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NMIH 202

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Peter Moules

on 30 May 2018

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Transcript of NMIH 202


NMIH 202
2018

Week One
Welcome to Country
Professional Behaviour Guidelines
WH&S
Case Studies
Literature Review
I would like to show my respect, and acknowledge the traditional owners of the land, elders past and present, on which this meeting takes place.
4 GROUPS....5 x 20 minute presentations
Class Timetable


Cardiac presentation 20-25 minutes

Respiratory presentation 20-25 minutes

GIT presentation 20-25 minutes

Renal presentation 20-25 minutes

Allocation and prep for next week 20 minutes
http://uow.libguides.com/refcite/uowharvard
Week 2
Anatomy and Physiology
E.C.G.
V1 4th intercostal space R
V2 4th intercostal space L
V4 5th intercostal space, mid clavicular
V3 Between V2 and V4
V6 L mid axillary line 5th space
V5 Between V4 and V6 (straight line)
Pt
may
sit to 45 degrees
Filter may be used after an ECG without filter is recorded
Check aVR should be mainly negative (confirms limb leads)
Special considerations...
Dextrocardia (V3-V6)
Posterior....
V7 (V5 of the back)
V8 Mid scapular same level
V9 L spinal border same level
Bipolar Leads
Einthoven's triangle...I, II, & III

Unipolar Leads
AVf, AVl & AVr

Chest Leads
V1-V6

Limb Leads
RA, RL, LA, & LL
The ECG
Cardiac Hx
Introduction, comfort, and consent
PP, and PQRST...Explore associated (dyspnoea, palpitations, syncope/dizziness, oedema, systemic ie weight loss, fatigue, fever)
Risk factors, HTN, Smoking, hyperlipidaemia, DM, Family Hx, Stress/Depression
pMHx, medical, surgical, admissions. Drugs (OCP, OTC, Herbal). ALLERGIES
Family Hx, Social Hx
P.I.E
Look, and Feel
Pallor
Pulses (radial, brachial, femoral, carotid)
Rate and Rhythm
Capillary refill, central and peripheral
Look, and Feel
Pallor
Pulses (radial, brachial, femoral, carotid)
Rate and Rhythm
Capillary refill, central and peripheral
CARDIAC ASSESSMENT
ELECTROCARDIOGRAPHS
Ischemia Vs Infarction
Review
History
Assessment
Interventions
Diagnostics
Communication
www.aci.health.nsw.gov.au/ie/projects/hiraid
Curtis K, Murphy M, Hoy S, Lewis MJ. The emergency nursing assessment process-A structured framework for a systematic approach. Australasian Emergency Nursing Journal. 2009;12(4):130-136.
Munroe B, Curtis K, Considine J, Buckley T. The impact structured patient assessment frameworks have on patient care: An integrative review. J Clin Nurs. 2013;22(21-22):2991-3005.

Kate Curtis

Belinda Munroe

Margaret Murphy




A+P
Patho
Introduction...
Hello my name is....



I am a ...



I am here to...
Presenting Problem:
(Historical Red Flags)
Why, When, Anything else?
Medical and Surgical Hx
Previous hx, family hx, Related hx etc
Medical Hx
Surgical Hx
Family Hx
Social Hx
Medications
Doctors
Operations
Hospital visits
Parents/Siblings
Drugs
Naturopathy
Disease related
Cardiac
Respiratory
Renal
Gastrointestinal
A
B
C
D
E
F
G
H
Abdo
Resp
Cardiac
Pain
AMI
APO
Infective Endocarditis
Pericarditis
Myocarditis
Asthma
Bronchiolitis
Pneumonia
Pneumothorax
Pulmonary Embolism
Cholecystitis
Appendicitis
Hepatitis
Bowel Obstruction
Hernia
UTI
Acute Nephrotic Syndrome
Renal Calculi
Kidney Cancer
Chronic Renal Failure
Signs and Symptoms
Treatment
Nursing Responsibilities
Vital Signs Monitoring

ECG Pathology

Blood Gases Xray

Ultrasound Nuclear medicine

CT MRI

Invasive Procedures Specialist tests
Who?
What?
How?
Why?
Medications
Procedures
Devices
Disposition
Lifelong?
Other
Case Study?
Oxygen supply
Resp function
Adequate circulation
Functioning Haemoglobin

