MEDICAL-SURGICAL NURSING Respiration – primary stimulant is ↑ CO2 in the blood

JOHN RICAFORT, RN
Common manifestations of patient with respiratory
OXYGENATION problems:
1. RESPIRATORY SYSTEM 1. cough – cardinal sign
2. CARDIOVASCULAR SYSTEM 2. dyspnea – 3 types: (semi-fowler’s – 20 to 35
3. BLOOD / HEMATOPOIESIS (serves as degrees)
medium for transport – oxygen and nutrients) a. exertional dyspnea – thru physical
exertion
RESPIRATORY SYSTEM b. orthopnea dyspnea – related to
• Gas exchange positioning
• Blood pH regulation • supine – fluid in the blood
• Sense of smell will cause congestion
• best position – semi-fowler’s
Upper respiratory tract  sneezing reflex (nose to c. paroxysmal nocturnal dyspnea – at
epiglottis)
night
• Fibrissae (nostril hair); cilia (hair-like structure) 3. chest pain – causes:
• Snot (“kugang”) a. respiratory problem
b. cardiac problem
Lower respiratory tract (below glottis) c. musculoskeletal problem
• Coughing reflex • evaluate type of chest pain
Pertussis – characterized by 5-10 consecutive
• First nursing action for chest pain  start
coughs with a stridor or whoop at the end. giving supplemental oxygen
• ♥common problem associated  HERNIA 4. Hemoptysis
• tearing of tissue that will lead to hernia pH content Appearance
• put abdominal support Hemoptysis base w/o food
frothy
Noisy breathing – common presentation of airway hematemesis With
obstruction (partial airway obstruction) food Non-frothy

Loss of voice – complete airway obstruction • Contra-indicated – chest physiotherapy

(CPT)
Goblet cells – mucous production 5. Clubbing of fingers
///////////////// - cilia
• ♥present only during CHRONIC hypoxia
ooooooooo – goblet cells
• Schamroth method analysis – face nails
CARINA – serves as an anatomical landmark for the together and there should be a diamond
placement of the tip of endoctracheal tube (for equal formed in between (normal)
distribution of air as manifested by symmetrical lung • ♥ normal degree – 160 degrees
expansion) o >160 deg. – early clubbing
• ♥ chest Xray – to check placement o >180 deg. – advanced clubbing
• position two hands at the back (lowest rib) with o 0 to 3 months – closed fists
the thumbs toward the spinal and fingers o 3 to 6 months – holds a bottle
spread to lateral side of the ribs; tghen ask o 6 to 9 months – pincer grasp
patient to inhale deeply. o 9 to 12 months – picks objects
• Right bronchus – larger 6. fever
2 major cells in alveoli: 7. crackles
• Type 1 – needed to combat infections 8. activity intolerance
• Type 2 – producing surfactant (↑ tension in 9. seizures
alveoli) 10. skin flushing - ♥ due to ↑ CO2 retention
• ♥ atelectasis – collapsed alveoli (SIDS) (hypercapnea)  causes vasodilation
11. altered level of consciousness
HERING BREWER REFLEX – responsible for inflation
and deflation process of alveoli 3 Categories for respiratory problem:
Disturbances or disorders
Right lung  3 lobes a. Restrictive lung disease – atelectasis,
Left lung  2 lobes pneumonia, PTB or chest trauma
b. COPD (Chronic obstructive pulmonary
Beta 1 receptor – heart disease) or CAL (chronic airflow limitation) –
Beta 2 receptor – lungs emphysema and bronchitis, asthma
c. Pulmonary vascular disease – Cor pulmonale,
2 layers of lung: pulmonary embolism
1. visceral (inner)
2. parietal (outer) RESTRICTIVE LUNG DISEASE
• must not exceed to 100 ml or cc  will • Any process that limits to lung expansion
cause hydrothorax or pleural effusion (INSPIRATION – problem)

Diaphragm – major muscle for respiration COPD / CAL

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 • Opposite of restrictive lung disease o Put patient in a mechanical ventilation
(EXPIRATION – problem)  to correct atelectasis, hypoxia and
• ♥ what is the appropriate fluid?  1 to 2 liters acidosis
per minute o ♥ continuously monitor
• can cause respiratory depression if > 2 cardiopulmonary and neurostatus
l/min. (because of hypoxia)

