Older4/16/14 12:40 PMHeart ValvesMitral valve: between left atria and ventricleAortic valve: between L ventricle and aorta\Ventricular contraction: mitral closes and aortic opensTricuspid: between R atria and ventriclePulmonary: between R ventricle and pulmonary arteryMurmursStenosis: valve opening problemEarly/Late peak sound, hear quiveringInsufficiency/Regurgitation: valve closing problemRegurgitation: sounds the same throughout S1/2, hear splashingInsufficiency: loud after S2

PVD vs. PADPAD (Lower Extremity Arterial Disease)Shiny, pale, cool temperature, capillary refill is greater than 3 seconds, pulses are weak/absent, lack hair, wound necrosis, sharp/stabbing pain, leg ulcers (ischemic)No edemaTissue in bottom of wounds is yellow/grayMost common cause is atherosclerosis, veins usually not affectedPVD (Chronic Venous Insufficiency)Pruritis, Hemosiderin staining (turn bronze on interior aspect of lower leg by medial malleolus due to saphenous vein), warm temperature, normal capillary refill, strong pulses, regular hair distribution, edema, achy/crampy painNo wound necrosisVenous stasis leg ulcersCommon cause is varicose veins, incompetent valves or muscle pump not workingTreatmentPAD: improve perfusion by pharmacological agents, building collateral circulation, revascularizationPVD: Compression therapy, elevate legs above heart, pain management, dermatitis treatment, edema causes lack of oxygenAuscultationLeaning slightly forward in E, supine, LLR positionListen with bell for murmursAsk patient to stop breathing when listening to carotid, should hear nothingCarotid should be synonymous with S1Listen for AV valves at apex of heartJVD: less than 9 cm is within normal limitsVein drains into SVC in R atriaIf see it at 45 degrees in upright patient, have RHFShould not have pulseInspection use tangential lightingXanthelasma (white around eyes) is normal, can indicate hyperlipidemia or atherosclerosisDont want pulsations larger than 1 cm, obliterate by pushing down on medial side of claviclePalpationSitting at 30 degrees, use 4 fingersLateral displacement: LV hypertrophy

CC: current problem + how long theyve been experiencing itCV4/16/14 12:40 PM

Survey of Chest TubeUnkinked tubing, collection device upright and below level of tube insertion, proper equipment (2 clamps in opposite directions, 1 vaseline gauze, 4x4 gauze, new drainage system, sterile water)Check water seal chamber tidaling, suction chamber bubbling, suction set at good levelUsually 20 cm of water, less water=more suctionDrains pleural space (between parietal and visceral membranes of lung), sutured with airtight dressingTubes placed between 2/3 or 8/9 IC, thoracostomyLook for subcu emphysema: palpate to feel rice crispies, document circumference, occurs when air collects due to punctured lung All connections should be taped, assess respiratory status, type/amount drainage*Never clamp except to change unitTypes of TubesWet: 3 tubes (patient, vent, suction), suction chamber is filled with water, water seal chamber prevents air from going back into patient (*always 2 cm water, tidals- rises during I, falls in E with air; no tidaling during suction), collection chamber emptied when full, air leak monitor (bubbles with pneumothorax, stops when resolves)Mini Express: increases mobility, dry suction mechanism (never fill with water, it is preset), for small amount of drainage (500 mL)Pleur X: used in home care for malignant ascites or chronic pleural effusion, fluid drained every 24-48 hours, use very sterile procedure to drainTube InfoCXR ordered to confirm placement, within hour of tube coming out and again in 24 hoursRemoval: assist, pre/post assessment (breath sounds, RR, O2, pain), pre medicatePatient cant breathe when tube comes outDocument: site of CT, amount/type drainage, bubbling/tidaling, subcu emphysema, type/integrity of dressing, pain, pain reliefETEnd before trachea bifurcates into RL bronchi mainstem (2 IC), short term, should not exceed 25 mmHgDo tracheostomy if more than 3 daysTracheostomyReplaces tube, mechanical ventilation, bypasses obstruction/removes secretions, more comfortable, can speak because it goes below larynxSingle/Double outer cannula (with disposable/permanent inner)Uncuffed: no risk of aspiration, no foreseeable need for mechanical ventilationCuffed: necessary to ventilated patients, decreases aspiration risk, prevents air leaksFenestrated: allows speech when cuff is deflated/external hole is covered, prevents aspiration when cuff is inflatedDouble lumen for patients with secretions, easier cleaningAlways suction before deflating cuffPatient can eat with inflated cuffHumidificationHME has none or 28% oxygen, for vented patients or those with ETTTraps moisture from E to use in next ICareVaso-vagal reaction: drops RR and BPStoma and dressing should stay clean/dry, use pre-cut non-raveling dressing, secure trachPPE: goggles, face shieldSpeaking valves (passy-muir): opens on I, air closes valve so it only escapes on ENeed to be alert/responsive, patent airway*Cant be used with ETT with cuffs, DONT inflate cuff of trach tube!Feel pressure in upper airway, deeper/hoarser voiceEmergency equipment: obturator, suction, O, new tubeSuctioningCauses hypoxia so attach to vent, one time use must be changed every 24 h, use PPE so not exposed to secretionsEndotracheal (to end of trach + 1 cm), nasopharyngeal (5-7 inches), oropharyngeal (3-5 inches)Assess before and after: effective cough, lung sounds, O2, RR/depth, signs of distress, history (deviated septum, nasal polyps, nasal injury, swelling, epitaxis/nosebleed), need for pre-medicationTube should be double the size of internal diameterHyperoxygenate, pre-test suctionUnconscious on side, conscious at 30-45 degreesDocument time, pre/post assessment, reason for suctioning, route used, characteristics, amountSputum cultureCan be suctioned or coughed up for Gram Stain/C+SRespiratory4/16/14 12:40 PM

