N444: Test 2

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N444: Test 2 by Mind Map: N444: Test 2

1. Cardiovascular Disease

1.1. Leading COD

1.1.1. Nearly half of all American deaths

1.1.2. Leading COD in both genders Men dominate ages 20-54 Women dominate ages 55-75+

1.1.3. Due to lifestyle

1.2. Review of CV system

1.2.1. Two-part circulation Pulmonary (R) Systemic (L)

1.2.2. Heart supply Vena cava (blood in) Pulmonary artery/vein Artery: Blood away from heart Vein: Blood to heart Aorta (blood out to systemic) Coronary arteries

1.2.3. Movement Systole (contraction) & diastole (relaxation) SA node (RA) controls heart action

1.2.4. Conduction system

1.2.5. Action potential Depolarization Repolarization Refractory periods Effective RP Relative RP

1.2.6. Cardiac output Stroke volume Cardiac output Preload Contractility Afterload Ejection fraction

1.3. Types of CVD

1.3.1. Atherosclerosis/CAD Deposits accumulate in arterial lumen Plaque buildup >> Damage in artery Various other causes High BP surges Elevated cholesterol/tri Cigarrete smoking

1.3.2. CHD

1.3.3. Angina pectoris

1.3.4. Arrhythmia

1.3.5. CHF

1.3.6. Stroke/CVA

1.4. Risk factors

1.4.1. Inflammatory processes

1.4.2. Abdominal obesity (>40 inches)

1.4.3. Triglycerides >150

1.4.4. Low HDL: <40M-50F

1.4.5. BP >130/85

1.4.6. Fasting glucose >100

1.5. Assessment

1.5.1. Health history Demographic info Genetic history Cultural/social factors

1.5.2. Risk factors Modifiable Non-modifiable

1.5.3. Manifestations Chest pain Dyspnea Peripheral edema Weight gain Fatigue Dizziness Syncope Altered LOC

1.5.4. Other areas Medications Nutrition, elimination Activity, rest Self-concept Roles, relationships Sexuality Coping skills Prevention strategies

1.6. Lab data

1.6.1. Cardiac biomarkers

1.6.2. CK, CK-MB

1.6.3. Myoglobin

1.6.4. Troponin T and I

1.6.5. Lipid profile

1.6.6. Brain (b-type) natriuretic peptide)

1.6.7. C-reactive protein

1.6.8. Homocysteine

1.7. Diagnostic studies

1.7.1. ECG 12-lead Various monitoring styles Cardiac stress test

1.7.2. Radionuclide imaging Myocardial perfusion imaging Ventricular function, wall motion tests CT, PET, MRI

1.8. Treatment

1.8.1. Cardiac cath

1.8.2. Hemodynamic monitoring

1.8.3. Coronary bypass surgery

1.8.4. Balloon angioplasty

2. Cardiovascular Disorders

2.1. Analyzing cardiac rhythm

2.1.1. Rate, rhythm, regularity

2.1.2. Measure ECG intervals P-wave: A. depol. PR-wave Start of atrial depol to start of ventricular depol Time required to send impulse through atria and AV node Lasts 0.12-0.20 sec QRS complex: V. depol. May not have all 3 waves Q - First downward deflection R - First upward deflection S - Second downward deflection Lasts 0.04-0.12 seconds ST segment: Isolectric line "At rest point" b/w ventricular depol & repol Elevation OR depression >0.5 Very significant QT interval: Beginning of QRS to end of T Ventricular depol & repol 0.38-0.42 seconds Less than half of R-R interval T wave: Rounded deflection slightly larger than P-wave Ventricular repol U-wave: Small, rounded; after T wave Late depol of papillary muscle

