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COPD Nursing Care Overview

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66 views77 pages

COPD Nursing Care Overview

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ

Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture

Module #1 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Lesson title: CHRONIC OBSTRUCTIVE PULMONARY DISEASE Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to: Reference:
1. Be acquainted with each other, orientation about the subject
and classroom regulations and procedures; Hinkle, J. L., & Cheever, K. H. (2018).
2. Describe the pathophysiology of the chronic obstructive Brunner & Suddarth’s textbook of
pulmonary disease (COPD); medical-surgical nursing (14th ed.).
3. Discuss major risk factors for developing COPD; and, Philadelphia, PA: Lippincott Williams
4. Describe nursing management of patients with COPD. &Wilkins.

A. LESSON PREVIEW/REVIEW

Introduction:
Hello, PHINMA Ed student! Welcome to Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations (Acute and Chronic) – Lecture. This professional subject of BS Nursing
deals with concepts, principles and techniques of nursing care of at-risk and sick adult clients with life-threatening
conditions, acutely ill/multi-organ problems, high acuity and emergency situation toward health promotion, disease
prevention, restoration and maintenance and rehabilitation.

In today’s session, you are tasked to set expectations as you get oriented with what the subjects is all about and to
determine the nature of your mode of learning. You may write in this area the vital policies, rules, and regulations to be
noted in this class. You may also refer to the Course Outline to be provided by your instructor.

B. MAIN LESSON

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

 This is a condition of chronic dyspnea with expiratory airflow limitation that does not significantly fluctuate.
 This has been defined by The Global Initiative as “a preventable and treatable disease with some significant
extrapulmonary effects that may contribute to the severity in individual patients.” This updated definition is a broad
description of COPD and its signs and symptom.

Classification
There are two classifications of COPD: chronic bronchitis and emphysema. These two types of COPD can be sometimes
confusing because there are patients who have overlapping signs and symptoms of these two distinct disease processes

Pathophysiology
 In COPD, the airflow limitation is both progressive and associated with an abnormal inflammatory response of the
lungs to noxious gases or particles
 An inflammatory response occurs throughout the proximal and peripheral airways, lung parenchyma, and
pulmonary vasculature.
 Due to the chronic inflammation, changes and narrowing occur in the airways.
 There is an increase in the number of goblet cells and enlarged submucosal glands leading to hypersecretion of
mucus.
 Scar formation. This can cause scar formation in the long term and narrowing of the airway lumen.
 Wall destruction. Alveolar wall destruction leads to loss of alveolar attachments and a decrease in elastic recoil.

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #1 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 The chronic inflammatory process affects the pulmonary vasculature and causes thickening of the vessel lining
and hypertrophy of smooth muscle.

Causes of COPD includes environmental factors and host factors. These includes
 Smoking depresses the activity of scavenger cells and affects the respiratory tract’s ciliary cleansing mechanism.
 Occupational exposure. Prolonged and intense exposure to occupational dust and chemicals, indoor air
pollution, and outdoor air pollution all contribute to the development of COPD.
 Genetic abnormalities. The well-documented genetic risk factor is a deficiency of alpha1- antitrypsin, an enzyme
inhibitor that protects the lung parenchyma from injury.

Clinical Manifestations: The natural history of COPD is variable but is a generally progressive disease.
 Chronic cough. Chronic cough is one of the primary symptoms of COPD.
 Sputum production. There is a hyperstimulation of the goblet cells and the mucus-secreting gland leading to
overproduction of sputum.
 Dyspnea on exertion. Dyspnea is usually progressive, persistent, and worsens with exercise.
 Dyspnea at rest. As COPD progress, dyspnea at rest may occur.
 Weight loss. Dyspnea interferes with eating and the work of breathing is energy depleting.
 Barrel chest. In patients with emphysema, barrel chest thorax configuration results from a more fixed position
of the ribs in the inspiratory position and from loss of elasticity.

Prevention of COPD is never impossible. Discipline and consistency are the keys to achieving freedom from chronic
pulmonary diseases.
 Smoking cessation. This is the single most cost-effective intervention to reduce the risk of developing COPD
and to stop its progression.
 Healthcare providers should promote cessation by explaining the risks of smoking and personalizing the “at-risk”
message to the patient.

Complications: There are two major life-threatening complications of COPD

 Respiratory failure. The acuity and the onset of respiratory failure depend on baseline pulmonary function, pulse
oximetry or arterial blood gas values, comorbid conditions, and the severity of other complications of COPD.
 Respiratory insufficiency. This can be acute or chronic, and may necessitate ventilator support until other acute
complications can be treated.

