Nursing Skills Archives - Page 15 of 18

Asthma Pathophysiology, Diagnosis, Medical Management & Nursing Care

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Asthma pathophysiology involves chronic inflammation of the airways that causes bronchoconstriction (constriction/narrowing of the smooth muscle of the bronchioles), leading to airway hyperresponsiveness (narrowing bronchioles in response to allergens), excessive mucus production and retention (cilia become paralysed in airway during chronic inflammation), and airway oedema. Asthmatic patients with airway inflammation, which is reversible, tend to experience symptom-free periods as well as acute asthma exacerbations.

Causes of asthma include allergies, exposure to airway allergens and air pollutants, exercise, stress, and medication such as NSAIDS (Ibuprofen, Voltaren etc.) and non-selective Type 2 Beta Blockers.

Asthma Signs and Symptoms:

Frequently presents at night or early morning
Dyspnoea
Wheezing (mostly on expiration…if present also at inhalation, patient condition is worse)
Cough with or without sputum
Central cyanosis (eg. blue lips)
Sweating
Tachycardia
Widened pulse pressure (a significant difference between the systolic and diastolic BP)
Other comorbidities such as GERD, COPD or respiratory tract infections increase risk for asthma

Asthma Complications:

Status asthmaticus (life threatening severe continuous reaction in which asthma exacerbation is completely unresponsive to bronchodilator treatment)
Pneumonia (infection originating from microorganisms that find their way to the lungs that inflames the alveoli in one or both lungs, causing accumulation of mucus, leading to cough with sputum, fever, chills and dyspnoea)
Respiratory failure (indicated by a decrease in BP, respiratory rate and heart rate)

Asthma Diagnosis Factors:

Family history of asthma
Reversibility (characteristic that differentiates asthma from other respiratory diseases)
Spirometry
Peak Expiratory Flow Rate (PEFR)
Respiratory acidosis is a very common acid base disturbance in acute severe asthma. Its early recognition and treatment is vital for the final outcome, as it can lead to respiratory failure and arrest if prolonged.

Asthma Pharmacological Therapy

QUICK RELIEF

short-acting beta 2 adrenergic agonists – bronchodilators eg. Salbutamol (Ventolin) that relieve bronchospasm by relaxing the smooth muscle leading to a decrease in bronchoconstriction as well as decrease excessive mucus (side effects include tachycardia, palpitations and nausea).
anticholinergic drugs – bronchodilators that can be used in combination with short-acting beta 2 adrenergic agonists eg. Ipratropium (Atrovent). Anticholergic drugs also decrease mucus secretions (side effect: dry mouth)
corticosteroids – eg. Prednisolone suppress inflammation leading to a reduction in hyperresponsiveness as well as a decrease in mucus production (side effect: hyperglycaemia).

LONG TERM MEDICATION

inhaled corticosteroids eg. Budesonide (Pulmicort) – administered as prophylaxis (as prevention) of acute asthma exacerbation
long-acting beta 2 adrenergic agonists eg. Tiotropium
Methylxanthines eg. Theophylline (prevent and treat wheezing, tachypnoea, and chest tightness)

Additional Interventions

In an emergency situation, quick administration of bronchodilators is recommended to relieve bronchospasms and systemic corticosteriods to reduce the inflammatory response.
Administration of IV fluids can help replace loss of fluid if patient is sweating profusely
Encouraging deep breathing and promoting a calm environment
Administer O2 if patient has a low SPO2
Encourage patient to sit down straight or slightly leaned forward to promote lung expansion
Teach pursed-lip breathing to promote an increase in lung ventilation

Monitoring an Asthmatic Patient Post-Treatment

Monitor SPO2
Monitor vital signs (heart rate, respiratory rate, temperature, blood pressure)
Auscultate for possible wheezing on inspiration or expiration and no use of accessory muscles whilst breathing
Perform PEFR to compare reading with the one taken prior to treatment
Monitor ABGs-PaO2 (arterial blood gases)
Monitor for anxiety level
Monitor for conversational dyspnoea

Below you can find a collection of videos that can help provide a more visual approach to asthma pathophysiology, diagnosis, medical management and nursing care.

Asthma Pathophysiology

Asthma Pathophysiology, Diagnosis, Medical Management and Nursing Care

Spirometry

Peak Expiratory Flow Rate (PEFR)

Expiratory Wheezing Sound – Asthma Pathophysiology

Rhonchi Lung Sound – Asthma Pathophysiology

How to use Metered Dose Inhaler (MDI)

How to use a Metered Dose Inhaler (MDI) with a Spacer

Pursed Lip Breathing Exercises

Oxygen Therapy Delivery Devices

Asthma Nursing Care

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Alila Medical Media, RegisteredNurseRN, Geeky Medics, EMTprep, UseInhalers Correctly, American Lung Association ,Oxford Medical Education and NURSINGcom.

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Hernia Repair – Hernia Locations, Types, Risk Factors, Symptoms & Surgery

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A hernia occurs when an internal body part such as the small intestine pushes through weak muscle or surrounding tissue. Hernia repair is ideally performed so as to avoid complications.

REDUCIBLE HERNIA: intestines push through muscle or tissue but can still be pushed back in.

IRREDUCIBLE / INCARCERATED HERNIA: intestines push through muscle or tissue and cannot be pushed back into their original position.

