Animated Discussion

Cardiovascular System

1. Angiography


2. Cardiac Catheterization


3. Echocardiography


4. Stress Testing or Exercise Testing


5. Echocardiography


6. Transesophageal Echocardiography (TEE)


7. Phlebography

Phlebography

Phlebography: involves injection of contrast media into the venous system through a dorsal vein in the foot.


B. Purposes of the Procedure

1. Useful for diagnosing isolated calf vein thrombosis or recurrent deep venous thrombosis (DVT)

2. This is a worthwhile procedure when there is a discrepancy between the clinical suspicion of deep venous thrombosis and the ultrasound result



C. Nursing Interventions Before the Procedure

1. Nothing per orem for 2-6 hours

2. Assess for allergy to seafoods and iodine.

3. Mild sedative is administered

4. Local anesthesia at the injection site

5. Procedure lasts 30-90 minutes




D. Nursing Interventions After the procedure

1. Monitor vital signs, level of consciousness, peripheral pulses

2. Assess puncture site for hematoma, bleeding

3. Bedrest for 6-8 hrs with the punctured extremity extended

4. Apply pressure dressing and small ice pack at the puncture site

5. Intravenous fluid for 6-8 hours to excrete contrast medium

Transesophageal Echocardiography (TEE)

Transesophageal Echocardiography (TEE) – provides a high resolution ultrasonic imaging of the posterior structures of the heart (e.g. left atrium, mitral valve and aorta) via the esophagus.


B. Purposes of the Procedure

1. Used to readily diagnose and quantify diseases of the aorta, such as aortic dissection

2. Indicated for defining the source of embolism

3. Atrial tumors and thrombi, patent foramen ovale, and aortic debris can be detected

4. Used to assess presence of vegetations for the diagnosis of infective endocarditis

5. Used during cardiac surgery to guide mitral valve repair and septal myectomy

6. Can evaluate suspected abnormalities of a metal prosthesis.

Transesophageal Echocardiography Findings



C. Nursing Interventions Before TEE

1. Ascertain history of esophageal surgery, malignancy, or allergy to anesthetics or sedatives

2. Nothing per orem for 4-6 hrs before the procedure

3. Encourage to void before the procedure

4. Remove dentures and other oral prosthetics

5. Administer sedatives as ordered

6. Keep suction and resuscitation equipment readily available

7. Cardiac monitoring is done during the entire procedure

8. Place patient in chin-to-chest position to facilitate passage of endoscope


Transesophageal Echocardiography Procedure



D. Nursing Interventions After TEE

1. Nothing per orem until gag reflex returns

2. Place in lateral or semi-Fowler’s position

3. Encourage to cough

4. Throat lozenges or rinses may be used to relieve throat soreness

5. Observe for signs and symptoms of complications, e.g. pharyngeal bleeding, cardiac dysrhythmias, vasovagal reaction, and transient hypoxemia

Echocardiography

Echocardiography

: a record of high-frequency sound vibrations that have been sent into the heart through the chest wall

: Cardiac structures return the echoes derived from the ultrasound. The motions of the echoes are traced on an oscilloscope and recorded on a film


B. Purposes of the Procedure

Clinical Usefulness:

> demonstration of valvular and other structural deformities (e.g. mitral stenoses)

> detection of pericardial effusion

> evaluation of prosthetic valve function

> diagnosis of cardiac tumors, asymmetric thickening of interventricular system

> diagnosis of ventricular hypertrophy (cardiomegaly)

Echocardiography Findings




C. Preparation of the Patient

1. No special preparation is required

2. Inform the client that the procedure is painless and takes approximately 30-60 minutes to complete


D. Procedure

1. The client has to remain still, in supine position slightly turned to the left side, with head of bed elevated to 15-20 degrees

2. Transducer is placed on the left sternal border and applied with ultrasonic gel to maintain airless contact between skin and transducer.