Assessment and Diagnostic Findings

 Health history. The nurse should obtain a thorough health history from patients with known or potential COPD.
 Pulmonary function studies are used to help confirm the diagnosis of COPD, determine disease severity, and
monitor disease progression.
 Spirometry is used to evaluate airway obstruction, which is determined by the ratio of FEV1 to forced vital
capacity.
 Arterial blood gas measurement is used to assess baseline oxygenation and gas exchange and is especially
important in advanced COPD.
 Chest x-ray may be obtained to exclude alternative diagnoses.
 CT scan may help in the differential diagnosis.
 Screening for alpha1-antitrypsin deficiency can be performed for patients younger than 45 years old and for
those with a strong family history of COPD.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, increased retrosternal air space, decreased
vascular markings/bullae (emphysema), increased bronchovascular markings (bronchitis), normal findings during
periods of remission (asthma).
 Pulmonary function tests: Done to determine cause of dyspnea, whether functional abnormality is obstructive or
restrictive, to estimate degree of dysfunction and to evaluate effects of therapy, e.g., bronchodilators. Exercise
pulmonary function studies may also be done to evaluate activity tolerance in those with known pulmonary
impairment/progression of disease.
 Arterial blood gases (ABGs): Determines degree and severity of disease process, e.g., most often Pao 2is
decreased, and Paco2 is normal or increased in chronic bronchitis and emphysema, but is often decreased
in asthma; pH normal or acidotic, mild respiratory alkalosis secondary to hyperventilation
(moderate emphysema or asthma).
 DL CO test: Assesses diffusion in lungs. Carbon monoxide is used to measure gas diffusion across the
alveocapillary membrane. Because carbon monoxide combines with hemoglobin 200 times more easily than
oxygen, it easily affects the alveoli and small airways where gas exchange occurs. Emphysema is the only
obstructive disease that causes diffusion dysfunction.
 Bronchogram: Can show cylindrical dilation of bronchi on inspiration; bronchial collapse on forced expiration
(emphysema); enlarged mucous ducts (bronchitis).
 Lung scan: Perfusion/ventilation studies may be done to differentiate between the various pulmonary
diseases. COPD is characterized by a mismatch of perfusion and ventilation (i.e., areas of abnormal ventilation in
area of perfusion defect).
 Complete blood count (CBC) and differential: Increased hemoglobin (advanced emphysema), increased
eosinophils (asthma).
 Blood chemistry: alpha1-antitrypsin is measured to verify deficiency and diagnosis of primary emphysema.
 Sputum culture: Determines presence of infection, identifies pathogen.
 Cytologic examination: Rules out underlying malignancy or allergic disorder.
 Electrocardiogram (ECG): Right axis deviation, peaked P waves (severe asthma); atrial dysrhythmias
(bronchitis), tall, peaked P waves in leads II, III, AVF (bronchitis, emphysema); vertical QRS axis (emphysema).
 Exercise ECG, stress test: Helps in assessing degree of pulmonary dysfunction, evaluating effectiveness of
bronchodilator therapy, planning/evaluating exercise program.

Medical Management: Pharmacologic Therapy

Healthcare providers perform medical management by considering the assessment data first and matching the
appropriate intervention to the existing manifestation.
 Bronchodilators relieve bronchospasm by altering the smooth muscle tone and reduce airway obstruction by
allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation.
 Corticosteroids. A short trial course of oral corticosteroids may be prescribed for patients to determine whether
pulmonary function improves and symptoms decrease.
 Other medications. Other pharmacologic treatments that may be used in COPD include alpha1-antitrypsin
augmentation therapy, antibiotic agents, mucolytic agents, antitussive agents, vasodilators, and narcotics.

Management of Exacerbations
 Optimization of bronchodilator medications is first-line therapy and involves identifying the best medications or
combinations of medications taken on a regular schedule for a specific patient.
 Hospitalization. Indications for hospitalization for acute exacerbation of COPD include severe dyspnea that does
not respond to initial therapy, confusion or lethargy, respiratory muscle fatigue, paradoxical chest wall movement,
and peripheral edema.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Oxygen therapy. Upon arrival of the patient in the emergency room, supplemental oxygen therapy is
administered and rapid assessment is performed to determine if the exacerbation is life-threatening.
 Antibiotics. Antibiotics have been shown to be of some benefit to patients with increased dyspnea, increased
sputum production, and increased sputum purulence.

Surgical Management
Patients with COPD also have options for surgery to improve their condition.
 Bullectomy. Bullectomy is a surgical option for select patients with bullous emphysema and can help reduce
dyspnea and improve lung function.
 Lung Volume Reduction Surgery. Lung volume reduction surgery is a palliative surgery in patients with
homogenous disease or disease that is focused in one area and not widespread throughout the lungs.
 Lung Transplantation. Lung transplantation is a viable option for definitive surgical treatment of end-stage
emphysema

Emphysema Chronic Bronchitis

PINK PUFFER BLUE BLOATER

Elastic recoil Alveolar detachment

FEV1V/FVC
Airway FEV1 Mucus
obstruction Hypersecretion
Lung compliance Destruction of Air trapping
Wheezing
capillary bed on expiration
Alveolar OXYGEN Productive cough with
Auto-PEEP hypoxia THERAPY
Perfusion copious sputum
Ventilation
Pursed-lip
breathing
Matched DLCO Pulmonary
End V:Q mismatch
V:Q defect vasoconstriction
Expiratory
volume

