NCLEX-RN: Medical–Surgical Nursing

Contents

Medical–Surgical Nursing: Diagnostic Procedures

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Chest X-Ray

Focus topic: Medical–Surgical Nursing

A. Silhouette of heart, chambers, and great vessels observed on routine chest x-ray.
B. Pulmonary vascular congestion seen when there is increased left heart pressure.
C. Enlarged heart seen with dilation/hypertrophy.

Medical–Surgical Nursing: 12-Lead Electrocardiography

Focus topic: Medical–Surgical Nursing

A. An electrocardiogram (ECG or EKG) is a surface record of the electrical activity of the heart.
B. Purpose: to determine areas of myocardial ischemia, injury or necrosis, cardiac irregularities, and electrolyte imbalances. (See Figures 8-1 through 8-9.)

  • Noninvasive.
  • Limited to resting state of heart function.

C. ECG components.

  • Normal cardiac cycle.
    a. P wave—atrial depolarization.
    b. P-R interval—conduction through the electrical system, SA node, AV node, and His–Purkinje system.

c. QRS wave—ventricular depolarization.
d. ST segment—early ventricular repolarization.
e. T wave—rapid ventricular repolarization.

  • Interpretation of ECG.
    a. Determine heart rate by calculating atrial rate (P-P interval) and ventricular rate (R-R interval). Normal 60 to 100—one P wave for each QRS complex.
    b. Determine regularity of rhythm (atrial and ventricular).
    c. Measure P-R interval to determine conduction time through electrical system (0.12 to 0.20 second).
    d. Measure QRS duration to determine ventricular conduction time (0.04 to 0.10 second).
    e. Measure Q-T interval—represents ventricular systole. Duration varies with heart rate.
    f. Note configuration and relation of P waves to QRS. Note for ST-segment depression or elevation, T-wave inversion.
  • Etiology of arrhythmias.
    a. Ischemia, electrolyte imbalance, acid–base imbalance, hypoxia, myocardial stretch, sympathetic stimulation, antiarrhythmic agents.
    b. Precipitating or contributing disease states—heart failure, coronary artery disease, myocardial infarction, congenital or acquired heart disease, hyperthyroidism.

Medical–Surgical Nursing

ECG pattern showing artifact

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Sinus bradycardia Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Atrial flutter Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Atrial fibrillation Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Multifocal PVCs

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Ventricular tachycardia

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Ventricular fibrillation

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Third-degree heart block

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Medical–Surgical Nursing: Echocardiography

Focus topic: Medical–Surgical Nursing

A. Noninvasive cardiac procedure that records sound vibrations and reflects mechanical cardiac activity.
B. Used to detect valvular/structural anomalies, ventricular wall thickness, decreased (hypokinesis) or absent (akinesis) wall movement, ventricular ejection fraction, intramural thromboses.
C. May demonstrate exercise-induced ventricular wall motion abnormalities when performed during exercise (or pharmacologic-induced stress).
D. Transesophageal (TEE): as probe passes through esophagus, strictures can be viewed without interference from lungs or ribs.

Medical–Surgical Nursing: Exercise Electrocardiography (Treadmill)

Focus topic: Medical–Surgical Nursing

A. Noninvasive electrocardiography procedure for evaluating myocardial response to increased demands (exercise).
B. Treadmill or bicycle used.
C. Monitor vital signs and ECG for ischemic changes.
D. Clients with positive test may be referred for cardiac catheterization and/or coronary arteriography.
E. Test often combined with scintigraphic studies or echocardiography.

Medical–Surgical Nursing: Ambulatory Electrocardiographic Monitoring

Focus topic: Medical–Surgical Nursing

A. Records ECG for 24–48 hours.
B. Identifies episodes of ischemic ST-segment depression, rhythm changes, and/or correlation with symptoms.
C. Silent (asymptomatic) episodes recorded.

