Cardiovascular System Assessment

In this article we will learn how to gather the patient's health history concerning the heart and peripheral vascular systems, conduct a physical examination of the heart and peripheral vascular system using appropriate techniques, and record the results of the cardiac and peripheral vascular assessment.

I. Overview of the Cardiovascular System 

The cardiovascular system assessment involves examining the peripheral vascular system by evaluating color, temperature, swelling, capillary refill, and peripheral pulses. It also includes examining the heart through inspection, palpation, and auscultation of specific heart landmarks.

II. Step-by-Step Assessment

• Wash hands thoroughly.
• Assess room for necessary contact precautions.
• Introduce yourself to the patient.
• Verify patient identity using two identifiers (e.g., name and date of birth).
• Explain the assessment procedure to the patient.
• Prepare all required equipment before beginning the examination.
• Conduct the assessment in an orderly and methodical manner.
• Employ effective listening and questioning techniques.
• Attend closely to any cues provided by the patient.
• Respect patient privacy and maintain dignity throughout.
• Adhere to principles of cleanliness (asepsis) and safety.
• Record vital signs.

Steps	Additional Information
1.Conduct a targeted interview regarding cardiovascular and peripheral vascular conditions.	Inquire about symptoms such as chest discomfort, irregular heartbeat (palpitations), difficulty breathing (dyspnea), cough, swelling, fatigue, known cardiac risk factors, leg discomfort, changes in skin condition, limb swelling, past medical history, and diabetes history.
2. Inspect: Face, lips, and ears for cyanosis, pallor Chest for scars, deformities, and visible pulsations Both arms/hands, noting color, temperature, moisture, movement, sensation (CTMMS), edema, nail beds, nail shape, and capillary refill Both legs, noting CTMMS, hair distribution, edema, nail beds, and capillary refill, numbness/tingling Calf size/pain for signs of deep venous thrombosis (DVT)	Cyanosis indicates reduced blood flow and oxygen levels. To assess capillary refill, press on the fingernails or finger pads until they blanch; release and note how quickly the original color returns. Normal capillary refill is within 2 seconds. Evaluate capillary refill on both lower legs. Assess capillary refill bilateral lower legs Changes and discrepancies in color, warmth, movement, and sensation (CWMS) may suggest underlying conditions or injury. When assessing capillary refill, also examine the angle of the nail base. Normally, the angle of the nail base is about 160 degrees. Clubbing of the fingers occurs when this angle increases beyond 160 degrees, often associated with chronic oxygen deprivation (hypoxemia). Clubbing fingers The sudden onset of severe, sharp muscle pain worsened by dorsiflexion of the foot suggests deep vein thrombosis (DVT), along with increased warmth, redness, tenderness, and swelling in the calf. Assess calf for CWMS Note: Immediate referral is necessary for deep vein thrombosis (DVT) due to the potential risk of developing a pulmonary embolism.
3. Auscultate: Aortic/Pulmonic/Erb’s point/Tricuspid/Mitral Auscultate apical pulse for one minute. Note the rate and rhythm.   Source: Heart sounds - wikidoc	Instruct the patient to breathe normally. Use the diaphragm side of the stethoscope to auscultate the five landmark areas: Aortic – 2nd ICS on the right sternal border. Pulmonic – 2nd left ICS ERB’s Point – 3rd left ICS Tricuspid– 4th left ICS (for children 4th or 5th left ICS) Mitral Area – 5th left ICS medial to the MCL Auscultate for rate, rhythm, and pitch (the quality of the sound). Auscultate apical pulse at the fifth intercostal space and midclavicular line. Note the heart rate and rhythm. Identify S1 and S2 and follow up on any unusual findings.
4. Palpate: Inspect and palpate of the heart Bilateral radial, brachial, dorsalis pedis, and posterior tibialis pulses. Skin turgor edema (Tip from CNC on palpating pulses- Pulses are felt best when the artery is pressed against a bone, example radial pulse felt best when pressed against the radial bone, dorsalis pedis artery felt best when you palpate at the roundest curve of the dorsum of the foot, carotid pulse felt best at the angle of the jaw but palpate for only 5 to 10 seconds)	The ball of the hand (at the base of the fingers) is the most sensitive at detecting thrills. Inspect and palpate for: Pulsations- are more visible when patients are thin. Pulsations may indicate increased blood volume or pressure. Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. Thrills- these are the vibrations of loud cardiac murmurs. Thrills occur with turbulent blood flow. The finger pads are more sensitive in detecting pulsations. Use the finger pads of index and middle fingers and apply light pressure on the pulsation site. If pulses cannot be felt, a Doppler to amplify the sounds can be used. While palpating the artery, note the rate (normal 60-100 beats/min), rhythm (normal: regular), amplitude (normal: easily palpable, 2+), and contour (normal: smooth and rounded).  Pulse Amplitude (strength): 0 = absent; 1+ = decreased, barely palpable; 2+ = normal; 3+ = Full volume; 4+ = bounding pulse Absence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction. To check skin turgor, use the thumb and index fingers to pinch an area of the skin and release it. It should instantly return to place. To check edema, press down the skin and release the pressure, the skin normally will return to place right away. Assessing edema. When the indentation of the thumb or any fingers remain in the skin, it is pitting edema. Source: Pitting Edema Assessment: Physical Exam (ebmconsult.com)    No clinical edema = 0 2-4 mm indentation = 2+ edema 4-6 mm indentation = 3+ edema 6-8 mm indentation = 4+ edema
5. Report and record assessment findings and associated health issues following organizational protocols.	Accurate and timely documentation and reporting promote patient safety.