Gas Exchange
Impaired O2
delivery
Oxygen carrying capacity of the blood
Alveolar changes
FACTORS THAT SHIFT THE DISSOCIATION CURVE
Carbon monoxide
Interferes with O2 transport
240 x the affinity for Hb than O2 -> small amounts of CO can tie up large portions of Hb -> decreases O2 concentration...therefore
oxy-Hb dissociation curve shifts to left -> favours uploading of O2
Temperature
Increased temperature RIGHT
Decreased temperature LEFT
pH
Decreased pH (acidosis) RIGHT
Increased pH (alkalosis) LEFT
CO2
Increased CO2 RIGHT
Decreased CO2 LEFT
Kidneys, Ureter, Bladder
Function
Removal of waste products
Regulation of vascular resistance (ie BP)
Regulation of H2O and electrolytes (Na, K, Ca)
Regulation of acid-base homeostasis
Regulation Vit D production
Control blood volume, and maintaining blood volume, and plasma osmolality
Gluconeogenesis
Glomerulus
Bowmans Capsule
Afferent arteriole
Efferent arteriole
Proximal convoluted tubule
Distal convoluted tubule
Collecting duct
Loop of Henle
Thick descending
Thin descending
Thin ascending
Thick ascending
Filtration
Reabsorption
Secretion
Excretion
F
E

S
R
S
R
R
R
R
Uric acid, organic acids
HCO3, K+, NaCl, H2O, Amino acids, glucose
H2O
NaCl
K+, H+
NaCl, H2O
Urea, NaCl, H2O
H2O, NaCl, K+, HCO3, Creatinine, Urea
Disorders
Pre
Reduced flow
to the kidneys, ie
Blood loss
Sepsis
Dehydration
Vessel blockage
Renal
Kidney problems
Disease,
Drug toxicity,
rhabdo,
infection
Post
Blockage of outflow, ie Stones,
retention
The Renin Angiotensin Aldosterone System
The Acid-Base System
To maintain homeostasis the body requires blood pH to be between 7.35-7.45.
In response to changes to this pH, the body uses 2 regulating systems, the respiratory system, and the renal system.
Respiratory-CO2 is acidic
Renal-HCO3 is base
Arrows indicate acidic changes
< 7.35-7.45
35-45 >
< 22-28
< -2-+2
pH
CO2
HCO3
Base Excess
Pharynx
Salivary Glands
Oesophagus
Spleen
Pancreas
Stomach
Small intestine
Bile Ducts/tract/tree/system Fundus/Body/Pyloris
Duodenum Jujonem Illeum Pancreatic Duct
Pyloric sphincter Cecum
Appendix Hepatic flexure Spleenic Flexure Hepatic Portal vein Hepatic arteries
Adrenal glands
Aorta
Inferior Vena Cava
Gall Bladder
Liver
Ascending Colon
Transverse Colon
Descending colon
Sigmoid Colon to rectum/anus
Kidneys
Ureters
Bladder
Omentum
Inspection
Symmetry


Contour



Skin condition
Umbilicus


Palpitations
Auscultation
Motility

Type of sound, pitch, and location
Stethescope (diaphragm)

All 4 quadrants
Borborygmi
loud prolonged gurgles in hunger, diahroea etc
High pitched sounds suggest fluid,
air under pressure (early obstruction)
Decreased sounds

Absence=5 minutes
Percussion
Sound
Description
Location
Tympany
Musical sound, high pitch
little resonance
Air filled viscera, large pneumothorax
Hyperresonance
Pitch sounds between
tympany and resonance
Emphysema, pneumothorax
Resonance
Dullness
Sustained sound of
moderate pitch
Normal lung tissue or the abdomen
Short high pitched sound
with little resonance
Solid organs, Liver, pneumonia
Flatness
Soft, short, abrupt sound
Muscle, bone, thigh, large pleural effusion
Palpitation
Size
Consistency
Texture
Fluid
Surgical emphysema
Texture and form of mass or structure
Inspection
Resp Rate (10-18)
Rhythm (reg, I:E, Kussmaul, Cheyne-Stokes
abdo or thorax origin)
Quality (Equal rise and fall)
Effort (accessory muscles)
Deformities (fingers, thorax)
Mental Status
Cough
Auscultation
(With or without a stethoscope)
Normal sounds- soft and breezy
Adventitious sounds
Such as crackles, or wheeze
Pulmonary Oedema
Asthma
Emphysema
Pneumonia
Pneumothorax