3. ECG is recorded simultaneously to time events within cardiac cycle


Echocardiography Procedure

Stress Testing or Exercise Testing

Stress Testing or Exercise Testing

: Assessment of the cardiac function by ECG, blood pressure, and pulse rate during sustained exercise on a treadmill, or a stationary bicycle

: the most sensitive non-invasive test in the diagnosis of coronary artery disease for the most number of patients.

B. Purposes of the Procedure

1. Identify ischemic heart disease

2. Evaluate patients with chest pain

3. Evaluate effectiveness of therapy

4. Develop individual fitness program


C. Preparation of the Patient

1. Obtain an informed consent

2. Attempt to allay the anxiety of the patient

3. Patient should have adequate sleep the night before the test

4. Ensure that the client does not drink coffee, tea, and alcohol on the day of the test

5. Ensure that the client does not smoke nor take nitroglycerine, 2 hours before test

6. Eat a light breakfast / lunch at least 2 hours before the test

7. Wear comfortable, loose-fitting clothes that buttons in front

8. Wear low-heeled, rubber-soled pair of shoes

D. Procedure

1. Ask the client to report dizziness, chest pain, dyspnea, fatigue, or nausea if experienced during the test.

2. Continually observe the client, the vital signs, and the ECG during the test

3. Ensure ready access to emergency cardiac drugs and equipment (e.g. defibrillator)

4. Observe the client after the test and reinforce any medical instructions as required.

5. Evaluate the client’s response to procedure

Procedure During A Stress Test



Findings as Treadmill Exam

Electrocardiography (ECK, EKG)

Electrocardiography (ECG, EKG)

: a graphical representation of the electrical activity of the heart as reflected by changes in electrical potential at the skin surface.

: It is the first diagnostic test done when cardiovascular disease is suspected.

B. Purposes of the Procedure

Clinical usefulness: evaluation of conditions that interfere with the normal electrophysiological function such as:

> disturbance of rhythm

> disorders of cardiac muscle

> enlargement of chambers of the heart

> presence of myocardial infarction

> electrolyte imbalance


Preparation of the Patient

> Inform the client that the procedure is painless. He will not experience electrocution or shock.

> Instruct client to lie still while the ECG is being done.

Procedure

ECG is obtained by placing leads on various parts of the body and recording the electrical impulse as tracing on a strip of paper or on the screen of the oscilloscope.




Normal ECG findings :

Rate: 60-100 beats / minute

P wave: 0.04 – 0.11 seconds (represent atrial depolarization)

PR interval: 0.12 – 0.20 seconds (time of impulse transmission from the sinoatrial node to the atrioventricular node)

QRS Complex: 0.05 – 0.10 seconds (represents ventricular depolarization)

ST segment: represents the plateau phase of the action potential

T wave: should not exceed 5 mm amplitude (represents ventricular repolarization

Cardiac Catheterization

Cardiac Catheterization

: introduction of a catheter into the heart via a peripheral blood vessel to measure oxygen concentration, saturation, and tension in the various chambers of the heart.

: a highly invasive procedure not performed routinely except in cases wherein the patient is experiencing limiting or escalating symptoms of cardiac dysfunction or myocardial ischemia

: used only when objective measures (such as stress test or echocardiography) suggest that the patient has a high risk of progressing deterioration, myocardial infarction, or other adverse events.


B. Purposes of the Procedure

1. Used to accurately characterize the extent and severity of coronary artery disease
and thereby help in deciding the most appropriate plan for medical, surgical, or
catheter-based treatment.

2. Utilized to assess oxygen levels, pulmonary blood flow, cardiac output, heart
structures, and coronary artery visualization



C. Preparation of the Patient

1. Obtain an informed consent; the client should be aware of the procedure’s purpose, its possible complications, and the sensations it causes (e.g. urge to cough, nausea,heat)

2. Provide psychosocial support.

3. Determine the presence of allergies, particularly to iodine / seafoods.

4. Obtain baseline vital signs.

5. Keep the patient on nothing per orem for 6-8 hours before the procedure.

6. Have client void.

7. Administer sedatives as ordered prior to the procedure.

8. Mark distal pulses.

9. Do cardiac monitoring.

10. Inform client that he may experience warm or flushing sensation as the contrast medium is injected. “Fluttering” sensation is felt, as the catheter enters the chambers of the heart.