Medical–Surgical Nursing

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Medical–Surgical Nursing: Scintigraphic (Nuclear Medicine) Studies

Focus topic: Medical–Surgical Nursing

A. Involves intravenous (IV) injection of radioactive isotopes; thallium-201 or technetium-99 sestamibi; myocardial uptake is proportionate to blood flow.
B. Special camera scans heart to identify areas of diminished uptake reflecting region of hypoperfusion.
C. When combined with exercise, or pharmacologic vasodilation, region of hypoperfusion may represent ischemia or scar, and may then perfuse at rest indicating reversible ischemia.
D. Technetium-99m pyrophosphate is taken up by an area of myocardial infarction and produces a “hot spot.”
E. Positron emission tomography (PET)—two radionuclides are used: one evaluates myocardial perfusion; the second shows myocardial metabolic function. In a normal heart, scans match; differences indicate ischemic or myocardial injury.

Medical–Surgical Nursing: Cardiac Magnetic Resonance Imaging

Focus topic: Medical–Surgical Nursing

A. Magnetic resonance imaging (MRI) provides high-resolution images of heart and great vessels without radiation exposure or use of iodinated contrast media.
B. Demonstrates pericardial disease, myocardial thickness, chamber size/defects, aneurysms.

Medical–Surgical Nursing: Cardiac Catheterization/Coronary Angiography

Focus topic: Medical–Surgical Nursing

A. Invasive angiography procedure in which a catheter is passed into the heart and its major vessels for examination of blood flow, pressures in chambers and vessels, and oxygen content and saturation. The catheter may be passed through the arterial system into the left side of the heart or through the venous system into the right side of the heart.
B. Radiopaque compound is injected into the heart chambers and coronary vessels for selective arteriography.

  • Evaluates blood flow through chambers.
  • Demonstrates anatomy of coronary circulation.
  • Reveals coronary occlusive disease.

C. Obtain baseline data prior to test.

  • History of allergy, especially shellfish, iodine, or drugs.
  • Serum blood urea nitrogen (BUN) and creatinine for renal function.
  • Obtain baseline vital signs.
  • Check coagulation studies.
  • Mark peripheral pulses bilaterally.

D. Nursing responsibilities prior to procedure.

  • Be sure consent form is signed.
  • Assess client/family understanding of the procedure.
  • Reinforce physician’s explanation.
  • Describe cath lab and equipment or show video.
  • Provide techniques to decrease anxiety and fear.
  • Keep NPO 8 hours or as ordered.
  • Administer pretest medications.

E. Postprocedure responsibilities.

  • Compare data with baseline data obtained prior to procedure.
  • Notify physician if blood pressure (taken every 15 minutes for 1 hour, then every 30 minutes for 2 hours) is decreased by 10% from baseline.
  • Take apical pulse for 1 full minute to determine if arrhythmia is present.
  • Monitor urine output.
  • Encourage increased PO fluid intake to flush system (contrast dye is nephrotoxic).
  • Keep on bed rest in supine position with leg straight for prescribed time.
  • Maintain hemostasis at access site by pressure (e.g., sandbag) for several hours.
  • Check puncture site frequently for bleeding, swelling, hematoma.
  • Observe for allergy to dye.
    a. Tachycardia.
    b. Nausea and vomiting.
    c. Shortness of breath.
    d. Rash.
  • Palpate pulses distal to catheter insertion site to assess for perfusion.
    a. Palpable pulses—bilateral and strong (grade 0, 1+, 2+, 3+, 4+).
    b. Color—no cyanosis or pallor.
    c. Temperature of skin—warm.
    d. No pain.

F. Observe for complications.

  • Respiratory complications—hypoventilation, hypoxia, pulmonary edema.
  • Hypovolemia due to osmotic diuresis.
  • Notify physician if peripheral pulse is lost or if pain, tingling, or coolness occurs.
  • Arrhythmias or alterations of heart rate.
  • Cardiac tamponade—notify physician immediately.
  • Decreased urine production (< 30 mL/hr).

