Preoperative Considerations and Surgical Team Roles Part 2

6. CAD risk factors, angina, hypertension, myocardial infarction ( 17 questions ) CAD: > Coronary Artery Disease ● arteries become occluded (gets fat) and the Blood flow decreases ● causes: MI, HTN, angina ● Patient education: - life modifications - meds: Statins ● RISKS: - HTN - MI - Stroke - Atherosclerosis - tobacco use - diabetes - alcohol use - metabolic syndrome - hs-CRP ● HI-C-SODA - HTN, inc alcohol, inc cholesterol, smoking, obesity, diabetes, age ANGINA: > chest pain ● how to attack - M: Morphine (relaxation) - O: O2 - N: Nitroglycerin (vasodilators) ● watch for HYPOtension ● check BP ● Check headaches! ● on at all times, keep in brown glass bottle, keep cool, 6 months ● under the tongue - A: Aspirin ● 81 milligrams ● for anticoagulation ● BV constrict- not enough 02 ● we need to dec O2 demand - to treat: ● nitro medication first every 3-5 mins (only 3x) ● give O2 ● check BP constantly ● Stable vs Unstable Consistent Chest pain (can be at home). Happens upon exertion. - give nitro - resides with rest Unstable occurs at rest - nitro wont help - GO TO HOSPITAL HTN: ● CONSISTENT- 2/3x BP reading of above 140/90 ● pressure within the BV ● comorbidities like: - diabetes - smoking - drug abuse - inc Na intake ● bc water follows Na and the BV are than compressed ● first intervention is lifestyle changes (Modifiable) - than meds: diuretics ● complications: - stroke - MI - atherosclerosis MI: ● dec blood flow to the heart - plaque/lipid build up - no perfusion = ischemia ● STEMI vs NON-STEMI STEMI - Clot does not dissolve (lodges permanently) - ST ELEVATION - dec O2 to rest of vesselso overtime the tissues breakdown and become ischemic Non STEMI - clot dissolves before permanent damage can occur - NO ST ELEVATION - ST DEPRESSION ● how - to attack M: Morphine (relaxation) O: O2 N: Nitroglycerin (vasodilators) ● watch for HYPOtension ● check BP ● Check headaches! ● on at all times, keep in brown glass bottle, keep cool - A: Aspirin ● 81 milligrams ● for anticoagulation 7. Heart Failure ( 5 questions ) Heart failure: > Heart failure (HF) is a clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of a ventricle to fill or eject blood; the heart is unable to pump enough blood to meet the body’s metabolic demands or needs - The term heart failure indicates myocardial disease, in which there is a problem with the contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) may cause pulmonary or systemic congestion *Some cases are reversible depending on the cause *Most HF is a chronic, progressive condition managed with lifestyle changes and medications Chronic Heart Failure ➢ The incidence of HF increases with age ➢ Approximately 6 million people in the United States have HF, and 870,000 new cases are diagnosed each year ➢ Most common reason for hospitalization of people older than 65 years and the second most common reason for visits to a provider’s office Clinical Manifestations of Heart Failure: RIGHT sided Ineffective pimping of the R ventricle causing backflow of blood to peripherals to sell the body ➔ ➔ ➔ ➔ ➔ ➔ Viscera and peripheral congestion Jugular vein distension (JVD) Dependent edema Hepatomegaly/splenomegaly Ascites Weight gain (loss of appetite) LEFT sided Ineffective pumping of the left ventricle causing backflow of blood in the lungs, if left untreated left takes over right leading to RHF ➔ ➔ ➔ ➔ ➔ ➔ Pulmonary congestion, crackles S3 or ventricular gallop Dyspnea on exertion (DOE) Low O2 sat Dry, nonproductive cough initially Oliguria Medical management of the patient with heart failure ➔ Vary according to the severity of the patient’s condition, comorbidities, and cause Treatments: ➔ Oral and IV medications ➔ Lifestyle modifications ➔ Supplemental O2 ➔ Surgical intervention: ICD and heart transplant ➔ Comprehensive education and counseling to patient and family is needed Medications used to treat HF 1. Diuretics: decreases fluid volume, monitor serum electrolytes 2. angiotensin - converting enzyme (ACE) inhibitors: vasodilation, diuresis, decreases afterload, monitor for hypotension, hyperkalemia, and altered renal function, side effect: dry cough 3. Angiotensin II receptor blockers: prescribed as an alternative to ACE inhibitors; work similarly 4. Beta-blockers: prescribed in addition to ACE inhibitors, may be several weeks before effects seem, use with caution in patients with asthma 5. Digitalis/digoxin: improves contractility, monitor for digitalis toxicity especially if patient is hypokalemic Isotopes - cardiac glycosides Prototype → digoxin Routes of administration → PO & IV Action → improves the contractility of the heart by blocking ion exchange. Decreases electrical impulsivity in arrhythmias Use → heart failure, a-fib, and a-flutter Adverse effects → very narrow therapeutic window Interactions → increased risk of dysrhythmias w/ epinephrine Contraindications → severe myocarditis, ventricular tachycardia, v-fib. Use caution with MI, heart block, stokes-adams syndrome, and Wolff-Parkinson-White syndrome, and electrolyte disturbances. Nursing Implications → therapeutic serum level 0.8-2.0 mg/mL. Draw level prior to administration and at least 6 hours after the last dose. If pulse is <60, dose is held. Toxicity Toxicity signs / symptoms Toxicity management ➢ ➢ ➢ ➢ Potentially life-threatening heart rhythm disturbances nausea/vomiting, appetite loss Abdominal discomfort, blurred vision Mental changes ➢ Discontinue administration → not just reduced dose ➢ Presence of