ml, 05 15% to 30% total circulating volume
- Class III: 1500 to 2000 ml, or 30% to 40% total circulating volume
- Class IV: >2000 ml, or > 40% total circulating volume. The patient's compensatory response intensifies as the percent of blood loss is increases.
Signs And Symptoms - Depends on the degree of blood loss and compensatory response.
Physical Examination Appearance - Anxiety progressing to coma
Vital signs - Blood pressure normal to unobtaionable
- Palpable radial pulse reflects systolic blood pressure of 80 mm Hg
- Palpable femoral pulse reflects systolic blood pressure of 70 mm Hg
- Palpable carotid pulse reflects systolic blood pressure of 60 mm Hg
- HR normal to > 140 beats/min
- RR normal to > 35 breaths/ min
Cardiovascular Pulmonary - Deep or shallow rapid respirations
- Lungs usually clear
Skin - Cool, clammy skin, pale color
- Delayed/ absent capillary refill
- Lips cyanotic (late sign)
Acute Care Patient Management Nursing Diagnosis: Ineffective tissue perfusion related to blood loss and hypotension. Outcome Criteria - Patient alert and oriented
- Skin warm and dry
- Peripheral pulses strong
- Urine output 30 ml/hr or 0.5 to 1 ml/kg/hr
- Hct – 32%
- Systolic blood pressure 90 to 120 mm Hg
- Mean arterial pressure 70 to 105 mm Hg
- Cardiac index 2.5 to 4 l/min/m2
- O2 sat ?95 %
Patient Monitoring - Monitor BP continuously via arterial cannulation because cuff pressures are less accurate in shock states.
- Obtain cardiac output and cardiac index at least every 8 hours or more frequently to evaluate the patient's response to changes in therapy.
- Monitor peripheral artery pressures and central venous pressure hourly or more frequently to evaluate the patient's response to treatment.
- Continuously monitor ECG to detect life-threatening dysrythmias of HR > 140 beats/min, which can adversely affect SV.
- Monitor hourly urine output to evaluate renal perfusion.
- Measure blood loss if possible.
Patient Assessment - Obtain vital signs every 15 minutes to evaluate the patient's response to therapy and to detect cardiopulmonary deterioration.
- Assess level of consciousness, mentation, skin temperature, and peripheral pulses to evaluate tissue perfusion.
- Assess for pressure ulcer development.
Diagnostic Assessment - Review Hgb and Hct levels and note trends. Decreased RBCs can adversely affect oxygen carrying capacity.
- Review lactate levels, an indicator of reduced tissue perfusion and anaerobic metabolism.
- Review ABGs for hypoxemia and respiratory or metabolic acidosis.
- Review BUN, creatinine, and electrolytes and more trends to evaluate renal function.
Patient Management - Use a large bore (16 to 18 gauge) cannula for intravenous lines to replace volume rapidly.
- Administer blood products or autotranfuse as ordered.
- Administer colloids and crytalloids in addition to blood products as ordered.
- Pharmacologic agents may be used to improve hemodynamic parameters if intravascular volume is replaced.
- Provide oxygen as ordered.
- Prepare the patient for surgical intervention is required.
- Institute pressure ulcer prevention strategies.
Related posts: - Hypovolemic Shock
- Cardiogenic Shock
- Cardiac Tamponade
  |