MEDULLA OBLONGATA – respiratory center

VENTURI MASK – most appropriate O2 device for 2. PNEUMONIA
COPD / CAL • refers to inflammation, infection of lung tissue
• most accurate O2 concentration • IP – 2 to 3 days
• next option  NASAL CANNULA • 2 types: (causative agents)
• ♥ most common complication  Cor o bacterial pneumonia
pulmonale (enlargement of Right ventricle)  streptococcus
 diplococcus
PULMONARY VASCULAR DISORDER o viral pneumonia
• disturbances in the vascular compartment of  H. influenzae
the pulmonary area • Pathognomonic signs:
o Strep./diplo. Pneu. – RUSTY
RESTRICTIVE LUNG DISORDERS – 3 conditions: PURULENT SPUTUM
1. ↓ lung capacity o Staphylococcal pneu. – YELLOW
2. ↓ elasticity or recoil BLOODY streak sputum
3. ↑ work of breathing o Microplasmal pneu.- NON-
PRODUCTIVE COUGH progressing to
1. ATELECTASIS mucoid
• collapsed of previously inflated lung tissue o Klebsiella pneu. – RED GELATINOUS
• 2 types: sputum
• Types of pneumonia:
1. Primary atelectasis  common to
newborn (premature) – common o LOBAR P. – site: either left or right
problem is surfactant lung
2. secondary atelectasis  due to o LOBULAR P. – entire lung; also called
compression and obstruction bronchopneumonia
• Classification of pneumonia – 4:
COMPRESSION OBSTRUCTION o Community acqd. Pneumonia (CAP)
Pneumothorax o Hospital acqd. Pneumonia (HAP) also
Hemothorax aspiration called nosocomial pneumonia
Pneumohemothorax o Aspiration pneumonia
hydrothorax o Pneumonia for immuno-compromise

• N. dx: Impaired Gas Exchange CAP – most common

• Manifestations: • Strepto / diplococcal
o Dyspnea • Rainy days
o Chest pain
o SOB HAP – staphylococcal
o Hypoxia • Acquired after 48 hours after admission or
discharge
o Asymmetrical lung expansion
o ↓ breath sound on affected lung Aspiration pneumonia – due to reflex of gastric
o signs of shock content into respiratory area
• Dx test: • Children and old people
o Chest Xray – confirmatory test • Neuro – problem, stroke, neuromuscular
o ABG – ↓ pH, ↑ PCO2, ↑ partial COs problem (myasthenia gravis)
and a ↓ O2 • Elevate HOB (20-35 deg.)
 Respiratory acidosis and
hypoxia Pneumonia for immuno-compromised
o Pulse oximetry - ↓ O2 saturation (N: • Patient with HIV, DM
95-100%) • Pneumocystic Carinii pneumonia (PCP) –
o ♥93% - O2 supplement (first nursing fungal or protozoal infection (cause)
action) • P.S. – Non-productive cough
• Management: • Drug of choice (DOC) – BACTRIM
o O2 supplement / therapy
(Trimethoprim-sulfamethorazole)  anti-
o Semi-fowler’s (to promote lung protozoal effect
expansion)
o Treat underlying cause (ex. Dx Test:
Hemathorax – chest tube insertion) • Chest Xray – confirmatory test (common
result: consolidation of lung tissue)
• Sputum exam