STRANGULATED HERNIA: intestines push through muscle or tissue, become stuck and result in impaired blood supply, causing it to become necrotic. This requires an emergency procedure where the intestines require to be resected before the hernia is repaired.

hernia repair reducible hernia irreducible hernia strangulated hernia — Accessed from https://www.pasindusarchives.com/2018/04/inguinal-hernia.html on 2nd March 2021

Inguinal Hernia

An inguinal hernia is the most common type of hernia, mostly presenting in men due to the testicle descent at birth. It is located in the lower abdomen above the leg crease or close to the pubic area. Inguinal hernias are most common with ageing since the abdominal muscles become weaker with age.

In the case of girls, ovarian herniation of the canal of Nuck, which can occur at any age, is most common in childhood. Early diagnosis is vital since incarceration of the ovary can lead to ovarian necrosis.

hernia repair hernia locations — Accessed from https://www.pinterest.com/pin/634796509968296748/ on 2nd March 2021

INDIRECT INGUINAL HERNIA: a natural defect known as the ‘internal inguinal ring’ which is caused by testicles not descending before birth does not seal properly, and eventually develops into a hernia. This usually reaches the scrotum. It is very common in children.

DIRECT INGUINAL HERNIA: acquired by continuous exertion on the muscles. Presents as a forward protrusion and is found in adults.

Hernia Risk Factors

WEAKENED TISSUE: caused by ageing, surgical wounds, smoking, steroids, immunosuppresive drugs and collagen disorders.

EXERTED TISSUE: caused by heavy lifting, coughing, constipation, pregnancy, muscle strain.

Hernia Signs and Symptoms

swelling which may or may not be painless which may worsen when standing or straining, and improve when lying down.
burning sensation in the bulging area
weakness or pressure in the groin

Immediate action should be taken if an inguinal hernia causes pain as well as nausea and vomiting, or swelling that feels firm and tender.

Hernia Repair – Surgical Approaches

HERNIOTOMY: removal of the hernia sac.

HERNIORRHAPHY: removal of the hernia sac AND inguinal canal posterior wall repair. Repair is performed using the patient’s own tissue, and sutures cause tension on both sides to keep it closed. Unfortunately this conventional method of hernia repair can cause pain and discomfort, and has an unfavourable recurrence rate.

HERNIOPLASTY a.k.a. Lichtenstein Repair: removal of the hernia sac AND inguinal canal posterior wall repair with a synthetic mesh. This is one of the most commonly used methods of hernia repair that poses no tension, and in which the mesh is sutured over the defect. The mesh is made out of polypropylene. It is thin, flexible and lightweight, and helps reduce the risk of pain and foreign body sensation, acting as a base for new tissue growth that eventually incorporates it into the area.

Laparoscopic Hernia Repair

Laparoscopic hernia repair is especially indicated in the case of bilateral inguinal hernia or when diagnosis is not clear enough. This type of hernia repair is free of tension and is completed with the use of a mesh. CO2 is used to inflate the abdominal cavity to allow easy access for surgery. Laparoscopic hernia repair allows the patient to return to normal in less time than when an open surgery is performed.

hernia repair open surgery laparoscopic surgery — Kurzer, M., et al., 2007. Inguinal hernia repair. *Journal of Perioperative Practice*, 17(7). Accessed on 2nd March 2021

Perioperative Nursing Care

Preoperative Care:

Assess pulmonary risk (if patient has a cold, coughing may exacerbate pain post-surgery).
Assess psychosocial patient needs including fear of anesthesia, fear of pain, fear of disruption of normal daily life.
Make sure patient is not given a gastrointestinal cleanser (laxative) in the case of an obstructed hernia.
Assure patient that pain relief will be given post-surgery as required. This may help alleviate any pain-management related worry.
Talk to the patient about what to expect to see post-surgery, eg. incision location and size, closure type, dressings, drains, tubes (including a NG tube, oxygen, IV and drains so the patient will feel prepared.
Monitor normal state of health, posture and other physical factors of the patient so as to be able to notice any important differences post-surgery.
Removal of hair is done with electric clippers and not blades, so as to minimise incisions (more infections risk).
Patient should fast for 6 hours from food or milk and 2 hours for clear fluid.
Sedatives may be administered to help reduce anxiety associated with surgery.

Intraoperative Care:

Correct positioning of patient on surgical table prior to surgery ensures patient comfort.
Avoid friction burns, shearing and damage to soft tissue of the patient.
Apply preventative measures against deep vein thrombosis by administrating Low Molecular Weight Heparin, using intermittent pneumatic compression devices and graduated compression stockings.
Use forced air warming blankets, warm IV fluids, irrigation and skin preparation fluids to prevent inadvertent hypothermia.
All swabs, instruments, needles and other surgical tools need to be accounted for and documented.

WHO surgical safety checklist — Accessed from https://www.who.int/patientsafety/topics/safe-surgery/checklist/en/ on 2nd March 2021

Postoperative Care:

Airway must be patent and clear, not with blood-tinged mucus.
Assist in supine or on the side to increase ventilation.
Monitor SP02.
Ensure bilateral even movement of the chest.
Respiratory changes may be a sign of respiratory or cardiac arrest.
Inspect wounds and drains for signs of haemorrhage.

