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Heart Valves Mitral valve: between left atria and ventricle Aortic valve: between L ventricle and aorta\ o Ventricular contraction: mitral closes and aortic opens Tricuspid: between R atria and ventricle Pulmonary: between R ventricle and pulmonary artery Murmurs Stenosis: valve opening problem o Early/Late peak sound, hear quivering Insufficiency/Regurgitation: valve closing problem o Regurgitation: sounds the same throughout S1/2, hear splashing o Insufficiency: loud after S2

PVD vs. PAD PAD (Lower Extremity Arterial Disease) o Shiny, pale, cool temperature, capillary refill is greater than 3 seconds, pulses are weak/absent, lack hair, wound necrosis, sharp/stabbing pain, leg ulcers (ischemic) No edema Tissue in bottom of wounds is yellow/gray o Most common cause is atherosclerosis, veins usually not affected PVD (Chronic Venous Insufficiency) o Pruritis, Hemosiderin staining (turn bronze on interior aspect of lower leg by medial malleolus due to saphenous vein), warm temperature, normal capillary refill, strong pulses, regular hair distribution, edema, achy/crampy pain No wound necrosis Venous stasis leg ulcers

o Common cause is varicose veins, incompetent valves or muscle pump not working Treatment o PAD: improve perfusion by pharmacological agents, building collateral circulation, revascularization o PVD: Compression therapy, elevate legs above heart, pain management, dermatitis treatment, edema causes lack of oxygen Auscultation Leaning slightly forward in E, supine, LLR position o Listen with bell for murmurs Ask patient to stop breathing when listening to carotid, should hear nothing Carotid should be synonymous with S1 Listen for AV valves at apex of heart JVD: less than 9 cm is within normal limits o Vein drains into SVC in R atria o If see it at 45 degrees in upright patient, have RHF o Should not have pulse

Inspection use tangential lighting Xanthelasma (white around eyes) is normal, can indicate hyperlipidemia or atherosclerosis Dont want pulsations larger than 1 cm, obliterate by pushing down on medial side of clavicle Palpation Sitting at 30 degrees, use 4 fingers o Lateral displacement: LV hypertrophy

CC: current problem + how long theyve been experiencing it


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Survey of Chest Tube Unkinked tubing, collection device upright and below level of tube insertion, proper equipment (2 clamps in opposite directions, 1 vaseline gauze, 4x4 gauze, new drainage system, sterile water) Check water seal chamber tidaling, suction chamber bubbling, suction set at good level o Usually 20 cm of water, less water=more suction Drains pleural space (between parietal and visceral membranes of lung), sutured with airtight dressing Tubes placed between 2/3 or 8/9 IC, thoracostomy Look for subcu emphysema: palpate to feel rice crispies, document circumference, occurs when air collects due to punctured lung All connections should be taped, assess respiratory status, type/amount drainage *Never clamp except to change unit Types of Tubes Wet: 3 tubes (patient, vent, suction), suction chamber is filled with water, water seal chamber prevents air from going back into patient (*always 2 cm water, tidals- rises during I, falls in E with air; no tidaling during suction), collection chamber emptied when full, air leak monitor (bubbles with pneumothorax, stops when resolves) Mini Express: increases mobility, dry suction mechanism (never fill with water, it is preset), for small amount of drainage (500 mL) Pleur X: used in home care for malignant ascites or chronic pleural effusion, fluid drained every 24-48 hours, use very sterile procedure to drain Tube Info ET CXR ordered to confirm placement, within hour of tube coming out and again in 24 hours Removal: assist, pre/post assessment (breath sounds, RR, O2, pain), pre medicate Patient cant breathe when tube comes out Document: site of CT, amount/type drainage, bubbling/tidaling, subcu emphysema, type/integrity of dressing, pain, pain relief

End before trachea bifurcates into RL bronchi mainstem (2 IC), short term, should not exceed 25 mmHg o Do tracheostomy if more than 3 days Tracheostomy o Replaces tube, mechanical ventilation, bypasses obstruction/removes secretions, more comfortable, can speak because it goes below larynx Single/Double outer cannula (with disposable/permanent inner) o Uncuffed: no risk of aspiration, no foreseeable need for mechanical ventilation

o Cuffed: necessary to ventilated patients, decreases aspiration risk, prevents air leaks o Fenestrated: allows speech when cuff is deflated/external hole is covered, prevents aspiration when cuff is inflated Double lumen for patients with secretions, easier cleaning Always suction before deflating cuff Patient can eat with inflated cuff Humidification Care Vaso-vagal reaction: drops RR and BP Stoma and dressing should stay clean/dry, use pre-cut non-raveling dressing, secure trach PPE: goggles, face shield Speaking valves (passy-muir): opens on I, air closes valve so it HME has none or <28% supplemental oxygen Water has >28% oxygen, for vented patients or those with ETT o Traps moisture from E to use in next I

only escapes on E o Need to be alert/responsive, patent airway* o Cant be used with ETT with cuffs, DONT inflate cuff of trach tube! o Feel pressure in upper airway, deeper/hoarser voice Emergency equipment: obturator, suction, O, new tube Suctioning

