High Risk Adult

HIGH RISK ADULT HEART FAILURE Is inability of the heart to maintain adequate circulation to meet the metabolic needs of the body .

Heart Failure – (RSHF) Assessment : Anorexia, nausea, weight gain

Types Left sided heart failure

Pitting edema, bounding pulse, hepatomegaly, cool extremities, oliguria

Right sided heart failure

Elevated CVP, decreased p02,increased SGPT

High output failure

Diagnostics: CXR

Types Left sided heart failure

2-D-ECHO

MI Hypertension Ischemic heart disease

HEART FAILURE[HF] Medical Management

Aortic valve disease

Determination & elimination/control of underlying cause.

Mitral stenosis

Drug therapy: digitalis, diuretics, vasodilators Sodium restricted diet to decrease fluid retention

Heart Failure ( LSHF)

Nursing intervention:

Assessment :

Monitor respiratory status and provide adequate ventilation

Dyspnea, orthopnea, PND, tiredness, muscle weakness, cough Tachycardia, wheezing, rales, cyanosis, pallor Decreased p02, increased pC02

Provide physical & emotional rest Increase cardiac output Reduce/eliminate edema

Diagnostics:

Provide client teaching discharge

CXR 2-D-ECHO

DYSRHYTHMIAS HEART FAILURE[RSHF] Right sided heart failure Left sided heart failure RV infarction Atherosclerotic heart disease

DYSRHYTHMIAS- Sinus node dysrhythmias Sinus tachycardia Heart rate >100 bpm originating in the SA node Cause: Fever, apprehension, physical activity anemia, hyperthyroidism

COPD

Drugs ( epinephrine, theophylline)

Pulmonic stenosis

Myocardial Ischemia , caffeine

Pulmonary embolism High output failure Hyperthyroidism

TX: correction of underlying cause, elimination of stimulant, sedatives, propranolol Sinus Bradycardia

Anemia

Slowed heart rate initiated by SA node

AV fistula

HR <60 bpm

pregnancy

Cause: Excessive vagal or decreased sympathetic tone MI , meningitis , myxedema, well-trained athletes

usually not needed

Hypertensive heart disease , CHD

Cardiac output inadequate : Atropine, isoproterenol Drugs not effective : Pacemaker

TX: digitalis, propranolol,direct current cardioversion Ventricular dysrhythmias

DYSRHYTHMIAS

Premature ventricular Complex ( PVC)

DISORDER IN THE FORMATION OR CONDUCTION OF ELECTRICAL IMPULSES WITHIN THE HEART.

Ventricular Tachycardia

Disruption in the normal events of the cardiac cycle TYPES:

Ventricular Fibrillation Ventricular dysrhythmias

Sinus node dysrhythmias

Premature ventricular Complex ( PVC)

Atrial dysrhythmias Junctional dysrhythmias

Firing of an irritable pacemaker in the ventricles before the next normal sinus impulse reaches the AV node.

Ventricular dysrhythmias

>6/min with normal beat – bigeminy

Conduction abnormalities

In pairs after every third beat – trigeminy

Atrial dysrhythmias

TX:

Premature atrial complex

IV push of Lidocaine ( 50-100mg) followed by IV drip of lidocaine at rate 1-4mg/min

Atrial flutter

Procainamide, quinidine Treatment of underlying cause

Atrial fibrillation Atrial dysrhythmias

Ventricular Tachycardia 3 or more PVC’s in a row

Premature atrial complex

Atrial: 60-100bpm / ventricular 110-250 bpm

“skipped beats or missed beats” Occur when an electrical impulse starts in the atrium prior to the next normal impulse of the sinus node

Maybe unresponsive or pulseless Cause:

Cause

Acute MI, CAD , digitalis intoxication, hypokalemia Nicotine , alcohol , anxiety, low K+ level, hypovolemia, myocardial ischemia

TX: IV push of lidocaine ( 1 mg/kg for dose of 50-100 mg) then IV drip of lidocaine 14mg/min

Atrial dysrhythmias Atrial flutter

Procainamide via IV infusion of 2-6 mg/min Atrial rate 250-400 bpm, ventricular rate 75-150 bpm

Direct current cardioversion

“saw-toothed pattern/shape ( F waves ) usually indicates the presence of organic heart disease

Propranolol (inderal) Ventricular Fibrillation

Cause:

Life threatening Valvular disease, hypertension, cardiomyopathy, hyperthyroidism , moderate to heavy alcohol consumption.