G. Discharge teaching.

  • Instruct client to
    a. Avoid strenuous activity as directed.
    b. Immediately report bleeding at insertion site, chest pain, shortness of breath, difficulty breathing, tingling, numbness, or change in color/temperature of extremities.
    c. Restrict lifting to < 10 lb for prescribed time.
  • Clients with stent placement will require anticoagulation therapy for 6–8 weeks. Instruct client to
    a. Take medication at the same time each day.
    b. Follow up with laboratory tests as ordered to maintain therapeutic blood levels.
    c. Avoid activities that could cause bleeding.
    d. Follow lifestyle guidelines recommended: smoking cessation; weight management; low-fat, low-cholesterol diet; limit alcohol intake; exercise.

Medical–Surgical Nursing: Hemodynamic Monitoring

Focus topic: Medical–Surgical Nursing

The goal of hemodynamic monitoring is to maintain adequate tissue perfusion.

A. Pulmonary artery catheter measures several parameters.

  • CVP 5–10 cm H2O (same as right atrial pressure—RAP): normal is 5 mm Hg.
  • Pulmonary artery pressure (PAP): normal is 20/10 mm Hg with mean of 15 mm Hg.
  • Pulmonary artery wedge pressure (PAWP): mean pressure 10 mm Hg.

B. Pulmonary artery catheter has four to five lumens.

  • Proximal lumen used to measure CVP and inject selected solutions.
  • Distal lumen used to measure PAWP.
  • Third lumen used for balloon inflation.
  • Fourth lumen used to measure cardiac output; includes temperature-sensitive wire that allows determination of cardiac output using thermodilution.

C. Prepare for insertion.

  • Prepare pressure (300 mm Hg) solution bag with heparin.
  • Balance zero transducer.
    a. Transducer must be at level of client’s right atrium (fourth intercostal space).
    b. Continuously monitor client’s ECG.
  • Assist physician to insert catheter.

D. Obtain pulmonary capillary wedge pressure (PCWP) readings.

  • Expose distal port for PAWP.
  • Inject air into balloon port and leave in no longer than required to obtain wedge.
  • Observe waveform change—wedge pressure “A” depicts left atrial contraction and left ventricular relaxation, and “V” depicts left atrial relaxation and left ventricular contraction.

Medical–Surgical Nursing: Central Venous Pressure Monitoring

Focus topic: Medical–Surgical Nursing

A. Central venous pressure (CVP) is pressure within right atrium and reflects right ventricular function—indicates the right side of the heart’s ability to manage fluid load.

  • CVP is a guide for fluid replacement.
  • It is a measure of circulating blood volume.

B. Changes in CVP correlate with client’s clinical status.

  • Elevated CVP can be late sign of left ventricular failure or hypervolemia.
  • Lowered CVP indicates hypovolemia.

C. CVP measured by height of column of water in a manometer (see Figure 8-10).

  • Measuring CVP is done by using zero mark on manometer as standard reference point.
  • Transducer placed at phlebostatic axis.
  • Normal CVP is 5–10 cm H2O.

Medical–Surgical Nursing

Medical–Surgical Nursing: System Implementation

Focus topic: Medical–Surgical Nursing

A. Monitor apical pulse for alterations in cardiac rhythm and rate.
B. Monitor for alterations in blood pressure.
C. Assess peripheral pulses to determine adequacy of circulation.
D. Monitor laboratory values for alterations in electrolytes, coagulation, and cardiac enzymes to prevent complications.
E. Provide diet appropriate for client’s need.
F. Provide emotional support for client and family when alterations in lifestyle are indicated.
G. Administer and instruct client on medications and their side effects.
H. Instruct client on preoperative and postoperative care modalities.
I. Monitor for complications following surgical intervention.
J. Plan an acceptable rehabilitation program with client and family.
K. Administer life support measures when client’s condition is compromised.