All About Clostridium Difficile Infection (CDI). Please Read to Prevent Its Spread!

 

Clostridium Difficile Infection (CDI) is the most common healthcare-associated infection, causing half a million infections and an estimated 29,000 deaths. Protect yourself and your family.  

Risk Factors for CDI
Most cases of C. diff occur when you’ve been taking antibiotics.

There are other risk factors: • Being 65 or older • Recent hospitalizations • A weakened immune system • Previous infection with C. diff or known exposure to the germs. 

Symptoms of CDI

Symptoms can vary depending on the degree of inflammation in the colon, ranging from mildly loose stools to over twenty episodes of diarrhea per day. Abdominal pain and fever may also manifest.

In severe instances, a C. difficile infection can lead to potentially life-threatening complications such as dehydration due to excessive fluid loss from diarrhea, low blood pressure, toxic megacolon (markedly distended colon requiring surgical intervention), and colon perforation.

Precautions

Healthcare professionals, including nurses and doctors, need to strictly adhere to isolation protocols to prevent the spread of this infection. These protocols involve contact and enteric precautions:

• Hand Hygiene: Healthcare providers and visitors should thoroughly wash their hands with soap and water before and after entering a patient's room, using the restroom, or moving between patients. Handwashing with soap and water is preferred over hand sanitizer for effectiveness.
• Personal Protective Equipment: Healthcare workers and visitors should wear disposable gowns and gloves when interacting with infected patients. Gloves are necessary when handling potentially contaminated materials, while gowns should be worn if there's a risk of fecal soiling. Proper removal of gowns and gloves followed by hand hygiene is crucial before leaving the patient's room.
• Room Placement: Ideally, patients with C. difficile should be isolated in private rooms with dedicated bathrooms. If private rooms are unavailable, patients can be grouped based on their C. difficile status.
• Environmental Cleaning: All surfaces in healthcare settings should be thoroughly disinfected using chlorine bleach products since C. difficile spores can survive on surfaces even after standard cleaning.

Enhanced Barrier Precautions For Nursing Homes:

Enhanced Barrier Precautions (EBPs) involve using personal protective equipment (PPE) to minimize the transmission of multidrug-resistant organisms (MDROs) in nursing home settings. EBPs are implemented during high-contact resident care activities and entail wearing gowns and gloves for residents known to be infected with or colonized by MDROs or those at a heightened risk of acquiring them. This includes residents with wounds, indwelling medical devices, central lines, urinary catheters, feeding tubes, tracheostomies, or ventilators.

MDRO transmission is common in skilled nursing facilities, and can lead to increased healthcare costs, as well as significant resident morbidity and mortality. 

Sending Specimen for C Diff Testing

• Do NOT send stool for C. difficile testing without diarrhea (≥ 3 loose bowel movements in 24 hours).
• Do not send stool if there has been recent use of laxatives. Discontinue laxatives and consider testing if diarrhea continues beyond 48 hours and there is no alternative explanation for the diarrhea.
• Testing requires approval from the ID attending on-call.
• Do not send repeat specimens to document “test of cure.” The test can remain positive for weeks after treatment
• Do not repeat testing in patients who have undergone recent fecal microbiota transplantation (FMT) for the same reason (Fecal microbiota transplantation 0r FMT, commonly referred to as stool transplant, is a medical procedure wherein beneficial bacteria from a healthy donor are transferred to the colon of a recipient. The aim is to alter the microbial composition of the recipient's gut, offering potential health advantages. FMT is widely accepted as the preferred treatment for recurrent C. diff  infections.)

Antibiotic Therapy for CDI

 The Agency for Healthcare Research & Quality (AHRQ) has launched a fresh online initiative, the Safety Program for Enhancing Antibiotic Use, designed to enhance antibiotic usage across acute, long-term, and ambulatory care settings by strengthening antibiotic stewardship programs. The objective is to discontinue antibiotics whenever feasible. Antibiotic usage stands as the foremost risk element for CDI (Clostridioides difficile infection). Specifically, broad-spectrum antibiotics such as clindamycin eliminate a wide range of gut bacteria, many of which play crucial roles in human health.  

