NSG 4100 MedSurg III: Exam 3Unit 6: Complex Perfusion Problems II latest update with complete solutions

MedSurg III: Exam 3
Unit 6: Complex Perfusion Problems II
CH: 24, 25, 26, 29
 Book & PPT, KEY POINTS, Lecture




Cardiac Tamponade
• MEDICAL EMERGENCY
• Pericardial effusion (accumulation of fluid in the pericardial sac)
o may accompany advanced HF, pericarditis, metastatic carcinoma, cardiac surgery, or
trauma
• Normally pericardial sac contains about 20 mL of fluid needed to decrease friction for the
beating heart
• An increase in pericardial fluid
o raises the pressure within the pericardial sac and compresses the heart
o This has the following effects:
▪ Elevated pressure in all cardiac chambers
▪ Decreased venous return due to atrial compression
▪ Inability of the ventricles to distend and fill adequately
• Pericardial fluid may build up slowly until a large amount (1 to 2 L) accumulates
o A rapidly developing effusion (e.g., hemorrhage into the pericardial sac from chest trauma)
• As pericardial fluid increases, pericardial pressure increases, reducing venous return to the
heart and decreasing CO
o This can result in cardiac tamponade, which causes low CO and obstructive shock
• Patho
o Accumulation of pericardial fluid  indicator of underlying disease
o Tamponade is the compression of heart chambers impairing filling
o If it can’t get into the right atrium its going to go back to the body pt will look poofy=
decreased CO
• Etiology
o Advanced HF
o Pericarditis
o Metastatic Carcinoma
o Cardiac sx
o Trauma
• Dx
o Compressed cardiac silhouette on radiographs
o Beck’s triad:
▪ Hypotension
▪ Distended neck veins
▪ Muffled heart sounds
o Echocardiogram
▪ Confirm the diagnosis and quantify the amount of pericardial fluid
▪ Shows tachycardia and may also show low voltage
o Chest x-ray
▪ May show an enlarged cardiac silhouette due to pericardial effusion.
• CM

, o Acute
▪ Sudden chest pain, tachypnea, and dyspnea.
▪ JVD  from poor right atrial filling and increased venous pressure.
▪ Hypotension  from low CO,
▪ Heart sounds are often muted (muffled heart sounds)
o Subacute
▪ Chest discomfort or a feeling of fullness; Dull chest pain
▪ Feeling of pressure in the chest from stretching of the pericardial sac
▪ Dyspnea, JVD, and hypotension over time
▪ Tachycardia  r/t low CO.
▪ Pulsus paradoxus, (cardinal sign)
• Rising filling pressures in heart chambers
• Systolic BP with an abnormal difference of at least 10 mm Hg that is LOWER
during inhalation.
o Diminished electrocardiographic amplitude
• NI
o Maintain continuous electrocardiography, BP, and pulse oximetry
o Monitor for signs and symptoms of arrhythmias
o Maintain oxygen therapy as prescribed.
o Monitor for signs and symptoms of pericardial tamponade.
o Pre/post op/procedure care
• Medical
o Pull fluid
o Pericardiocentesis
o Pericardiotomy
o Can go into vtach, v-fib, if needle touches cardiac tissue
o Once fluid is removed s/s improve pt can breathe
o EDUCATE
• Tx
o Collaborative outcomes: Restore physiologic stability
o Indicators of Physiologic Stability:
▪ Oxygen saturation >95%
▪ Normal Sinus Rhythm
▪ No life-threatening dysrhythmias
▪ No chest pains
▪ Pulse regular rhythm, rate 60 to 100 beats/min
▪ BP: Systolic >120 mm Hg. Diastolic >85 mm Hg
▪ Urine output >0.5 mL/kg/hr




Cardiogenic Pulmonary Edema
• Patho
o Acute event that results from left ventricular failure
o Occurs after acute MI or as an exacerbation of chronic HF
o Fluid within alveoli mixes with air producing the classic sign of pulmonary edema
▪ Frothy pink (blood-tinged) sputum
▪ The large amounts of alveolar fluid create a diffusion block that severely impairs gas
exchange
▪ The results s hypoxemia which is often severe
o Lungs
▪ Pulmonary veins
▪ LV failing

, ▪ Blood backs up into pulmonary circulation, aorta, body
• Dx
o Cardiac monitor
o Labs ABGS, electrolytes, BUN, Creatinine
o CXR
o Abrupt onset of signs of LEFT sided HF & pulmonary edema may occur
• CM
o Restlessness
o Anxious
o Sudden onset of breathlessness
o Sense of suffocation
o Tachypnea
o Noisy breathing
o Skin & mucus membrane pale to cyanotic
o Tachycardia
o JVD
o Incessant coughing
o Increased amts foamy sputum
o Confusion
o stupor
• NI
o Positioning the patient to promote circulation
o Providing psychological support
o Monitoring medications
• Medical
o Diuretics: Lasix
o Vasodilators
▪ Nitroglycerin  relieve s/s
▪ Don’t give to pt with LOW BP monitor closely
o Oxygen NONRB mask




Cardiomyopathy
• Disease of the heart muscle that is associated with cardiac dysfunction.
• Patho
o Series of events that culminate in impaired cardiac output. DCM, HCM, RCM
o Decreased stroke volume (amt of blood pumped by the LV in one contraction) =
end diastolic volume – end systole volume stimulates the sympathetic nervous system
and the renin–angiotensin–aldosterone response,
▪ resulting in increased systemic vascular resistance and increased sodium
and fluid retention, which place an increased workload on the heart.
▪ Sodium is the major electrolyte involved with cardiomyopathy
▪ Cardiomyopathy often leads to heart failure which develops in part from fluid
overload
▪ Fluid overload is often associated with elevated sodium levels
o These alterations can lead to heart failure

Dilated Cardiomyopathy Hypertrophic Cardiomyopathy Restrictive Cardiomyopathy
(DCM) (HCM) (RCM)

• Dilation of one or both • Stiff, fibrotic ventricle
ventricular chambers, • Autosomal dominant genetic with impaired diastolic
reduced contractility, and disorder that leads to filling (Rare form)
low ejection fraction increased heart muscle size • Characterized by diastolic
• Most common form of and mass, along the septum dysfunction caused by
cardiomyopathy rigid ventricular walls
• Muscle tissue shows that impair diastolic
• Thickened wall chambers,
filling and ventricular