Relatively well- RV
oxygenated blood TLC
until late stage Hypoxemia Hypercarbia Pulmonary Hypertension
VC
LV output RHF

Work of
breathing Barrel chest Respiratory Circulating Cor
Polycythemia
acidosis volume pulmonale

Cyanosis Activation JVP Loud

Dyspnea Cachexia Osteoporosis Heart disease
of RAAS P2
Parasternal
Inflammation heaves
FOR ALL COPD Fluid retention Peripheral
edema

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

NURSING MANAGEMENT
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Assessment of Diagnosis of COPD Goals to achieve Maintain airway To achieve airway During evaluation,
the respiratory would mainly in patients with patency. Instruct clearance. the effectiveness
system should depend on the COPD include: patient in direct of the care plan
be done rapidly assessment data and controlled would be
yet accurately. gathered by the Improvement in coughing. measured if goals
healthcare team gas exchange. were achieved in
Assess members. Assist with This measure will the end and the
patient’s Achievement of measures to improve breathing patient:
exposure to risk Impaired gas airway clearance. facilitate gas pattern.
factors. exchange due to exchange. Identifies the
chronic inhalation of Improvement in hazards of
Assess the toxins. breathing pattern. Instruct patient on To determine cigarette
patient’s past inspiratory muscle informational smoking.
and present Ineffective airway Independence training, needs of the
medical history. clearance related in self- diaphragmatic client and Identifies
to care activities. breathing and significant others. resources for
Assess the bronchoconstriction, purse lip smoking
signs and increased mucus Improvement in breathing cessation.
symptoms of production, activity
COPD and their ineffective cough, intolerance. Enhance Enrolls in
severity. and other nutritional intake. smoking
complications. Ventilation/oxyge cessation
Assess the nation adequate Ascertain program.
patient’s Ineffective to meet self-care understanding on
knowledge of breathing needs. nutritional needs. Minimizes or
the disease. pattern related to eliminates
shortness of breath, Nutritional intake Assess dietary exposures.
Assess the mucus, meeting caloric habits &
patient’s vital bronchoconstriction, needs. nutritional needs. Verbalizes the
signs. and airway irritants. need for fluids.
Infection treated Prevent Is free of
Assess breath Self-care or prevented. complications, infection.
sounds and deficit related to slow progression
pattern. fatigue. Disease of condition. Practices
process/prognosi breathing
Activity s and therapeutic Encourage the Patient is prone to techniques.
intolerance related regimen patient to be respiratory
to hypoxemia and understood. immunized infection. Performs
ineffective breathing against S. activities with less
patterns. Plan in place to pneumonia. shortness of
meet needs after breath.
discharge.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Discharge and Home Care Guidelines

It is important for the nurse to assess the knowledge of patient and family members about self-care and the therapeutic
regimen.
 Setting goals. If the COPD is mild, the objectives of the treatment are to increase exercise tolerance and prevent
further loss of pulmonary function, while if COPD is severe, these objectives are to preserve current pulmonary
function and relieve symptoms as much as possible.
 Temperature control. The nurse should instruct the patient to avoid extremes of heat and cold because heat
increases the temperature and thereby raising oxygen requirements and high altitudes increase hypoxemia.
 Activity moderation. The patient should adapt a lifestyle of moderate activity and should avoid emotional
disturbances and stressful situations that might trigger a coughing episode.
 Breathing retraining. The home care nurse must provide the education and breathing retraining necessary to
optimize the patient’s functional status.

Documentation Guidelines
Documentation is an essential part of the patient’s chart because the interventions and medications given and done are
reflected on this part.
 Document assessment findings including respiratory rate, character of breath sounds; frequency, amount and
appearance of secretions laboratory findings and mentation level.
 Document conditions that interfere with oxygen supply.
 Document plan of care and specific interventions.
 Document liters of supplemental oxygen.
 Document client’s responses to treatment, teaching, and actions performed.
 Document teaching plan.
 Document modifications to plan of care.
 Document attainment or progress towards goals.

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. The term “pink puffer” refers to the client with which of the following symptoms?
a. ARDS c. Chronic obstructive bronchitis
b. Asthma d. Emphysema.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. The underlying pathophysiology of COPD is:

a. inflamed airways that obstruct airflow.
b. mucus secretions that block airways
c. overinflated alveoli that impair gas exchange.
d. characterized by variations of all of the above.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

3. The abnormal inflammatory response in the lungs occurs primarily in the:

a. airways.
b. parenchyma.
c. pulmonary vasculature.
d. areas identified in all of the above.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. Two diseases common to the etiology of COPD are:

a. asthma and atelectasis.
b. chronic bronchitis and emphysema.
c. pneumonia and pleurisy.
d. tuberculosis and pleural effusions.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. The term “blue bloater” refers to which of the following conditions?