Postoperative Complications:

Infection indicators include fever, erythema (superficial reddening of the skin), increased exudate and/or change in its colour, malodour, localised heat and/or pain, delayed healing. A well-balanced diet high in Vitamin C and protein may help reduce wound infection and quicker healing.

Fluid deficiency may lead to hypovolaemia (low blood volume) and hypotension (low blood pressure). Monitor blood pressure and pulse, intake and output, and note urine colour and concentration. Inspect mucous membranes, skin turgor (pinching up a small portion of skin and assessing whether it remains raised or not after letting go), and capillary refill (monitors amount of blood flow to the tissue).

Read more perioperative nursing care considerations here.

Below you can find a collection of videos that can help provide a more visual approach to hernia locations, types, risk factors, symptoms and hernia repair.

What is a Hernia?

Hernia Symptoms

Inguinal Hernia

Inguinal Hernia Symptoms & Hernia Repair

WARNING! GRAPHIC CONTENT! Paediatric Open Herniotomy

WARNING! GRAPHIC CONTENT! Robotic Inguinal Herniorrhaphy Surgical Video

WARNING! GRAPHIC CONTENT! Inguinal Hernia Repair With Mesh

Hernia Repair Complications

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Buck Parker MD, Howard County General Hospital, drgursev : The Pediatric Surgery Specialist, Plexus Surgical Video Productions, Gajendra Singh, MD and California Hernia Specialists: Specialty Care for Hernia Repair.

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Anatomy of the Respiratory System

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When looking into the anatomy of the respiratory system, one needs to take a look at all the components involved in breathing. Through respiration, lungs experience ventilation (breathing), an exchange of gases happens between air and blood and between blood and cells, which cause oxygen perfusion throughout the whole body on a cellular level.

Respiratory System Functions:

provides the body with an oxygen supply
eliminates carbon dioxide
allows gas exchange
provides a path to and from the alveoli
provides a sense of smell through the olfactory system
acts as a humidifier by warming incoming air
maintains a balanced pH in the body
allows expulsion of abdominal content (such as during childbirth)

The respiratory system can be divided into the following sub-categories:

Upper Respiratory Tract:

Accessed from https://www.physio-pedia.com/Upper_respiratory_airways on 23rd February 2021

Nose: includes nostrils (nares), guard hairs (vibrissae, which help prevent insects and large particles from entering the nose), posterior nasal apertures (choanae), nasal cavity, nasal septum (composed of bone and cartilage), nasal fossae, nasal conchae, hard palate, soft palate, paranasal sinuses (which help decrease weight of skull due to its air content), goblet cells, respiratory epithelium of ciliated pseudostratified columnar type, and olfactory epithelium; functions include warming, humidifying and cleansing the inhaled air, providing a sense of smell, and helping in voice amplification.
Pharynx: a muscular structure about 5 inches long that acts as a common passageway for food and air consisting of the nasopharynx (lined with pseudostratified columnar epithelium), oropharynx and laryngopharynx (both lined with stratified squamous epithelium, making it a hard surface to be able to tolerate abrasion caused by the swallowing of food); includes an auditory tube, pharyngeal tonsil, palatine tonsils and lingual tonsils (tonsils help combat infection).
Larynx: plays an important role in speech through the vocal cords; comprises of 9 rigid hyaline cartilages with a flap of elastic cartilage known as the epiglottis that helps lead air and food into their appropriate pathways.

Accessed from https://sen842cova.blogspot.com/2015/08/pharynx-and-larynx-anatomy.html on 23rd February 2021

Lower Respiratory Tract:

Trachea: contains c-shaped hyaline cartilage rings that help support it (open parts of ‘c’ face the oesophagus to allow expansion whilst swallowing; lined with ciliated pseudostratified columnar epithelium with a lot of goblet cells that cause mucus production; mucus traps any debris, pushing it upwards through the mucociliary escalator towards the pharynx to be swallowed.
Bronchi: formed by the division of the trachea, just beneath the carina; supported by hyaline cartilage with a smooth muscle layered wall. These are further divided into secondary bronchi, one for every lobe within the lungs.
Bronchioles: the smallest of all bronchi, which end up with alveolar sacs; do not contain cartilage but are supported by smooth muscle, making them able to dilate or contract to cause bronchodilation or bronchoconstriction.
Alveoli: comprised of a single thin layer of squamous alveolar cells that facilitate gas exchange; contain alveolar macrophages (white blood cells) that engulf any bacteria or other debris; great alveolar cells produce a lipid molecule ‘surfactant‘ which coats the alveolar surfaces, preventing the alveoli walls from sticking together, thus allowing them to inflate easily during inhalation; air that enters the alveoli becomes available for gas exchange.
Lungs: found within the thoracic cavity; the stroma, which is made of elastic connective tissue, allows the lungs to recoil passively during exhalation; contain the visceral pleura (which ‘hugs’ the lungs), the parietal pleura (the outer layer), both encasing the pleural cavity which contains fluid that helps reduce friction between the lungs and the ribcage while they expand and contract); the two lungs are separated by the mediastinum which is the space found between the two lungs containing the heart, oesophagus and the major blood vessels. The right lung has 2 fissures, forming the superior lobe, middle lobe and inferior lobe. The left lung has 1 fissure, forming the superior lobe and the inferior lobe. The left lung also has the ‘cardiac notch‘, which is the area that houses the heart.