Medical–Surgical NursingCoronary Artery Disease

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Coronary Atherosclerosis

Focus topic: Medical–Surgical Nursing

Definition: The most common type of cardiovascular disease—occurs as the result of accumulation of fatty materials (lipids and, the primary one, cholesterol) and fibrous tissue, which narrow the lumen of coronary arteries. Clinical manifestations of disease reflect ischemia to the myocardium, resulting from inadequate blood supply to meet metabolic demands.

Characteristics
A. This form of heart disease originates from an abnormal accumulation of fatty substances and fibrous tissue.
B. Continued development of coronary artery disease (CAD) involves an inflammatory response.
C. Deposits are formed on vessel walls called atheromas or plaque, which narrows vessel and obstructs blood flow.
D. Fibrous cap of plaque may be thick and stable or thin; if thin, it may rupture and form a thrombus.
E. The thrombus may obstruct blood flow and lead to sudden cardiac death or myocardial infarction (MI).

Assessment
A. Assess for presence of risk factors.
B. Evaluate chest pain.

  • Angina, burning, squeezing, crushing tightness substernally or in precordial area. Pain may radiate to neck, jaw, shoulder, arms.
  • Associated with nausea, vomiting, increased perspiration, and cool extremities.

C. Assess heart sounds for presence of arrhythmias and/or murmurs.

Implementation
A. Risk reduction (lifestyle modification).

  • Engage in regular aerobic exercise.
  • Reduce caloric intake if overweight.
  • Refrain from smoking.
  • Control hypertension, diabetes.
  • Nutritional therapy: Adhere to a diet that emphasizes a decrease in saturated fat and cholesterol.
    a. American Heart Association (AHA) Step 1 diet.
    b. For further restrictions of saturated fats and cholesterol, an AHA Step 2 diet is recommended.
    c. For elevated triglycerides, eliminate or reduce simple sugars and alcohol.
  • Stress reduction.

B. Lipid-lowering agents.
C. Revascularization.

  • Percutaneous transluminal coronary angioplasty (PTCA).
  • Stent placement.
  • Atherectomy.
  • Laser angioplasty.
  • Coronary artery bypass grafting (CABG).

D. In-hospital care.

  • Monitor vital signs, particularly blood pressure and pulse.
  • Evaluate ECG findings for changes of ischemia, injury, or necrosis.
  • Administer nitrates if chest pain present.
  • Evaluate chest pain—type, duration, radiation, relieved with medication.
  • Monitor breath sounds and signs of peripheral edema to detect early complications.

Medical–Surgical Nursing

Medical–Surgical Nursing: Types of Angina

Focus topic: Medical–Surgical Nursing

Stable Angina Pectoris
Definition: Intermittent chest pain or discomfort due to the inability of coronary arteries to meet oxygen needs of myocardium. Angina is the result of ischemia caused by reversible cell injury.

Assessment
A. Precipitating factors:

  • Physical exertion.
  • Emotional upset.
  • Tachyarrhythmias.
  • Extremes of temperature, especially cold.
  • Smoking.
  • Consumption of heavy meal.
  • Sexual activity.

B. Evaluate pain.

  • Location: precordial, substernal.
  • Character: compressing, choking, burning, squeezing, crushing heaviness.
  • Radiation: arm or jaw, neck, back.
  • Duration: usually 5–15 minutes, relieved by rest or nitroglycerin.

C. Observe for signs of dyspnea, diaphoresis, unrelieved discomfort.

D. Assess ECG changes (may not be present at rest); ST-segment depression or elevation during pain.

Implementation
A. Current approach to therapy is to decrease oxygen demand of myocardium—restrict activity.