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 • Throat culture
Manifestations / SS of pneumonia:
1. productive cough
2. chest pain
3. hemoptysis
4. dyspnea
5. crackles
6. fever (infection)
7. anorexia
8. ↑ fremitus  vibration – movement of
air (ask patient to say 99 and feel for
the vibration – start up downwards –
diminishing fremitus)
9. egophony – distortion of “e” sound to
“a” sound (ask patient to say e, and
you will hear a sound during
auscultation)
10. whispered pectoriloque – sound can
be heard clearly because sound
travels faster in solid – (+) pneumonia
- an audible whispered 1-2-3
(instruct patient to whisper
123)
- normal: not clear
Management:
1. O2 supplement (dyspnea)
2. semi-fowler’s position
3. ↑ oral fluid intake (OFI)
4. give nutritious food
5. adequate rest
6. give antibiotic – DOC: penicillin or erythromycin
7. turn patient to sides q 2 hours – prevent pulling of
secretions on the lower lobe, which can cause dyspnea
(prevent hypostatic pneumonia)
• ♥ position to promote ventilation:
o RIGHT LUNG pneumonia – unaffected
side (left)
o Ventilation – good lung down
3. TUBERCULOSIS
• Highly infectious respiratory infection caused
by tubercle bacilli
• 3 common (most common – microbacterium
tuberculosis)
• 75 Filipinos die everyday (PTB)
• 1993 – Global emergency (WHO declared PTB
outbreak)
• manifestations:
o fatigue, malaise, anorexia, weight loss
(early signs)
o chronic cough (productive) - > 2 weeks
o night sweats
o hemoptysis (advanced state)
o low grade fever (afternoon)
Best sputum specimen – contains bronchial
secretions and mucous (not saliva)
Best time for PPD  after 72 hours (exposure)
• induration of <4 mm – negative
• 5-9 mm – doubtful result (give INH for 6 to 12
months)
o <35 y/o – INH – 6 to 12 mos
o >35 y/o – INH – 6 to 9 mos. (risk of
drug induced hepatitis)
• 10 mm – (+) for exposure
• tuberculin skin testing – if immuno-
compromised - > 4 months
Multi-drug therapy – prevention of emergence of drug
resistance
4. Chest trauma
1. accident (common cause)
o nonpenetrating / blunt – flail chest
(chest is still intact)
o penetrating – break in the chest wall
integrity (stab wound, gunshot)
 hemothorax, pneumothorax,
hemopneumothorax and
tension pneumothorax (cause
mediastinal shift)
Flail chest  multiple rib fracture or rib fracture
adjacent to each other
Hemothorax  lower lobe
Pneumothorax  upper lobe
tension pneumothorax  injury that resulted to
a one-way valve increasing tension in the
lungs.
Chest tube  purpose: to DRAIN (valsalva maneuver
not allowed)
2. for insertion or removal of chest tube (instruct
patient to do valsalva maneuver)
3. DRAIN air (pneumothorax) – site: 2nd or 3rd
ICS
4. Insertion – 7th or 8th ICS
5. After insertion: NR
o Check site
o Check V/S
o Position: semi-fowler’s position
(promotes lung expansion)
 Unaffected side (to drain)
 ↓ pressure – affected side
6. check for tidalling or oscillation – refers to
fluctuation of fluid
o needle is out – it there is no tidalling
o inspiration – fluid falls or goes down
o expiration – fluid rises
7. ♥nursing alerts
o keep bottle below the heart
o clamp the tube as close to the
patient’s body
o don’t clamp the tube for long period of
time – can cause tension
pneumothorax
o don’t milk the tube – will create suction
site and can cause trauma to the
tissue
o chest drainage – clamp or forceps
should be at the bedside (to clamp
tube incase bottle will break)
o extra bottle with water should also be
at the bedside  20 cms. High
o submerge tube to the water, which will
