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b. Infective endocarditis c. Myocarditis d. Pericarditis e. Valvular disease f. Heart failure 3. Describing the diagnostic results used to confirm the diagnosis of cardiac disorders 4. Discussing the interprofessional management of: ESSENTIAL TERMS Acute coronary syndrome Angina

coronary angioplasty (PTCA) Pericardial effusion Pericardiocentesis Pericarditis Prinzmetal’s/variant angina Pulmonary edema Orthopnea Regurgitation Stable angina Stenosis Tamponade Transcatheter aortic valve replacement Unstable angina

Cardiac

Maximize oxygenation and promote comfort l Medication administration as ordered: • Administer diuretics. Diuretics decrease volume, thus preload. • Administer ACE inhibitors, ARBs, ARNIs, and vasodilators. Angiotensin-converting enzyme inhibitors, ARBs, ARNIs, and vasodilators decrease afterload, which helps to decrease the workload on the heart and decrease myocardial oxygen consumption. • Administer beta blockers. Beta blockers decrease the sympathetic response (heart rate), thus reducing myocardial oxygen consumption. • Administer inotropic agents. Enhance contractility • Administer sodium glucose cotransporter 2 inhibitors (STGLC2i) Promote fluid excretion l Fluid and sodium restriction To prevent fluid overload ■ Teaching l Medication management Understanding and adhering to the medication treatment plan are essential for effective medication treatment. l Maintain activity as tolerated. Alternate rest and activity periods. To reduce muscle wasting and functional losses; to decrease workload on the heart l Low-salt diet To prevent fluid retention and exacerbation of HF l Daily weight at home at the same time each day, preferably in the morning after voiding Evaluate fluid retention and need to call provider l Cardiac rehabilitation l Oxygenation l Perfusion Aortic stenosis Atherosclerosis Cardiac rehabilitation Compensatory mechanism Coronary artery bypass graft (CABG) Coronary artery disease (CAD) Ejection fraction Embolization Exercise stress test Friction rub Heart failure Infective endocarditis (IE) Ischemia

tions due to even small changes in fluid status, salt intake, or being exposed to common ailments such as a cold. Reducing stressors that can lead to exacerbations is key. Successful management requires collaboration with the patient and family and the interprofessional team (phy- sician, pharmacist, respiratory care therapist, dietitian, diagnostic technicians, social workers, and palliative care) to develop and implement a treatment plan. That plan should include frequent assessment, comprehensive patient education, and self-management. A well-managed patient has reduced dyspnea and fatigue, is able to actively participate in activities of daily living, and has reduced hospitalizations. rehabilitation Compensatory mechanism Coronary artery bypass graft (CABG) Coronary artery disease (CAD) Ejection fraction Embolization Exercise stress test

ING OUTCOMES this chapter is designed to assist in: g the epidemiology of cardiac disorders g clinical manifestations to pathophysiological processes of: ry artery disease e endocarditis ditis ditis r disease ailure g the diagnostic results used to confirm the diagnosis of cardiac

Murmur Myocardial tissue Myocarditis Percutaneous transluminal coronary angioplasty (PTCA) Pericardial effusion Pericardiocentesis Pericarditis Prinzmetal’s/variant angina Pulmonary edema Orthopnea Regurgitation Stable angina Stenosis Tamponade Transcatheter aortic valve replacement Unstable angina

a. Coronary artery disease b. Infective endocarditis

STEP #1 Build a solid foundation. CONCEPTS c. Myocarditis d. Pericarditis e. Valvular disease f. Heart failure 5. Developing a comprehensive plan of nursing care for patients with cardiac disorders 6. Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with cardiac disorders TEXT

Friction rub Heart failure Infective endocarditis (IE) Ischemia

Making Connections

g the interprofessional management of: ry artery disease e endocarditis

CASE STUDY: WRAP-UP Mr. Thompson’s ECG reveals atrial fibrillation with a heart rate of 130 to 140 bpm. His blood pressure continues to be high at 185/102 mm Hg. His respirations are still slightly labored and fast at 40 per minute. He continues on oxygen at 4 L/min via nasal cannula, with an oxygen saturation of 95%. The results of Mr. Thompson’s diagnostic tests reveal the following: • A chest x-ray indicates LV hypertrophy. • A transthoracic echocardiogram indicates an EF of 30%. • Cardiac biomarkers are negative for ischemia, with troponin I less than 0.1 ng/ml. • Renal function tests reveal borderline failure, with a creatinine of 1.5 mg/dL and a BUN of 30 mg/dL. • His BNP value is elevated to 500 pg/mL. • Serum electrolytes reveal elevated potassium at 6.0 mEq/L. It is determined that Mr. Thompson is in HF, and he begins treat- ment. A diuretic is administered; an ACE inhibitor and a beta blocker are ordered. His SOB and color begin to improve. His transient chest pain resolves with treatment. Case Study Questions 1. The nurse has received the following orders for Mr. Thomp- son. Which order should the nurse implement first? A. Furosemide (Lasix) 40 mg IV B. Insert a Foley catheter C. Low-sodium, low-fat diet D. Apply sequential compression device 2. The nurse correlates which finding with Mr. Thompson’s atrial fibrillation with a heart rate of 120 to 140 beats per minute? A. Acute decompensation requiring immediate cardioversion B. Loss of atrial kick requiring fluid resuscitation C. Increased workload of the heart requiring beta blockers D. Cardiac ischemia requiring immediate cardiac catheterization 3. The nurse understands that Mr. Thompson’s sublingual nitro- glycerin decreases chest pain through which mechanism of action? A. Dilating the coronary arteries to improve blood flow B. Decreasing preload to relieve symptoms of dyspnea C. Decreasing heart rate to decrease cardiac workload D. Converting atrial fibrillation into sinus rhythm 4. Which statement by Mr. Thompson indicates that teaching about hyperkalemia has been effective? A. “The water pill makes my potassium level high.” B. “I should eat bananas because they make my potassium go down.” C. “My liver is not working, so it holds on to the potassium.” D. “My kidneys are not working, which makes my potassium high.” 5. The nurse providing care for Mr. Thompson should include which of the following in the discharge teaching plan? (Select all that apply.) A. Sodium restriction B. Daily weight