Palpation
Assess bilateral movements
Surgical emphysema
Pain
E.C.G.
V1 4th intercostal space R
V2 4th intercostal space L
V4 5th intercostal space, mid clavicular
V3 Between V2 and V4
V6 L mid axillary line 5th space
V5 Between V4 and V6 (straight line)
Pt
may
sit to 45 degrees
Filter may be used after an ECG without filter is recorded
Check aVR should be mainly negative (confirms limb leads)
Special considerations...
Dextrocardia (V3-V6)
Posterior....
V7 (V5 of the back)
V8 Mid scapular same level
V9 L spinal border same level
Cardiac Hx
Introduction, comfort, and consent
PP, and PQRST...Explore associated (dyspnoea, palpitations, syncope/dizziness, oedema, systemic ie weight loss, fatigue, fever)
Risk factors, HTN, Smoking, hyperlipidaemia, DM, Family Hx, Stress/Depression
pMHx, medical, surgical, admissions. Drugs (OCP, OTC, Herbal). ALLERGIES
Family Hx, Social Hx
P.I.E
Look, and Feel
Pallor
Pulses (radial, brachial, femoral, carotid)
Rate and Rhythm
Capillary refill, central and peripheral
Look, and Feel
Pallor
Pulses (radial, brachial, femoral, carotid)
Rate and Rhythm
Capillary refill, central and peripheral
Set Up
Privacy
Position
Pain assessment
P
Q
R
S
T
S
O
C
R
A
T
E
S
rovoke/relieve
uality/quantity
egion/radiation
everity
iming/duration/treatment
ite
nset
haracter
adiation
ssociated symptoms
ime course/pattern
xac/relieving factors
everity
Facial Injury
Burns/Inhalation
FB/Obstruction
Trachea


NECK
Vocal sounds/pitch
Stridor


Patient symptoms

Refer to D

C Spine tenderness
Rate ***
Depth
Symmetry
Effort ***
Rhythm ***
Injury
Shape
Fingers/Fingers/
Lips
Position
Adventitious sounds
Bedside/stethescope

Speech limit ie words,
phrases, sentences

Cough

Subcutaneous emphysema

Swelling
Physiological differences Adults v Peads
Smaller nasopharynx,
more easily occluded

Smaller Nares

Larges tongues

Long floppy epiglottis

Larynx higher,
easier aspiration

Thyroid, cricoid, tracheal cartilage
immature, easier to collapse if neck flexed

Fewer muscles in airway, less able to compensate

Large amounts soft tissue, loosely anchored mucousa increased risk edema and obstruction

Large tonsils and adenoids

Lower blood volume, glucose stores, less compensation overall

Diaphragm is flatter making each
breath less effecient
Rapid deterioration
Rapid decompensation
Listen to Parents
Nasal Breathers, cant feed
Nursing assessment and considerations
Tracheal tug

Clavicular recession

Intercostal and subcostal recession

Abdo/Accessory muscle use

Stridor

Periods of apnea/Rhythm/Rate

Cough

Tripod/Position

Wheeze/Creps/Rhonchi

Cyanosis-central/peripheral

Level of conciousness

Fluids in v out

Capillary refill

Heart rate

Speaks words/phrases/sentences

O2sats

Chest rise/fall/symmetry
Altered Resp rate
Cough
O2sats 90-95
Raised CO2
Increased Resp effort
Speaks sentences
Speaks phrases or words
Tripod position
Stridor or other airway issue
Unconcious
O2sats<90%
Haemodynamic changes
Apnea
Increasing O2 requirements, or not responding to treatment
Pursed lip breathing
Confusion
Oxygen Saturations
Red light and Infared light absorbed differently by oxy hB and De Oxy hB
Optical Shunting (FIT), Ambient light, Electromagnetic interference, Hyperoxia, Calibration (different humans), Nail Polish, Poor Peripheral Perfusion (Cold), Movement, Abnormal Hb or CO (carboxy Hb)
Refer to D
AIRWAY
: Patent, trachea midline, nil stridor or vocal changes. Nil neck tenderness

BREATHING
: RR , nil resp distress, normal effort, equal chest rise and fall, equal air entry bilaterally, O2sats 98%RA, speaks sentences.

CIRCULATION
: HR 76 , strong radial pulse, regular, normotensive, ECG attended, warm peripherally, pink well perfused. IVC and bloods??

DISABILITY
: GCS 15, nil reported pain. Normal affect, appropriate behaviour and cognition.

EXPOSURE
: T ??, nil abrasions or breaks in skin, nil rashes.

FLUIDS
(in): Normal intake recently
FLUIDS
(out):Normal fluid out as reported by pt, Last voided , Last BO .