a. adult respiratory distress syndrome
b. asthma
c. chronic obstructive bronchitis
d. emphysema
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. The most important environmental risk factor for emphysema is:

a. air pollution. c. infectious agents.
b. allergens. d. cigarette smoking.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. A 66-year-old client has marked dyspnea at rest, is thin and uses accessory muscles to breathe. He is tachypneic,
with a prolonged expiration phase. He has no cough. He leans forward with his arms braced on his knees to support
his chest and shoulder for breathing. This client has symptoms of which of the following respiratory disorder?
a. ARDS c. Chronic obstructive bronchitis
b. Asthma d. Emphysema
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

8. Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the following reasons explains why?
a. reducing fluid volume reduces oxygen demand
b. reducing fluid volume improves clients’ morbidity
c. restricting fluid volume reduces sputum production
d. reducing fluid volume improves respiratory function
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Teaching for a client with chronic obstructive pulmonary disease (COPD) should include which of the following topics?
a. How to have his wife learn to listen to his lungs with a stethoscope
b. How to increase his oxygen therapy
c. How to treat respiratory infections without going to the physician
d. How to recognize the signs of impending respiratory infection.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to
experience what type of acid- base imbalance.
a. respiratory acidosis c. metabolic acidosis
b. respiratory alkalosis d. metabolic alkalosis
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

MINUTE PAPER
This strategy provides feedback on whether or not you understand the lesson. Use the space provided in this activity
sheet to answer the following questions. Make sure to not miss a tiny detail!

1. What was the most useful or the most meaningful thing you have learned this session?

2. What question(s) do you have as we end this session?

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #2 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Lesson title: PULMONARY EMBOLISM (PE) AND ACUTE Materials:

RESPIRATORY DISTRESS SYNDROME (ARDS) Electronic gadget, pen, & notebook

Learning Targets: Reference:

At the end of the module, students will be able to:
1. Define pulmonary embolism and ARDS; Hinkle, J. L., & Cheever, K. H. (2018).
2. Trace the pathophysiology of the disease conditions; Brunner & Suddarth’s textbook of
3. Discuss symptoms and management of PE & ARDS; and, medical-surgical nursing (14th ed.).
4. Utilize nursing process in taking care of clients with PE and Philadelphia, PA: Lippincott Williams
ARDS. &Wilkins.

A. LESSON PREVIEW/REVIEW

Let us have a quick review of what you have learned from the previous session. Kindly answer the posted task on the
space provided. You may use the back page of this sheet, if necessary. Here is the task:

Differentiate emphysema and chronic Bronchitis. State at least five characteristics.

B. MAIN LESSON

PULMONARY EMBOLISM (PE) refers to the obstruction of the pulmonary artery or one of its branches by a thrombus
that originates somewhere in the venous system or in the right side of the heart.
 Pulmonary embolism is a common disorder that is related to deep vein thrombosis (DVT).

Deep Vein Thrombosis (DVT), a related condition, refers to thrombus formation in the deep veins, usually in the calf or
thigh, but sometimes in the arm, especially in patients with peripherally inserted central catheters.

Classification
Most commonly, pulmonary embolism is due to a blood clot or thrombus, but there are other types of emboli: fat,
air, amniotic fluid, and septic.
 Fat emboli. Fat emboli are cholesterol or fatty substances that may clog the arteries when fatty foods are
consumed more.
 Air emboli. Air emboli usually come from intravenous devices.
 Amniotic fluid emboli. Amniotic fluid emboli are caused by amniotic fluid that has leaked towards the arteries.
 Septic emboli. Septic emboli originate from a bacterial invasion of the thrombus.

Pathophysiology: A series of happenings will occur in patient’s body when he/she has emboli.
1. Obstruction. When a thrombus completely or partially obstructs the pulmonary artery or its branches, the
alveolar dead space is increased.
2. Impairment. The area receives little to no blood flow and gas exchange is impaired.
3. Constriction. Various substances are released from the clot and surrounding area that cause constriction of the
blood vessels and results in pulmonary resistance.

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #2 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

4. Consequences. Increased pulmonary vascular resistance due to regional vasoconstriction leading to increase in
pulmonary arterial pressure and increased right ventricle workload are the consequences that follow.
5. Failure. When the workload of the right ventricle exceeds the limit, failure may occur.

Causes: Pulmonary embolism is linked to a lot of causes and these are the most common.
 Trauma. Trauma anywhere in the body could cause PE especially if a clot is released from the venous system.
 Surgery. Certain surgical procedures such as orthopedic, major abdominal, pelvic, and gynecologic surgeries
could cause PE.
 Hypercoagulable states. A patient with hypercoagulability disorders would most likely develop a clot that could
result in PE.
 Prolonged immobility. Being unable to move for a prolonged time predisposes a person to PE.

Clinical Manifestations: Symptoms of pulmonary embolism depend on the size of the thrombus and the area of the
pulmonary artery occluded by the thrombus.
 Dyspnea. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent
of embolization.
 Chest pain. Chest pain occurs suddenly and is pleuritic in origin.
 Tachycardia. Increase in heart rate occurs because the right ventricle catches up with its workload.
 Tachypnea. The most frequent sign is tachypnea.