ditis ditis r disease ailure ng a comprehensive plan of nursing care for patients with cardiac

l Caring l Infection l Inflammation

a teaching plan that includes pharmacological, dietary, and lifestyle tions for patients with cardiac disorders

Finding Connections

being nonadherent with his meds because “I feel okay.” He reports he was in his usual state of health until about 3 weeks ago. At that point, he reports feeling short of breath and fatigued unrelated to physical activity. Over the past 3 weeks, his symptoms have pro- gressed to the point where he sleeps in his recliner every night. He is admitted to the step-down unit for further management.

PTS

l Oxygenation l Perfusion

Cardiac rehabilitation reduces mortality, improves functional status, reduces hospitalization, and improves quality of life. l Signs and symptoms of worsening HF checklist (edema, SOB, fatigue, and orthopnea) Knowing the symptoms can expedite treatment and reduce hospitalizations. l Immunization needs Patients with HF are vulnerable to communicable diseases such as influenza, COVID, and pneumonia. being nonadherent with his meds because “I feel okay.” He reports he was in his usual state of health until about 3 weeks ago. At that point, he reports feeling short of breath and fatigued unrelated to physical activity. Over the past 3 weeks, his symptoms have pro- gressed to the point where he sleeps in his recliner every night. He is admitted to the step-down unit for further management. CASE STUDY: EPISODE 1 Follow this patient throughout the chapter. Mr. Walter Thompson is a 57-year-old man with no significant past medical history except high blood pressure. He admits to ..

ion

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Unit VI Promoting Health in Patients With Circulatory or Perfusion Disorders

g Connections

628

Complications The primary complication of CAD is ACS, which includes unstable angina and MI. Myocardial infarction is discussed in detail in Chapter 32. Coronary artery disease may also result in dysrhythmias and heart failure. Women and other vulnerable populations, such as persons from rural areas, persons with low socioeconomic status, and persons from underserved areas, have higher rates of adverse outcomes from CAD in general. These outcome differences have been attributed to healthcare provider biases such as gen- der and race, limited access to healthcare facilities and resources, delays in seeking care, limits in the diagnosis and treatment of nonobstructive CAD, and increased risks related to social determinants of health. Connection Check 30.1 After a percutaneous coronary angioplasty, what assess- ment should most concern the nurse? A. Back discomfort B. Chest pain C. Capillary refill of less than 3 seconds D. Hypoactive bowel sounds 4736_Ch30_628-657.indd 628 Connection Checks test your mastery of the chapter content.

l Pain assessment utilizing provoking factors, quality, region/radiation, severity, time (PQRST) Angina can be nonspecific in some patients; establishing lo tion and quality can aid in the diagnosis of cardiac chest p and disease progression. Headache can result from nitrogl erin administration. l Electrocardiogram and continuous cardiac monitor Depressed ST segment or flat or inverted T waves are ind ative of ischemia; ST elevations are indicative of acute inju Cardiac dysrhythmias may result from ischemia or infarct l Physical assessment Pallor, clamminess, nausea, vomiting, shortness of breath, and diaphoresis may indicate cardiac ischemia. Xanthoma raised, waxy, yellowish skin discolorations, are associated with hypercholesterolemia. l Patient history Evaluate CAD risk factors and anginal patterns. Fatigue and weakness may be indicative of CAD. Identify potentia noncardiac causes of chest pain, such as gastroesophageal reflux or respiratory disorders. l Recreational drug use Illicit drug use (i.e., cocaine) can cause vasospasm, obstruc ing blood flow and causing symptoms that resemble CAD. l Depression screening Depression may increase morbidity and mortality. l Laboratory values • Cardiac biomarkers: troponin Troponin levels (a protein released into the bloodstream when there is cardiac muscle damage) rise when the hea sustains an acute injury. Troponin can help differentiate between angina and MI pain. • Creatinine, blood urea nitrogen Assess renal function. The contrast dye used during hea rounding the manifestation include an e cardiac comp resonance im pain control ties include p of treatment of pericardia priorities inc heart attack t appropriately CHAPTER SUMMARY 05/04/23 4:58 PM 656 Unit VI Promoting Health in Patients With Circulatory or Perfusion Diso factors for C are used to r ing CAD is a with CAD is ping the agg endothelium of the endoth neous translu most commo care prioritie and administ factors and r understandin lifestyle to lim Infective e of the innerm heart valves transthoracic ing the prese IV antibiotic biotic therap ment. Nursin especially for of ongoing a nance of goo provider abo procedure. Myocardit dium most co mune disease dysrhythmias failure. Medi heart failure that may occ includes med Pericardit C. Medication teaching D. Vigorous daily exercise E. Carbohydrate counting Making Connections to Clinical Judgment 1. Recognizing Cues: What clinical findings of heart failure does Mr. Thompson have? 2. Analyzing Cues: How do the physical findings relate to the pathophysiology of heart failure? 3. Prioritizing Hypotheses: What are the highest priority findings that need to be addressed? Why? 4. Generating Solutions: What interventions would best address Mr. Thompson’s respiratory needs? 5. Taking Actions: What are the nursing intervention priorities? 6. Evaluating Outcomes: What are the findings related to fluid balance that would indicate an effective response? 05/04/23 4:58 PM 05/04/23 4:58 PM

