Student Nurse Resources, Study Tips, Skills and more…
Author: Claire
Claire Galea is the founder and director of Mariposa Holistic Care, providing personalised, holistic care services that prioritise individual needs, dignity and wellbeing.
With formal nursing education and extensive clinical training at the University of Malta, Claire brings a strong foundation in healthcare to her work. Passionate about health education, person-centred care and lifelong learning, she uses her blog Student Nurse Life to share knowledge, encourage reflection and inspire a more informed, compassionate and positive approach to health and everyday life.
More than 90% of hospitalised patients receive some form of IV therapy. Unfortunately, about 1/5 of patients on IV therapy experience complication or death due to lack of administration care, especially since IV medication is administered directly into the venous system. This emphasises the importance of IV therapy safety.
WHO, 2017. Medication Without Harm. Retrieved from https://www.who.int/initiatives/medication-without-harm on 7th March 2021
Ingram, P., & Irene, L. (2005). “Peripheral intravenous therapy: key risks and implications for practice.” Nursing Standard, 19(46), p. 55+. Gale Academic OneFile, . Accessed 6 Mar. 2021
High Risk Medication = drugs with a high potential of significant harm to the patient if administered incorrectly eg. Potassium Chloride, Glucose (50% or more), Sodium Chloride (more than 0.9%), anticoagulants (injectable), Vitamin K, Insulin and Opiates.
Label Medication = this can be beneficial especially in the case of multiple medication syringes. Label one medication at a time whilst preparing them (do not pre-label empty syringes) and take only labelled medication near your patient to avoid mistakes. Do not administer any unattended or unlabelled medications.
Flushing = use 10ml syringe for flushing, especially in Central Line; flush with double the medication amount using a bigger than needed syringe (eg. flush 5ml using a 10ml syringe)
Peripheral Venous Cannula (PVC) Site Care:
use smallest cannula size possible
label with date and time
remove after 3 days
use transparent dressings to assess site
clean around cannula site using 2% Chlorhexidine in 70% Isopropyl
do not attempt to cannulate more than two times, if unsuccessful seek assistance
clean infusion equipment with Clinell (NOT an alcohol swab)
IMPORTANT! a cannula infection can cause sepsis and even death…remove if unnecessary, do not leave in situ just in case
Accessed from https://www.pinterest.com/pin/AducalWbg8Y2seyS3UYT1lIUzDEoUNEebnW8ArPfuuTWJ6f4ygco7VM/ on 7th March 2021
Fluid Therapy: 5 R’s of Fluid Management
Resuscitation
Routine Maintenance
Replacement
Redistribution
Reassessment
Fluid therapy is administered as a continuous infusion for a maximum of 24 hours followed by a review, or a bolus. Always assess for dehydration and fluid overload!
IV Line Management
replace IV tubings whenever cannula is changed
do not disconnect tubing and lines unless really necessary
change tubing every 96 hours
Below you can find a collection of videos that can help provide a more visual approach to IV Therapy Safety.
Committing To Patient Safety – IV Therapy Safety
IV Push / Bolus Infusion Administration
Intermittent IV Administration
Continuous IV Administration
Peripheral IV and Central Venous Line IV Administration
Aseptic Non Touch Technique To Administer IV Medication – IV Therapy Safety
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Preoperative Phase: when the patient is prepared and transferred to the theatre prior to undergoing surgery;
Intraoperative Phase: during surgery and in the recovery room;
Postoperative Phase: from the recovery room to the ward and until discharge, ending completely after being reviewed at the Outpatients Department.
Preoperative Nursing Care
Surgery may be required for the following reasons:
when further exploration is required to reach a proper diagnosis
as a preventative measure such as for the prevention of cancer spread
for treatment purposes
for palliative purposes such as the removal of tumors
for cosmetic and reconstructive purposes
PLANNED SURGERY: not an urgent requirement. It is usually scheduled weeks, months and at times years ahead.
EMERGENCY SURGERY: urgent requirement, usually performed for lifesaving purposes, as well as to stop bleeding (eg. internal bleeding) or to preserve an organ or limb (eg. in compound/open fractures where bones are protruding from the skin.