2.2. Specific alterations

2.2.1. CHD aka CHD or IHD Obstructed blood flow Atherosclerosis Reduced blood flow to myocardium Most prevalant CVD in adults Statistics 500K deaths 2 M hospitalizations $8.5B for meds $133.2B total Manifestations Chest pain (most common) Angina pectoris MI HF Sudden cardiac death May be asymptomatic May have "atypical" presentation Risk factors Hyperlipidemia Smoking Sedentary lifestyle Alcohol Hyperhomocystinemia Oral contraceptives Stress Lab tests (see pp. 706) Cardiac enzymes, biomarkers Lipid profile Electrolytes CRP Coag studies ABGs Thyroid studies Urine protein Diagnostic tests ECG Cardiac cath Myocardial imaging Stress test X-Ray EKG

2.2.2. Angina Episodes or paroxysmal pain Tightness, choking, heavy sensation Retrosternal pain that may radiate Often accompanied by anxiety Usually subsides with rest or nitroglycerin Caused by insufficient coronary blood flow Triggered by physical or emotional stress Associated symptoms Dyspnea/SOB Dizziness N/V Treatment Decrease myocardial oxygen demand Increase oxygen supply Medications Oxygen therapy Address risk factors Reperfusion therapy Nursing care Assessment Diagnoses Collaborative problems Planning Treatment

2.2.3. MI Permanent destruction of a part of myocardium Caused by rupture of plaque >> thrombus >> obstruction Same disease process as unstable angina but at different stages ACS = MI + UA Manifestations Chest pain Other symptoms Diagnosis ECG Lab tests Treatment Diagnostic studies w/i 10 min of admission Oxygen, medications Bed rest! Need for percutaneous coronary intervention Need for thrombolytic therapy Give IV heparin or LMWH, clopidogrel/ticlopidine, glycoprotein 2B/3A inhibitors

2.2.4. ACS Assessment Vital component Review all symptoms Compare to baseline and recent data Watch the ECG Diagnoses Collaborative problems Acute pulm. edema HF Cardiogenic shock Dysrhythmias, cardiac arrest Pericardial effusion Cardiac tamponade Planning Relieve pain, ischemic signs Limit damage Reduce anxiety Maintain tissue perfusion and good RR Adherence/compliance Recognize complications early

2.2.5. HF Overview Inability of heart to meet perfusion needs Fluid overload OR inadequate tissue perfusion Indicates a myocardial disease Either systolic (contraction) or diastolic (filling) May be reversible, but usually progressive Manifestations R. side L. side Chronic HF = biventricular Classification NYHA ACC/AHA Type = treatment Medical management Address the cause Reduce AL/PL >> Reduce workload Optimize therapy Prevent exacerbations Utilize medications Nursing care Health history Personal patterns Physical exam Diagnoses Collaborative problems Planning

2.3. Cardiac rehab

2.3.1. Phase 1 Inpatient Soon after stable Recognize emergency Rest-activity balance

2.3.2. Phase 2 Outpatient for 2-6 weeks Individualized exercise plan Support, teaching

2.3.3. Phase 3 Outpatient For life

3. Genitourinary Dysfunction

3.1. BPH

3.1.1. Normal prostate characteristics Large walnut to kiwi size Round, rubbery, free of nodules or masses Two lateral lobes separated by palpable groves 3 zones Peripheral Central (EJD) Transitional

3.1.2. Disease overview Non-malignant Increases with age 50% of men by age 60 90% of men by age 85

3.1.3. Risk factors Gender, age, family history, race Smoking, heavy alcohol use Obesity, inactivity HTN Western diet Heart disease Diabetes Marital status

3.1.4. Prevention No smoking Moderate alcohol consumption Healthy, balanced diet Treat and control other dx Weight loss or maintenance Exercise

3.1.5. Pathophysiology Tissue closest to urethra starts to grow >> Pressure on urethra >> Restricted flow >> More effort by bladder >> Thickened wall >> Decreased storing capacity

3.1.6. Manifestations Hesitancy Abdominal straining Weak stream of urine Interrupted steam Dribbling Urinary retention F/U/N Incomplete emptying

3.1.7. Complications Recurrent UTIs Azotemia Bladder stones RF

3.1.8. Assessment Health history UT problems Family history DRE Patient-voiding diary

3.1.9. Diagnostics Urinalysis, urine culture PSA >4.0 ng/mL Urinary flow-rate recording Cytoscopy Ultrasound AUA Symptom Index