STUDY: EPISODE 1 atient throughout the chapter.

er Thompson is a 57-year-old man with no significant al history except high blood pressure. He admits to

Case Studies help you make the connections. Finding Connections introduces a patient related to the chapter content. Follow the scenario as it unfolds throughout the chapter, illustrating key points and bringing the content to life. Making Connections provides a wrap-up of the case and concludes with questions to apply what you’ve learned. 4736_Ch30_628-657.indd 655

Nursing Management Assessment and Analysis Making Connections to Clinical Judgment presents questions aligning the case study to the six steps of the NCSBN Clinical Judgment Measurement Model to build your clinical judgment skills and prepare for the Next Gen NCLEX®. Suggested answers can be found online on Davis Advantage. Careful assessment of chest pain and other manifestations of CAD is required to identify those patients with CAD and those patients who have stable angina that may be progress- ing to ACS. The clinical manifestations of CAD are the result of the imbalance of oxygen supply and demand to the myocardial tissue. The most common symptom is chest pain.

very low doses to reach therapeutic levels, whereas oth- ers require very high doses. Pharmacogenetics is the study of how a person’s genes affect responses to med- ications. With scientific advances, genetic testing can now be used to determine responsiveness. In the case of warfarin, some patients are genetically fast metaboliz- ers, which can result in an increased risk of clotting and the need for higher or more frequent doses. In contrast, slow metabolizers have an increased risk of bleeding and require lower or less frequent doses. Patients who are fast or slow metabolizers may also respond similarly to other types of medications. Pharmacogenetic testing is not widely used due to availability, clinician knowledge, and regulatory and reimbursement issues, but it may be valuable. sants such as corticosteroids, azathioprine, cyclosporine, and methotrexate and immunotherapies such as immuno- globulin G (IgG) may be used but have limited supporting evidence. Complications Myocarditis is the most frequent cause of dilated cardio- myopathy. Heart failure, cardiogenic shock, and dysrhyth- mias, including sudden cardiac death, especially in young persons, are also complications. Nursing Management Assessment and Analysis Clinical manifestations of myocarditis, such as SOB, chest pain, fatigue, and dysrhythmias typical of the manifesta- tions of heart failure, are due to the weakened or damaged heart muscle. Nursing Diagnosis/Problem List l Risk for decreased cardiac output related to myocar- dial dysfunction l Pain l Dysrhythmias Nursing Interventions ■ Assessments l Vital signs Hypotension, hypertension, tachycardia, tachypnea, and hypoxia are signs of heart failure. Fever is indicative of infection. l Cardiac rhythm Dysrhythmias are a common and dangerous clinical manifes- tation and must be identified and treated promptly. l Assess for crackles, edema, jugular vein distention (JVD), weight gain, and decreased urine output. These are evidence of the weakened heart muscle seen with heart failure. ■ Actions l Administer antivirals, antimicrobials, immunosuppres- sives, and immunoglobulins as ordered. Medications are administered depending on the cause of myocarditis. l Administer heart failure medications as needed. Heart failure is a common manifestation and must be treated to optimize cardiac output and tissue perfusion. l Provide emotional support. The diagnosis of myocarditis can cause fear and anxiety. ■ Teaching l Complete the full medication treatment regimen. Patients should continue to take medications as directed even if feeling better to ensure an effective/positive result. l Avoid strenuous activities. Athletes should not par- ticipate in competitive sports while inflammation is present and need to be reevaluated in no less than 3 to 6 months before resuming sport. Activity restrictions may reduce the risk of sudden cardiac death. Nursing Diagnoses/Problem List 633

05/04/23 4:58 P Pathophysio The heart is su which protects structures, and sure. The toug dium; the inner The space betw pericardial flui friction betwee becomes inflam The primary go reducing the s diomyopathy a patient is free o able to tolerate PERICARDI Epidemiolog Pericarditis , i nosed in about and 5% of em pain not related pathic (unknow a viral infectio MI, occurring The true prev mine because p seek treatment more in male persons. Recur persons having categorized as sitic), noninfec trauma, drug o carditis can als rent. The prog mortality rate o Clinical Man The most com pleuritic chest and can be dif tends to be re and worsens w scratchy sound auscultated in assess for a fr include the foll l New or wors l ECG change depression (6 l Low-grade f

ers are also prescribed in ACS management. Treatment for nonobstructive CAD is being studied. Statins, angiotensin- converting enzyme (ACE) inhibitors, and beta blockers may be beneficial.

Safety Alert

Medication Safety Alert: Nitroglycerin

Nitroglycerin is a treatment for angina. Patients should be instructed to take this medication as prescribed, typically one tablet or spray under the tongue not to exceed three doses taken 5 minutes apart. If the symptom of angina (chest pain) is not relieved with three doses or if the pain worsens, they should be instructed to call emergency personnel. In addition, patients using medications such as sildenafil citrate (i.e., Revatio, Viagra) should be educated on the increased risk of hypotension with coadministration with nitroglycerin.