MEDICAL HISTORY: this should include information about the patient’s current health condition, known allergies, current medications list, drug abuse, past surgeries experience if any, and the identification of risk factors especially in the case of past problems with anesthesia.
PSYCHOSOCIAL STATE: evaluating the patient’s situation in relation to psychological and social wellbeing can help identify possible barriers to the recovery phase post-surgery. Reassurance can help alleviate fear, anxiety and stress pre-surgery. If needed, a patient can be referred to a social worker for additional support eg. if patient has left children behind at home, alleviating fears and concerns about their care helps reduce the person’s anxiety and stress.
EDUCATION: the patient should be provided with clear and understandable explanation with regards to what the surgery entails as well as what perioperative nursing care may be required, both verbally and in writing. The patient should also be advised about postoperative monitoring equipment which may be needed, as well as possible tubes, drains and other related equipment use in perioperative nursing care. Pain management should also be discussed with the patient in advance.
INVESTIGATION: blood tests (including CBC, urea, electrolytes and creatinine, INR or APTT and glucose), X-Rays, MRIs and CT Scans, ECG and a crossmatch (a.k.a. X-Match). Wherever possible, preoperative care should include the treatment of any existing infections, monitoring and if possible stabilising existing chronic diseases such as hypertension and diabetes, dietary deficiency and fluid and electrolyte imbalance correction, and if need be, weightloss in obese patients.
RISK FACTORS: can impact surgery success and recovery. Risk factors include age, malnutrition or obesity, pregnancy, as well as infection, diabetes, CVD, renal disease, malignancy, pulmonary disease, hepatic disease, immobility and hypovolaemia (excessive bleeding).
INFORMED CONSENT: patient signature should be acquired by the consultant prior to surgery. The nurse should make sure that information about the procedure or surgery is provided and any questions are addressed so the patient is able to give informed consent; the nurse should also make sure that informed consent has been acquired.
Preoperative Nursing Care:
address anxiety through communication and if needed adding music therapy, deep breathing, etc; address any body image concerns in relation to the surgery
nail polish should be remove so SP02 can be monitored correctly
bathing (4% chlorhexidine solution if patient is MRSA colonised; 2% chlorhexidine solution if undergoing a major operation; soap and water if patient is undergoing minor operation
shaving should be done using hair clipper so as to avoid skin abrasions, thus minimising the risk of developing a Surgical Site Infection; shaving should be done closest to the surgery time so as to avoid having enough time for bacteria from cultivating within any possible skin abrasions
make sure surgery site has been pre-marked by surgeon or consultant prior to being transferred to the theatre
keep patient warm using blankets if needed, as this will help prevent development of SSIs
surgical site observation
monitoring and documentation of patient vital signs
tubes eg. nasogastric tube or urinary catheter (although these may be inserted during surgery)
administration of recommended pre-surgery medication eg. prophylactic antibiotics
completing pre-op checklist
if a patient with diabetes is scheduled for surgery, he should be started on the diabetic protocol since being NBM makes him prone to hypoglycaemia
in the case of an amputation, make sure that the leg to be amputated has been marked by the physician
if patient has left children behind at home, talk and empathise with the patient to help alleviate any concerns; if need be, refer to a social worker so as to ensure help will be provided during this time and during post-op period
if spiritual concerns are involved eg. existential problems, referring to a spiritual advisor may also help
if patient seems to be experiencing psychological issues in relation to surgery, referring to a psychologist may help
if patient is eager to know, explain the whole procedure eg. where patient is to be transferred to, what to expect right after surgery, recovery area, post-op pain management, etc.
NOTE: If patient is on Steroids pre-op for inflammation, consider that steroid side-effects include hyperglycaemia (attn. if patient is diabetic), affecting the immune system (attn. if patient is immunocompromised), and affecting the peripheral nervous system (attn. if patient has been or is being amputated or has existing issues with his arms and legs).
Transferring patient from ward to the theatre:
Check patient ID
Check allergy bracelet
Explain procedure
Ensure patient safety
Provide accurate handover to the theatre nurse
Postoperative Nursing Care
This period starts right after surgeons finish the operation (an anesthetist and a theatre nurse stays with the patient after surgeon leaves), up until the 1st review after discharge as an outpatient.