3.1.10. "Look Alike" problems Urethral stricture Prostate or bladder cancer Neurogenic bladder Urinary bladder stones

3.1.11. Medical management Goals QOL Urine flow Obstruction Progression Complications Types Watchful waiting Pharm therapy Minimally invasive procedures Surgical resection Treatment Medications MITs Surgery

3.2. Prostate cancer

3.2.1. 2nd most common cancer in men

3.2.2. 2nd most common COD in American men

3.2.3. High risk group: AA men (2x more likely)

3.2.4. Age = primary risk factors

3.2.5. Survival rates 98% five years 84% ten years 56% fifteen years

3.2.6. Risk factors Diet, hormones Gender, age, race, family history HPC1 BRCA1 and 2

3.2.7. Prevention Avoid excessive red meat and high-fat dairy 5-alpha reductase inhibitors can lower risk

3.2.8. Pathophysiology Starts in peripheral zone near the rectum Uncontrolled tumor growth >> mutations >> progression Usually adenocarcinomas Slow-growing 47% asymptomatic until advanced Urinary problems Sexual dysfunction Hematuria or blood in semen Frequent pain in lower back, hips, upper thighs

3.2.9. Assessment Health history DRE PSA >4 TRUS with biopsy

3.2.10. Diagnostics Gleason score 2-10 Lower: Less aggressive Higher: More aggressive Staging 1-2 localized 3: Advanced, outside gland 4: Metastasis to lymph nodes or organs

3.3. Prostate surgery

3.3.1. Treatment Highly variable Watchful waiting Surgery Radiation therapy Hormonal therapy Chemotherapy Other therapy (see pp. 1522) Radical prostatectomy Standard First-line therapy Localized tumor Post-op complications Bleeding Clots/DVT Cath obstruction Sexual dysfunction, incontinence Infection Transurethral resection syndrome

3.3.2. Nursing care Activity tolerance, ADLs HPI, specific symptoms, FH Anxiety Knowledge deficit Pain, discomfort Maintain FVB Stop complications from occuring Patient education Expectations Equipment Wound care Monitoring for complications What to report to MD Perineal exercises Activity limitations post-op Prevent dehydration Ambulation

3.4. Testicular cancer

3.4.1. Great survival rate if localized

3.4.2. Most common cancer in young men

3.4.3. Modifiable risk factors Cryptochoridism Occupational exposure to chems

3.4.4. Prevention Treat undescended testis Avoid occupational exposure

3.4.5. Classification Germinal 90% of cases In sperm-producing tissues Seminomas Non-seminomas Nongerminal Supportive and hormonal tissues

3.4.6. Manifestations Mass, swelling, enlargement Usually painless Heaviness or ache in lower areas

3.4.7. Assessment History, phys exam Elevated tumor markers AFP Beta-hCG Inguinal orchiectomy required to diagnosis

3.4.8. Treatment Remove testis via orchiectomy through inguinal incision Can bank sperm BEFORE treatment (not after) Radiation is usually for sperminomas (can preserve fertility in unafffected testis) Chemo is for all types Combo therapy is best

4. Chronic Renal Dysfunction

4.1. Normal kidney functions

4.1.1. Body water regulation Urinary output Blood pressure

4.1.2. Excretory regulation Nitrogenous wastes Drug metabolites Other wastes Uric acid

4.1.3. Metabolic/endocrine regulation E-poietin RAA Vitamin D

4.1.4. Acid-base balance Metabolic compensation

4.1.5. Electrolyte balance

4.2. Renal dysfunctions

4.2.1. Chronic kidney disease (CKD) Umbrella term Kidney damage Decreased GFR over >3 months Decreased QOL; increased $$$ Premature death Can progress to ESRD >> dialysis/transplant Risk factors Diabetes** CVD HTN Obesity Family history Cancer Stages 1) GFR = 90 2) GFR = 60-89 3) GFR = 30-59 4) GFR = 15-29 5) GFR = <15 Clinical appearance Elevated serum creatinine Anemia Metabolic acidosis Electrolyte abnormalities Fluid retention HTN Diagnostic findings GFR Creatinine Medical management Treat cause Routine visits Prevention Control risk factors Gerontological considerations Increased kidney dysfunction and renal failure Predisposed b/c of systemic diseases Medication precautions