act as seal
o interpretation:
 intermittent bubbling –
indicates that the lungs have
re-expanded continuous
bubbling – indicates leakage
COPD / CAL  problem: EXPIRATION
1. EMPHYSEMA (irreversible) – PINK PUFFER
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 • Most appropriate device: VENTURI
MASK
• 1 to 2 liters / min.
• O2 saturation – 95 to 100%
• Loss of lung elasticity (alveoli wall)
• Common cause: smoking (n. mgt.:
cessation of smoking)
• Exposure to chemicals – asbestos
• Deficiency of anti-trypsin (protein that
will neutralize trypsin)
Pathologic changes in emphysema:
1. Loss of lung elasticity
2. Formation of bulla / bullae
(air sac) – because alveoli wall due to loss of
elasticity will not deflate properly causing air
sac
3. Hyperinflation of lung tissue
- 2˚ to loss of elasticity (affects inflation /
deflation)
• Common result in Xray – “barrel chest”
(↑ anterior-posterior diameter than
transverse diameter
• There is air trapped inside –
Hyperresonance during percussion
4. small air trappings and collapse
• Hypercapnea - ↑ CO2
PINK PUFFER – associated with smoking
• ↑ CO2 retention (pink) – loss of lung
elasticity
• no cyanosis
• dyspnea
• ineffective cough
• hyperresonance on chest percussion
• orthopneic
• barrel chest
• exertional dyspnea
loss of lung elasticity  impaired gas exchange  ↑
CO2 retention  vasodilation  blood will congest 
resulting to pinkish discoloration
Dx Test: CXR – reveals barrel chest
• history of smoking
ABG – respiratory acidosis and hypoxia (↓ pH, ↑
PCO2, ↑ partial COs and a ↓ O2)
Pulmonary function test – INCENTIVE
SPIROMETER (measures total lung capacity)
o done to enhance deep inspiration
Incentive Spirometer:
Tidal volume N: 500 ml
Residual vol. N: 1200 ml
Inspiratory reserve volume N: 3,000-3,300 ml
Expiratory Reserve volume N: 1000-1200 ml
Tidal volume – amount of air that enters and leaves the
lungs
Residual volume – amount of air present inside the
lungs after a Normal expiration
Inspiratory Reserve volume – amount of air that can be
forcibly inspired after a normal inspiration (↓
IRV – emphysema)
Expiratory Reserve volume – amount of air that can be
expired (emphysema - ↓ ER)
3 types of emphysema:
1. Pon lobular emphysema – upper lobe (most
common)
2. centro lobular emphysema – central lobe
3. paraseptal distal acinar emphysema – distal
lower lobe
Management:
1. cessation of smoking
2. O2 supplement – 1 to 2 liters/min.
3. position: semi-fowler’s
4. antibiotics – affect coughing reflex, which
makes a patient at risk to infection
5. diuretics
Lobectomy – removal of a lobe
• position: (post) affected side
Pneumonectomy – removal of a lung (entire)
• position: (post) semi-fowler’s
BRONCHITIS (reversible) – BLUE BLOATERS
• inflammation of the bronchus
• termed as smoker’s coughs
• N. Dx: Ineffective Airway Clearance
• Color: dusky to cyanotic
• Recurrent cough and ↑ sputum production
• Hypoxia
• Hypercapnea
• Acidosis
• Edematous
Management:
1. avoidance of irritating substances
2. cessation of smoking
3. ↓ physical stimuli ( to ↓ O2 demand)
4. Drugs:
a. Anti-inflammatory (corticosteroids)
i. Don’t take corticos-teroids for
long period of time – cause
immune suppression, Cushing
syndrome
ii. Watch for S/S of immune
suppression
iii. Don’t stop corticosteroids
abruptly
b. Bronchodilator – salbutamol,
theophylline, aminoptylline (N:
theophylline level – 10 to 20)
i. Signs of theophylline toxicity
1. tremors
2. palpitations
3. nausea
4. headache
5. dizziness
c. antibiotics – prevent secondary
infection