A more invasive surgical treatment is coronary artery bypass grafting (CABG) . With CABG, blockages in coronary arteries are bypassed using other arteries from the chest or arm or veins from the legs. In the traditional CABG, patients undergo general anesthesia. A large inci- sion through the sternum is made, and a cardiopulmonary bypass (CPB) is begun through large catheters in the vena cava or right atrium and aorta. A CPB provides continuous

Safety Alerts focus on potential hazardous or high-risk issues. Percutaneous transluminal coronary angioplasty (PTCA) is the procedure most commonly performed to relieve symptoms caused by atherosclerotic changes in the coronary vessels. During this procedure, after the patient receives monitored anesthesia care (MAC), a catheter

Nursing Management provides clear and well-defined nursing care guidance to help you to understand the nurse’s role. Begin with scientific explanations for presenting clinical manifestations, then follow the nursing process to prioritize care. For easy reference, Nursing Interventions are formatted into Assessments , Actions , and Teaching categories with bulleted rationales that explain the ‘hows’ and ‘whys’ of treatment.

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Chapter 30 Coordinating Care for Patients With Cardiac Disorders

Table 30.2 Medications Used in the Treatment of Coronary Artery Disease

Medication Classification

Mechanism of Action

Exemplars

Nursing Implications

HMG-CoA reductase inhibitors (statins)

Atorvastatin (Lipitor) Simvastatin (Zocor)

Monitor: l Cholesterol levels l For side effects such as muscle pain, cramping, and weakness. Severe side effects include liver failure and rhabdomyolysis. Monitor: l Liver function l Urine output amount and color l Myoglobin levels Administered via subcutaneous injections every 2–4 weeks. An alternative for patents who cannot take statins. Teach self-administration technique. Monitor: l Cholesterol levels l For side effects such as back pain, cold/flu symptoms

Statins reduce cholesterol synthesis in the liver and increase clearance of LDL from the blood.

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(Statins)

Medication Tables outline the medications used in the treatment of disorders, detailing Medication Classification , Mechanism of Action , Exemplars , and Nursing Implications .

PCSK9 inhibitors

Evolocumab (Repatha)

Increase LDL breakdown by blocking the action of a protein that destroys receptor cells in the liver that aid in eliminating cholesterol

Uncorrected page proofs may vary upon publication.

Cholesterol absorption inhibitors

Inhibit the absorption of cholesterol through the small

Ezetimibe (Zetia)

Monitor:

Cholesterol levels

LEARN STEP #2

Make the connections to key topics.

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Unit VI Promoting Health in Patients With Circulatory or Perfusion Disorders

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Chapter 30 Coordinating Care for Patients With Cardiac Disorders

Pathophysiology Infective endocarditis is defined as an infection of the innermost layer of the heart, the endocardium, most typ- ically affecting the heart valves. Infective endocarditis begins with damage to the endocardial lining of the heart, which can occur as a result of turbulent blood flow. Tur- bulent blood flow is often caused by valve dysfunction. Platelet and fibrin deposit onto the injured area, forming what is known as a nonbacterial thrombotic endocardial lesion . Microorganisms introduced into the bloodstream through patient exposures circulate and can become trapped under the layers of platelet and fibrin deposits. These microor- ganisms and deposits grow into clumps known as vegeta- tion . This vegetation can severely damage the valves of the heart (Fig. 30.4). The etiology of IE is generally of bacterial origin, although other pathogens have been reported. The most common causative microorganisms are Staphylococcus aureus and Streptococcus . Infective endocarditis can also be caused by other bacteria, viruses, and fungi. The source of expo- sure to microorganisms in the blood has been historically linked to dental and other invasive procedures. However, it has been suggested that repeated exposures to microor- ganisms are more likely to cause IE than random exposure during a single dental or other invasive procedure. Clinical Manifestations Clinical manifestations of IE include red, painful nodes in the pads of the fingers and toes—Osler’s nodes—and red, painless spots on the palms and soles, called Janeway lesions. Splinter hemorrhages, tiny blood clots that run vertically under nails, may also be present . Most patients have a heart murmur , the sound heard when there is turbulent blood flow across a heart valve. They can also experience heart

failure (HF), arrhythmias, weight loss, or night sweats. Other symptoms are similar to those of any infectious pro- cess, such as the following: l Fever l Fatigue l Confusion (in older adults) Interprofessional Management Medical Management Diagnosis Diagnostic Tests Tests used to confirm the diagnosis of IE are blood cul- tures, two sets from different sites, and transthoracic echo- cardiogram (TTE) or transesophageal echocardiogram (TEE). Echocardiography can identify valve dysfunction, vegetative growth, abscesses, and changes in heart size and pumping ability that can occur with IE. Echocardiogra- phy is described in more detail in Chapter 28. An elevated white blood cell count may also be indicative of infection. Medications Medication management consists primarily of IV antibi- otic therapy. The increasing trend of microbial resistance has led to the use of combination therapy. The standard duration of treatment is 4 to 6 weeks but may be longer for prosthetic valves. Patients are often discharged to home on IV antimicrobial therapy. Shorter duration is recom- mended for some combination therapies. Oral antimicro- bial agents are rarely used as initial treatment. Repeated blood cultures may be obtained until results are negative, indicative of adequate bactericidal effects. Prophylactic use of oral antibiotics is not routinely recommended but is used for patients at high risk (see Safety Alert). The choice of antimicrobial agents is complex and based on the organism cultured and the sensitivity report,

right-sided versus left-sided IE, native versus prosthetic valve involvement, patient comorbidity, and other factors. Infectious disease specialists are often consulted. Penicillin G, ceftriaxone, vancomycin, ampicillin, daptomycin, and gentamicin may be considered in various combinations for the treatment of IE. Supportive treatment for the common complications of IE, especially HF, is also indicated to optimize cardiac output and tissue perfusion.