C diff treatment is based on the severity of symptoms. Below are some treatment guidelines followed by hospitals as recommended by Infectious Disease (ID) doctors. Always follow your hospital policy.

Severity	Clinical Manifestations	Treatment
Asymptomatic colonization	Positive C. difficile test without diarrhea, ileus, or colitis	No treatment necessary
Non-severe	Positive C. difficile test with diarrhea and no manifestations of severe disease	Vancomycin 125 mg* every 6 hours PO/NGT for 10 days (pre-approved)
Severe	Positive C. difficile test with diarrhea and ≥ 1 of the following attributable to CDI ·  WBC ≥ 15,000 · Serum Cr > 1.5 mg/dL	Vancomycin 125 mg* every 6 hours PO/NGT for 10 days (10 days are pre-approved) Consider GI consultation for Fecal Microbiota Transplantation (FMT) in patients without improvement on 5 days of therapy
Fulminant*	Criteria as above with ≥ 1 of the following attributable to CDI · Hypotension · Toxic megacolon · Lactate ≥ 4 · ICU admission for severe disease	Vancomycin 500 mg PO/NGT every 6 hours AND Metronidazole 500 mg IV every 8 hours If unable to tolerate oral therapy can consider Vancomycin retention enema (500 mg in 100 mL Normal Saline every 6 hours) Please consult GI for Fecal Microbiota Transplantation (FMT) Please consult ID and Surgery

(Note: There is a difference between infected and colonized by C Diff. Those who are infected are 'symptomatic". While those who are colonized are "asymptomatic" but still carry the organism in their system. Always observe handwashing and barrier precautions in both cases.)

Other treatment recommendations:

 Avoid use of anti-motility agents in patients with CDI.

 Avoid use of binding agents (e.g. cholestyramine) as they can bind oral vancomycin.

 If patient is not improving on vancomycin, other causes should be evaluated and/or FMT considered. Fidaxomicin is not to be used as a rescue medication if patient is not improving on vancomycin.

 Routine prophylactic use of metronidazole or oral vancomycin is not recommended. There may be specific situations where this is warranted and this should be discussed with ID.

 

Recurrent CDI

 Defined as episode of symptom onset and positive assay result following an episode of positive assay result in previous 2-8 weeks

 Resistance to either metronidazole or vancomycin has not been described.

 Recurrence occurs in approximately 25% of patients and can be due to failure to eradicate spores or acquisition of a new strain. The risk for recurrence increases with every bout of CDI.

I hope you learned something from this article and please check out the references below for more information about CDI. Thank you.

Please watch the YouTube videos that covers this topic: 

Clostridium Difficile Infection Lecture Part 1

 

Clostridium Difficile Infection Lecture Part 2

 

References:

https://apic.org/professional-practice/implementation-guides/

https://apic.org/resources/topic-specific-infection-prevention/clostridium-difficile/

https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html#:~:text=1.,wounds%20or%20indwelling%20medical%20devices).

https://cdiff.org/wp-content/uploads/2023/10/seecdiff_factsheet.pdf

https://cdiff.org/c-diff-myths/

https://cdiff.org/clinician-resources/?gad_source=1&gclid=CjwKCAjwmYCzBhA6EiwAxFwfgDkf9tLA-SmZSpF199MUVuYeXFZ6GoFDEwUrzpSGKFlfzARAnRQJgRoCu1oQAvD_BwE

Just Culture in Healthcare

 

Just Culture in Healthcare

The single greatest impediment to error prevention in the medical industry is “that we punish people for making mistakes.”   

- Dr. Lucian Leape Professor, Harvard School of Public Health Testimony before Congress on Health Care Quality Improvement

“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.”

- Don Norman, Author, “The Design of Everyday Things

Traditionally, what happen to the staff who made an error? 

 coach or re-educate 

 formal written warning in their file

 immediate suspension until investigation complete

 termination

What is a Just Culture

A “Just Culture” is an open and fair culture in which all members of an organization are accountable, in a fair and just way, for making safe behavioral choices.

“Just Culture” strives to be the balance between “blame-free” and “punitive”.

The emphasis is to maintain individual accountability for unsafe behaviors, while acknowledging that most errors occur as a result of system flaws.