THE CONDUCTING ZONE forms a continuous passageway for air to move in and out of the lungs:

Nose > Pharynx > Larynx > Trachea > Bronchi > Bronchioles > Terminal Bronchioles

THE RESPIRATORY ZONE forms a passageway in which air is exchanged:

Respiratory bronchioles > Alveolar ducts > Alveolar sac

The respiratory membrane consists of squamous alveolar cell, squamous endothelial cell that lines the capillary, and a shared thin basement membrane, all of which help facilitate gas exchange.

Below you can find a collection of videos that can help provide a more visual approach to the anatomy of the respiratory system.

Anatomy of the respiratory System – Animation

https://www.youtube.com/watch?v=kacMYexDgHg

Overview of the Respiratory System – Animation

Lung Anatomy

The Respiratory System

Respiratory System Physiology

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Alila Medical Media, Registered Nurse RN, KhanAcademyMedicine and Professor Dave Explains.

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Cardioprotective Drugs – Increasing Survival & Decreasing Symptoms

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Cardioprotective drugs aim to increase survival and decrease symptoms of cardio-related issues through primary and secondary risk factor prevention. Blood pressure, lipid management, diabetes mellitus and metabolic syndrome are among the targeted concerns. Apart from pharmaceutical therapy, weight management, an increase in physical activity as well as smoking cessation help in providing a total holistic approach for the patient.

Cardioprotective Drugs – Anti-Platelet Therapy

Aspirin 75mg

provides an irriversible anti-thrombotic effect that lasts throughout the whole platelet life, which is between 9-10 days
provides secondary prevention of cardiovascular events (not to be used as primary prevention due to its increased risk of bleeding

Clopidogrel

provides an anti-thrombotic effect which is similar to Aspirin
should be given to patients who are allergic to aspirin
may be combined with Aspirin and administered post coronary stenting or acute coronary syndrome for a year

Prasugrel

should be given to patients unresponsive to Clopidogrel

Cardioprotective Drugs – Beta-Blockers

beta-blockers names end with _lol
reduce blood pressure and oxygen demand by reducing the heart rate and contractility of the heart
reduce symptoms of angina – unless contraindicated, patients with angina requiring regular symptomatic treatment should be prescribed beta blockers
possible side effects include bradycardia, worsening of respiratory symptoms such as in asthma and COPD (switching to beta 1 selective agents may help reduce this)
erectile dysfunction
rebound angina and an increase in cardiac events may be possible if medication is discontinued abruptly

Cardioprotective Drugs – Calcium Channel Blockers

improves angina
non-dihydropyridines such as Verapamil and Diltiazem help lower the heart rate, reducing contractility, heart rate and AV node conduction, but they may worsen heart failure; may cause side-effects such as bradycardia, conduction disturbances and constipation; can be used with beta-blockers in symptomatic patients (but be careful about possible severe bradycardia)
dihydropyridines, including Nifedipine and Amlodipine, may cause side effects such as headaches, flushing and ankle oedema

Cardioprotective Drugs – ACE Inhibitors

helps in treating stable angina pectoris as well as related hypertension, diabetes, heart failure, asymptomatic left ventricular dysfunction or MI injury
may cause a persistent dry cough, causing some patients to have to switch to an ARB instead
rarely causes angioedema

Cardioprotective Drugs – Nitrates

Short-Acting Nitro Glyceral Spray

results in vasodilation
provides pain relief and anti-ischaemia effects
sublingual Nitro Glyceral spray reduces angina pectoris attacks and may also be used in prophylaxis
side effects include headache and flushing, as well as possible orthostatic hypotension
angina unresponsive to nitroglycerin should be assessed as a possible MI or non-cardiac pain

Long-Acting Nitrates

provides relief for symptomatic angina
patient tolerance to oral or transdermal nitrates happens fast, thus, nitrate-free intervals are recommended (eg. nitrate patch should be reduced during the night)
side effects include headache and orthostatic hypotension

Trimatazidine

anti-angina properties
side effects include fatigue and drowsiness

Ivabridine

preserves AV and intraventricular conduction of the myocardium
slows heart rate

Statins

used as primary and secondary preventative measures along with healthy lifestyle changes
lowers lipid levels, inhibiting cellular cholesterol production, reducing LDL cholesterol by up to 40%, thus accounting to a reduction in coronary events
may increase HDL (the ‘good’ cholesterol)
reverses endothelial dysfunction, decreases thrombogenicity and reduces inflammation
stabilise lipid-rich atherosclerotic plaques, making them less vulnerable to become unstable and possible rupture
should be prescribed for all patients with Ischaemic Heart Disease due to their long-term benefits
patients with acute coronary syndrome taking statins are less likely to experience a MI or acute arrhythmias
patients admitted to hospital with acute coronary syndrome should be prescribed statins independently of their LDL level
side effects may include skeletal muscle damage which may be indicated by symptoms, Creatine Kinase level elevation and possibly rhabdomyolysis
OTHER LIPID LOWERING DRUGS include Bile Acid Binding Resins, Fibric Acid derivatives, Nicotinic Acid and Ezetimibe

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Cardiac Catheterisation To Diagnose and Treat Cardiovascular Conditions

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Cardiac catheterisation is an invasive diagnostic procedure where a catheter is inserted through a peripheral blood vessel to acquire important information about the structure and function of the heart. Through angiography, x-ray images are produced, showing the coronary arteries supplying blood to the myocardium. Treatment of cardiovascular conditions are also possible through cardiac catheterisation.