typically seen in the hands and feet, are due to infection. Sepsis can occur in conjunction with IE. Septic emboli can alter CNS and systemic perfusion. The damage to the heart valves can cause a new murmur and heart failure. Nursing Diagnoses/Problem List l Infection related to an invading organism secondary to IE l Ineffective tissue perfusion related to emboli l Decreased cardiac output related to valve dysfunc- tion, altered rhythm, and/or altered stroke volume l Fever l Fatigue Nursing Interventions ■ Assessments l Vital signs Fever is indicative of ongoing acute infection. Hypotension, tachycardia, tachypnea, and low SpO 2 can be signs of sepsis or heart failure. l Auscultate breath sounds. Crackles may be a sign of heart failure related to valve dysfunction. l Auscultate heart sounds. A new or worsening murmur may occur due to valve damage. l Assess neurological function. Neurological changes or deficits in pupils, grips, foot pushes, facial droop, and speech may be signs of CNS embolization. l Assess extremities. Cyanosis or pallor, delayed capillary refill, and decreased peripheral pulses may indicate peripheral embolization. Edema could be a sign of heart failure related to valve dysfunction. l Skin assessment Osler’s nodes, Janeway lesions, and splinter hemorrhages are indicative of IE. l Monitor diagnostic test results. Repeated culture reports are used to evaluate the effective treatment of IE. White blood cell (WBC) counts can indicate responsiveness to infection. Echocardiograms can evaluate the size of vegetation and valve function and can be used to predict the risk of complications. l History of drug use, invasive procedures, implanted vascular or cardiac devices, or valve replacement surgery Common risk factors for IE ■ Actions l Administer antibiotics as prescribed. Treatment for IE is long-term IV antibiotic treatment. l Maintain IV access for antibiotic administrations. Intravenous access is essential for antibiotic administration. Long-term venous access, such as a peripherally inserted central catheter (PICC), may be considered. l Administer heart failure medications as needed. Heart failure treatment optimizes cardiac output and tissue perfusion.

Safety Alert

Routine antibiotic prophylaxis is no longer recommended for patients who

have mechanical or bioprosthetic valves for the pre- vention of IE because this contributes to antimicrobial resistance and has not been proven to reduce infection risk. Prophylactic antibiotics are recommended before genitourinary procedures or in high-risk patients such as those with active infections or who may be immunosup- pressed. Meticulous oral hygiene should be encouraged for patients at highest risk, such as those with a history of IE, intracardiac prosthetic material such as valves and defect closure devices, cardiac transplant, and congenital heart disease. Surgical Management The surgical treatment options for IE include valve repair or replacement. Surgery can remove infected tissue and reduce mortality and complications, but it also has sig- nificant risk. Recent evidence suggests that early surgery within the first 7 days has reduced mortality, embolisms, and recurrence when compared to delayed surgery. Complications Embolic events are the major complication of IE and occur in 22% to 50% of cases. Embolization occurs when frag- ments of vegetation break free from the valve and travel to other parts of the body through the bloodstream. Embolic events are often a complication of left-sided IE and are rarely seen in right-sided IE. The emboli can travel ran- domly to any organ or tissue, resulting in obstructed blood flow and potential spreading of infection. Emboli from left-sided IE typically travel to the central nervous system (CNS; 65%) but can also affect the kidneys, spleen, bowel, and extremities. Emboli traveling to the CNS cause tran- sient ischemic attacks or strokes. Right-sided IE is associ- ated with pulmonary emboli. Heart failure and dysrhythmias can also occur due to valvular dysfunction and abscesses in the conduction sys- tem. Strokes, heart failure, and dysrhythmias can be a part of the presenting symptoms of IE because they compel

Vegetation

Left atrium

Mitral valve

patients to seek treatment. Nursing Management Assessment and Analysis

Left ventricle

The clinical manifestations of IE, such as positive blood cultures combined with fever, fatigue, and the lesions

FIGURE 30.4 Mitral valve vegetation in infective endocarditis.

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Post-Assessment for COPD

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Vital Signs

antihypertensive

The nurse is caring for a 52-year-old client coming to the emergency department with peripheral edema, periorbital edema, flank pain, and shortness of breath. The nurse is preparing to notify the provider of the client’s status. Complete the below using the dropdown choices.

MEDS2-RDC-16

Renal Disorders

Immediate Feedback with comprehensive rationales explains why your responses are correct or incorrect. Page-specific references direct you to the relevant content in your text, while Test-Taking Tips improve your test-taking skills.

Clinical Judgment, Elimination, Fluid and Electrolytes, Oxygenation Perfusion

Evaluation [Evaluating]

Chapter 62: Coordinating Care for Patients with Renal Disorders

Vital Signs

pp. 1452-1459

antihypertensive

Rationale: The client is demonstrating signs of acute kidney injury, oliguric phase. This is identified by low urine output, edema, shortness of breath, hypertension, hyperkalemia, elevated BUN/creatinine, anemia, and hyponatremia. It is anticipated that this client has a compromised GFR due to risk factors of poorly controlled diabetes and reoccurring UTIs. The risks for developing acute kidney injury include infection and medications. Fever, elevated WBCs, flank pain are signs of a kidney infection, and extended to excessive use of NSAIDS will impair kidney function, leading to injury. In evaluating the client data, the nurse should be most concerned about the changing vital signs, including a rising temperature, heart rate, respiratory rate, and blood pressure, as the SpO2 decreases. This indicates a deterioration of oxygenation and perfusion. Priority medical management is the delivery of oxygen and an antihypertensive to prevent tissue hypoxia and stroke. The nurse should also notify the provider about the hyperkalemia, hyperglycemia, anemia, renal impairment shown in the lab results, and the assessment findings of oliguria, edema, crackles, and bounding pulses.