4.2.2. End-stage renal disease (ESRD) 5th and final stage of CKD Needs permanent replacement therapy Uremia >> Decline in function + progression of ESRD Underlying disorder Urinary excretion of protein HTN Clinical manifestations Variable HTN, edema Crackles Anemia Cramps, weakness Gray-bronze skin color Dry, flaky skin Repro/neuro alterations Ammonia breath Metallic taste Diagnosed by GFR, C, BUN Complications Hyperkalemia Pericardial alterations HTN Anemia Bone disease Metastatic, vascular calcifications Treatment Maintain function Treat reversible factors Meds, diet Dialysis Nursing care Fluid status Diet education Self-care Emotional support Patient knowledge Collaborative problems Hyperkalemia Percarditis, pericardial effusion Pericardial tamponade HTN Anemia Bone disease, metastatic calcifications

4.3. Goals

4.3.1. Maintain IBW w/o excess fluid

4.3.2. Good nutritional intake

4.3.3. Increased knowledge

4.3.4. Participation in activity w/i tolerance

4.3.5. Improved self-esteem

4.3.6. Abscence of complications

4.4. Renal replacement therapies

4.4.1. Hemodialysis Most common (80%) Acute illness Intermittent (2-3x per week) Two main purposes Removes toxins/wastes by... Complications HF, CHD, angina, stroke, PVI HTN, vascular calcifications Itching r/t phosphorous deposits Sleep disturbances (very common) SOB, hTN, muscle cramps Dysrhythmias, air embolus (rare) Dialysis disequilibrium Leading COD = ??? Malnutrition Bone pain, fractures

4.4.2. Continuous RRT Certain groups Too unstable for HD Oliguric RF >> Fluid overload Kidneys can't handle needs No rapid fluid shifts, arterial access, machinery

4.4.3. Peritoneal dialysis (PD) Goals Remove wastes Fluid, electrolyte balance For those who cannot have HD or transplant Slower rate of exchange >> fewer comlications Utilizes the peritoneal membrane Complications Acute Long-term

4.4.4. Nursing management Home HD Usually an outpatient procedure Highly motivated and adaptable Caregiver committment Medications Timing is important Water-soluble meds removed by HD Avoid toxicity Patient education to dosing, timing Use volumetric IV pump Protecting vascular access No BP or sticks on that side Assess bruit or thrill q8hr Assess site for infection and dressing Hospitalized patients S/S uremia Fluid overload, HF, PE, pericarditis Discomfort Pain management Site care Preventing infection Avoid K or Mg supplements

5. Fluid & Electrolyte Balance

5.1. Fluids

5.1.1. 60% of adult body is fluid Variable ICF ECF Intravascular Interstitial Transcellular

5.1.2. Regulation Movement depends on pressure HP: Exerted on walls on BVs OP: Exerted by protein in plasma Types of movement Osmosis: Low to high Diffusion: High to low Filtration: High HP to low HP Active transport: Pump from low to high

5.1.3. Gerontological considerations Reduced homeostatic mechanisms Decreased body fluid percentage Medication use May appear differently Easily overloaded Dehydration

5.1.4. Imbalances FVD Loss of ECF exceeds water intake Causes Risk factors Manifestations Lab data Nursing care FVE R/T fluid overload or diminished mechanisms Risk factors Contributing factors Manifestations Nursing care

5.2. Electrolytes

5.2.1. Carry a charge

5.2.2. Variable concentration by compartment

5.2.3. Imbalances by electrolyte Na Hyponatremia Hypernatremia K Hypokalemia Hyperkalemia Ca Hypocalcemia Hypercalcemia Mg Hypomagnesmia Hypermagnesmia P Hypophosphatemia Hyperphosphatemia Cl Hypochloremia Hyperchloremia