Cardiac Catheterisation Indications

Emergency situation eg. STEMI or NSTEMI presenting with chest pain;
Urgent situation eg. STEMI treated with fibrinolysis or NSTEMI;
Elective situation eg. in stable coronary artery disease (patient experiences pain during exercise or climbing a flight of steps which goes away after rest – non-urgent situation where planning is possible).

Cardiac Catheterisation Contraindications

anaemia
electrolyte imbalance
uncontrolled hypertension
arrhythmias
renal impairment
allergy to radiographic contrast used in procedure (in which case a different technique may be used)
peripheral vascular disease (in this case the best route to be used to advance catheter should be sought)
recent cerebrovascular accident
severe cardiac failure (in which case patients should NOT be put in supine position due to dyspnoea)
coagulopathy (patient could bleed excessively)
uncontrolled diabetes mellitus (blood glucose should be controlled prior to the procedure)
pregnancy (dye used in procedure could be toxic for the foetus)

Nurse Responsibilities

know about the patient’s comorbidities that may increase complication rate
allergy history especially to drugs and iodine/seafood
know patient haemoglobin level before patient reaches operating table so as to know how to manage bleeding if needed
acquire patient signature on consent form
explain frequently experienced sensations such as hot flush or metallic taste that comes with the procedure when dye is injected
keep patient monitored on ECG with remote defibrillation pads available especially with unstable patients during procedure (a rapid pulse is a normal finding)

Access Route

Cardiac catheterisation is done through the femoral or radial artery. The radial artery is quicker and safer (due to the palmar arch) than the femoral artery since it is wider, making it easier to advance wire through it. It also allows the patient to sit up right after the procedure, whereas in femoral access the patient has to stay on bed rest with the femoral area frequently monitored. However, the femoral artery is still preferred by many operators.

Femoral Arterial Sheats Removal Nurse Responsibilities

Ensure that the patient has been prescribed analgesia prior to sheath removal.

In hypertensive patients, prolonged manual pressure should be applied before sheath removal.

If a haematoma is present, blood flow to the lower limb could be compromised. Thus, the nurse should access the pedal pulse to confirm if blood flow is being impeded. Comparing both limbs and asking the patient to move toes may also help. Manual pressure or through a mechanical device should be used in the case of a haematoma.

Gelafundin, which is a sterile powder indicated in surgical procedures to obtain haemostasis, can be helpful when dealing with a haematoma, however it has an effect on blood pressure. The systolic pressure needs to be less than 90 to use Gelafundin.

Record length and width of haematoma by marking the edges so you can compare later on to confirm whether it is spreading or reducing.

Bleeding

In the case of bleeding from the angio site, occlude femoral artery with manual pressure and assess whether bleeding stops. If it doesn’t stop it means that the bleeding is superficial. In this case apply manual pressure. For mild bleeding apply pressure for 10-20 minutes either using manual pressure or FemoStop, which is a compression device. In the case of major bleeding, a drop in haemoglobin may be noted. This may require blood transfusion. For this reason, the patient should be cross-matched prior to the procedure.

Pseudoaneurysm happens when blood flowing through the tunica media is captured behind the tunica advanticia, which can lead to a rupture due to its weakness. Pseudoaneurysm can cause nerve compression leading to neuralgia.

In retroperitoneal bleeding, which is the result of a ruptured pseudoaneurysm, the patient deteriorates in a very short time, especially since this cavity is very big and can accumulate a large amount of blood which leads to cardiogenic shock. Symptoms of retroperitoneal bleeding include hypotension and severe back pain. It should be reported immediately.

Patient Education

apply pressure to femoral site when coughing or sneezing, or if warmth or wetness is felt
after femoral sheath removal, patient should stay on bed rest for 4 hours
unless contraindicated, fluid intake should be encouraged to promote contrast medium excretion
patient should report any bleeding or pain at the angio site immediately

Below you can find a collection of videos that can help provide a more visual approach to cardiac catheterisation.

Cardiac Catheterisation Procedure

Angioplasty Procedure

Cardiac Catheterisation Sheath Removal

FemStop Femoral Artery Compression Device

TR-Band Radial Compression Device

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Beaumont Health, Fortis Healthcare, Houston Methodist DeBakey CV Education, Nicole McMullen and Radcliffe Group.

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Smoking Cessation Nicotine Replacement Therapy, ENDDs & Medication

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Smoking cessation should be regarded as a holistic treatment method, be it with nicotine replacement therapy, electronic nicotine delivery devices and prescription medication.

Tobacco smoking is the most significant cause of premature death, causing almost 700,000 yearly deaths. Smoking causes cancer, heart disease, ischaemia, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis. It also increases risk for tuberculosis, eye diseases, and problems within the immune system, including rheumatoid arthritis.

Behaviour change techniques should be based on providing clear and concise understanding regarding all factors involved in smoking and smoking cessation. According to The National Centre for Smoking Cessation and Training (NCSCT), health practitioners should ask ALL patients whether they smoke or not. If a patient smokes, advice should be given on how to quit, as well as a point of reference on behavioural support and prescription medication.