ASTHMA
• is a hypersensitivity reaction characterized by
abnormal breath sounds secondary to
histamine release
• effects of histamine:
o cause vasodilation
o cause bronchoconstriction
o ↑ mucous production
o bronchospasm
• N. Dx: Ineffective Airway Clearance
• Wheezes – expiration (expiratory wheezes –
P.S.)
• Hypersensitivity
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 • ↑ occurrence in males 2. dyspnea
• onset before 12 y/o 3. SOB
• retractions 4. tachycardia
• hypoxemia 5. signs of shock
o tachycardia
o ↑ restlessness Dx Test:
1. CXR
o tachypnea
2. ECG
• familial cough 3. ABG
• cough 4. Pulmonary angiography – confirmatory test
• ↑ mucus (invasive)
• SOB • N. priority – check peripheral pulses
• Expiratory wheezed (P.S.) (popliteal, dorsalis pedis, posterior
• ↑ CO2 retention pedialis)
• prolonged expiration • Damage of femoral line – diminish
peripheral pulses
2 major types of ASTHMA:
Management:
1. INTRINSIC ASTHMA – non-allergic (ex. 1. O2 supplement
Stress, infection, sudden change in weather) 2. Semi-fowler’s (20 to 35 degrees)
2. EXTRINSIC ASTHMA – allergic asthma attack 3. mechanical ventilation
a. IgE – mediated 4. ↓ physical stimuli
5. drugs:
b. Common cause: DUST a. analgesic – Morphine Sulfate
b. anti-coagulant – aspirin, heparin (PTT,
Management:
antidote: protamine sulfate),
1. O2 supplement
coumadin/warfarin (PT, antidote: Vit.
2. position: semi-fowler’s
K)
3. stay with patient
c. thrombolytics – dissolves clot
4. ↓ physical stimuli – to decrease oxygen
(streptokinase, TPA)
demand
5. Drugs: 6. Surgery – removal of clot (embolectomy)
a. Bronchodilators
b. Corticosteroids N. Dx for pulmonary embolism
c. Antii-histamine (♥ S/E – drowsiness  • Alteration in
discourage driving and avoid operating • Impaired Tissue Perfusion
machineries)
6. Avoidance of allergens
BLEEDING TENDENCIES
PULMONARY VASCULAR DISORDER 1. DISSEMINATED INTRAVASCULAR
1. Cor Pulmonale – refers to enlargement of Right COAGULATION
ventricle (R ventricle hypertrophy) • Common cause: SEPTICEMIA, ABRUPTIO
PLACENTA
• Common cause: COPD
• Management – blood transfusion (platelet
• COPD  narrowing of pulmonary vessels  ↑ concentrate)
resistance of blood flow to the lungs  ↑ 2. HEMOPHILIA
functional demand of heart (R ventricle) to • A bleeding disorder due to chromosomal
pump blood  compensation (hypertrophy) problem (male)
• Carrier – women
Manifestation of Cor Pulmonale  Right sided heart • Asymptomatic
failure • Earliest manifestation – bleeding of the umbilicus
or during circumcision
Management – treat respiratory problem
• Ratio and proportion
PULMONARY EMBOLISM
P.S. of hemophilia – HEMARTHROSIS (bleeding in the
• Refers to occlusion in one or more pulmonary joints)
veins
• Earliest manifestation – reluctance to move a
• Blood clot (♥ don’t forget – patients with oral body part
contraceptives - ↑ risk of clotting formation)
• (pediatric) – pad the joints and extremities
• Origin: LOWER extremities because there is bleeding
• Cholesterol • with active hemarthrosis – CBR
• Amniotic fluid • 2 types of hemophilia:
• Air (fatal: 10 cc) o A – CLOTTING FACTOR VIII (anti-
• Best position: (air embolism) head lower than the hemolytic factor)
body and on left side-lying (air normally goes up) o B – clotting factor IX (Christmas factor)
 left side lying so air bubbles won’t go on right – also called Christmas Disease
side • Dx Test – Partial Thromboplastin Time (PTT)
• Cryoprecipitate  administer plasma (to supply
Manifestations:
the needed clotting factors)
1. acute chest pain

