Nursing Competencies Ch 35&40: Oxygenation and Tissue Perfusion Essay Example
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-decreased oxygen carrying capacity: Hgb carries O2 to tissues, anemia and inhalation of toxic substances (carbon monoxide) decrease O2 carrying capacity by reducing the amount of available Hgb to transport O2 -hypovolemia: reduced circulating blood volume, conditions such as shock and severe dehydration cause ECF fluid loss leading to hypovolemia -decreased inspired O2 concentration: w/ the decrease in the fraction of inspired O2 concentration (FiO2), O2 carrying capacity of the blood decreases -increased metabolic rate: increased metabolic activity increases O2 demand, level of oxygenation declines when body systems are unable to meet this demand, not enough blood to supply the demands of the body -conditions affecting chest wall movement: any condition reducing chest wall movement results in decreased ventilation so less O2 is delivered to alveoli and tissues (pregnancy, obesity, trauma)
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physiological factors affecting oxygenation
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-hypoventilation: occurs
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when alveolar ventilation is inadequate to meet the O2 demand of the body or eliminate sufficient CO2 -hyperventilation: state of ventilation in which lungs remove CO2 faster than it's produced by cellular metabolism -hypoxia: inadequate tissue oxygenation
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alterations in respiratory functioning
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-conduction disturbances: caused by electrical impulses that don't originate from the SA node, called dysrhythmias-irregular heart beat -cardiac functional alterations: left sided heart failure-pulmonary congestion, right sided heart failure-systemic congestion -impaired valvular function: hardening (stenosis) or impaired closure (regurgitation) of valves -myocardial ischemia: angina and MI
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alterations in cardiac functioning
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-peripheral arterial disease -venous leg ulcers -venous thromboembolism (VTE/DVT): SED need
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to be on if pt is immobile
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vessel diseases
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-inspiration: rib cage expands as rib muscles contract, diaphragm moves down (contracts); active process -expiration: rib cage gets smaller as rib muscles relax, diaphragm moves up (relaxes); passive process
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ventilation
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certain guidelines and standards that must be met for specific diseases, disease processes that must be reported to the TJC, each one should be treated in a similar fashion -pneumonia: O2 can't get across the secretions to the capillaries and blood doesn't become oxygenated well -heart failure -acute MI -stroke (CVA) -venous thromboembolism (VTE/DVT)
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TJC core measure sets
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-subjective data -objective data -VS -diagnostic tests
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assessment-tissue perfusion (pg. 831)
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subjective -past medical hx: smoker, COPD, asthma, heart failure or MI in the past, lung cancer, stroke, pacemaker, pneumonia, bronchitis -past surgical hx: cardiac surgery, coronary artery bypass graft -chest pain: location; quality-sharp, dull; does it feel like a pressure; rate on scale of 0-10 -fatigue: have you been excessively tired lately; cells aren't getting enough O2 -dyspnea: SOB, DOE-SOB on exertion -orthopnea: can't breath when lying flat (3 pillow orthopnea) -cough: if yes, is it productive? if yes, how much sputum are you coughing up? copious amounts or a little, color and odor of sputum, blood (hemoptosis) -wheezing -allergies: food, seasonal -meds: what they take at home, anticoagulants, Digoxin, inhalers, anit-hypertensives, taking BP meds -infection: any recurrent respiratory infections
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subjective data-tissue perfusion
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1. inspection: work of breathing (WOB), color, barrel chest, IV access, telemetry, supplemental oxygen 2. palpitation: peripheral pulses, capillary refill, edema; point of maximal impulse (PMI)-apical pulse, mitral sounds, 5ICS-MCL (if not in right place heart may be enlarged) 3.