Smoking is an addiction prone to relapse, with many going through multiple attempts to stop smoking before doing so successfully. Behavioural support should be combined with nicotine replacement therapy and/or medication so as to increase the chance of successfully quitting.

Maltese Health Promotion Leaflet Download

Below you can find a collection of videos that can help provide a more visual approach to smoking cessation nicotine replacement therapy, ENDDs including e-cigarettes and prescription medication.

Smoking Cessation

Nicotine Replacement Therapy

Electronic Nicotine Delivery Devices

Bupropion (Zyban) and Varenicline (Champix)

Special thanks to the creators of the featured videos on this post, specifically Youtube Channel Portico Network.

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Cardiovascular Health Nutrition – CVD Non Pharmacological Intervention

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Approximately a third of all deaths can be attributed to cardiovascular disease (CVD), making it the leading cause of morbidity and mortality worldwide. 72% of these deaths can be attributed to poor diet, making cardiovascular health nutrition a very important factor to reducing cardiovascular disease.

While low calorie diets can be helpful in improving overall health, long term calorie restriction is usually difficult to adhere to.

cardiovascular health nutrition — Accessed from https://www.pinterest.com/pin/314618723944586389/ on 30th January 2021

Dehydration happens when there is negative fluid balance in the water due to a decrease in water consumption, increased fluid loss or fluid shifts.

Over-Hydration happens when there is an increase in the extracellular fluid in the body (ECF), usually causing oedema.

In cardiovascular health nutrition, fatty acids (for lipoprotein levels), minerals (for blood pressure), vitamins and fiber are the most important nutrients.

Avoid…

Sugar Sweetened Beverages: associated with body weight increase as well as increased effects on fat deposition, lipid metabolism, blood pressure, sensitivity to insulin and lipogenesis.
Added Sugars: sucrose, fructose and such sugars (mostly found in sugar sweetened beverages) have been associated with an increased risk of cardiovascular disease due to lowered high density lipoprotein cholesterol, increased plasma triglyceride concentration and increased blood pressure.
Coffee: more than 8 cups per day may increase blood pressure drastically.
Alcohol: studies show that consuming one to two drinks per day has no negative impact on cardiovascular health. Moderate alcohol intake can be attributed to an increase in high density lipoprotein cholesterol, apolipoprotein A1, adiponectin and decreased fibrinogen levels. Heavy drinkers however show an increased risk of cardiovascular disease when compared to moderate drinkers.
French Fries: associated with an increased risk of hypertension, diabetes (type 2) and coronary heart disease.
High GI Diet: associated with an increase risk of coronary heart disease.
Processed Meat: attributed to an increase in cardiovascular disease risk and mortality.
Red Meat: high consumption may lead to a significant increase in blood pressure, oxidative stress, lipid peroxidation and negative changes within the gut microbiome.
Sodium: high intake is attributed to an increase in blood pressure. Reducing sodium by 1g per day accounts to a reduction in the systolic blood pressure by 3.1mmHg in hypertensive patients.

ABCDE of primary prevention CVD — Accessed from https://kahn642.medium.com/understanding-the-new-2019-acc-aha-guideline-on-the-prevention-of-cardiovascular-disease-in-under-f7f862980ebb on 30th January 2021

clinical signs and symptoms of nutritional deficiencies — Accessed from https://www.slideshare.net/ahmedabudeif/nutritional-assessment-71093757 on 31th January 2021

ABCD Systematic Approach Assessment

A = Anthropometric: measuring body composition – weight and height, BMI, circumferences, skinfolds. If further info is required, Bioelectrical Impedance Analysis (BIA), Dynanometry (hand grip), Hydrodensinometry, and DEXA scan.

B = Biochemical Data: help detect early changes in metabolism and nutrition prior to clinical signs onset – blood tests, haemoglobin, urine and stool sample testing, kidney function test, liver function test, cholesterol and lipids (triglycerides), blood sugar, scrapings and biopsy samples.

C = Clinical Exam: patient history, drug history and risk assessment, food intake, conditions affecting digestion, absorption and excretion of nutrients, as well as emotional and mental health.

D = Dietary Assessment: diet history, food frequency questionnaire, and food diary.

metabolic syndrome CVD — Accessed from https://slideplayer.com/slide/1507908/ on 30th January 2021

Below you can find a collection of videos that can help provide a more visual approach to cardiovascular health nutrition.

Cardiovascular Disease Primary Prevention

Cardiovascular Disease Secondary Prevention

Cardiovascular Health Nutrition: The Dash Diet

Cardiovascular Health Nutrition: the Mediterranean diet

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Johns Hopkins Medicine, World Heart Federation, Well+Good and LLUHealth.

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Acute Coronary Syndrome – STEMI, NSTEMI, Necrosis and Angina

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Acute coronary syndrome refers to a range of conditions associated with sudden reduced blood flow to the heart. Such conditions include:

STEMI – a very serious MI during which one of the heart’s major arteries is more than 70% blocked. An ST segment elevation is an abnormality detected on the 12-lead ECG in STEMI. Treat immediately!

NSTEMI – non-ST elevation MI: may progress to STEMI so treat with importance.

MINIMAL MYOCARDIAL NECROSIS – cardiomyocytes cell death related to irreversible myocardial injury.