Prevention: For patients at risk for PE, the most effective approach for prevention is to prevent DVT.
1. Avoid venous stasis. Active leg exercises, early ambulation, and use of anti-embolism stockings are general
preventive measures for DVT.
2. Sequential compression devices. These are plastic sleeves that can be inflated with air for compression
and relaxation of calf muscles.
3. Mechanical prophylaxis. Mechanical prophylaxis can be classified as static or dynamic.
4. Graduated compression stockings. This involves the sequential movement of air in the sleeve up the leg,
followed by relaxation of the sleeve.
5. Anticoagulant therapy. Anticoagulant therapy may be prescribed for patients whose hemostasis is adequate
and who are undergoing major elective abdominal or thoracic surgery.

Complications: When caring for a patient who has had PE, the nurse must be alert for potential complications.
 Cardiogenic shock. The cardiopulmonary system is endangered in a massive PE.
 Right ventricular failure. A sudden increase in pulmonary resistance increases the work of the right ventricle.

Assessment and Diagnostic Findings

Death from PE commonly occurs within one (1) hour after the onset of symptoms; therefore, early recognition and
diagnosis are priorities.
 Chest x-ray is usually normal but may show infiltrates, atelectasis, elevation of the diaphragm on the affected
side, or a pleural effusion.
 ECG usually shows sinus tachycardia, PR-interval depression, and nonspecific T-wave changes.
 ABG analysis may show hypoxemia and hypocapnia; however, ABG measurements may be normal even in the
presence of PE.
 Pulmonary angiogram allows for direct visualization under fluoroscopy of the arterial obstruction and accurate
assessment of the perfusion deficit.
 V/Q scans evaluate the different regions of the lung and allow comparisons of the percentage of ventilation
and perfusion in each area.

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #2 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Medical Management: Because PE is often a medical emergency, emergency management is of primary concern.
 Anticoagulation therapy. Heparin, and warfarin sodium has been traditionally been the primary method for
managing acute DVT and PE.
 Thrombolytic therapy. Urokinase, streptokinase, alteplase are used in treating PE, particularly in patients who
are severely compromised.

Surgical Management: Removal of the emboli may sometimes need surgical management.
 Surgical embolectomy. This is the removal of the actual clot and must be performed by a cardiovascular
surgical team with the patient on cardiopulmonary bypass.
 Transvenous catheter embolectomy. This is a technique in which a vacuum-cupped catheter is introduced
transvenously into the affected pulmonary artery.
 Interrupting the vena cava. This approach prevents dislodged thrombi from being swept into the lungs while
allowing adequate blood flow.

Nursing Management: A key role of the nurse is to identify the patient at high risk for pulmonary embolism, and to
minimize the risk of PE in all patients.

Nursing Assessment: All patients are evaluated for risk factors for thrombus formation and pulmonary embolus.
1. Health history. Health history is assessed to determine any previous cardiovascular disease.
2. Family history. History of any cardiovascular disease in the family may predispose the patient to PE.
3. Medication record. There are certain medications that can increase the risk for PE.
4. Physical exam. Extremities are evaluated for warmth, redness, and inflammation.

Diagnosis: Based on assessment data, the following nursing diagnoses for a patient with PE are developed:
 Ineffective peripheral tissue perfusion related to obstructed pulmonary artery.
 Risk for shock related to increased workload of the right ventricle.
 Acute pain related to pleuritic origin.

Nursing Care Planning and Goals

 Planning and goals for a patient with pulmonary embolism include the following:
 Increase perfusion
 Verbalize understanding of condition, therapy regimen, and medication side effects.
 Display hemodynamic stability.
 Report pain is relieved or controlled.
 Follow prescribed pharmacologic regimen.

Nursing Interventions: Nursing care for a patient with pulmonary embolism includes
 Prevent venous stasis. Encourage ambulation and active and passive leg exercises to prevent venous stasis.
 Monitor thrombolytic therapy. Monitoring thrombolytic and anticoagulant therapy through INR or PTT.
 Manage pain. Turn patient frequently and reposition to improve ventilation-perfusion ratio.
 Manage oxygen therapy. Assess for signs of hypoxemia and monitor the pulse oximetry values.
 Relieve anxiety. Encourage the patient to talk about any fears or concerns related to this frightening episode.

Evaluation
 Success of the treatment plan will be evaluated with the following:
 Increased perfusion.
 Verbalized understanding of condition, therapy regimen, and medication side effects.

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #2 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Displayed hemodynamic stability.

 Reported pain is relieved or controlled.
 Followed prescribed pharmacologic regimen.