percussion 4. auscultation: cardiac sounds (irregular, murmurs, bruits), lung sounds (crackles, wheezing); normal (S1, S2, ventricular sound) special-assessment of hypoxia (tissue deprived of air) -LOC: restlessness, appear nervous, may become confused later on -capillary refill is slow -skin color and temp: pallor (pale) -respiration: tachypneic at 1st, develop bradypnea later on -respiratory distress: use of accessory muscles, nasal flaring, tracheal tugging (can see the trachea moving), lung sounds, panic/anxiety, VS, early vs late
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objective data-tissue perfusion
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-heart rate and rhythm: tachycardia and bradycardia -respiratory rate and rhythm, work of breathing -pulse oximetry -BP
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vital signs-tissue perfusion
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-blood venous: CBC (done 1st)-are they anemic? shows platelets ability to clot; troponin-measures when heart is damaged, little pieces of heart muscle break off and circulate, troponin tells us if person has had a heart attack, troponin (.2 indicates heart attack) test done 3 times in a row; serum electrolyte (potassium), lipid profile (cholesterol, LDLs, HDLs) -blood arterial: interpretation, compensation occurs -TB (PPD): redness isn't the determining factor, area needs to be raised as well -sputum and culture sensitivity -radiology -bronchoscopy: look into lungs through camera, can see airways, check for tumors, inflammation or sputum in the area -thoracentesis: fluid or air is in the pleural spaces pushing on the lung, tube is put
in to drain fluid or allow air to escape -ECG: picture of electrical activity of heart -echocardiogram: assesses mechanical activity of the heart -cardiac catheterization: done if pt has chest pain, determines if someone has a blockage in coronary artery -pulmonary function test (PFT) or spirometry: tests lung volume and ability to exhale -stress test -imaging: chest X-ray (CXR)-look at size of heart, tumors, diaphragm, used check if central line or tracheal tube are in the right place, detects atelectasis
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diagnostic tests-tissue perfusion
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-*ineffective airway clearance* -ineffective breathing pattern -impaired spontaneous ventilation -*impaired gas exchange* -decreased CO -ineffective tissue perfusion -deficient knowledge -activity intolerance -insomnia -imbalanced nutrition -acute pain -*fatigue* -impaired verbal communication -risk of infection
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nursing diagnoses-tissue perfusion
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-ineffective airway clearance -; NANDA label -r/t: thick, tenacious secretions -; etiology -AEB: PMH of chronic bronchitis, Dx: pneumonia, thick productive cough, copious secretion, "I feel like drowning" -; things identified in pt that made you choose the diagnosis -interventions: increase fluid intake, sit pt up, suction
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nursing diagnosis: ineffective airway clearance
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-impaired gas exchange -r/t: diseased arteries -AEB: PMH of PAD and DM (heart pt), Dx: right below the knee amputation (BKA), peripheral pulse in L foot only found by doppler, L foot cool to the touch, CR;5 sec, "This wound keeps getting worse and worse"
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nursing diagnosis: impaired gas exchange-peripheral
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-fatigue -r/t: decreased O2 carrying capacity -AEB: decreased Hgb/Hct (pt is anemic), pt becomes
exhausted when ambulating to bathroom, "I'm just too tired to shower now" -interventions: space out activities to give pt periods of rest
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nursing diagnosis: fatigue
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-SMART -pt education: "pt will verbalize understanding of the need to increase oral hydration by end of shift: -pt safety: "pt will ambulate around nurses station w/o becoming fatigued" -pt will effectively clear secretions by discharge -pt will have sputum that is thin and clear colored by end of hospitalization
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outcomes/goals-tissue perfusion Ex
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-open the airway -suctioning -chest physiotherapy (CPT) -supplemental O2 -medications/nebulization: adds moisture or meds to inspired air by mixing particles of varying sizes w/ the air, moisture added improves clearance of pulmonary secretions -pulmonary toileting: effective coughing -incentive spirometer: encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume, prevents or treats atelectasis in postop pt -pursed lip breathing: effective due to deep breathing and prolonged expiration -hydration: keeps mucous membranes from drying up -chest tubes: allows drainage of fluid or air (pneumothorax) -oscillating PEP "flutter": positive expiratory pressure, blow into it, sets up a vibration that loosens secretions -pulse oximetry -tobacco addiction protocols
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general nursing interventions-respiratory
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-positioning: sit pt up -oral airway: holds tongue out of the way -nasal trumpet: used w/ awake pt, soft flexible tube passed through nose into upper airway -endotracheal (ET) tube: prevents aspiration, keeps trachea open, cuff at end that inflates w/ air, high risk for ventilator assisted pneumonia (VAP) -tracheostomy: surgical incision through trachea, establishes airway, more
long term, mouth care is important, need to use 4x4 w/ a slit for trach tubes (fenestrated); tracheotomy-stoma 1. outside cannula 2. obturator 3. suctioning-sterile procedure, suction on the way out of tube 4.