Causes hypoxia so attach to vent, one time use must be changed every 24 h, use PPE so not exposed to secretions Endotracheal (to end of trach + 1 cm), nasopharyngeal (5-7 inches), oropharyngeal (3-5 inches) Assess before and after: effective cough, lung sounds, O2, RR/depth, signs of distress, history (deviated septum, nasal polyps, nasal injury, swelling, epitaxis/nosebleed), need for pre-medication Tube should be double the size of internal diameter Hyperoxygenate, pre-test suction Unconscious on side, conscious at 30-45 degrees

Document time, pre/post assessment, reason for suctioning, route used, characteristics, amount Sputum culture Can be suctioned or coughed up for Gram Stain/C+S

IV Therapy

4/16/2014 9:40:00 AM

Peripheral IV, CVAD (non-tunneled, tunneled, implanted port), PICC o Gauges are 14-24G, 14 is bigger than 24 o Average is 20, 22 too small for blood transfusion o Magma is orange (14), dirt is gray (16), grass is green (18), flowers are pink (20), sky is blue (22), sun is yellow (24) Peripheral IV: most common, short term, for IV fluid/medication, blood products o Use superficial veins of hand/forearm, start as distal as possible o Change site every 72-96 hrs Primary line is continuous, lock is intermittent; not appropriate for vesicant medicine, TPN, pH 5< or >9, osmolality >600 o Metacarpal, basilica, cephalic Monitor continuous every hour for right fluid (drug)/dose (rate), tolerance to fluid volume, dressing integrity, flush saline locks (2 mL every 12 hrs, pulsatile or + pressure) Infiltration treatment: remove catheter, elevate extremity and place compress (warm for normal-high pH and cold for low), start somewhere else, document infiltration and treatment Phlebitis prevention: when in doubt, take it out, dilute infusate, stabilize device, pick right catheter (avoiding mechanical irritation) o Chemical irritation: pH o Dilute for chemical irritation by decreasing infusion rate of piggy backing Phlebitis treatment: remove catheter, warm compress, restart not near phlebitis, document and how treated Extravasation: infiltration of vesicant drug that can cause blistering, tissue injury/necrosis (chemotherapies vinca alkaloids; catecholamines- dopamine E, NE; gentamycin, mannitol) o Risk factors: fragile vessels, location o Necrosis can occur 6+ months later, ulceration 2-3 days to weeks o Treatment: stop infusion, attach syringe to IV and aspirate, elevate extremity, notify MD, call pharmacy for antidote, document (medical record, incident/safety report)

o Apply ice for 15-20 m x 48 hrs for all except vinca alkaloids and catecholamines (heat) Systemic complications o Fluid overload: turn off/slow down rate, speed shock is worse, change to saline lock HTN, increased pulse/RR, JVD, crackles in lungs o Sepsis: take out IV if occurring there, always see fever o Air embolism: leave IV in unless you can see air Pulse increases but BP drops, confused, cyanosis o Speed shock: vitals increase, dizzy, flushed face, headache, back pain, hard time breathing


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Wounds Put external pressure on wound, then capillary pressure is overcome Protein helps with angiogenesis, collagen synthesis, supports immune function Drains put in primary intention wounds Drains Penrose: passive, placed through stab wound adjacent to incision, not sutured in place o Cant go home with it, have to be careful when changing dressing because it could be pinned to drain JP: gentle negative pressure, can have more than 1, sutured in place, empty when half full, maintain sterility o 50 or 100 mL Hemovac: negative pressure, sutured in place through a stab wound, maintain sterility o Large amounts of drainage (up to 800 mL) o Changed when half full VAC: applied uniform negative pressure along edges of wound,

fenestrated tube in foam, occlusive dressing, prevents infection and promotes healing o For stage ulcers, wounds that wont heal easily, traumatic o Wounds that should not have a VAC are malignant, anaerobic, exposed veins/arteries, anticoagulants, fistulas Removal: pre-medicate Dressings DSD: put over primary intention or shallow secondary Saline moistened (Wet to dry, wet to moist): promotes healing, clean from center out, pack lightly but completely o For secondary intention o Wet to dry for debridement Assess for tunneling, undermining, color, drainage, tissue, size Irrigate wound with NaCl and lactated ringers, medication, enzymes o Use 30-35 mL syringe with 1819 g needle Pneumatic Compression Devices Check CSM and skin every 8 hours

Contraindicated: DVT, PAD, severe edema, cellulitis, skin graft, infected extremity o PAD: would make it harder for blood to flow o DVT: could dislodge o Edema/cellulitis: would compress too much and cause trauma o Infection/grafts: need blood flow to heal


4/16/2014 9:40:00 AM

Leading causes of death are HD and cancer Subjective health is ability to function Take medication history, including vitamins Prioritize problems to restore highest function Mental/Social history is 2nd most important assessment area Sleep disorders Problems with eating Incontinence Confusion Evidence of falls Skin breakdown