ACUTE RESPIRATORY DISTRESS SYNDROME

 ARDS is a life-threatening lung condition. It is a form of breathing failure that can occur in very ill or severely
injured people.
 It is not a specific disease.
 It starts with swelling of tissue in the lungs and build-up of fluid in the tiny air sacs that transfer oxygen to the
bloodstream. This leads to low blood oxygen levels.
 ARDS is similar infant respiratory distress syndrome, but the causes and treatments are different. ARDS can
develop in anyone over the age of one year old.
 Also known as Adult Respiratory Distress Syndrome, Respiratory Distress Syndrome,

Causes:
Direct injury to the lungs:
1. Chest trauma 3. Breathing smoke, chemicals or salt water
2. Breathing vomit 4. Burns
Indirect Injuries
1. Severe infection
2. Massive blood transfusion
3. Pneumonia
4. Severe inflammation of the pancreas (pancreatitis)
5. Overdoses of alcohol or certain drugs (e.g., aspirin, cocaine, opioids, phenothiazine, and tricyclic antidepressants)
6. Lung and bone marrow transplantation–within few days of a lung transplant, the recipient is prone to development
of ARDS.

Risk Factors
 ARDS usually develops in people who are already in the hospital and are being treated for an injury listed above.
 However, only a small number of people who have these injuries actually develop ARDS.
 While none can predict who will get ARDS, cigarette smokers, those with chronic lung disease, or those who are
over age 65 are more at risk of developing ARDS.

Symptoms
 Shortness of breath
 Fast, labored breathing
 Bluish skin or fingernail color
 Rapid pulse

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #2 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

PATHOPHYSIOLOGY OF ACURE RESPIRATORY DISTRESS SYNDROME

Acute Lung Injury

Inhilation of inflammatory-
immuneresponse
Release of mediators

Increase capillary
Decrease in airway diameter Injury to pulmonary vasculature
permeability

Pulmonary vasoconstriction
Alveolar flooding with loss of Increase airway resistant -Decrease
Microemboli Formation
surfactant lung complinace
Pulmonary Hypertension

Increase work of Decreased cardiac

Alveolar collapse Alveolar dead space
breathing output.

Alveolar
hypoventilation
intrapulmonary
shunting

HYPOXEMIA

Diagnosis:
 A person suffering from severe infection or injury develops breathing problems
 A chest x-ray shows fluid in the air sacs of both lungs
 Blood tests show a low level of oxygen in the blood
 Other conditions that could cause breathing problems have been ruled out
 Blood pressure check
 Blood tests for oxygen levels and signs of infection as well as levels of BNP (brain natriuretic peptide) a marker of
heart failure
 Chest x-ray
 Analysis of coughed-up matter
 Occasionally, an echocardiogram (heart ultrasound), to rule out congestive heart failure
 Pulmonary artery catheterization to aid in diagnostic work-up

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #2 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Bronchoscopy to analyze airways. A laboratory examination may indicate presence of certain viruses, cancer cells
etc.
 Open lung biopsy is reserved for cases when diagnosis is difficult to establish.

Nursing Diagnoses
 Ineffective Airway Clearance  Impaired Gas Exchange
 Ineffective Breathing Pattern  Anxiety

Treatment
1. Treating the underlying cause or injury
2. Providing support until the lungs heal:
 Mechanical ventilation (a breathing machine) through a tube placed in the mouth or nose, or through an opening
created in the neck
 Monitoring blood chemistry and fluid levels
 Often, ARDS patients are sedated to tolerate these treatments.

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism?
(Select all that apply.)
A. A client who has a BMI of 30
B. A female client who is postmenopausal
C. A client who has a fractured femur
D. A client who is a marathon runner
E. A client who has chronic atrial fibrillation
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is
anxious because she feels that she cannot get enough air. Vital signs are: heart rate 117/min, respiratory rate 38/min,
temperature 38.4° C (101.2° F), and blood pressure 100/54 mm Hg. Which of the following actions is the priority
action at this time?
A. Notify the provider.
B. Administer heparin via IV infusion.
C. Administer oxygen therapy.
D. Obtain a spiral CT scan.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #2 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

3. A male patient’s X-ray result reveals bilateral white- outs indicating adult respiratory distress syndrome (ARDS). This
syndrome results from;
A. Cardiogenic pulmonary edema
B. Respiratory alkalosis
C. Increased pulmonary capillary permeability.
D. Renal failure
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse
expect to note in the client?
A. Pallor
B. Low arterial PaO2
C. Elevated arterial PaO2
D. Decreased respiratory rate.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse
expect to find? (Select all that apply.)
A. Bradypnea
B. Pleural friction rub
C. Hypertension
D. Petechiae
E. Tachycardia
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. You’re providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-
rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute
respiratory distress syndrome (ARDS)?
A. The patient is experiencing bradypnea.
B. The patient is tired and confused.
C. The patient’s PaO2 remains at 45 mmHg.
D. The patient’s blood pressure is 180/96.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #2 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

7. A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical
findings commonly accompany respiratory alkalosis?
A. Nausea and vomiting
B. Abdominal pain or diarrhea
C. Hallucination or tinnitus
D. Lightheadedness and paresthesia
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. A client is suspected of having pulmonary embolism. A nurse assesses the client, knowing that which of the following
is a common clinical manifestation of pulmonary embolism?
A. Dyspnea
B. Bradypnea
C. Bradycardia
D. Decrease respiration
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. A patient has been hospitalized in the ICU for a near drowning event. The patient’s respiratory function has been
deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray
is ordered. What finding on the chest x-ray is indicative of ARDS?
A. infiltrates only on the upper lobes
B. enlargement of the heart with bilateral lower lobe infiltrates
C. white-out infiltrates bilaterally
D. normal chest x-ray
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. Which patient below is at MOST risk for developing ARDS and has the worst prognosis?
A. A 52-year-old male patient with a pneumothorax.
B. A 48-year-old male being treated for diabetic ketoacidosis.
C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection.
D. A 30-year-old female with cystic fibrosis.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #2 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