Heart Catheterization Laboratory




D. Procedure

1. Percutaneous femoral approach: small diameter (2-3mm), hollow plastic tubes or catheters are inserted into the femoral artery (for left heart catheterization) and the femoral vein (for right heart catheterization).

2. Done under local anesthesia.

3. The catheter is advanced under fluoroscopic into the central aorta, where pressure is measured and recorded.

4. Next, the catheter is advanced in retrograde fashion across the aortic valve into the left ventricle, where pressure is measured.




E. Nursing Interventions Post-Catheterization

1. Maintain bed rest for the prescribed number of hours.

2. Monitor vital signs, especially peripheral pulses distal to the insertion site.

3. Monitor electrocardiogram, note for dysrhythmias.

4. To prevent bleeding, apply pressure dressing and a small sand bag or ice over the puncture site.

5. Immobilize affected extremity in extension.

6. Do not place the client’s bed in Fowler’s position if the femoral artery approach was used.

7. Monitor extremities for color, temperature and tingling.

8. Observe for nausea, vomiting, flushing and rash (signs and symptoms of hypersensitivity reaction to contrast media).


Cardiac Catheterization Findings

Angiography

Angiography
: involves introduction of contrast dye into the vascular system to outline the heart and blood vessels

: used to visualize the patency of an artery


Purposes of the Procedure
> Used in the detection of artery stenoses

> Utilized for the detection of congenital anomalies of the coronary circulation, coronary arteriovenous fistulas, and patency of coronary artery bypass grafts

> Used to determine the location, severity, and morphology of stenotic lesions. The resulting information is used to plan either bypass surgery or catheter-based interventions

Coronary Angiography Result




Preparation of the Patient:

> Inform the client of the risks involved in this procedure (allergic reaction, embolus, cardiac dysrhythmia).

> Obtain a signed informed consent.

>Ask the patient about allergies to iodine or shellfish

> Determine the location and strength of peripheral pulses.

> Administer mild sedative as ordered before procedure


Procedure:

1. Angiography is performed with the patient awake but sedated. This is usually performed on an outpatient basis, with the patient discharged 4 to 6 hours after the procedure.

2. Placement of the catheter tip into the arteries is carried out under fluoroscopic guidance, and contrast agent is injected by hand during recording of the radiographic image.


Angiography



Post-procedure Care:

> Observe the client for complications.

> Check the injection site for bleeding and inflammation, assessing circulatory status of the extremities, and enforcing bed rest.

> Evaluate client’s response to procedure.

Laboratory Test for Respiratory System


1. Bronchoscopy


2. Chest X-ray


3. Computed Tomography of the Chest (CHEST CT Scan)


4. Thoracentesis


5. Spirometry


6. Sputum Smear Test

VI. Sputum Smear Test

A. Definition of the Procedure

Sputum Smear Test : sputum is obtained for evaluation of gross appearance, for microscope examination, for gram staining and culture to identify the predominant organisms and cytologic examination.

B. Purpose of the Procedure

a. direct smear : shows presence of white blood cells and intracellular (pathogenic) and extracellular (non-pathogenic) bacteria.
b. sputum culture : to make the diagnosis, to determine sensitivity and to serve as a guide for drug treatment.
c. sputum cytology (Papanicolau method) : used to identify non-invasively the presence of malignancy

C. Preparation of the Patient

1. Teach patient the proper way of expectoration
2. If the sputum is not spontaneously being produced, make the patient inhale an irritating aerosol, such as hypertonic saline (sputum induction)



D. Procedure B
1. Early morning sputum is to be collected
2. Rinse mouth with plain water
3. Use sterile container
4. Sputum specimen for culture and sensitivity is collected before the first dose of antibiotics
5. For Acid Fast Bacilli (AFB) staining, collect sputum specimen for 2 consecutive mornings (3 specimens).