 Principles of Just Culture

It will require a Just Culture, where all staff feel comfortable reporting errors–including their own

 feel that their errors will be judged fairly

 feel they won’t get blamed and punished for system errors

 know about unsafe/risky choices and try not to make them

 know that Reckless and Disruptive Behavior is unacceptable

Behaviors that Undermine a Culture of Safety

Disruptive Behavior is any conduct or behavior including but not limited to, sexual harassment, 

ethnic or racial slandering, and/or any forms of unacceptable behavior

Unacceptable Behaviors includes:  Belittling criticism in front of other staff, patient, or visitor  Slamming or throwing of objects  Retaliation against any person for reporting a violation of the code of behaviors/policy

Not only are these behaviors unacceptable, but these behaviors also undermine a culture of safety. A staff person who has been criticized or belittled may not speak up when a next event happens.

THE JUST CULTURE PROCESS

References:

Quality & Safety: ‘Just Culture’ Provides Process to Review, Correct Mistakes for Optimal Patient Care | Department of Medicine (arizona.edu)

Management of Sepsis

 

Management of Sepsis

Sepsis is a critical medical condition caused by organ dysfunction due to an abnormal response to infection. 

The Goals of treatment are: 

 To reduce mortality in adult and pediatric patients with severe sepsis and septic shock by developing a protocol-based approach to case identification and rapid treatment. 

Rapid identification and communication regarding patients with sepsis, severe sepsis and septic shock. 

Treatment measures include: • Blood culture before antibiotics • Antibiotics • Lactate level • Fluid resuscitation • Use of vasopressors if persistent hypotension

Sepsis Definitions

Sepsis Bundles

Effectively managing sepsis and septic shock involves a team effort from healthcare professionals including doctors, nurses, patient care technicians, and pharmacists, among others, to improve patient-centered care and outcomes. 

The most effective way to reduce in-hospital mortality in sepsis patients is through early identification and prompt implementation of treatment bundles according to your hospital's protocols.

Sources: 

Severe Sepsis and Septic Shock: Management Bundle Measure (cms.gov)

Pearls and Pitfalls: CMS and Sepsis – CriticalCareNow

Did You Know That Bruce Lee Died of Heat Stroke? Let's Learn How to Manage Heat Related Illnesses

 How to Manage Heat Related Illnesses

Did you know that martial arts movie icon Bruce Lee died of a heat stroke at the age of 32 on July 20, 1973, the hottest day of the month that year in Hong Kong? 

Several months before his death, Lee underwent surgery to remove the sweat glands from his armpits, believing that sweaty armpits looked unattractive on screen. This surgery reduced his body's ability to cool itself. On May 10, ten weeks before his death, Lee went into a small dubbing room to re-record dialogue for "Enter the Dragon." 

The sound engineers turned off the air conditioner to prevent noise interference with the recording. After about 30 minutes in the stifling room, Lee fainted and began convulsing. He was rushed to the hospital and nearly died from cerebral edema, which the doctors managed to diagnose and treat just in time.

The medical team did not recognize that his collapse was most likely caused by heat stroke, a common cause of death among young athletic men during the summer. In the United States, an average of three high school and college football players die each year from heat stroke. Autopsies of heat stroke victims often reveal cerebral edema. 

According to Dr. Lisa Leon, an expert in hyperthermia at the U.S. Army Research Institute of Environmental Medicine, “A person who has suffered one heat stroke is at increased risk for another. Patients experience multi-organ dysfunction during the hours, days, and weeks of recovery, which increases the risk of long-term disability and death.”

Heat Related Illnesses

Heat-related illnesses vary in severity from mild to life-threatening. Additionally, heat exposure worsens many common health conditions such as heart, respiratory, and kidney diseases. As summer is drawing near, we have to be aware of heat related illnesses and its management.

                 

Heat Syncope: This refers to dizziness or fainting due to standing up too quickly in the heat or pooling of blood in the limbs from vasodilation, especially when no other cause is identified. It is more frequent in individuals with heart conditions or those taking diuretics. Treatment: Remove the patient from the heat and treat with rest in a supine position, passive cooling, and rehydration (either oral or intravenous). If recovery is prolonged or if there are concerns about a cardiac cause, especially in patients with cardiac risk factors, further evaluation is necessary.

Heat Edema: This is a mild swelling in dependent areas of the body, typically seen in people who are not yet acclimated to hot environments.  Treatment: Remove patient from heat and elevate the legs. Diuretic agents are not indicated.

Heat Cramps: Painful muscle spasms in the abdomen, arms, or legs can occur during or after activity in the heat, often due to excessive salt loss from sweating during physical exertion. Treatment: Remove patient from heat, treat with rest, oral electrolytes, and fluid repletion.

Heat Exhaustion (Prostration) - Profound fatigue, weakness, nausea, headache, or dizziness (or a combination of these symptoms) can result from decreased body water content or blood volume due to water or salt depletion from heat exposure. Mild body temperature elevation (below 40°C) may be present, but there is no altered mental status. Treatment: Remove the patient from the heat and treat with rest in a supine position, evaporative cooling, and rehydration (intravenous or oral). Monitor mental status, and if there is a delayed response to treatment, further evaluation is needed.