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 • Yellow discoloration of skin (pooling of plasma
due to too much plasma)
3. THROMBOCYTOPENIA
• An ↑ in platelet (N: 150000-450000 mm3)
• Due to exposure to agents or drugs
a. Alcohol
b. Chemotherapy drugs – cause bone
marrow suppression
c. Radiation exposure
d. Viral exposure – ex. Dengue, ebola
virus (ebola Zaire – causative agent)
e. Thrombolytics – anti-coagulants
f. Chloramphenicol
g. Corticosteroids – bone marrow
suppression
h. Phenobarbital
i. Penicillin
• Platelet count that can lead to bleeding  <
50,000 mm3
• Management – blood transfusion (platelet
concentrate)
• Nursing alerts (for bleeding disorders)
a. No invasive procedure
b. Avoid astering, no anti-coagulant, no
thrombolytics
c. Avoid extreme temperatures
d. Observe safe administration /
transfusion of blood
e. No drugs that are psychophlegics
(drugs that can cause paralysis in the
ocular muscles) – can cause bleeding
of the eyes
f. Pad extremities and joints of patients
CARDIAC DISTURBANCES
CARDIO-VASCULAR – a system that circulates blood
around the body
Heart
• 3 layers:
 Pericardium (outermost)
 Myocardium (thickest layer)
 Endocardium (innermost)
 4 chambers – Right and left atrial and
ventricles
 valve – to prevent regurgitation or reflux
• AV valve
 Right tricuspid
 Left mitral
• SEMILUNAR valve
 Pulmonary SL valve
 Aortic SL valve
• LUBB DUBB – sounds due to
valvular closure (Lubb – S1,
closure of AV valve; Dubb – S2,
closure of SL valve)
Pacemaker – SA node (conductive system)
– recorded in ECG
SA node – AV node – Bundle of His – Right and Left
Branches – Purkinje Fiber
ECG
 electrical activities will be presented by waves
 P wave – atrial depolarization
 QRS wave – atrial repolarization & ventricular
depolarization
 T wave – ventricular repolarization
DEPOLARIZATION – stimulated stage / phase
REPOLARIZATION – resting stage / phase
BASIC ECG INTERPRETATION
Normal rate 60 – 100 bpm
N P-R 0.12 – 0.20 seconds
N QRS 0.08 – 0.12 seconds
One small box = 1 mm
One big box = 5 mm
Normal sinus rhythm:
 300, 150, 100, 75, 60, 50
 look for R wave that falls in the dark line
 R wave >100 –tachycardia
 R wave < 100 – bradycardia
1. Standard ECG – composed of 12 leads
2. Holter Test – also called ambulatory ECG
3. Stress Test
12 leads – divided into 2 divisions, which shows
different angles of the heart:
1. chest
a. V1 and V2 – Right side of heart
b. V3 and V4 – Septum
c. V5 and V6 – left side
2. limb
a. I
b. II – most important lead and most stable
(where dysrhythmia is checked)
c. III
d. AVR
e. AVL
f. AVE
♥Nursing alerts:
1. Can’t cause electrocution
2. No metals in the body
3. Breath normally and lie still
4. Holter test  report electrical activity of the heart
for 24 hours
a. ♥ Don’t forget to instruct patient to jot down
the activities during reporting period
b. ♥advise to do usual ADLS – No variations
c. ♥ Don’t moist / wet the apparatus
d. ♥Don’t operate machineries / appliances –
will affect the result of the test
STRESS TEST – evaluate cardiac function once the
patient is subjected to physical exertion
 ♥diet – light diet meal (crackers and soup)
 attire – proper footwear (rubber shoes)
 Don’t leave the patient alone
 Check the V/S before, during and after the test
 Stop the test when the patient complaints cardio-
pulmonary manifestations (ex. Dyspnea)
DISTURBANCES:
1. INFECTION – RHEUMATIC HEART DISEASE
 RHD