Colour (Pallor)-skin, lips,and nailbed

Oral mucousa
Heart sounds???
Pt complaints
Pulses-radial, brachial, carotid, femoral
Rate,Strength, and regularity
Clamminess
Warmth-peripheral and central
Skin turgor
Cap refill-peripheral and central
Considerations
Glasgow Coma Scale...limitations, use, indications

Limb strength/movement/sensation

Pain
AMI
ATHEROSCLEROSIS - Fatty plaque, hardening
(narrowing of the arteries)




Platelet aggregation
Decreased blood flow through coronary artery affected, to myocardial tissue
Tissue hypoxia
Anaerobic metabolism
Cell Death in a localised area
Male
Age
Ethnic Background
Family Hx
Smoking
High Cholesterol
HTN
DM
Inactive/Sedentary
Overweight
Unhealthy diet
Depression
Direct Causes
ie Illegal Drugs
Cardiac conditions
Illness
Treatment
Oxygen
Anginine
Nursing Considerations
No evidence that demonstrates
improvement with routine O2
RCT suggests increased infarct size
in routine O2 use
Current practice is administration of O2 in
patients with O2sats <93%
Glyceryl Trinitrate (GTN) Spray, transdermal, or Sublinguil tablet. Every 5/60, up to 3 doses
Effect:
Vasodilation
Adverse:
Hypotension, headaches
Contraindications:
?Erectile dysfunction?, HOCM, ?defibrillation?,
Strict Expiry date
O2 therapy
Chest pain assessment
including ECG
Analgesia with GTN, then opiates
Bed rest, elevate head, reassurance
Monitoring, and frequent vital signs
Bloods including troponin
Chest pain pathway
CXR
Aspirin, then other anticoagulants
Fibrinolytics (Clot dissolving drugs)
Tenectaplase
Reteplase
Alteplase
Streptokinase
Bolus
Bolus, then further bolus 30 minutes later
Bolus then infusion
Infusion
*Streptococcus antibodies
Anticoagulant Agents
Aspirin
Clopidogrel or Prasugrel
Heparin
Percutaneous Coronary Intervention
(PCI)
Time sensitive (<12hrs)

Can be activated rapidly, hospital protocols

Urgent balloon angioplasty
Signs and Symptoms
Acute Pulmonary Oedema
(APO)
Cardiogenic v Non Cardiogenic
Acute decompensated Heart Failure
Wet Lung
>Capillary hydrostatic pressure as a result of >pulmonary venous pressure
ie Blood returning to left atrium, exceeds that leaving Left Ventricle
Treatment
Reduce afterload

Provide Oxygen and pressure
Reduce overload?
Cause?
Nursing
Medications
GTN, Lasix, Morphine
Manage BiPAP
Monitoring
Pathology, blood gases
Holistic
The itis's
Endocarditis
Heart valves
Malaise, fever, murmurs, arthralgia
Stigmata-splinter haemorrhages Osler Nodes, Janeway lesions, microhaematuria, retinal infarcts, finger clubbing
Septic emboli
Dx based on criteria, ie Dukes
Ix, Echo, CXR, Path (BC's)
Treatment...ABs +/- Valves
Myocarditis
Viral
Flu like + exertional dyspnea, palpitations, chest pain
Tachycardia, dysrhythmia, heart failure
ECG changes-T wave inversion, increased PR, QRS interval
Cardiomegaly, increased troponin
Treatment-supportive
Dx Symptoms + Cardiac abnormalities
Pericarditis
Often secondary to non infective process
Often self limiting
+/- Fever, Chest pain, Cough, increased symptoms lying down
ECG changes-widespread ST elevation or PR changes
Treatment-Supportive +/- cause
Asthma
Cough
Shortness of Breath
Dyspnea
Chest tightness/pain
Panic/anxiety
Pallor Cyanosis
Pulsus paradoxis
Syncopoe
Death
Risk Factors
Family Hx
Viral Resp Infections
Allergies
Occupational Exposure
Smoking
Air pollution
Obesity
Eczema
Allergies
Asthma
Triggers
Smoke Pollution Pet Dander
Dust mites/cockroaches Mould Illness
Emotions Exercise Sex
Pollen Dust Medications
Treatment
Remove precipitant Relieve anxiety
Position Oxygen??
Ventolin
Beta agonist
Atrovent
Muscuranic antagonist
Corticosteroids
Adrenaline, theophyline, aminophyline
Support breathing, and treat illness
Nursing
Support the patient
Monitor progression
Sats, assessment, auscultate
Administer medications
Educate re devices
and precipitants