Navigate the EHR trends by looking at how the cues presented relate to each other. Make the connection between the information to reach priority conclusions.

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Table of Contents

Unit I Professional Founda2ons of Medical-Surgical Nursing 1. Founda)ons for Medical-Surgical Nursing 2. Interprofessional Collabora)on and Care Coordina)on 3. Cultural Considera)ons 4. Ethical Concepts 5. Pallia)ve Care and End-of-Life Issues Unit II Clinical Principles of Medical-Surgical Nursing 6. Geriatric Implica)ons for Medical-Surgical Nursing 7. Oxygen Therapy Management 8. Fluid and Electrolyte Management 9. Acid-Base Balance 10. Overview of Infusion Therapies 11. Pain Management 12. Complementary and Alterna)ve Care Ini)a)ves 13. Overview of Cancer Care 14. Overview of Shock and Sepsis*

Unit III Managing the Surgical Experience 15. Priori)es for the Preopera)ve Pa)ent 16. Priori)es for the Intraopera)ve Pa)ent 17. Priori)es for the Postopera)ve Pa)ent Unit IV Promo2ng Health in Pa2ents With Immune Disorders 18. Assessment of Immune Func)on 19. Coordina)ng Care for Pa)ents With Immune Disorders 20. Coordina)ng Care for Pa)ents With Connec)ve Tissue Disorders 21. Coordina)ng Care for Pa)ents With Mul)drug-Resistant Organism Infec)ous Disorders 22. Coordina)ng Care for Pa)ents With HIV Unit V Promo2ng Health in Pa2ents With Oxygena2on Disorders 23. Assessment of Respiratory Func)on 24. Coordina)ng Care for Pa)ents With Infec)ous Respiratory Disorders 27. Coordina)ng Care for Cri)cally Ill Pa)ents With Respiratory Dysfunc)on* Unit VI Promo2ng Health in Pa2ents With Circulatory or Perfusion Disorders 28. Assessment of Cardiovascular Func)on 29. Coordina)ng Care for Pa)ents With Cardiac Dysrhythmia 30. Coordina)ng Care for Pa)ents With Cardiac Disorders 31. Coordina)ng Care for Pa)ents With Vascular Disorders 32. Coordina)ng Care for Cri)cally Ill Pa)ents With Cardiovascular Dysfunc)on* Unit VII Promo2ng Health in Pa2ents With Hematological Disorders 33. Assessment of Hematological Func)on 25. Coordina)ng Care for Pa)ents With Upper Airway Disorders 26. Coordina)ng Care for Pa)ents With Lower Airway Disorders

34. Coordina)ng Care for Pa)ents With Hematological Disorders Unit VIII Promo2ng Health in Pa2ents With Neurological Disorders 35. Assessment of Neurological Func)on 36. Coordina)ng Care for Pa)ents With Brain Disorders 37. Coordina)ng Care for Pa)ents With Spinal Cord Disorders

38. Coordina)ng Care for Pa)ents With Peripheral Nervous System Disorders 39. Coordina)ng Care for Cri)cally Ill Pa)ents With Neurological Dysfunc)on* Unit IX Promo2ng Health in Pa2ents With Endocrine Disorders 40. Assessment of Endocrine Func)on 41. Coordina)ng Care for Pa)ents With Pituitary Disorders 42. Coordina)ng Care for Pa)ents With Adrenal Disorders 43. Coordina)ng Care for Pa)ents With Thyroid and Parathyroid Disorders 44. Coordina)ng Care for Pa)ents With Diabetes Mellitus Unit X Promo2ng Health in Pa2ents With Sensory System Disorders 45. Assessment of Visual Func)on 46. Coordina)ng Care for Pa)ents With Visual Disorders 47. Assessment of Auditory Func)on 48. Coordina)ng Care for Pa)ents With Hearing Disorders Unit XI Promo2ng Health in Pa2ents With Integumentary Disorders 49. Assessment of Integumentary Func)on 50. Coordina)ng Care for Pa)ents With Skin Disorders 51. Coordina)ng Care for Pa)ents With Burns* Unit XII Promo2ng Health in Pa2ents With Musculoskeletal Disorders 52. Assessment of Musculoskeletal Func)on 53. Coordina)ng Care for Pa)ents With Musculoskeletal Disorders 54. Coordina)ng Care for Pa)ents With Musculoskeletal Trauma Unit XIII Promo2ng Health in Pa2ents With Gastrointes2nal Disorders 55. Assessment of Gastrointes)nal Func)on 56. Coordina)ng Care for Pa)ents With Oral and Esophageal Disorders 57. Coordina)ng Care for Pa)ents With Stomach Disorders 58. Coordina)ng Care for Pa)ents With Intes)nal Disorders 59. Coordina)ng Care for Pa)ents With Hepa)c Disorders 60. Coordina)ng Care for Pa)ents With Biliary and Pancrea)c Disorders Unit XIV Promo2ng Health in Pa2ents With Renal Disorders 61. Assessment of Renal and Urinary Func)on 62. Coordina)ng Care for Pa)ents With Renal Disorders 63. Coordina)ng Care for Pa)ents With Urinary Disorders Unit XV Promo2ng Health in Pa2ents With Reproduc2ve Disorders 64. Assessment of Reproduc)ve Func)on 65. Coordina)ng Care for Female Pa)ents With Reproduc)ve and Breast Disorders 66. Coordina)ng Care for Male Pa)ents With Reproduc)ve and Breast Disorders 67. Coordina)ng Care for Pa)ents With Sexually Transmi[ed Infec)on Unit XVI Promo2ng Health in Special Popula2ons