VADs:Peripheral IV, CVAD (non-tunneled, tunneled, implanted port), PICCGauges are 14-24G, 14 is bigger than 24Average is 20, 22 too small for blood transfusionMagma is orange (14), dirt is gray (16), grass is green (18), flowers are pink (20), sky is blue (22), sun is yellow (24)Peripheral IV: most common, short term, for IV fluid/medication, blood productsUse superficial veins of hand/forearm, start as distal as possibleChange site every 72-96 hrsPrimary line is continuous, lock is intermittent; not appropriate for vesicant medicine, TPN, pH 5< or >9, osmolality >600Metacarpal, basilica, cephalicMonitor continuous every hour for right fluid (drug)/dose (rate), tolerance to fluid volume, dressing integrity, flush saline locks (2 mL every 12 hrs, pulsatile or + pressure)Infiltration treatment: remove catheter, elevate extremity and place compress (warm for normal-high pH and cold for low), start somewhere else, document infiltration and treatmentPhlebitis prevention: when in doubt, take it out, dilute infusate, stabilize device, pick right catheter (avoiding mechanical irritation)Chemical irritation: pHDilute for chemical irritation by decreasing infusion rate of piggy backingPhlebitis treatment: remove catheter, warm compress, restart not near phlebitis, document and how treatedExtravasation: infiltration of vesicant drug that can cause blistering, tissue injury/necrosis (chemotherapies vinca alkaloids; catecholamines- dopamine E, NE; gentamycin, mannitol)Risk factors: fragile vessels, locationNecrosis can occur 6+ months later, ulceration 2-3 days to weeksTreatment: stop infusion, attach syringe to IV and aspirate, elevate extremity, notify MD, call pharmacy for antidote, document (medical record, incident/safety report)Apply ice for 15-20 m x 48 hrs for all except vinca alkaloids and catecholamines (heat)Systemic complicationsFluid overload: turn off/slow down rate, speed shock is worse, change to saline lockHTN, increased pulse/RR, JVD, crackles in lungsSepsis: take out IV if occurring there, always see feverAir embolism: leave IV in unless you can see airPulse increases but BP drops, confused, cyanosisIV Therapy4/16/14 12:40 PMSpeed shock: vitals increase, dizzy, flushed face, headache, back pain, hard time breathing

WoundsPut external pressure on wound, then capillary pressure is overcomeProtein helps with angiogenesis, collagen synthesis, supports immune functionDrains put in primary intention woundsDrainsPenrose: passive, placed through stab wound adjacent to incision, not sutured in placeCant go home with it, have to be careful when changing dressing because it could be pinned to drainJP: gentle negative pressure, can have more than 1, sutured in place, empty when half full, maintain sterility50 or 100 mLHemovac: negative pressure, sutured in place through a stab wound, maintain sterilityLarge amounts of drainage (up to 800 mL)Changed when half fullVAC: applied uniform negative pressure along edges of wound, fenestrated tube in foam, occlusive dressing, prevents infection and promotes healingFor stage ulcers, wounds that wont heal easily, traumaticWounds that should not have a VAC are malignant, anaerobic, exposed veins/arteries, anticoagulants, fistulasRemoval: pre-medicateDressingsDSD: put over primary intention or shallow secondarySaline moistened (Wet to dry, wet to moist): promotes healing, clean from center out, pack lightly but completelyFor secondary intentionWet to dry for debridementAssess for tunneling, undermining, color, drainage, tissue, sizeIrrigate wound with NaCl and lactated ringers, medication, enzymesUse 30-35 mL syringe with 1819 g needlePneumatic Compression DevicesCheck CSM and skin every 8 hoursContraindicated: DVT, PAD, severe edema, cellulitis, skin graft, infected extremityPAD: would make it harder for blood to flowDVT: could dislodgeEdema/cellulitis: would compress too much and cause traumaWounds4/16/14 12:40 PMInfection/grafts: need blood flow to heal

Leading causes of death are HD and cancerSubjective health is ability to functionTake medication history, including vitaminsPrioritize problems to restore highest functionMental/Social history is 2nd most important assessment area

Sleep disordersProblems with eatingIncontinenceConfusionEvidence of fallsSkin breakdown