tracheostomy care 5. accidental decannulation
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open the airway
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keep at bedside: -2 extra tracheostomy tubes -obturator -O2 source -suction catheter -bag valve mask to hyperoxygenate pt
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tracheostomy
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oropharyngeal/nasaopharyngeal; orotracheal/nasotracheal; tracheal -no more than 15 sec in and out -preoxygenation -sterile technique -rotate catheter -no suctioning on the way down -proper PPE
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suctioning
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-loosens mucus in the airway so that it can be coughed out -for those w/ cystic fibrosis (excessive amount of mucus) -postural drainage: technique for loosening mucus in the airway so that it may be coughed up, head and body angled down - chest percussion: on back and sides, cup hand -vibration: loosens mucus
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chest physiotherapy (CPT)
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-O2 is a medication, need MD order -O2 delivery systems, advantages and disadvantages 1. nasal cannula: 24-44% FiO2 at flow rates of 1-6 LPM (LPM-velocity O2 is traveling) 2. simple face mask: 40-60% FiO2 at flow rates of 5-8 LPM 3.
partial non-rebreather mask w/ reservoir bag: 60-70% FiO2 at flow rates of 6-10 LPM (keep bag inflated) 4. non-rebreather mask: 60-80% FiO2 at 10-15 LPM, highest amount of O2 that can be delivered, be prepared to intubate pt (ET tube) if using this system 5. venturi mask: 24-60% FiO2 at flow rates of
4-12 LPM, can control O2, delivers most precise dose of O2 6. face tent: 24-100% FiO2 at flow rates > 10 LPM, provides high level of humidification 7. noninvasive continuous positive airway pressure (CPAP/BiPAP): patients sleep w/ this at night, sealed around mouth, keeps tissue in the mouth pushed to the sides so obstruction doesn't occur, for people w/ obstructive sleep apnea
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supplemental oxygen (green-O2, yellow-air) (pg.
851)
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-continuous assessment -prevention of complications from O2 supplement -promotion of healing -pt education -respiratory distress -O2 toxicity -O2 induced hypoventilation
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nursing considerations for providing supplemental O2
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upper airway-tracheostomy, neck/face trauma; lower airway-pneumonia, tuberculosis, lung cancer; obstructive lung disease-asthma, COPD, cystic fibrosis; hyperventilation; hypoventilation
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respiratory conditions
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surgical incision through trachea (windpipe) that creates an opening to allow direct access to the breathing tube, a tube is usually placed through this opening to provide an airway and to remove secretions from the lungs
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tracheostomy
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-fluid builds up in the lungs (alveoli), O2 can't get across the secretions to the capillaries and blood doesn't become oxygenated well -TJC core measures: blood cultures before antibiotics (abx) therapy, appropriate abx therapy
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pneumonia
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bacterial infection that can spread through the lymph nodes and bloodstream to any organ in your body, caused by mycobacterium tuberculosis-aerobic bacillus resistant to drying (can live in dried sputum for weeks), body's immune system attacks the mycobacterium w/ macrophages which
engulf the bacteria but can't destroy it, necrosis occurs and the body seals it off creating granulomas in the lungs, TB bacteria causes death of tissue in the organs they infect
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tuberculosis
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an inflammatory disorder of the airway walls associated w/ a varying amount of airway obstruction; lung tissue reacts to factors that stimulate bronchoconstriction, inflammation and swelling of mucous membranes and mucus production (episodes) constrict the airways Interventions: 1. assess 2. supplemental O2 3. medications-breathing Txs (hand held nebulizer) 4.