68. Managing Care for the Adult Pa)ent With Obesity 69. Emergency, Trauma, and Environmental Injuries* 70. Substance Use Disorders in the Adult Popula)on 71. Disasters, Mass Casualty Incidents, and Complex Emergencies*

*Denotes chapters dedicated to cri)cal care

Chapter 24 Coordinating Care for Patients With Infectious Respiratory Disorders Stephanie Walter Coleman

LEARNING OUTCOMES Content in this chapter is designed to assist in: 1. Describing the epidemiology of infectious airway disorders 2. Correlating clinical manifestations to pathophysiological processes of:

ESSENTIAL TERMS Airborne Airborne precautions Alveolar Aspiration Bactericidal

Lobar Mantoux test Mucociliary escalator Parenchyma Polymerase chain reaction test (RT-PCR) Primary progressive TB infection (PPTBI) Primary tuberculosis infection (PTBI) Quarantine Rapid influenza diagnostic tests (RIDTs) Transmission Vaccination Virulent

a. Influenza b. COVID-19

Close contact Colonization Community spread Consolidation Directly observed therapy (DOT) Droplet Droplet precautions Drug-resistant TB infection (MDR TB) Epidemic Fomites Incubation period Isolation precautions Latent tuberculosis infection (LTBI)

c. Pneumonia d. Tuberculosis 3. Describing the diagnostic results used to confirm the diagnosis of infectious airway disorders 4. Discussing the interprofessional management of:

a. Influenza b. COVID-19

c. Pneumonia d. Tuberculosis 5. Developing a comprehensive plan of nursing care for patients with infectious airway disorders 6. Designing a teaching plan that includes pharmacological, dietary, and lifestyle considerations for patients with infectious airway disorders

CONCEPTS

l Acid-Base Balance l Caring l Infection

l Medication l Oxygenation

Finding Connections

Pulse oximetry (SpO 2 ) = 92% Temperature (T) = 100.3°F (38°C)

Mr. Markham works as a volunteer in the food service depart- ment of an HIV community support center. His past history con- sists of coronary heart disease with two cardiac stents (placed last year), mild emphysema, long-term type 2 diabetes, and arthritis. His current home medications are aspirin, 81 mg daily; ipratropium (Atrovent), 2 puffs three times daily; celecoxib, 100 mg twice daily; metformin, 500 mg twice daily; and an over-the- counter daily multivitamin…

CASE STUDY: EPISODE 1 Follow this patient throughout the chapter. Mr. Harold Markham is a 70-year-old man who presents to the emergency department with fatigue, weight loss, and night sweats. He complains of a cough that produces rusty-colored or blood-streaked sputum. His vital signs are as follows: Blood pressure (BP) = 145/85 mm Hg

Heart rate (HR) = 95 bpm Respiratory rate (RR) = 22

477

478

Unit V Promoting Health in Patients With Oxygenation Disorders

INTRODUCTION All body functions require a constant supply of oxygen to support their many metabolic activities. As a consequence of supplying continual oxygen, the respiratory tract maintains a persistent interface with the external physical environ- ment, resulting in a high degree of direct exposure to micro- organisms. It is for this reason that the respiratory tract is a common site of infection by pathogens. Fortunately, there is a series of complex, comprehensive, and efficient protective and defense mechanisms against harmful pathogens for both the upper and lower respiratory tracts. The Upper Respiratory Tract A wide variety of pathogens can produce infection within the respiratory tract, including bacteria, viruses, and fungi. As environmental air is inhaled, the first line of defense lies within the upper respiratory tract, which consists of the nasal cavities, the pharynx, and the larynx. The nares and nasal cavities are equipped with coarse hairs (vibrissae) and a mucous layer that filter out and trap macroparticulates (large particles). In addition, the nasal cavities are lined with epithelial tissues and blood vessels that filter and warm the inspired air. The surface epithe- lium secretes antimicrobial peptides that exert a bacte- ricidal effect on a variety of pathogens. The endothelial lining of the nasal cavities contains hairlike projections, called cilia, that, through their wavelike motion, transport any particles trapped by the mucous lining through a mech- anism called the mucociliary escalator . This allows the particulate matter to be expelled from the respiratory tract by the protective sneezing and coughing reflexes. After inhaled air moves through the nasal cavities, the anatomy of the upper airway changes direction, causing any remain- ing large particles to come in contact with the back of the throat. The tonsils and adenoids (lymphoid organs) play an integral role in the development of an immune response to pathogens remaining in contact with the mucoid surfaces of the throat through trapping and filtering. Next, the larynx (voice box), which houses the epiglottis, provides mechanical protection of the airways. During breathing, the epiglottis remains open to allow air to pass into the trachea. While food and fluids are swallowed, the epiglottis closes, directing solid material into the esophagus and pre- venting aspiration , or movement of gastric contents into the airways. Additional protective mechanisms of the upper respira- tory tract are provided by the colonization (a collection of a number of bacteria small enough not to cause infection) of resident bacteria and some viruses. Examples of resident bacteria and viruses include but are not limited to forms of Staphylococcus, Streptococcus, spirochetes, mycobacteria, Pseudomonas, Proteus, and Enterococcus . This “normal flora” functions to maintain a healthy respiratory status by com- peting with pathogens for attachment sites in the respiratory mucous lining and producing bactericidal substances that destroy harmful microorganisms.