TX: correction of underlying problem, betablockers, calcium channel blocker, amniodarone,digitalis Atrial fibrillation Rapid disorganized and uncoordinated twitching of atrial musculature Different rates radial & apical Rhythm: atrial & ventricular – regularly irregular Cause: Rheumatic – mitral stenosis Thyrotoxicosis, cardiomyopathy

Disorganize ventricular rhythm Absence of audible heartbeat , palpable pulse & respiration Cause: Idiopathic sudden death, electrical shock TX: counter-shock - DEFIBRILLATION Conduction abnormalities First degree atrioventricular(AV) Block Second degree AV Block type I Second degree AV Block type II

Third degree AV block

Severe brain injury

Conduction abnormalities

Dysfunction of the chest wall Musculoskeletal disorder

First degree atrioventricular(AV) Block

Muscular dystrophy

All atrial impulses are conducted into the AV node at a slower rate than normal

Polymyositis Myastenia gravis Second degree AV Block type I

Spinal cord disorder

All but one of a series of atrial impulses are conducted through the AV node. Conduction abnormalities

CAUSES: Dysfunction of the lung parenchyma

Second degree AV Block type II

Pleural effusion

Only some atrial impulses conducted to the AV node

Hemothorax Pneumothorax

Third degree AV block

Pneumonia

No atrial impulse is conducted to the AV node

Status asthmaticus Lobar atelectasis

RESPIRATORY FAILURE

Pulmonary edema

Sudden and life threatening deterioration of the gas exchange function of the lungs 2 types :

RESPIRATORY FAILURE Acute respiratory failure ( ARF)

CRF Causes

Chronic respiratory failure ( CRF)

COPD

ARF –

NEUROMUSCULAR DISEASE

decrease in arterial 02 tension <50 mmHg (hypoxemia) Increase PaC02 > 50 mm Hg ( hypercapnia)

s/sx

pH < 7.35

Early sign : restlessness, fatigue, headache, dyspnea, air hunger, tachycardia & inc. BP

CRF – Deterioration in the gas exchange function of the lung that has developed insidiously after episode of ARF

Late sign: confusion, lethargy, tachycardia, tacypnea, central cyanosis, diaphoresis & respiratory arrest

ARF – Ventilation Or Perfusion Mechanism In The Lung Are Impaired. CAUSES:

RESPIRATORY FAILURE-ARF Decrease Respiratory drive Dysfunction of the chest wall Dysfunction of the lung parenchyma

RESPIRATORY FAILURE-ARF CAUSES: Decrease Respiratory drive Severe hypothyroidism Sedative medication

PE : Decrease Breath sound Medical Mgt: Correct underlying cause Restore adequate gas exchange in the lung Mechanical ventilation (MV) & oxygenation Nursing Mgt:

Assist with intubation Maintain MV

RENAL FAILURE

Care @ ICU ( turning sched, mouth care, skin care, range of motion exercise)

Acute renal failure

Assess respiratory status Monitor level of responsiveness , ABG

Sudden inability of the kidneys to regulate fluid and electrolyte balance and remove toxic products from the body.

pulse oximeter & VS Causes:

Nursing Mgt: Assess patient understanding of the Mgt strategies that are used

Prerenal Interfers with perfusion decrease blood flow & GFR

Initiate form of communication to enable patient to express concern & needs health care team Provides teaching as appropriate to address disorder.

Ex: CHF, cardiogenic shock, hemorrhage, burns, sepsis, hypotension. Intrarenal Cause that damage the nephrons Acute tubular necrosis, DM,AGN, tumor, blood transfusion reaction

ACUTE RESPIRATORY DISTRESS SYNDROME ( ARDS)

Postrenal

Severe form of acute lung injury

Mechanical obstruction ( tubules to urethra) Calculi , BPH , stricture, blood clots, trauma, anatomic malformation

Severe ventilation-perfusion mismatching Assessment:

Assessment : s/sx : sudden & progressive pulmonary edema Rapid onset  severe dyspnea ( 12-48H) Arterial hypoxemia CXR: increase bilateral infiltrates

Oliguric Phase Diuretic Phase Recovery or convalescent phase Nursing intervention

Causes: Smoke inhalation- direct

Monitor & maintain fluid & electrolyte balance

Pneumonia

Promote optimal nutritional status

Drug overdoses Shock – indirect Fluid volume overload Assessment:

Prevent complication from impaired mobility Prevent fever/ infection Support client/ relieve anxiety

Dyspnea, cough, tachypnea with ICS/suprasternal retraction

Provide care for the client receiving dialysis

Changes in orientation, tachycardia, cyanosis

Provide client teaching & discharge

Increased pC02 and decreased p02 hypoxemia Cause of death : Multiple-system organ failure + sepsis

Chronic Renal failure Progressive, irreversible destruction of the kidneys that continues until nephrons are replaced by scar tissue Loss of renal function gradually RENAL FAILURE-CRF

Mortality rate: 50-60% Management Promote optimal ventilatory status Promote rest by spacing activities Maintain fluid and electrolyte balance Treat cause

Assessment: N/V, diarrhea or constipation, decreased Urine output, dyspnea Early – hypotension ; late : hypertension Lethargy, convulsions , Heart failure Diagnostics: Urinalysis

Specific gravity, platelets and calcium decreased

Administer enemas, cathartics, intestinal antibiotics and lactulose as ordered to reduce ammonia levels.