Spirometry

A. Definition of the Procedure

Spirometry : series of test used to detect problems in the performance capabilities of the pulmonary system
B. Purpose of the Procedure

1. Used to measure amounts of gas exchanged between the client and the atmosphere
2. Used in the diagnosis of chronic airflow limitation such as emphysema and bronchitis

C. Preparation of the Patient

1. Explain procedure to the client to allay anxiety and promote compliance at time of test.
2. Notify the respiratory therapist of all medications the client is receiving that affect respiratory function
3. Evaluate client’s response to procedure.

Spirometer



Spirometry Procedure



D. Procedure

1. Vital capacity : the maximum volume of air that can be exhaled after a maximum inhalation.
Reduced in chronic obstructive pulmonary disease
2. Tidal volume : the volume of air inhaled and exhaled with normal quiet breathing
3. Inspiratory Reserve Volume : the maximum volume of air that can be inhaled following a normal quiet exhalation.
4. Expiratory reserve volume : the maximum volume of air that can be exhaled following a normal quiet inhalation.
5. Functional residual capacity : the volume of air that remains in the lungs after normal, quiet exhalation.
6. Residual Volume : the volume of air that remains in the lungs after forceful exhalation


Spirometry Result

Thoracentesis

A. Definition of the Procedure:

Thoracentesis : the aspiration of fluid or air from the pleural space

B. Purposes of Procedure

a. to remove fluid and air from several cavity
b. to obtain diagnostic aspiration of pleural fluid
c. to obtain pleural biopsy
d. to install medication into the pleural space


C. Preparation of the Patient

1. Secure consent
2. Take initial vital signs
3. Prepare Abbocath gauge #16, 5 sterile specimen bottles, 1 liter sterile bottle, 50 cc syringe, 3 way stopcock, Lidocaine ampules
4. Position patient upright, leaning on overbed table
5. Instruct to remain still, avoid coughing during insertion of needles.
6. Pressure sensation is felt on insertion of needle.

D. Procedure

1. Maximum drainage : 1-1.5 liters x 24 hours
2. Usual site of insertion : 8th intercostal space posterior axillary line




E. Post-thoracentesis

Nursing Interventions:

> Turn on the unaffected side to prevent leakage of fluid into the thoracic cavity
> Bed rest
> Note for signs of respiratory distress and expectoration of blood
> Monitor vital signs

Doctor’s Orders
1. Repeat CXR (PA, Lateral) after thoracentesis
2. Serum Lactate Dhydrogenase (LDH) , Total Protein, Albumin, Globulin (TPAG), Glucose simultaneously.
3. Send specimen:
Bottle 1 : Cell count, Differential Count, Total Protein, LDH (5-10 mL EDTA)
Bottle 2 : AFB, Gram Stain, Culture and Sensitivity
Bottle 3 : Cytology and Cell Block (obtain 200 cc of fluid or more to increase yield)

Computed Tomography of the Chest (CHEST CT Scan)

Definition of the Procedure:

Computed Tomography :
an imaging method by which the lungs are scanned in successive layers by a narrow beam x-ray, a computer print out is obtained of the absorption values on the tissues in the plane that is being scanned

Purpose of Procedure:

>used in assessing hilar and mediastinal disease
>used to define pulmonary nodules, small tumors adjacent to pleural surfaces or spine
>an important tool in staging of lung cancer with the additional use of contrast material, CT also makes it possible to distinguish vascular from non-vascular structures, which is particularly important in distinguishing lymph nodes and masses from vascular structures




Preparation of the Patient:

> Remove metallic objects from chest
> Elicit history of allergies if contrast material will be used
> Ensure adequate renal function if contrast material will be used

Procedure:
> Must remain absolutely still during the procedure
> Time is approximately 20 mins if without contrast medium; 60 mins if with contract medium
> Sedation if unable to remain still
> Nothing per orem 4-6 hrs if contrast medium is used.
> Observe for allergic reaction to iodinated contrast material

Chest CT Scan procedure

Chest X-ray

A . Definition of the Procedure

Chest Roentgenogram :
a form of electromagnetic radiation with extremely short-wave lengths and great penetrating power. It is used in medicine to help diagnose certain diseases, to find the extent and location of injuries.