pt teaching
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asthma
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due to airway obstruction w/ increased resistance to airflow in lung tissues-emphysema, chronic bronchitis 1. similar to asthma 2. pt teaching: smoking cessation, hydration, breathing exercises-pursed lip breathing, nutrition, avoid people w/ pulmonary infections
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COPD
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occurs when alveolar ventilation is inadequate to meet the O2 demand of the body or eliminate sufficient CO2
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hypoventilation
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state of ventilation in which lungs remove CO2 faster than it's produced by cellular metabolism
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hyperventilation
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CO (responsible for perfusion of our tissues)=SVxHR -SV: preload, afterload and contractility -preload: pressure inside ventricle caused by filling (filling vol.) -afterload: pressure against which ventricle must pump to force blood into circulation (pulmonary and systemic pressures -contractility: inherent ability of the force of contraction goal -> perfuse tissues w/ O2, to increase O2 carrying capacity of the blood
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vocabulary-cardiac
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conduction disturbances-dysrhythmias,
CO alterations, alterations in circulating blood, alterations in peripheral vessels, alterations in cerebral vessels
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cardiac conditions
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-conduction disturbances - atrial: superventricular tachycardia (SVT), sinus bradycardia, sinus tachycardia, atrial fibrillation, 3rd degree heart block -ventricular: premature ventricular contractions (PVCs), ventricular fibrillation (Vfib)/ventricular tachycardia (Vtach) -> one leads to another (PVCs to Vfib/Vtach or vice versa)
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dysrhythmias
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assessment -is pt symptomatic? (SOB, diaphoresis, CP) -investigate cause: fever, pain, hypovolemia interventions -O2 supplementation -pt safety -valsalva maneuver: bearing down, don't want pt straining; drops HR -cardioversion: shock heart back to preferred rhythm
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superventricular tachycardia (SVT)
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firing of the sinus node, rate > 100bpm, increased O2 demands on the heart and decreased CO because there's not enough time for heart chambers to fill-not efficient Sx: dyspnea, SOB, syncope, feel like heart is "racing"
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sinus tachycardia
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assessment -symptomatic? (decreased LOC, low O2 output, syncope, hypotension, decreased HR) -investigate cause interventions -O2 supplementation: nasal cannula 2L/min -pt safety
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sinus bradycardia
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assessment -symptomatic? -monitor VS -irregular pulse? -risk for stroke interventions -O2 -anticoagulants -antidysrhythmics
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atrial fibrillation
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assessment -symptomatic? -monitor VS interventions -O2 -ECG (big bad/wide and ugly): QRS complex is wide, concerned when pt has too many -continuous monitoring pt can go into Vfib if beats get too close to T wave, a few are ok, too many is bad (6 or
more per min)
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premature ventricular contractions (PVCs)
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Vtach: heart is pumping but not perfusing well Vfib: heart quivering, no perfusion assess: check pt, LOC-may pass out, pulse: Vtach-may feel pulse, Vfib-no pulse -call code -chest compressions -defibrillation -meds
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Vfib/Vtach
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-assess! VS -BLS if necessary - ensure pt airway -O2 supplementation -12 lead ECG: allows MD to look at heart at several different angles -telemetry: used for patient who are at risk of abnormal heart activity, generally in a coronary care unit, patients are outfitted with measuring, recording and transmitting devices -ensure IV access -pacemaker status/ICD: what is the underlying rhythm? (normal rhythm for pt), atrial, ventricular, implantable cardioverter defibrillation-delivers electrical shock if the heart stops or if HR gets too low -meds -prepare for ACLS (advanced cardiac life support): decision tree/protocol/algorithm for emergency situations, if pt codes the same protocol is used in all hospitals 1. emergency meds-used in code situations 2. defibrillation-when heart is in quivering fibrillation, delivers shock to pt 3.