Patient Assessment Right After Surgery
PULSE: monitor pulse volume and regularity
SKIN: check for any signs of cyanosis and monitor SPO2
CONSCIOUSNESS: is the patient conscious or semi-conscious? Prior to transfer to ward, patient should be fully conscious
AIRWAY: assess respiratory rate and depth
Patient Assessment In Recovery Room
understand and follow up on anesthetist and surgeon’s instructions
pain management: PCA pump if provided; prescribed medication, including PRN medication if needed
monitor vital signs and level of consciousness
assess level of pain, at rest and when ambulating; if noticing increased pain during ambulation, prophylactic pain medication may be administered pre-ambulation so as to reduce the pain and increase effectiveness of ambulation
monitor surgical site for bleeding and signs of infection
monitor input and output for urinary retention and/or for renal function indications
assess for signs of complications post-surgery, especially in relation to cardiovascular and pulmonary related comorbidities eg. Pneumonia (see pneumonia prevention section in link for preventative measures)
monitor for fluid imbalance (possible loss of fluid during surgery)
report any changes in patient condition and document changes
keep NBM for a couple of hours due to relaxed reflexes as an effect of anaesthesia
for diabetic patients, keep monitoring for hypoglycaemia especially whilst NBM
Patient Transfer From Theatre to Ward
Patient needs to be fully conscious and stabilised before being transferred to the ward. Monitor for any neurological impairment such as lack of movement of limbs, IV fluids and drip rate, drains, as well as same monitoring undergone in the recovery room.
Post-Surgery Investigations
check CBC (haemoglobin due to bleeding during and post-surgery, white cells, platelets, sodium, potassium, urea [to monitor for kidney function], creatinine and glucose [in diabetic patients, glucose status should be checked routinely])
X-Rays
MRI
CT Scan
Patient Care In The Ward
Observe IV Infusion,IV Pumps and Cannula Site
Assess For Nausea: patient may be administered an antiemetic drug to prevent nausea and vomiting
Personal Hygiene: bathing and mouth care
Patient Repositioning: to avoid pressure sores
Monitor for Confusion and Delirium
In case of Altered Level of Consciousness post-op, provide safety eg. side rails pulled up, personal items at reach etc
Monitor for Drug Allergy Symptoms
Patient Mobilisation: earliest possible ambulation if not contraindicated as it helps prevent complications in relation to respiration, deep vein thrombosis and pulmonary oedema; assist during ambulation
Encourage Deep Breathing and Coughing Exercises
Promote Exercise and Movement
Ensure Adequate Fluid Intake: start with encouraging small sips if not contraindicated
Wound Care: assess for infection and change dressings as required
Tracheostomy Care: including suctioning if present
Monitor for Urinary Retention: can cause restlessness, bladder distension, suprapubic discomfort and confusion; insert catheter to eliminate retention and confusion
If Increased Wound Bleeding is noticed, DO NOT remove the existing bandages, but apply extra pressure with another bandage on top and inform physician
Tackling Loss in Perioperative Nursing – Stages of Loss / Stages of Grief
Retrieved from https://www.mhpcolorado.org/weekly-wellness-blog-learn-the-stages-of-grief/ on 24th January 2022
Below you can find a collection of videos that can help provide a more visual approach to perioperative nursing – preoperative, intraoperative and postoperative care.
Preoperative Nursing Care
Intraoperative Nursing Care
Postoperative Nursing Care
Types of Wound Drainage
Caring for a Post-Surgery Wound Drainage System and Gauze Dressing
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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.
Accessed from https://vector.childrenshospital.org/2013/12/the-obesity-asthma-connection-a-link-in-the-innate-immune-system/ on 3rd March 2021
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.
Assessed from https://www.actwell.com.au/info/news/asthma-management on 4th March 2021
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
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
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
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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.
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.
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.
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.
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
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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:
Assessed from https://www.therespiratorysystem.com/category/lower-respiratory-tract/ on 23rd February 2021
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:
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.
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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.
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
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
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
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
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 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).
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.
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.
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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.
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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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.
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.
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.
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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.
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 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
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.
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