serious dysrhythmias indicate use of ○ Potassium chloride, lidocaine ○ Atropine, other dysrhythmias ○ Digoxin immune fab Gerontologic considerations: ● May present with atypical signs and symptoms such as fatigue, weakness, and somnolence ● Decreased renal fxn can make older patients resistant to diuretics and more sensitive to changes in volume ● Administration of diuretics to older men requires nursing surveillance for bladder distension caused by urethral obstruction from an enlarged prostate gland Assessment of the patient with heart failure: ➢ Focus ➢ Effectiveness of therapy ➢ Patient’s self-management ➢ S&S of increased HF ➢ Emotional or psychosocial response ➢ Health history ➢ Assess for ○ Mental status; lung sounds: crackles and wheezes; heart sounds: S3; fluid status or signs of fluid overload; daily weight and I&O; assess responses to medications Collaborative problems and potential complications of the patient with HF ➔ Pulmonary edema (flash edema*) ➔ Hypotension, poor perfusion, and cardiogenic shock ➔ Arrhythmias ➔ Thromboembolism ➔ Pericardial effusion Planning & goals for the patient with heart failure ★ Promote activity and reduce fatigue ★ Relieve fluid overload symptoms ★ Decrease anxiety or increase the patient’s ability to manage anxiety ★ Encourage the patient to verbalize his or her ability to make decisions and influence outcomes ★ Educate the patient and family about management of the therapeutic regimen Nursing interventions for the patient with heart failure: Promote activity tolerance ➔ Bed rest for acute exacerbations ➔ Encourage regular physical activity; build up to about 30 minutes daily ➔ Exercise training ➔ Pacing of activities; wait 2 hours after eating for physical activity ➔ Avoid activities in extreme hot, cold, or humid weather ➔ Modify activities to conserve energy ➔ Positioning; elevation of the head of bed to facilitate breathing and rest, support of arms Manage fluid volume ➔ Assess for FVE, daily weight, I & O, diuretic therapy, sodium restriction 8. PVD, PAD, Raynaud’s, VTE ( 6 questions) Raynaud’s Phenomenon: ➢ ➢ ➢ ➢ ➢ ➢ ➢ Intermittent arterial vasoocclusion, usually of the fingertips or toes Raynaud’s disease: primary or idiopathic Raynaud’s syndrome: associated with other underlying disease such as scleroderma Manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning pain Episodes brought on by a trigger such as cold or stress Occurs most frequently in young women Protect from cold and other triggers. Avoid injury to hands and fingers Venous thromboembolism (VTE) > occurs when a blood clot forms in a vein, this can include DVT and PE ● Deep vein thrombosis (DVT): when a blood clot forms in a deep vein ○ Lower legs, thigh, pelvis, can occur on the arms particularly with use of central lines ● Pulmonary embolism (PE): when a blood clot breaks loose and travels through the bloodstream to the lungs At risk? → immoble, low activity, bed rest, sedentary lifestyle Preventative measures → daily activity, compression stockings, medications (blood thinners), Cues → pain, red, warm, cramping pain, swelling Preventive Measures: ➢ Early ambulation and leg exercises ➢ graduated compression stockings ➢ Intermittent pneumatic compression devices ➢ Subcutaneous heparin or LMWH ➢ Lifestyle changes ➢ Weight loss ➢ Smoking cessation ➢ Regular exercise 9. Diuretics, Nitrates, ACE Inhibitors, Beta blockers, anticoagulants Medications to KNOW! DIURETICS Action Help kidneys produce more urine and excrete excess fluid from the body Assessment & monitoring - Assess for sulfa allergies because some diuretics are sulfonamide derivatives I&O Daily weights Monitor blood pressure Monitor BUN, creatinine, and electrolyte imbalances Side effects - Polyuria Dizziness Nausea & fatigue Erectile dysfunction Hypotension Electrolyte imbalance If K+ sparing → hyperkalemia Contraindications - Hx of hypokalemia & hyponatremia Anuria Hypotension Before surgeries or procedures Patient education - Take medications at the same time every day Significant weight changes Change positions slowly and with caution Know the signs of dizziness NITROGLYCERIN Action Used to treat chest pain Assessment & monitoring - Assess BP before & after each dose Assess pain status Assess vitals Side effects - Dizziness Weakness headache Contraindications - Low BP sensitivities Patient education - do not take before exercise - Expires after 6 months Do not remove from container Don’t take the medication if blood pressure is low ACE INHIBITORS (-prils) Action Lowers BP by blocking the ACE enzyme stopping angiotensin II causing high BP Assessment & monitoring - Monitor electrolyte levels (hyperkalemia) Monitor BP Side effects - Dry annoying cough Hyperkalemia Headaches Contraindications - Pregnancy Liver issues Patient education - Watch for dizziness Know the signs of low BP BETA BLOCKERS - atenolol Action Lowers BP by blocking the beta receptors in the heart Assessment & monitoring - Monitor BP & HR before & after admin Side effects - Bradycardia Dizziness Fatigue Contraindications - Hypotension Severe bradycardia Patient education - Take at the same time every day Do not take more than prescribed ANTICOAGULANTS (warfarin aka coumadin) Action Prevent or reduce coagulation of blood, prolonging the clotting time. Assessment & monitoring - Monitor platelet count Assess pulses Side effects - Hemorrhage Excessive bleeding Contraindications - Surgery Patient education - Active bleeding - Use electric razor when shaving Caution when flossing/brushing teeth Don't drink