synchronized cardioversion
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general nursing interventions for conduction disturbances
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heart failure, valvular dysfunction, myocardial ischemia
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CO alterations
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blood is pumped at a reduced vol. due to damaged ventricles or atria-thin walls, muscles of heart are worn out -LHF: causes pulmonary congestion; Sx-crackles, wheezing, tissue hypoxia, hemoptysis (coughing up blood), SOB, dyspnea, coughing, tripod position, barrel chest, use of accessory muscles for breathing -RHF: results from pulmonary disease or chronic LHF, causes systemic congestion, increases
workload of the heart and O2 demand; Sx: weight gain, distended neck veins, congestion in organs, hepatomegaly, splenomegaly and large kidneys due to fluid build up, peripheral edema (feet and legs) -cardiogenic shock: heart can't pump enough blood to meet the body's needs
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heart failure
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interventions-done to decrease workload on the heart -assess: monitor pt for increased BP, respiratory status, peripheral edema, fatigue -O2: supplementation of O2, continuous O2 saturation monitoring -I&Os: so you know how much fluid is going in and coming out of pt, is there a balance? -medications: diuretics, vasodilators-antihypertensives, inotrope-digoxin -fluids: fluid restrictions, decrease Na+ intake, decreased oral and IV intake -daily weights -pt education: reduce weight, diet and lifestyle modification -decrease demand on the heart: schedule rest and activity periods, decrease anxiety -decrease preload: administer diuretic, fluid restriction (IV & PO), Na+ restriction, positioning-set pt up -decrease afterload: vasodilators, antihypertensives -increase contractility: administer inotrope-digoxin -diagnostic tests: BNP (beta natriuetic peptide), CXR, ECG, echocardiogram
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nursing interventions-heart failure
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-discharge instructions -evaluation of LVS function -ACEI (angiotensin-converting-enzyme inhibitor) or ARB (angiotensin II receptor blockers) for LVSD (left ventricular systolic dysfunction) -adult smoking cessation advice/counseling
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TJC core measure-HF
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caused by atherosclerosis, atherosclerosis w/ blood clot, coronary spasm; angina and MI
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myocardial ischemia
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occurs when there's a transient imbalance between myocardial O2 supply and demand, pt experiences pain from the ischemia -stable: predictable, lasts 3-5 min, pain stops when resting, relieved w/ nitroglycerin -prinzmetal's: occurs
at rest, spasm of coronary artery -unstable: caused by the rupture of thickened plaque, angina w/ increased frequency, duration and severity, occurs even at rest, isn't relieved w/ nitroglycerin
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angina
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-assess pain: implement pain scale assessment for CP, have you had this pain before?, pain scale, quality of pain, radiation of pain, what were you doing when pain started? -O2 -diagnostics: ECG, cardiac enzymes (troponin x3 q 6hrs), CBC, chemistry panel, lipid panal, CXR -medications: O2, morphine, nitroglycerin protocol-NTG x3 q 5min prn CP (if pain isn't relieved, seek medical help), antiplatelet therapy, beta blockers, heparin, direct thrombin inhibitors, ACEI -monitor BP -cardiac catheterization (cath lab): allows visualization of the vessels to see whether plaque has occluded the coronary artery before administering NTG, check BP and HR because NTG causes BP to drop, if that happens, the heart tries to compensate by increasing the rate which will increase the workload of the heart
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nursing interventions-myocardial ishemia
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Morphine*-vasodilator, pain reliever Oxygen- Nitroglycerin*-vasodilator Aspirin-antiplatelet properties *work well together
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medications that help relieve symptoms of myocardial ischemia
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women's Sx of MI are different then men's interventions -implement pain scale assessment for CP -O2 supplementation -monitor VS: HR, BP, respiratory rate, temp. -diagnostics (same as ischemia) -percutaneous coronary intervention (PCI): non-surgical procedure performed to open blocked coronary arteries caused by CAD & to restore blood flow to the heart tissue; using a guidewire, a special catheter (long hollow tube) that contains a tiny balloon is inserted into the coronary
artery & past the blockage, when in place, the balloon is inflated, the inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow -smoking cessation medications -ASA -ACEI or ARB -beta blocker -statin