Heat Stroke

Heat stroke is the least common but most dangerous heat illness, often fatal without immediate treatment. The most frequent victims are the urban elderly poor. It is identified by a body temperature exceeding 40ºC.

    Predisposing Factors: Salt and water depletion, infections, fever post-immunization, lack of acclimatization, obesity, drug use, fatigue, and various medical conditions like cardiovascular disease, diabetes, malnutrition, alcoholism, hyperthyroidism, impaired sweating, and potassium deficiency. 

Heat stroke can be categorized into two forms: classic and exertional.

1. Classic Heat Stroke: Occurs after several days of high temperatures (above 37.0ºC) or lower temperatures with high humidity. Continuous sweating eventually ceases, causing a rapid rise in body temperature. The first symptom may be sudden collapse. In 80% of cases, onset is abrupt with the patient becoming delirious, comatose, or having seizures. In the remaining 20%, symptoms like weakness, dizziness, nausea, fainting, or frontal headache precede collapse. Muscle cramps are rare. Patients typically have hot, dry skin but may continue sweating. Progression to coma is common.

2. Exertional Heat Stroke: Occurs with activities that increase internal heat production. In the U.S., it commonly affects long-distance runners, football players, and military recruits. Intense physical activity usually precedes heat stroke. Overuse of salt supplements with insufficient water can be fatal. Core temperatures might not exceed 40ºC and still be lethal, while in classic cases, patients have survived with temperatures as high as 43.7ºC. Rapid cooling is crucial to prevent extensive tissue necrosis. Common complications include thrombocytopenia, prolonged PT and PTT, marked DIC, hypotension, shock, acute pulmonary edema, and rhabdomyolysis. Severe hypoglycemia and death often result from acute hyperkalemia or renal failure due to extensive muscle breakdown.

Heat Stroke Management: Immediate cooling is critical. Delays in cooling due to misdiagnosis, underestimation of severity, or lack of facilities are major factors leading to death or disability. The ABCs (Airway, Breathing, Circulation) are the first priority. Effective cooling methods include ice water immersion or evaporative cooling with fans and skin wetting. Cooling should cease when core temperature reaches 39º-40ºC, as body temperature will continue to fall. Avoid large initial IV fluid amounts due to the risk of pulmonary edema; use fluid boluses with careful CVP and urine output monitoring. Avoid alpha-adrenergic drugs like norepinephrine. Check glucose levels and administer D50% if needed, especially in exertional heat stroke. Severe rhabdomyolysis may cause hyperkalemia and myoglobinuria, leading to renal failure, shock, and diaphragm necrosis with respiratory failure. Hyperthermia may recur within 3-4 hours, requiring repeated cooling. ICU admission is warranted for management of end-organ sequelae. Monitor patients closely as they may lose the ability to sweat for several weeks.

References:

Treatment and Prevention of Heat-Related Illness | New England Journal of Medicine (nejm.org)

How Did Bruce Lee Die? | HISTORY

LABORATORY AND DIAGNOSTIC PROCEDURES NURSING RESPONSIBILITY

LABORATORY AND DIAGNOSTIC PROCEDURES NURSING RESPONSIBILITY

 

This is a list of some laboratory and diagnostic procedures that I have compiled through the years. I have used it for teaching when I used to work in the academe. 

Here I have summarized the correct preparation, education, and post-test care for patients undergoing diagnostic and laboratory tests in general. Please always follow your hospital protocol.

NERVOUS SYSTEM

Skull and Spinal X-ray

Lumbar Puncture

 CT Scan

 MRI

 

SKULL X-RAY

S-ize

S-hape

S-uture separation

S-ome calcification

S-hows erosion and fracture

 

SPINAL X-RAY

A-bnormal spine and dislocation

B-one degeneration

C-ompression

D-eformed curvature

E-rosion

F-racture

 

SKULL AND SPINAL X-RAY

X-clude metal items from body parts

R-eassure nursing support

A-ccurate documentation if with thick and heavy hair

Y-ou immobilize 

 

LUMBAR PUNCTURE

 Insertion of a spinal needle through the L3-L4  interspace into the lumbar subarachnoid space to obtain cerebrospinal fluid, measure CSF fluid or pressure, or instill air, dye, or medications.