i. Complication or se sequelae of frequent
and untreated GABS infection (sore throat)
ii. Common: 5 to 15 y/o
iii. Auto-immune problem
iv. Target: connective tissue (muscles, joints, bones
and blood)
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v. Manifestations (Major symptoms – JONES 5. distended jugular veins
criteria) 6. anorexia and complaints of GI distress
1. carditis – inflammation of 3 layers of the heart 7. swelling in hands and fingers
2. valvular defect – mitral valve 8. dependent edema
3. chorea – St. Vitus dance
a. refers to LSHF – S/S;
abnormal jerking 1. paroxysmal nocturnal dyspnea
movement 2. elevated pulmonary capillary wedge pressure
b. upper extremities, (PCWP)
face – usually at night 3. cough
c. loud music – 4. crackles
aggravates 5. wheezes
d. self-limiting (3 6. blood-tinged sputum
mos.) 7. restlessness
4. Rashes on abdominal area going to peripheral 8. confusion
parts – erythema marginatum 9. orthopnea
5. subcutaneous nodules (self-limiting – requires 10. tachycardia
no treatment) 11. exertional dyspnea
6. Polyarthritis – inflammation of 2 or more joints 12. cyanosis
a. Put some bed
cradle Management:
 ↑ force of contraction without increasing HR
vi. Minor symptoms:
1. fever U – Upright position (prevent pulmonary congestion –
2. chest pain Cause dyspnea)
3. frequent sore throat N – Nitrates will be given – vasodilator of BVs
4. ↑ ASO titer (anti-streptolysin-O) L – Lasix – loop diuretics (remove congested fluids)
a. if >333 – indicates O – O2 (congestion – altered tissue perfusion)
GABS infection A – Aminophylline (bronchodilator– prevents dyspnea)
D – Digoxin (DOC) - ↑ force of contractions without
Diagnosing RHD criteria: Increasing HR
 1 major symptom (+) 2 minor symptoms F – Fluid restriction (1,000 – 1,300 ml/day)
 2 major symptoms (+) 1 minor symptom A – Afterload decrease (↓ O2 consumption) Beta-
Blocker, Ace inhibitors
Dx test – no specific test: S – Sodium restriction
 throat culture T – Test for ABG and K(+)
 serum / blood analysis - ↑ ASO titer
 ↑ ESR ↑ urine  fluid loss  K (+) excretion  Hypokalemia
 2 dimensional echocardiography  hydrogen (H+) elimination  ↑pH  alkalosis
o mitral valve
↑K(+) = H+ retention  acidosis (Hyperkalemia - ↓pH)
Management: ↓K(+) = H+ elimination  alkalosis (Hypokalemia-↑pH)
1. give aspirin
2. corticosteroids DIGOXIN – effective: ↑ urine output (↑GFR)
3. drug of choice (DOC)  penicillin drug  ♥check for HR and B/P
4. treatment for active RHD (3 to 6 years)   don’t give if HR <50bpm or <90/60(B/P)
compliance of patients to meds – problem  ♥check for digoxin level
 N: 0.5 – 2.0 g/dl
♥RHD i. 2.0 – digitalis toxicity – S/S
1. Take antibiotic prior to dental work-up or surgery – 1. bradycardia
prophylaxis 2. hypotension
2. Stress importance of good oral hygiene 3. dizziness
3. Compliance to treatment regimen 4. nausea and vomiting
4. Regular physical exam (annual 2D echo) 5. visual disturbances (yellow to yellow-green
5. provide comfort – put some bed cradle halos around the light
ii. antidote: DIGIBIND – or Digoxin Immune Fab
2. CONGESTIVE HEART FAILURE (CHF)
 Inability of the heart to pump properly 3. CORONARY ARTERY DISEASE (CAD)
 Types of CHF:  Affects normal perfusion of blood from heart
i. RSHF – systemic i. Atherosclerosis
ii. LSHF – pulmonary ii. Arteriosclerosis
iii. Angina pectoris
RSHF – blood will accumulate in systemic iv. MI
LSHF – pulmonary manifestations  Improve perfusion