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myocardial infarction
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-ASA on arrival -ACEI or ARB for LVSD -adult smoking cessation advice/counseling -fibrinolytic therapy received within 30 min of hospital arrival -primary PCI received within 90 min of hospital arrival -discharge meds: ASA, ACEI or ARB for LVSD, beta blockers, statin
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TJC core measures-MI
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If there's not enough blood returning to the heart then there's a signal sent from the R atrium to conserve fluid; Kidneys try to compensate for decreased blood flow by increasing HR to keep CO up. If too much volume comes back to the heart, the heart can't handle it and blood begins backing up (like w/ HF) into the circulation causing problems w/ periphery -blood volume (venous return to the heart -> preload -> CO): hypovolemia, hypervolemia -blood pressure: hypertension, hypotension -blood content: anemia, polycythemia, sickle cell disease
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alterations in circulating blood
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-caused by dehydration (loss of water from all fluid compartments), hemorrhage (loss of fluid from intravascular compartment), obstruction at venous end (pregnancy-don't lie on back due to obstruction), decreased vascular tone (shock, not enough fluid is getting back to the heart) interventions -assess and monitor VS O2 -diagnostic tests -orthostatic hypotension -administer IVFs, blood products -invasive monitoring -I&O's -daily weights
-occult blood: hemoccult, gastroccult -meds -pt teaching and pt safety
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hypovolemia
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excessive amount of circulating blood, causes pulmonary edema interventions -assess -O2 -I&O's -daily weights -dietary and fluid restrictions -pt safety and pt teaching -monitor peripheral edema and respiratory status -slow administration of blood or IVFs
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hypervolemia
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these patients usually have comorbid diseases interventions -assess -I&O's and daily weights: monitor these because BP is effected by excessive amounts of fluid -meds -pt education: lifestyle changes, nutrition, smoking cessation, increased activity, home BP monitoring, meds
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hypertension
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orthostatic hypotension: if pt is supine, take BP (take BP when pt is lying flat, sitting up and standing up); a decrease of 20mmHg or more in systolic BP, a decrease of 10mmHg or more in diastolic BP and/or an increase of 20 bpm in pulse interventions -assess -diagnostic tests -orthostatic blood pressures -fluids, blood products -invasive monitoring -I&O's -occult blood -meds -pt safety and pt teaching
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hypotension
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O2 carrying capacity is decreased; put pt on O2 at 2L/min to increase BP, have pt rest interventions -monitor for fatigue -O2 -diagnostics: Hgb, Hct -rest -blood products
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anemia (neutropenia, thrombocytopenia)
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-neutropenic precautions -avoid raw fruits, meats, vegetables -avoid dehydration -PPE (protect pt) -screen visitors: no sick people allowed -hand hygiene -pt and family education -draw WBC count: indicates pt's ability to fight infections (low neutrophil count)
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neutropenia
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-monitor pt for bruises (ecchymosis), petechiae (pinpoint hemorrhages), bleeding from gums/nose, occult blood -prevent injury: use safety razors rather than razor blade, needle sticks bleed longer, wear shoes rather than being bare foot, suppositories -* hold firm pressure after blood draw*: when d/c IVs check if pt is on an anticoagulant because they will bleed a lot
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thrombocytopenia
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increase production of RBCs
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polycythemia
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the body's attempt to avoid malaria (sickle cell disease won't develop if cells are sickled), cells clog circulation and cause a lot of pain -implement pain scale assessment -O2 -pain relief
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sickle cell disease
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peripheral arterial disease and atherosclerosis, venous leg ulcers, venous thromboembolism (VTE)
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alterations in peripheral vessels