 

LUMBAR PUNCTURE DIAGNOSTIC

 

Suspected meningitis

Subarachnoid hemorrhage

Hydrocephalus

Benign Intracranial hypertension

 

THERAPEUTIC

Spinal anesthesia

Chemotherapy

 

 LUMBAR PUNCTURE CONTRAINDICATIONS

S-coliosis

I-CP unidentified

C-oagulopathy

K-yphosis

 

LUMBAR PUNCTURE PRETEST

Form of informed consent

Free of urine bladder

Fetal position

 

LUMBAR PUNCTURE INTRATEST

S-hrimp or Fetal position

S-pecimens to be collected

S-terile vials- 4 or 5 (Tube 1 - chemistry Tube 2 - stat gram stain and culture (C+S), Tube 3 – cell                                      

          count, Tube 4 - for comparison, Tube 5 (optional) - virology, mycology, cytology, etc.)

S-trict asepsis

 

LUMBAR PUNCTURE POST TEST

F-lat 12-24 hrs

F-or vital signs and LOC monitoring

F-orce fluid unless contraindicated

P-uncture site for bleeding, CSF leakage

P-erform CMS assessment (Circulation, motion, sensation)

 

LUMBAR PUNCTURE COMPLICATION Spinal Headache

F-lat

F-luids

P-ain Management

      (Note: in some cases may need “blood patching” to close off the hole)

 

CT SCAN Scans the following in successive layers by a narrow beam of x-rays:

 

Angiogram of Head

Belly and Pelvic

Chest

D ’ heart

Extremities

CT SCAN PRETEST:

Assess allergies to iodine and seafoods

Be sure to obtain informed consent

Conscious sedation for claustrophobia

Do remove jewelries and hair pins

Explain hot flushed sensation and metallic taste in the mouth when dye is injected

Fluids and hydration

Give instruction to lie supine with small pillow under the head

Hold if pregnant

It takes 20 minutes

 

CT SCAN POSTTEST:

Allergic reaction check

Be sure to replace fluid

CMS (Circulation, motion, sensation)

Distal pulse check

Extremity color check

Find bleeding and hematoma

 

MRI

M-RI is nonivasive

R-eveals types of tissue, tumors and vascular abnormalities

I-s similar to CT scan

 

MRI PRETEST

M -etal objects must be removed

A-ssess for ineligibility and contraindications

G-ive instruction to lie supine with small pillow under the head

N-ormal audible humming, thumbing, grating, or knocking sounds

E-ncourage conscious sedation for claustrophobia

T-akes 45 to 60 minutes

I -nformed consent

C-ompletely enclosed in scanner

 

MRI POSTTEST

Resume normal activities

Fluids and hydration

 

MRI Ineligible to undergo MRI:

Automatic Internal Defibrillator

Cerebral Aneurysm Clip

Cochlear Implant

Hip Replacement

Knee Replacement

Non-removable dental prosthesis

Pacemaker

Prosthetic Valve Replacement

Soldiers

 GI

Hepatobiliary iminodiacetic acid (HIDA) scan is an imaging procedure used to diagnose problems of the liver, gallbladder and bile ducts

 

Before the scan:

Fast for four hours

Stop certain medications and supplements

Have a fat-rich meal six hours before

Remove metal accessories

Inform about claustrophobia

 

During the scan:

Tracer injected into arm vein

May feel pressure or cold

 

After the scan:

Flush toilet three times after urinating

Wash hands thoroughly

Avoid breastfeeding for at least 48 hours

Discard pumped breast milk

CARDIOVASCULAR SYSTEM

Electrolytes Coagulation Studies,  Erythrocyte Studies, White Blood Cell Count, Serum Enzymes and Cardiac Markers, Serum Lipids

 

ELECTROLYTES SODIUM

A –bsorbed from the small intestine and excreted in the urine in amounts dependent on

    dietary intake

S-ustains osmotic pressure and acid base balance

I-s major extracellular cation

N-ormal daily requirement is 15 mEq

SODIUM Nursing Consideration: Drawing blood samples soon after an intravenous infusion of sodium chloride will increase the level, producing an inaccurate result.

ELECTROLYTES POTASSIUM

P-romote cellular water balance, electrical conduction in muscle cells, and acid base balance O-btains K through dietary ingestion and the kidneys preserve or excrete K

T-o evaluate cardiac, renal, and gastrointestinal function

A-major intracellular cation

POTASSIUM Nursing Consideration:

A -ccurate note if the patient is receiving K supplement

B-lood should not be drawn from site where an IV infusion exists

C-lenching and unclenching of hand can increase the level

D-o identify elevated WBC and platelet counts

 

ELECTROLYTES CHLORIDE

H-ighly abundant body anion in the extracellular fluid

C-ounterbalance cations and buffer

L -ets digestion and maintenance of osmotic pressure and water balance

 

CHLORIDE Nursing Consideration:

D-raw blood from an extremity that does not have normal saline infusing into it

D -o not allow the client to clench and unclench his or her hand before drawing blood

D-iarrhea and prolong vomiting will alter chloride results

 

ELECTROLYTES MAGNESIUM

Clotting mechanism

Controls neuromuscular activity
Cofactor that modifies activity of many enzymes

Calcium metabolism

 

MAGNESIUM Nursing Consideration:

P -rolong use of magnesium products will cause increased serum levels

P -arenteral nutrition therapy or excessive loss of body fluids may decrease serum levels

 

ELECTROLYTES CALCIUM

B - one formation

C-onversion of prothrombin to thrombin

T -ransmission of nerve impulse

C-ontraction of skeletal and myocardial muscles

CALCIUM Nursing Consideration: Instruct the client to eat a diet with a normal calcium level (800 mg/day) for 3 days before the test. Instruct the client that fasting may be required for 8 hours before the test .