Medical Management:

Protect client from injury

Diet restriction

Avoid administration of drugs detoxified in liver

Multivitamins

Maintain client on bed rest to decrease metabolic demands on liver

Hematinics Aluminum hydroxide gel antihypertensive Nursing Management: Prevent neurologic complication Promote G.I function Monitor fluid & electrolyte & balance

DIABETIC KETOACIDOSIS(DKA) Diabetes Mellitus- DKA Acute complication of DM characterized by hyperglycemia and accumulation of ketones in the body. Occurs in insulin-dependent diabetic clients WHAT HAPPEN??? Decrease glucose utilization

Assess for hyperphosphatemia

Insulin required for the entrance & utilization of glucose by cell.

Promote maintenance of skin integrity

Increased fat mobilization

Monitor bleeding complication, prevent injury to client

Glucose not available fat stores are consumed leading to KETONE FORMATION

Promote/ maintain maximal cardiovascular function

Increased protein utilization

Provide care for client receiving dialysis

HEPATIC Encephalopathy Terminal complication in liver disease

Lack of insulin  protein wasting & higher glucose level Inadequacy of prescribed therapy for DM Precipitating factor: Undiagnosed diabetes

Diseased liver in unable to covert ammonia to urea neurologic toxic symptoms

Neglect of treatment

Cause:

Infection

Cirrhosis

Cardiovascular disorder

GI hemorrhage Uremia Assessment: Early course : changes in mental functioning, insomnia, slow slurred speech, slight tremor, hyperactive reflexes. Progressive :asterixis, disorientation,apraxia,tremor Late: coma, absent reflexes Diagnostics:

Blood glucose level - >350 mg/dl Elevated ketone levels fruity” breath odor Metabolic acidosis HCO3 level less than 10 mEq/L ; CO2 level less than 10 mEq/L Hyperventilation with possible Kussmaul’s respiration pattern Flushed appearance Dry skin , thirst , anorexia, vomiting ( hypovolemia)

Increased serum ammonia level

Drowsiness

PT prolonged

Shock & coma

Decreased Hgb & Hct

Mild hyponatremia , extreme hypokalemia

Nursing intervention: Neurologic assessment and report deterioration Restrict protein in diet, provide high carbohydrate intake and vitamin K supplements.

DKA Diagnostics: Serum glucose and ketones elevated BUN/crea , Hct elevated

sNa decreased , K normal or elevated at first

High mortality rate

ABG : metabolic acidosis

HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNK)

DKA- Nursing intervention

Nursing intervention: Same as DKA except treatment for ketosis & metabolic acidosis

Maintain a patent airway Administer IV therapy as ordered NSS (0.9% NaCl)

THYROID Storm

When blood sugar drops to 250mg/dl may add 5% dextrose to IV

Uncontrolled and potentially life threatening hyperthyroidism caused by sudden and excessive release of thyroid hormone into the blood stream.

K+ will be added when urine output is adequate

Precipitating factors: Stress, infection, unprepared thyroid surgery

Administer insulin as ordered Regular insulin IV drip ( drip or push) or subcutaneously

Assessment finding: Apprehension, restlessness

Monitor blood glucose level frequently

Extremely high temperature, tachycardia, HF, respiratory distress

Check urine output every hour Monitor VS Assist client with self care Provide care for the unconscious client if in a coma Discuss with client the reason for ketosis & provide additional diabetic teaching

Delirium, coma Maintain patent airway and adequate ventilation Administer 02 as ordered Administer medication as ordered Antithyroid drugs Corticosteroids

HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNK)

Sedatives

Complication of diabetes characterized by hyperglycemia and a hyperosmolar state without ketosis.

Cardiac drugs

Occurs in non-insulin-dependent diabetics or nondiabetic persons HHNK

ADRENAL CRISIS

Precipitated by physical stress , infection For Non-diabetic due to tube feeding with supplemental water Too rapid rate of infusion for parenteral nutrition

ADRENAL CRISIS- ADDISONIAN CRISIS

Serum glucose 600 to 2,400 mg/dL

Life threatening if untreated

Slight drowsiness, insidious stupor, or frequent coma

CBR

Polyuria for 2 days to 2 weeks before clinical presentation Absence of hyperventilation, no breath odor

Condition characterized by severe hypotension, shock, vasomotor collapse and coma

Avoid stimuli

Extreme volume depletion (dehydration, hypovolemia)

High dose of hydrocortisone

Occasional gastrointestinal symptoms

Treat shock ADRENAL CRISIS

Failure of thirst mechanism, leading to inadequate water ingestion CNS symptoms (disorientation, focal seizures) HCO3 level greater than 16 mEq/L ; CO2 level normal

Nursing intervention: Administer IV fluids ( D5NSS) as ordered

Usually normal serum potassium

Administere IV glucocorticoid (hydrocortisone-solu-cortef) and vasopressor

Hypernatremia

If crisis precipitated by infection, administer antibiotic as ordered

Ketonemia absent

Maintain strict bed rest and eliminate all forms of stressful stimuli

Lack of acidosis

Nursing intervention:

Monitor vs, I&O, daily weights Protect client from infection Provide client teaching and discharge planning Life long replacement therapy- never omit medication Need to avoid stress & trauma & strenuous exercise Diet modification- high in protein, carbohydrates and sodium) Use of salt tablet or ingestion of salty food- increase sweating Alternate regular exercise with rest period MULTI-SYSTEM ORGAN FAILURE