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PAD: causes intermittent claudication-pain in the lower extremities; revascularization; Sx-edema and inflammation (red fiery legs), hair loss (no hair on legs) interventions (for both PAD and athero.) -assess, surgeries, hydration, meds, pt safety and teaching PAD/PVD interventions -implement pain scale assessment (intermittent claudication) -monitor LE's (lower extremities) -palpate pulses -check capillary refill -ankle brachial index -wound care: assess how well wound will heal -monitor amputations which are secondary to DM or PVD -monitor blood sugar: keep on tight control to promote optimal level of healing-healing occurs when blood sugar is in normal range, pt is on sliding scale insulin -teaching: avoid standing or sitting in a dependent position -don't cross legs, elevate legs -risk factor modification: smoking
cessation, physical exercise, ideal body weight, tight glucose control, tight BP control, hyperlipidemia
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peripheral arterial disease and atherosclerosis
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interventions -assess: monitor LE's, wounds, VS -compression stockings (Lifetime): not the same as antiembolic stockings, takes the place of incompetent valves and encourages blood to move back up the leg to the heart -wound care: VAC -pt safety -pt education: compression stocking for life, avoid standing or sitting w/ feet dependent for long periods of time, nutrition, weight reduction
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venous leg ulcers
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interventions 1.
assess: identify high risk patients, leg pain, chest pain 2. move you pt: if immobile turn q 2hrs 3. immobile patients -bed exercises -ROM -antiembolic stockings (compression hose) -intermittent/sequential compression devices (SCDs) or Vemodynes: inflates w/ air to accelerate venous return -*anticoagulant therapy* "risk for bleeding" ii. assess for bleeding iii. minimize injections iv. humidification of O2, skin moisturizer v.
don't use electric razors vi. don't move the established clot vii. limit tape application viii. meds and their antidotes-stool softeners ix.
pt education 4. greenfield filter: inferior vena cava filter, catches clots and the imbedded meds dissolve them TJC core measures: VTE prophylaxis, discharge instructions
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venous thromboembolism (VTE)
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1. Enoxaparin (Lovenox): acts similar to Heparin, has low molecular weight compared to Heparin (milder version), half life is much shorter so anticoagulation ability disappears quicker than Heparin which is why it's prescribed a lot in the hospital 2. Heparin: antidote-protamine sulfate (antagonist to Heparin) 3. Warfarin (Coumadin): antidote-Vitamin K (antagonist to Warfarin)
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*anticoagulant
therapy* -drugs
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-transient ischemic attack (TIA): pt has Sxs of stroke for a short period of time -ischemic stroke: clot stops blood supply to an area of the brain -hemorrhagic stroke: rupture of blood vessels, hemorrhage/blood leaks into brain tissue
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alterations in cerebral vessels
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-recognition -LOC: low -gaze: gaze off into space -visual fields -facial palsy -drift in extremities: Ex. may be able to raise one arm but not the other -limb ataxia: lack of muscle control during involuntary movements -sensory -language, dysarthria: difficulty controlling muscles for speech or weakening of muscles -extinction or inattention -distal motor function -diagnostic tests: CT, CTA (angiography), MRI, MRA
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assessment-stroke
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-ineffective airway clearance r/t decreased LOC or decreased/absent gag and swallowing reflexes -impaired swallowing r/t weakness or paralysis of affected muscles -situational low self esteem r/t actual or perceived loss of function and altered body image -decreased intracranial adaptive capacity -impaired physical mobility -impaired verbal communication -unilateral neglect -impaired urinary elimination
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nursing diagnoses-stroke
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-management of HTN -seizure precautions -monitor neuro, VS, VTE, skin breakdown -constipation, incontinence -speech therapy -aspiration precautions -communication needs -sensory: perceptual alterations -psychosocial needs
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interventions-stroke
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-VTE prophylaxis -d/c on antithrombotic therapy -thrombolytic therapy -antithrombotic therapy by end of hospital day 2 -discharged on statin med -stroke education -assessed for rehabilitation
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TJC core measures-stroke
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