11. The nurse assesses a patient for possible pulmonary embolism. The nurse looks for the most frequent sign of:
A. Cough
B. Hemoptysis
C. Syncope
D. Tachypnea
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

12. The following are nursing intervention to assist in the prevention of pulmonary embolism in a hospitalized patient
include all except:
A. A liberal fluid intake
B. Assisting the patient to do leg elevation above the level of the heart.
C. Encouraging the patient to dangle his or her legs over the side of the bed for 30 minutes, four times a day.
D. The use of elastic stocking, especially when decreased mobility would promote venous stasis.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

13. You are caring for a patient with acute respiratory distress syndrome. As the nurse you know that prone positioning
can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was
beneficial for your patient with ARDS?
A. Improvement in lung sounds
B. Development of a V/Q mismatch
C. PaO2 increased from 59 mmHg to 82 mmHg
D. PEEP needs to be titrated to 15 mmHg of water
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

14. A patient is experiencing respiratory failure due to pulmonary edema. The physician suspects ARDS but wants to rule
out a cardiac cause. A pulmonary artery wedge pressure is obtained. As the nurse you know that what measurement
reading obtained indicates that this type of respiratory failure is NOT cardiac related?
A. >25 mmHg
B. <10 mmHg
C. >50 mmHg
D. <18 mmHg
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #2 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

15. Which of the following is a type of embolism?

A. Travelling emboli
B. Fat emboli
C. Burn emboli
D. Diabetic emboli
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

CAT 3-2-1

This strategy provides a structure for you to record your own comprehension and summarize your learning. Let us see
your progress in this chapter!

Three things you learned:

1. _______________________________________________________________________________________

2. _______________________________________________________________________________________

3. _______________________________________________________________________________________

Two things that you’d like to learn more about:

1. __________________________________________________________________________________________

2. __________________________________________________________________________________________

One question you still have:

1. __________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #3 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Lesson title: PNEUMONIA Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to: Reference:
1. Define pneumonia and differentiate its classification;
2. Trace the pathophysiology of the disease condition; Hinkle, J. L., & Cheever, K. H. (2018).
3. Discuss its causes and manifestations; Brunner & Suddarth’s textbook of
4. Identify preventive measures; medical-surgical nursing (14th ed.).
5. Formulate nursing diagnosis for the disease; and, Philadelphia, PA: Lippincott Williams
6. Develop nursing care plans for clients with pneumonia. &Wilkins.

A. LESSON PREVIEW/REVIEW

Enumerate the causes of direct and indirect injuries to the lungs. Provide clinical examples commonly found in patients.

B. MAIN LESSON

PNEUMONIA is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria,
mycobacteria, fungi, and viruses.

Pneumonitis is a more general term that describes the inflammatory process in the lung tissue that may predispose and
place the patient at risk for microbial invasion.

Classification: Pneumonia is classified into four: community-acquired pneumonia (CAP) and hospital-acquired
pneumonia (HAP), pneumonia in the immunocompromised host, and aspiration pneumonia.

Community-Acquired Pneumonia
 CAP occurs either in the community setting or within the first 48 hours after hospitalization.
 The causative agents for CAP that needs hospitalization
include streptococcus pneumoniae, H. influenza, Legionella, and Pseudomonas aeruginosa.
 Only in 50% of the cases does the specific etiologic agent become identified.
 Pneumonia is the most common cause of CAP in people younger than 60 years of age.
 Viruses are the most common cause of pneumonia in infants and children.

Hospital-Acquired Pneumonia
 HAP is also called nosocomial pneumonia and is defined as the onset of pneumonia symptoms more than 48
hours after admission in patients with no evidence of infection at the time of admission.
 HAP is the most lethal nosocomial infection and the leading cause of death in patients with such infections.
 Common microorganisms that are responsible for HAP include Enterobacter species, Escherichia
coli, influenza, Klebsiella species, Proteus, Serratia marcescens, S. aureus, and S. pneumonia.
 The usual presentation of HAP is a new pulmonary infiltrate on chest x-ray combined with evidence of infection.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Pneumonia in the Immunocompromised Host

 Pneumonia in immunocompromised hosts includes Pneumocystis pneumonia, fungal pneumonias and
Mycobacterium tuberculosis.
 Patients who are immunocompromised commonly develop pneumonia from organisms of low virulence.
 Pneumonia in immunocompromised hosts may be caused by the organisms also observe in HAP and CAP.