B. Understand medication usage for stable angina.

  • Action of nitroglycerin medication.
    a. Dilates coronary arteries that are not atherosclerotic to increase blood flow to myocardium.
    b. Lessens cardiac work by decreasing venous return—decreases peripheral vascular resistance.
  • Beta blocker—reduces cardiac response to exertion and stress.
  • Aspirin (acetylsalicylic acid; ASA) inhibits platelet activity.
  • Morphine sulfate for relief of pain from myocardial ischemia.
  • Side effects: hypotension, headache, bradycardia.
  • Instruct in use of sublingual nitroglycerin (tablets or metered-dose mouth spray).
    a. Usual recommended dosage: one tablet; may be repeated at 5-minute intervals until pain is relieved, up to three doses.
    b. If pain persists after 15 minutes, instruct client to seek immediate medical attention (call 911 where available).
    c. May be used prophylactically before engaging in activity known to precipitate angina.
    d. Take precautions for postural hypotension.
    e. Keep tablets in tightly closed, dark-glass bottle.
    f. Do not allow tablets to age—drug potency is 3–6 months.
    g. Wear Medic-Alert band and keep medication on person at all times.
  • Alternative: Instruct client in use of nitroglycerin ointment/transdermal patch.
    a. Apply directly to skin.
    b. Remove patch and wash off remaining ointment before new application.
    c. Change skin placement with each application.
    d. Wear patch as directed by physician.

C. Provide client instruction.

  • Learn to live in moderation; physical activity should be sufficient to maintain general physical state, but short of causing angina.
  • Change in lifestyle.
    a. Avoid stress and emotional upset.
    b. Engage in regular exercise.
    c. Reduce caloric intake if overweight.
    d. Refrain from smoking.
    e. Avoid saturated fats and cholesterol.
    f. Instruct client in use of medication.

D. Other antianginal agents.

  • Beta blockers: Inderal (propranolol), Tenormin (atenolol) reduce myocardial oxygen requirements during exertion and stress.
  • Calcium-entry blocking agents: Calan, Isoptin (verapamil), Cardizem (diltiazem) dilate coronary arteries, lower blood pressure, reduce heart rate—effective for vasospastic angina.
  • Platelet-inhibiting agents: low-dose aspirin or Plavix (clopidogrel).

E. Myocardial revascularization (if medical management ineffective).

  • Percutaneous transluminal coronary angioplasty (PTCA).
  • Stent placement.
  • Atherectomy.
  • Laser angioplasty.
  • Coronary artery bypass grafting (CABG).

Unstable Angina
Definition: Also called preinfarction angina—previously stable angina has new onset while at rest, lasts longer, is less responsive to medication. Signifies dynamic change in the vessel (a supply problem). Most clients have complex coronary stenoses with plaque rupture, ulceration, or hemorrhage with subsequent thrombus formation; may occur due to vasospasm.

Assessment
A. Unstable angina leads to myocardial infarction (MI).

  • ST-elevated MI (STEMI).
  • Non-ST-elevated MI (non-STEMI).

B. ECG changes—transient ST-segment depression or T-wave flattening or inversion, or ST-segment elevation (vasospastic angina).
C. Serial ECG recordings ordered.
D. Presence of S3 diastolic filling sound.
E. Serial cardiac enzyme determinations (troponin elevation may indicate small amount of myocardial damage).
F. Unstable status may progress to complete occlusion and MI or may resolve and return to stable angina.
G. Noninvasive and invasive cardiac diagnostic procedures to identify diseased coronary artery.

Implementation
A. Immediate medical intervention; bed rest, with cardiac and hemodynamic monitoring.
B. Heparin infusion (weight-based bolus, then infusion titrated to achieve activated partial thromboplastin time [APTT] ratio 1.5–2.3).
C. Platelet-inhibiting agents (ASA, Plavix).
D. Narcotic pain management (morphine sulfate).
E. Oxygen administration (2–4 L/min).

F. Tridil (nitroglycerine) infusion titrated for pain relief (requires continuous blood pressure monitoring for hypotension).

  • Potent, concentrated drug; must be diluted in glass bottle of D5W or sodium chloride 0.9%.
  • Given as a continuous infusion. Begin at 5 μg/min.
  • Increase by increments every 3–5 minutes,
    until the desired response occurs.
  • IV infusion pump is used to deliver continuous
    flow rate.
    5. Closely monitor blood pressure (BP), PAP,
    PCWP, HR, CO.