The Lower Respiratory Tract The trachea marks the beginning of the lower respira- tory tract, along with the bronchi, bronchioles, and alve- oli. A layer of ciliated cells and the mucous-secreting cells within the trachea, bronchi, and bronchioles protect the lower respiratory tract via the mucociliary escalator from smaller-size particles that have avoided the upper airway defenses. Any pathogens that reach this area are trapped in an additional ciliated mucous layer and are driven upward via ciliary motion to the larynx and oropharynx, where they are swallowed and eventually destroyed by digestive enzymes in the stomach. The lower respiratory tract houses no resident flora and is considered a “sterile site.” This is in part due to the efficiency of the upper respiratory tract’s ciliated epithelial lining in eliminating the majority of inhaled pathogens. Should pathogens gain access to the lowest portion of the respiratory tract (the alveoli), alveolar macrophages are the most important means of eliminating microorganisms from this area by phagocytosis. It is of the utmost impor- tance that the alveoli remain free of pathogens because it is here that the vital exchange of gases occurs (Fig. 24.1). It is only when the respiratory epithelium becomes damaged or the sheer numbers of inhaled pathogens exceed the ability

Deoxygenated blood from pulmonary artery

Oxygenated blood to pulmonary vein

Terminal bronchiole

Alveolar- capillary interface

Capillaries

Alveolus

Deoxygenated blood cell

Carbon dioxide

Capillary wall

Oxygen

Alveolus wall

Oxygenated blood cell

FIGURE 24.1 Gas exchange at the alveolar level: gases moving from areas of higher to lower concentration. Oxygen moves into the blood; carbon dioxide moves out of the blood.

479

Chapter 24 Coordinating Care for Patients With Infectious Respiratory Disorders

of these protective mechanisms to function that a respira- tory infection occurs. Establishment of a Respiratory Tract Infection In order for a respiratory infection to be fully established in the lower respiratory tract, the following barriers must be avoided and conditions met: 1. Avoidance of trapping in the mucociliary layer of the upper respiratory tract. 2. Avoidance of the phagocytic action of the alveolar macrophages in the lower respiratory tract. 3. Infectious organisms must be airborne (particles less than 5 μm that remain suspended in the air for a pro- longed period of time) and have the ability to remain virulent (toxic) while in the air. 4. There must be sufficient numbers of infectious organisms inhaled and deposited on susceptible tissues within both the upper and lower respiratory tracts, preventing innate protective mechanisms from func- tioning effectively. The Inflammatory Response of the Respiratory Tract Once pathogens have been established in the respiratory tract, an inflammatory response is initiated. Direct stim- ulation by infecting organisms leads to the secretion of pro-inflammatory cytokines (interleukin [IL] and tumor necrosis factor [TNF]) by airway epithelial cells. Neu- trophils (a type of white blood cell [WBC]) are recruited to the infected alveoli along with other immune cells and serum components (see Chapter 18). Capillary permea- bility increases, and the alveoli fill with fluid and plasma proteins. This accumulation of exudate (a mass of cells and fluid) provides the perfect medium for the proliferation of the infecting organism(s) and assists with movement

to other nearby alveoli. The fluid- and exudate-filled alveoli are prevented from effective gas exchange at the alveolar-capillary level. This produces varying degrees of hypoxia depending on the severity of the infection.

INFLUENZA Epidemiology

Influenza is a highly contagious infection that is rapidly spread from one individual to another. Outbreaks of influ- enza are tracked, recorded annually, and reported by the Centers for Disease Control and Prevention (CDC). The extent and severity vary widely among geographical areas throughout the United States. Localized outbreaks that affect more than the expected population (e.g., when the disease is expected to affect 15% of the population, but 40% become infected) are called epidemics . They occur at varying intervals, usually every 1 to 3 years. Epidemics typically begin abruptly, peak at 2 to 3 weeks, last approxi- mately 2 to 3 months, and then rapidly subside. Global out- breaks (outbreaks that spread across a large geographical area) or outbreaks that are limited to a smaller geographi- cal area but affect more people than expected (again using the example of an expected outbreak of 15%, but 70% of the population is affected) are referred to as pandemics. They also occur at variable intervals but less frequently than local outbreaks. The last influenza pandemic was the H1N1 pandemic in 2009, where estimates of the number of deaths ranged from 151,700 to 575,400. Morbidity and mortality rates were high, predominantly among those with underlying comorbid medical conditions or those of very young or advanced age. Other predominant risk factors for influenza are outlined in Table 24.1. The CDC reported the highest influenza burden in the 2017–2018 season since the 2009 pandemic. Estimates for

Table 24.1 Risk Factors for Influenza Infection

Risk Factor

Description

Age

Young children and older adults (younger than 2 years and older than 65 years) due to immature or less active immune systems Healthcare workers, family caregivers, daycare providers, and early childhood educators are more likely to be in frequent contact with those who are infected with the influenza virus. People living in dormitories, military quarters, and long-term care facilities who remain in close proximity for lengthy periods of time Those with malignancies treated with chemotherapy, transplant recipients receiving antirejection medica- tions, individuals with HIV/AIDS with CD4+ counts less than 200 cells/mm 3 People with diabetes, renal failure, asthma, and cardiac and respiratory diseases are at higher risk for develop- ing serious complications. Patients who are considering pregnancy, are pregnant, or have recently given birth are at greater risk for devel- oping severe viral pneumonia and have a fourfold overall mortality rate, even if they are otherwise healthy.

Occupation

Environmental

Immune system compromise

Chronic illness

Pregnancy

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