B. Purpose of Procedure
1. detect tumors, foreign bodies, etc.
2. show position or normal structures, displacements and presence of abnormal shadows.
3. chest x-rays may reveal extensive pathology in the lungs in the absence of symptoms.

Procedure during Chest X-ray




C. Preparation of the Patient
1. Practice the client on how to hold his breath and to do deep breathing
2. Instruct client to remove metals from the chest

D. Procedure
1. Posteroanterior and Lateral Views: routine chest radiography which is an integral part of the diagnostic evaluation of diseases involving the pulmonary parenchyma, the pleura, and to a lesser extent, the airways and the mediastinum
2. Lateral decubitus : useful for determining whether pleural abnormalities represent freely-flowing fluid
3. Apico-lordotic views : visualizes diseases of the lung apices better than the standard posteroanterior view
4. Anteroposterior view : utilized for acutely ill patients who either cannot be transported to a radiology suite or cannot stand up for posteroanterior and lateral views.

Normal Chest X-ray (PA) findings



Bronchoscopy

Definition of the Procedure:

BRONCHOSCOPY :
a direct inspection and observation of the larynx, trachea, and bronchi through a flexible or rigid bronchoscope, has both diagnostic and therapeutic use.

Purpose of Procedure

Diagnostic Uses:
>to collect secretions for cytologic and bacteriologic studies
>to determine location and extent of pathologic process and to obtain biopsy for diagnosis
>to determine whether a tumor can be resected surgically
>to diagnose bleeding sites (source of hemoptysis)

Therapeutic Uses:
>Remove foreign objects
>Excise lesions



Preparation of the Patient :

Nursing instructions before bronchoscopy
>Informed consent, permit needed
>Atropine and diazepam pre-procedure; topical anesthesia sprayed followed by local anesthesia injected into larynx
>Nothing per orem for 6-8 hours
>Remove dentures, prostheses, contact lenses

Procedure

1. Rigid Bronchoscopy
>Generally performed in an operating room, with the patient under general anesthesia
>Rigid bronchoscopes are used for the retrieval of foreign bodies and the suctioning of massive hemorrhages, for which the small suction channel of the fiberoptic bronchoscope may be insufficient.

2. Flexible Fiberoptic Bronchoscopy
>This is an outpatient procedure usually performed in an awake but sedated patient.
>Port of entry is either thru the mouth or the nose, between the vocal cords, and into the trachea
>The ability to flex the scope makes it possible to visualize virtually all airways to the level of the subsegmental bronchi.
>Thru this method, we are able to identify endobronchial pathology, including tumors, granulomas, bronchitis, foreign bodies and site of bleedings. There are several methods for getting samples from airway lesions:
4.1. Washing : involves installation of sterile saline through a channel of the bronchoscope and onto the surface of the lesion
4.2. Brushing : using a small brush at the end of the long cable inserted through a channel of the bronchoscope, allows recovery of cellular materials or tissue for analysis by standard cytologic and histopathologic method
4.3. Biopsy : involves use of biopsy forceps or a hollow-bore needle passed through the bronchoscope for sampling of tissue.

Flexible Fiberoptic Bronchoscopy


Nursing Interventions After Bronchoscopy:
>Side-lying position
>Check for the return of cough and gag reflex before giving fluid per orem
>Watch for cyanosis, hypotension, tachycardia, arrythmias, hemoptysis, and dyspnea. These signs and symptoms indicate perforation of the bronchial tree

Bronchoscopy Result


Tribute to Nurses

Of all the gifts God made
To care for all the sick
Your special role portrays
The reason you were picked

Your role was heaven made
So very long ago
The Angel's sang with pride
To see God's love bestowed

And every Angel knows
The radiance of this gift
That God almighty gave
They see it shift to shift

As in your heart of gold
You comfort healing hearts
At every patient's side
God's love you do impart

To honor your hard work
A treasured prize was made
It sits in heaven's home
On shelves all made of jade

Of all the gifts God gave
For patient's to get well
Your heart of gold has won

Truly a Prize Nobel.

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