S/S of RSHF: 1) Atherosclerosis (fatty deposition) – form of

1. fatigue arteriosclerosis
2. ↑ peripheral venous pressure  ↑ cholesterol level
3. ascites
4. enlarged liver and spleen

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 an abnormal accumulation of lipid, or fatty  Drugs – decongestants (can cause constriction
substances and fibrous tissues in the vessel wall of the blood vessels
o cholesterol: o Types of AP:
 HDL – good cholesterol  Stable angina
 LCL – bad cholesterol (Hard to metabolize –  Unstable angina
most abundant)  Variant angina
 Triglycerides  Intractable or refractory angina
 Silent angina
LDL (low density level) – deposited in the tunica intima  Ludwig’s angina
(inner lining of the BV)
 WBC and macrophages will modify LDL, so HDL Stable angina – when under stress (tired) –
can remove it (might cause injury – fibrous formation) arteriosclerosis (common cause)
o Thick capsule – can impede circulation of the Unstable angina – may lead to MI (also called
blood preinfarction angina) – even at rest (atheroscle-
o Thin capsule – can result to rupture (aneurysm) rosis – cause)
or emboli to be released to the blood stream (injured Variant angina – or nocturnal angina (at night only) or
tunica intima) – releases fibrous tissue Prinzmetal angina (vasospasm – cause)
Intractable or Refractory angina – will not respond to
2) Arteriosclerosis – hardening of the blood vessel Drug (severe pain); vasocompression – cause
wall (secondary to aging process) Silent angina – asymptomatic (ECG – inverted T wave
But no pain)
Risk factors for CAD: Ludwig’s angina – drug-induced AP
1. NON-MODIFIABLE:
 Family history of CAD Manifestations of AP:
 Increasing age 1. chest pain - <15 mins. To 30 mins.
2. nitroglycerin or rest – pain will disappear
 Gender (male)
3. radiating pain – chest to left arm
 Race (African American)
4. Levine sign – grasping outer chest
2. MODIFIABLE:
Classifi- Activity Evoking Limits to
 High B/P (↑s chances of atherosclerosis)
cations Activity
 Cigarette smoking (nicotine will promote I Prolonged exertion None
accelerated atherosclerosis)
II Walking more than 2 Slight
 High blood cholesterol level blocks
 DM III Walking < 2 blocks Marked
 Lack of estrogen in women IV Minimal activity or at severe
 Physical inactivity rest
 Obesity
Management for AP:
Normal cholesterol: 1. Supplemental O2
N total serum cholesterol – 150 to 240 mg/dl 2. Position: semi-fowler’s (lung expansion promotion
N HDL – 29 to 77 mg/dl – improve perfusion)
N LDL – 60 to 160 mg/dl 3. ↓ physical stimuli (↓ O2 demand)
Triglycerides – 10 to 190 mg/dl 4. drugs:
a. aspirin – anti-coagulant (prevents formation of
Desired level of LDL: new clot)
 If one (1) risk factor or no risk factors – 160 b. nitroglycerin or nitrates – vasodilation to improve
mg/dl flow and perfusion
 2 or more risk factors - <130 mg/dl o comes in several packages:
 Dx: CAD  <100 mg/dl o tablet – must be stored in a dark, dry place and
o If not corrected – result to angina pectoris (AP) tightly cupped container
 ♥If not corrected – result to Angina Pectoris (AP)  must be taken
 AP  refers to chest pain/discomfort sublingually (burning
sensation – effective)
o Cause: Myocardial ischemia (inability of the
 light-headedness and
coronary arteries to supply blood to the heart)
nausea are expected
 Inverted T wave – ischemia
 taken 1 tablet at a
normal time at 5 mins. Interval for
3 tablets
 ♥ same with spray (3
abnormal
doses at 5 mins. Interval)
 discard nitroglycerin
o Factors that affect AP (which will lead to after 6 months - potency
(4th month – patency
myocardial ischemia)
starts to ↓)
 Atherosclerosis
 Arteriosclerosis o spray
 Vasospasm o patch
 Vasocompression  Nursing alerts:

8
 Don’t touch medicated surface – cause
hypotension
 Place the patch on a non-hairy spot (shaved
site) – shave along the hair growth to prevent skin
breakdown
 Anterior chest (site of patch) – intermittent R & L
o Parenteral – don’t give rapid infusion

MYOCARDIAL INFARCTION (MI)

o Coronary occlusion or “heart attack”
o Causes: same with AP
o Chest pain is >15 – 30 mins.
o Levine sign
o Radiating pain
o Manifestations:
o D – dyspnea
o A – anxiety
o N – N/V
o C – crushing substernal pain
o E – elevated temperature
o P – pallor
o A – arrhythmia
o D – diaphoresis
o Lactic acid can cause chest pain
o Cardiac enzymes ↑ (activation of pyrogenes - ↑s
temperature) – due to injury
o LDH
o CPK
 Rises 4 to 8 hours after attack
 Peak of CPK – ½ to 1 ½ days
 Normalizes 3 to 4 days after
o Troponin T & I – most reliable
 (-) Normal
 rises: immediately
 peak: 4 to 24 hours
 normalizes: 1-3 weeks after
o Lactic dehydrogenase
 100 to 190 in/liter
 rises: 12 to 24 hours after
 peak: 2 to 6 days after

Management of MI:
M – Morphine sulfate (narcotic analgesic)
O – O2 (improve tissue perfusion)
A – Aspirin and Ace inhibitors (anti-coagulant;
↓ afterload)
N – Nitroglycerin/nitrates (vasodilator)
S – streptokinase (thrombolytic – dissolves a
clot)
best time: within 3 hours after the attack

o pathological Q wave or very large Q wave

N. Dx (MI) – alteration in comfort and pain

Ace inhibitors – “pril” captopril

Streptokinase – substance derived (bacteria)

N. alerts:♥
o best given within 3 hours after attack
o don’t give to active streptococcal infection
patients
o don’t give to immunocompromise – cause septic
shock
o don’t give to patients with thrombocytopenia - ↓
platelet can cause bleeding