 

COAGULATION STUDIES

ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT)

A - mount of time it takes in seconds for recalcified plasma to clot after partial

      thromboplastin is added

P-erformed for patient receiving heparin

T -est for deficiencies and inhibitors of clotting factors

T -ime: 20 to 36 seconds

 

ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT) Nursing Consideration:

A -spirate blood sample 1 hour before next scheduled heparin dose

P-erform blood exraction from arm into which heparin is not infusing

T -ransport specimen to the laboratory immediately

T -ime: 1.5 to 2.5 times normal if on heparin therapy

 

COAGULATION STUDIES PROTHROMBIN TIME (PT) and INTERNATIONAL NORMALIZED RATIO (INR)

P -rothrombin is a vitamin K dependent glycoprotein produced by the liver for fibrin clot

                       formation

T-o monitor response to warfarin sodium (Coumadin)

 

PROTHROMBIN TIME (PT) and INTERNATIONAL NORMALIZED RATIO (INR) Normal Values: PT: 9.6 to 11.8 secs (male)

                  9.5 to 11.3 secs (female)

          INR: 2.0 to 3.0 (standard warfarin tx) 3.0 to 4.5 (high dose warfarin tx)

 

PROTHROMBIN TIME (PT) and INTERNATIONAL NORMALIZED RATIO (INR) Nursing Considerations:

A- baseline PT should be drawn before anticoagulation therapy

B-e sure to apply direct pressure to the venipuncture site

C-oncurrent warfarin therapy with heparin therapy can lengthen the PT

D -iets high in green leafy vegetables can shorten PT

E-xpect 1.5 to 2 times longer PT if on anticoagulation therapy

F-or PT greater than 30 secs, initiate bleeding precautions

 

COAGULATION STUDIES CLOTTING TIME

C -lient should not receive heparin 3 hours before specimen collection

L-onger if pt on any anticoagulation therapy

O –r has thrombocytopenia

T-ime: 8 to 15 minutes

 

COAGULATION STUDIES PLATELET COUNT

Plug formation

Clot retraction

Coagulation factor activation

 

PLATELET COUNT 150T – 400T cells/mm3

<PLT – thrombocytopenia (risk for bleeding)

>PLT – thrombocytosis (risk for clot) – prophylaxis by Anticoagulant - Lovenox

 

PLATELET COUNT Nursing Considerations:

B -leeding precautions should be instituted in clients with low platelet

M -onitor venipuncture site

C -hronic cold weather, high altitudes, and exercise increase platelet count

 

ERYTHROCYTE STUDIES ERYTHROCYTE SEDIMENTATION RATE (ESR)- 0 to 30 mm/hr

I ndirectly measures how much inflammation is in the body.

Special preparations not needed, but fatty meal may cause plasma alterations

Rate at which erythrocytes settle out of anticoagulated blood in 1 hour

 

ERYTHROCYTE STUDIES RED BLOOD CELLS

R -esults in the delivery of oxygen to the body tissues

B -lood diseases diagnosis

C-irculate for 120 days and are removed from the blood via the liver, spleen, and bone marrow

S-pecial preparation not needed

 

RED BLOOD CELLS 4.5-5.5 million/mm3

 <RBC – Anemia (Fatigue, SOB)

>RBC – Polycythemia (erythrocytosis) – management phlebotomy

 

ERYTHROCYTE STUDIES HEMOGLOBIN and HEMATOCRIT

Hemoglobin is the main component of erythrocytes and serves as the vehicle for transporting O2 and CO2

Normal Values: 14 to 16.5 g/dl (male) 12 to 15 g/dl (female)

Hematocrit represents red blood cell mass and is an important measurement in the identification of anemia or polycythemia

Normal Values: 42% to 52% (male) 35% to 47% (female)

 

WHITE BLOOD CELL COUNT

 WHITE BLOOD CELL Immune defense system of the body

WBC 5,000-10,000 cells/mm3

 <WBC – leukopenia (risk for infection)

>WBC – leukocytosis (infection/inflammation)

>100,000 – incapable of phagocytosis (leukemia)

 

CARDIAC MARKERS CREATINE KINASE (CK) Found in:

CK-MB (Cardiac)--- 0% to 5%

CK-BB (Brain)--- 0%

CK-MM (Muscles)--- 95% to 100%

 

CREATINE KINASE (CK)

Onset: 6 hours

Peak: 18 hours

Return to Normal: 2 to 3 days

 

CREATINE KINASE (CK) Nursing Considerations: CK-MM:

Avoid strenuous physical activity for 24 hours before the test

Avoid ingestion of alcohol for 24 hours before the test

Avoid invasive procedures and intramuscular injection:  may falsely elevate CK levels

 

CARDIAC MARKERS LACTASE DEHYDROGENASE (LDH)

Onset: 24 hours

Peak: 48 to 72 hours

Return to Normal: 7 to 14 days

 

LACTASE DEHYDROGENASE (LDH) Nursing Considerations: LDH isoenzyme levels should be interpreted in view of the clinical findings

Testing should be repeated on 3 consecutive days

 

CARDIAC MARKERS TROPONIN

T - and I

R-egulatory protein found in striated muscle AND

O-n bloodstream when an infarction causes damage to the myocardium

 

TROPONIN I

 >1.5 ng/ml… MI

Onset: 3 hours

Returns to Normal: 7 to 10 days

 

 TROPONIN T

 >0.1 to 0.2 ng/ml… MI

Onset: 3 hours

Returns to Normal: 7 to 14 days

 

TROPONIN Nursing Considerations: Testing is repeated  q 8 hours X 3.

 Rotate venipuncture sites.

 

CARDIAC MARKERS MYOGLOBIN Oxygen-binding protein found in striated muscle that releases oxygen at very low tensions

Injury to skeletal muscle will cause a release of myoglobin into the blood

 

MYOGLOBIN

 >90 mcg/L… MI

Onset: 1 to 2 hours

Peak: 4 to 6 hours

Return to Normal: 24 to 36 hours

           

SERUM LIPIDS

Total Cholesterol--- 140 to 199 mg/dl

 Low Density Lipoprotein (LDL)--- <130 mg/dl

High Density Lipoprotein (HDL)--- 30 to 70 mg/dl

Triglycerides--- < 200 mg/dl

SERUM LIPIDS Nursing Considerations:

No oral contraceptives

NPO except water for 12 to 14 hours

No alcohol for 24 hours

No high cholesterol foods the evening meal before the test

 

RESPIRATORY SYSTEM

Chest X-ray, Sputum Specimen, ABG Analysis, Peak Flow Meter

 

CHEST X-RAY

 A-natomy

A-ppearance

 

CHEST X-RAY PREPROCEDURE:

Remove all jewelry and other metal objects from the chest area

Assess the client’s ability to inhale and hold his or her breath

You question women regarding pregnancy or possibility of pregnancy

 

CHEST X-RAY POSTPROCEDURE: Help the client get dressed

 

SPUTUM SPECIMEN

Specimen thru expectoration

Suctioning of the trachea

Sputum amount: 15 ml

 

SPUTUM SPECIMEN PREPROCEDURE:

A-lways collect the specimen before antibiotic therapy

B-e sure that the client rinse mouth with water

C-lient to take several deep breaths and then cough deeply

 

SPUTUM SPECIMEN POSTPROCEDURE:

If a culture of sputum is prescribed, transport the specimen to the laboratory immediately

Assist the client with mouth care

 

ABG ANALYSIS Measurement Oxygen Carbon dioxide Arterial blood Acid base state

 

ABG ANALYSIS PREPROCEDURE:

A- llen’s test before drawing radial artery specimens

B-efore specimen collection, client to rest for 30 minutes

G-iving suction before drawing ABG sample is avoided

 

ABG ANALYSIS POSTPROCEDURE:

Place the specimen on ice

Note the client’s temperature on the laboratory form

Note the oxygen and type of ventilation that the client is receiving on the laboratory form

 

Apply pressure to the puncture site for 5 to 10 minutes or longer if the client is taking anticoagulant therapy or has a bleeding disorder

Transport the specimen to the laboratory within 15 minutes

 

ABG ANALYSIS Normal Arterial Blood Gas Values:

 pH          7.35 to 7.45

PCO2       35 to 45 mmHg

HCO3     22 to 26 mmHg

PO2        80 to 100 mmHg

O2 sat    96% to 100 %

 

ABG ANALYSIS

 R - espiratory

O - pposite

M - etabolic

E - qual

 

PEAK FLOW METER determines the effectivity of bronchodilator for asthmatic patients

PEAK FLOW METER Management:

1.Diary

2.Weeks period that the child is well

3.Blows

Results: GREEN: 80 to 100%... Very Good

             YELLOW: 50 to 80%... Beginning Attack

             RED: <50%... Bring to ER