UNSTABLE ANGINA – experiencing pain even when resting (may progress to STEMI if undiagnosed or not treated in time).

STABLE ANGINA – experiencing pain during exacerbating physical activity.

acute coronary syndrome diagnosis — Assessed from https://en.wikipedia.org/wiki/Acute_coronary_syndrome on 28th January 2021

Plaque Rupture Triggers

Vulnerable Plaque – eg. Statin therapy causes plaque to become vulnerable
Inflammatory Cytokines
Emotional Stress – can change the physiological status of the body through high BP, increased heart rate etc.
Physical Stress – strenuous exercise in unfit individuals
Plaque Rupture – thin fibrous cap with lipid beneath makes plaque susceptible to rupture

Myocardial injury extent depends on facturs such as the oxygen demand of the affected tissue, tissue response (younger individuals usually respond better and deal in a better way with an MI than older individuals), rate of flow etc.

Myocardial Infarction Symptoms

pain, pressure and heat sensation usually in the chest area but possibly radiating to the jaw, back, left arm or both arms;
sweating, clammy cold skin, tachycardia
weakness, nausea and vomiting
mild fever
dyspnoea

NOTE: an individual may experience a MI but still be asymptomatic!

Diagnosis of an Acute MI

Obtain information directly from patient; ask questions regarding family history (parents or siblings), degree of pain, how it all started, etc.
Assess symptoms to make sure they are coronary-related
Monitor for ECG changes: check for signs of Ischaemia and MI
Monitor serum cardiac biomarkers: necrosis causes sarcolema disruption, releasing macro-molecules in circulation
Monitor Troponin I & T (absent in healthy individuals, rise 3-4hrs after a MI and peak at 18-36hrs before declining slowly within 10-14 days)
Monitor Creatinine Kinase (CK): injury to the heart is marked as an elevation in CK; CK-MB rises 4-8hrs post MI and peak by 24hrs before returning to normal in 48-72hrs; a 2nd CK-MB indicates a re-infarction (can be noticed easier as CK-MB returns to normal quicker)

Acute Coronary Syndrome Treatment

Morphine: decrease anxiety and pain associated with ACS
Oxygen: monitor SP02 and administer Oxygen on demand
Anti-Ischaemic Therapy: Beta-Blockers, Nitrates and Calcium Channel Blockers (CCB are not to be administered in case of heart block or heart failure)
Anti-Thrombotics – Aspirin (300gm) & Clopidogrel (300-600mg loading dose, then 75mg): balance platelet aggregation
Anti-Coagulants – Enoxaparin OR IV Heparin OR Fondaparinux OR Bivalirudin (the latter only for patients undergoing Percutaneous Coronary Intervention)
Statin: anti-cholesterol drug that reduces infarction and mortality
ACEi: helps control blood pressure – excellent drug for patients with low ejection fraction

Percutaneous Coronary Intervention VS Thrombolytics

PCI vs Thrombolytics — Accessed from https://www.researchgate.net/figure/Advantages-and-disadvantages-of-thrombolysis-vs-PPCI_tbl1_230724181 on 29th January 2021

Myocardial Infarction Complications

Cardiogenic Shock

Cardiogenic shock is caused by either a massive Myocardial Infarction or a valve issue. If a patient presents with a prominent jugular vein, low blood pressure and high heart rate consider as emergency…monitor closely!

Below you can find a collection of videos that can help provide a more visual approach to Acute Coronary Syndrome.

Acute Coronary Syndrome Detailed Overview

Special thanks to the creator of the featured videos on this post, specifically Youtube Channel Armando Hasudungan and Thrombosis Adviser.

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Cardiac Pacing – Saving Endangered Lives With A Cardiac Pacemaker

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Through cardiac pacing a pacemaker delivers an electrical impulse to a chosen part within the myocardium with the aim of causing depolarisation. This leads to the spreading of the action potential to all parts within the heart.

Pacemakers are able to monitor the natural pacemaker of the heart (SA Node). If this is fully functioning, the pacemaker lets it work uninterrupted, but if or when needed, the pacemaker paces.

Pacemakers are considered to be anti-bradycardia devices. They are individually programmed so as not to fall below a certain heart rate, allowing a low heart rate momentarily so that it is recorded into the patient’s device statistics.

Some pacemakers are also able to defibrillate so as to restart the electrical rhythm of the heart to a sinus rhythm.

Cardiac pacing is used in the case of:

2nd and 3rd degree AV blocks
AV blocks with chronic atrial fibrillation
SA Node disease
Heart failure
Genetic-related long QT syndrome
Anterior Myocardial Infarction with AV block
Drug-induced blocks (eg. digoxin intoxication)
Atrial fibrillation prevention
Hypertrophic Cardiomyopathy (thickened heart muscle)

Cardiac Pacing Sites

RA Appandage = paced P-wave resembling normal activity P-wave

RV Apex = paced QRS complex that is usually prolonged with a following wider looking T-wave

CSL Coronary Sinus Lead = implanted into the LV. A third lead benefits cardiac output by correcting and syncronising both left and right ventricles

Temporary Cardiac Pacing

Temporary pacing is used in emergency settings such as on patients experiencing ventricular bradyarrhythmias, post cardiac surgery (when the patient is susceptible to tachyarrhythmias so temporary pacing can be available immediately on demand with low sensitivity), and whilst undergoing evaluation for a permanent pacemaker.