Bronchiolitis
Pneumonia
Classified by...
Severity of symptoms
Likely contagion (HAP v CAP)
Treatment/Management
ABs
Symptomatic/supportive, ie IVT, steroids, analgesia, position, oxygen, ventilation support
Pneumothorax
Pulmonary Embolism
(P.E.)
Cholecystitis
Diagnosis
Risk factors
Pain assessment
US or CT
Bloods-bilirubin
Fever
Treatment
ABs
Supportive-IVT,
analgesia, NBM
OT
Appendicitis
Hepatitis
The Chole's
Cholecystitis
Cholelithiasis
Cholecystectomy
Choledocholithiasis
Cholangitis
Cholesterol
Cholera
The Hepa's
Hepatitis
Hepatomegaly
Hepatectomy
Hepatotoxic
Heparin
Biliary Colic
"Gall stone attack"
Temporary,
blockage in bile duct.
Usually with normal vital signs

Associated with N+V
May radiate to R shoulder
usually begans after a meal,
especially fatty
Acute Cholecystitis
Biliary colic,
becomes constant and severe
+ Fever
+ Abnormal bloods
Colic
Form of pain that stops and starts abruptly,
Usually associated with blockage
Cholelithiasis
Presence of gall stones
HEPATITIS
A
-Virus, food or water
Often self limiting
B
-Blood products, body fluids/contact
Often self limiting
C
-Blood products
Never self limiting
D
-Supervirus with B
E
-Water,
Self resolving
Alcoholic or
Auto-immune
Disrupted liver
cell function
Impaired bilirubin conversion and
excretion
Disrupted blood flow through the liver
Oedema in peripheral tissues and ascities (low albumin)
Risk of bleeding
Disrupted glucose metabolism and storage (hyper and hypoglycaemia)
Reduced bile production, impaired absorption of minerals/vitamins (VitK)
Impaired metabolism steroid hormones, feminisation men, and irreg menses in women
Jaundice
Portal hypertension
JAUNDICE
eg. Samuel Shem's, The House of God, Yellow Man
PRE
HEPATIC
POST
Bilirubin is to blame...
Starts as a result of
RBC breakdown...

Then goes to the liver...

Synthesised and mixes
with bile to be stored in
the gall bladder
Haemolytic anaemia
Hepatitis
Cholelithiasis
Portal Hypertension
Impaired blood flow through the liver increases pressure in the portal system that drains into the GIT
Dilation of veins in GIT
& abdo wall...congestion.
Decreased appetite
Varices
Haemorrhoids
Spleenomegaly
Ascities
Hepatorenal syndrome
Hepatic encephalopathy
Accumulation of waste products as blood bypasses the liver
Nursing Considerations
Bowel Obstruction
(SBO)
Nursing+Management
Rest bowel V OT
Treat Cause
Monitor
Analgesia
Anti emetic
IVT
Analgesia
NGT insertion and management
Strict Fluid balance
Bowel chart
Hernia
UTI
Acute Nephrotic Syndrome
Renal Calculi
Renal Cancer
Chronic Renal Failure
ECGs
Blood Gases
Look for p waves?
If present=Sinus Rythm
Count the rate in lead II
P wave
ST Elevation
ST Depression
Reciprocal changes
No P waves?
Atrial Fibrillation
(Irregular rate)
Broad Complex Tachycardia=
Ventricular Tachycardia (VT)
Narrow Complex tachycardia
Look at the rate?
Supraventricular Tachycardia (SVT)
Blood Gas analysis 101
Normal
pH 7.35-7.45
CO2 35-45
HCO3 22-28
BE (-2) - (2)
Acidic changes
Acidic Changes
Acidic Changes
This is what a blood gas looks like in the real world. Ask and answer these questions...

1. Is the pH Normal, Acid, or Alkaline?



2. Is the cause respiratory (CO2) or metabolic (HCO3/BE)?
(ie Which value has changed in the SAME direction, acid or alkaline, as the pH?)
ACIDOSIS
RESPIRATORY
7.550
16
26
1.
2.
6.991
35
18
ANSWERS
1.Respiratory Alkalosis
2. Metabolic Acidosis
3. Respiratory Acidosis
4. Metabolic Alkalosis
3.
4.
7.309
52
32
7.490
52
32
In case you were interested? Some causes...
Metabolic Acidosis

Toxins
DKA
Renal failure
Gi Loss
Metabolic Alkalosis
Loss of chloride, ie loss of gastric juice
Diuretics
Respiratory Acidosis

T2 Respiratory failure (retention of CO2)
Respiratory Alkalosis

Hyperventilation
Full transcript