G. Administration of beta blockers.
H. Antiembolytic therapy.
I. Revascularization management (PTCA, CABG).

Medical–Surgical Nursing: Myocardial Infarction

Definition: The process by which cardiac muscle cells die due to insufficient blood supply (oxygen deprivation). Caused by vessel occlusion due to thrombus formation on ruptured or eroded coronary artery atheroma; coronary artery embolism or vasospasm; decreased blood volume with shock and/or hemorrhage; direct trauma.

Assessment
A. Assess pain (history very important)—precipitating factors, interventions leading to relief, associated symptoms.
B. Identify anxiety, feeling of doom.
C. Note dyspnea, nausea, vomiting, and diaphoresis.
D. Low-grade temperature elevation after 24 hours.
E. Diagnostic findings.

  • History of ischemic type chest discomfort (very important).
  • Serial 12-lead ECGs to note evolutionary changes that reflect areas of involvement.
    a. ST elevated (STEMI, acute injury).
    b. ST-segment depression (subendocardial infarction).
    c. Evolving abnormal Q waves (transmural infarction).
  • Serial cardiac enzymes lab tests.
    a. Elevated creatinine kinase-myocardial band (CK-MB)—rises in 3–6 hours after onset of myocardial damage, peaks in 12–24 hours, returns to normal in 48–72 hours.
    b. Myoglobin—protein found in cardiac and skeletal muscle. Sensitive and early indicator of myocardial infarction, occurring 1–2 hours following injury. Declines rapidly after approximately 7 hours.
    c. Troponin—myocardial muscle protein released after injury.
    (1) Troponin T—peaks in 12 hours; high specificity at 3–6 hours following onset of injury.
    (2) Troponin I—rises in 4–6 hours (remains elevated 6 days).
  • Elevated white blood cells (WBCs) and sedimentation rate.
  • Isotope scanning of myocardium.
  • Echocardiogram.

F. Infarction sites.

  • Transmural—entire thickness of myocardium involved—produces Q wave on reflecting ECG leads.
  • Subendocardial—death confined to inner layer of myocardium—produces non–Q wave MI.
  •  Location: depends on which coronary artery is occluded.
    a. Most MIs occur in left ventricle, with damage limited to area supplied by blocked vessel.
    b. Left ventricular infarcts may be localized to anterior, septal, inferior, posterior, or lateral walls.
    (1) RCA blockage = inferior wall infarcts.
    (2) LAD blockage = anterior or anteroseptal infarcts.

Implementation
A. Immediate hospitalization for early diagnosis of acute myocardial injury by ECG, serial enzymes.
B. Pain management with sublingual Tridil (nitroglycerine) or intravenous narcotics (morphine sulfate).
C. Early reperfusion therapy by PTCA or thrombolysis (streptokinase, tissue plasminogen activator; tPA) to reduce infarction size.
D. Antiplatelet therapy.E. Anticoagulant continuation therapy following reperfusion (heparin weight-based bolus, then infusion titrated to keep APTT ratio 1.5–2.3).
F. Coronary care unit continuous monitoring.

  • Physical and emotional rest.
  • Bed rest with bedside commode.
  • Liquid diet for 24 hours, then advanced.
  • Stool softeners to prevent constipation/Valsalva maneuver.
  • Beta blocker therapy (reduces reinfarction rate and sudden death).
  • Angiotensin-converting enzyme (ACE) inhibitor if low ejection fraction (reduces mortality).
  • Lidocaine for frequent and complex premature ventricular contractions (PVCs), ventricular tachycardia.
  • Lipid-lowering agents (if appropriate).

G. Monitor for complications.

  • Arrhythmias.
  • Heart failure.
  • Cardiogenic shock.
  • Papillary muscle dysfunction (new murmur).
  • Pericarditis (friction rub).
  • Ventricular aneurysm/cardiac rupture.

H. Step-down care with telemetry cardiac monitoring progressive ambulation.
I. Rehabilitation with progressive ambulation and client teaching about lifestyle modification, prudent (AHA) Step 2 diet, medications, etc.

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