Pacemakers are able to:

pace – at a fixed rate (asynchronous) independently of intrinsic cardiac rhythm OR on demand – only if intrinsic cardiac rhythm is absent
sense – they are considered to be anti-bradycardia devices since they can sense if the heart rate falls below their programmed lower rate, and in that case, pace

NOTE: a TPM (temporary pacemaker) malfunction, including battery failure, falls under the responsibility of the nurse! Thus, ensure proper checking of equipment, battery, threshold, and that leads and connection points are secured well.

Transcutaneous Cardiac Pacing (Temporary)

Transcutaneous pacing = used in emergency settings as a short term pacing method, easily set up by nurses with an AED device. A spike can be captured to mechanically function the heart temporarily. Although it’s quite a quick pacing method, it is not always tolerated by the patient, and may also be unstable.

Retrieved from https://cardiovascmed.ch/article/doi/cvm.2018.00554 on 9th January 2023

Transvenous Cardiac Pacing (Temporary)

Transvenous pacing = a reliable pacing method that is more tolerated than the transcutaneous method by patients, established within 10-30 minutes by a physician. Transvenous pacing is done via the axillary-subclavian vein or the femoral vein in Endocardial Pacing, or via the axillary-subclavian vein in Epicardial LV Pacing.

may induce ventricular tachycardia
abdominal twitching (voltage should be checked and possibly lowered)
infection may be possible especially if wire is left more than 48 hours in situ (transparent dressings should be used for possible infection monitoring)
perforation of the myocardium whilst advancing wire into the heart
pneumothorax – puncturing of the lungs (may be confirmed by x-ray)

Permanent Cardiac Pacing

Permanent pacing = a fully programmable device implemented through elective surgery.

The NGB Code

pacemaker nbg codes — Accessed from https://www.ecgmedicaltraining.com/the-basics-of-paced-rhythms-part-1/ on 28th January 2021.

Pacemaker Nursing Management

note pacemaker settings and compare with ECG recordings
ensure that all spikes are followed by a P and/or QRS complex
monitor for pacemaker malfunction – ensure it is both capturing and sensing as it should
monitor route of insertion for bleeding, haematoma formation, and signs of infection – measure the patient’s body temperature every 4 hours
monitor white blood cell count which should be within normal range (5000-10000/mm3)

NOTE: report to cardiologist if malfunction is noted.

Patient Education

When using a temporary pacemaker, patient should remain in bed. Area from where the lead has been inserted should remain immobilised, as if mobilised, lead may become easily displaced. Patients should also restrict activity on the implantation side. Mobile devices should be used on the opposite side of the pacemaker implantation. Patients should keep their 6 monthly or yearly appointments as required. A pacemaker’s battery life is usually between 6-20 years, depending on its use.

Prior to being discharged, ensure that the patient knows how to look for signs and symptoms of infection and when to seek medical attention, and is aware of how to avoid electromagnetic interference.

Whilst nursing a patient with a pacing box, it is important to check the wires for any loose points and to monitor the battery.

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Anti Arrhythmic Drugs – Indications, Side Effects & Contraindications

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Anti-arrhythmic drugs are used to manipulate how the electrical impulses of the heart are generated and conducted, to restore cardiac rhythm to normal where needed, as well as to effect the cardiac cells’ action potential in changing their impulse initiation and conductivity. Unfortunately, most anti-arrhythmic drugs can aggravate or cause new arrhythmias.

The phrase cardiac action potential (AP) refers to the change in voltage across the cell membrane of cardiac cells caused by the movement of ions between the inside and the outside of the cell through ion channels. An action potential happens when different ions cross the neuron membrane.

There are 5 phases in a Cardiac Action Potential:

Phase 4 – resting phase a.k.a. resting membrane potential (when the heart is into diastole)
Phase 0 – opening of the fast sodium channels causing sodium to move into the cell
Phase 1 – initial rapid repolarisation: when fast sodium channels close
Phase 2 – plateau phase caused by calcium moving in and potassium moving out (ST segment in an ECG)
Phase 3 – repolarisation: potassium channels stay open allowing potassium to move out and repolarise the cell; when membrane potential reaches certain level, potassium channels close (T-wave on ECG)

Anti-Arrhythmics, which are classified according to the Vaughn Williams classification, are organised into 4 major classes:

CLASS 1 AGENTS: Fast sodium channel blockers (affect the depolarisation phase)

CLASS 2 AGENTS: Beta-blockers (affect depolarisation)

CLASS 3 AGENTS: Potassium channel blockers (reduce potassium current during the repolarisation phase)

CLASS 4 AGENTS: Calcium Channel Blockers (cause cardiac cells conduction to slow down)

OTHER ANTI-ARRHYTHMICS: Digoxin, Adenosine and Magnesium Sulphate

Class 1 Agents are further sub-divided into 3 types of anti-arrhythmics:

1A Quindine, Procainamide, Disopyramide

1B Lidocaine, Mexiletine

1C Flecanide, Propafenone

Below you can find a collection of videos that can help provide a more visual approach to Anti-Arrhythmic Drugs.

Cardiac Action Potential Animation

Anti-Arrhythmic Drugs Animation

Anti-Arrhythmics

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Alila Medical Media, MedLecturesMadeEasy

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