Aspiration Pneumonia
 Aspiration pneumonia refers to the pulmonary consequences resulting from entry of endogenous or exogenous
substances into the lower airway.
 The most common form of aspiration pneumonia is a bacterial infection from aspiration of bacteria that normally
reside in the upper airways.
 Aspiration pneumonia may occur in the community or hospital setting.
 Common pathogens are S. pneumonia, H. influenza, and S. aureus.

Pathophysiology
 Having an idea about the disease process helps the patient understand the treatment regimen and its importance,
increasing patient compliance.
 Pneumonia arises from normal flora present in patients whose resistance has been altered or from aspiration of
flora present in the oropharynx.
 An inflammatory reaction may occur in the alveoli, producing exudates that interfere with the diffusion of oxygen
and carbon dioxide.
 White blood cells also migrate into the alveoli and fill the normally air-filled spaces.
 Due to secretions and mucosal edema, there are areas of the lung that are not adequately ventilated and cause
partial occlusion of the alveoli or bronchi.
 Hypoventilation may follow, causing ventilation-perfusion mismatch.
 Venous blood entering the pulmonary circulation passes through the under ventilated areas and travels to the left
side of the heart deoxygenated.
 The mixing of oxygenated and poorly oxygenated blood can result to arterial hypoxemia.

Epidemiology
 Pneumonia has affected a lot of people, especially those who have a weak immune system. Learning statistics on
pneumonia could give you an idea about how many has fallen victim to this respiratory disease.
 Pneumonia and influenza account for nearly 60,000 deaths annually.
 Pneumonia also ranks as the eighth leading cause of death in the United States.
 It is estimated that more than 915, 000 episodes of CAP occur in adults 65 years old and above in the United
States.
 HAP accounts for 15% of hospital-acquired infections; leading cause of death in patients with such infections.
 The estimated incidence of HAP 4 to 7 episodes per 1000 hospitalizations.

Causes: Each type of pneumonia is caused by different and several factors.

Community-Acquired Pneumonia
 Streptococcus pneumoniae. This is the leading cause of CAP in people younger than 60 years of age without
comorbidity and in those 60 years and older with comorbidity.
 Haemophilus influenzae. This causes a type of CAP that frequently affects elderly people and those with
comorbid illnesses.
 Mycoplasma pneumoniae.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Hospital-Acquired Pneumonia
 Staphylococcus aureus. Staphylococcus pneumonia occurs through inhalation of the organism.
 Impaired host defenses. When the defenses of the body are down, several pathogens may invade the body.
 Comorbid conditions. There are several conditions that lower the immune system, causing bacteria to pool in the
lungs and eventually result in pneumonia.
 Supine positioning. When the patient stays in a prolonged supine position, fluid in the lungs pools down and stays
stagnant, making it a breeding place for bacteria.
 Prolonged hospitalization. The risk for hospital infections or nosocomial infections increases the longer the patient
stays in the hospital.

Clinical Manifestations
Pneumonia varies in its signs and symptoms depending on its type but it is not impossible to diagnose a specific
pneumonia through its clinical manifestations.
 Rapidly rising fever. Since there is inflammation of the lung parenchyma, fever develops as part of the signs of an
infection.
 Pleuritic chest pain. Deep breathing and coughing aggravate the pain in the chest.
 Rapid and bounding pulse. A rapid heartbeat occurs because the body compensates for the low concentration of
oxygen in the body.
 Tachypnea. There is fast breathing because the body tries to compensate for the low oxygen concentration in the
body.
 Purulent sputum. The sputum becomes purulent because of the infection in the lung parenchyma which produced
sputum-filled with pus.

Prevention: It is better to prevent the occurrence of pneumonia instead of treating the disease itself. Here are several
ways that can help prevent pneumonia.
 Pneumococcal vaccine. This vaccine can prevent pneumonia in healthy patients with an efficiency of 65% to 85%.
 Staff education. To help prevent HAP, the CDC (2004) encouraged staff education and involvement in infection
prevention.
 Infection and microbiologic surveillance. It is important to carefully observe the infection so that there could be an
appropriate application of prevention techniques.
 Modifying host risk for infection. The infection should never be allowed to descend on any host, so the risk must
be decreased before it can affect one.

Complications: Pneumonia has several complications if left untreated or the interventions are inappropriate. These are
the following complications that may develop in patients with pneumonia.
 Shock and respiratory failure. These complications are encountered chiefly in patients who have received no
specific treatment and inadequate or delayed treatment.
 Pleural effusion. In pleural effusion, the fluid is sent to the laboratory for analysis, and there are three stages:
uncomplicated, complicated, and thoracic empyema.

Assessment and Diagnostic Findings of pneumonia must be accurate since there are a lot of respiratory problems that
have similar manifestations. The following are assessments and diagnostic tests that could determine pneumonia.
 History taking. The diagnosis of pneumonia is made through history taking, particularly a recent respiratory tract
infection.
 Physical examination. Mainly, the number of breaths per minute and breath sounds is assessed during physical
examination.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Chest x-ray. Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple abscesses/infiltrates,
empyema (staphylococcus); scattered or localized infiltration (bacterial); or diffuse/extensive nodular infiltrates
(more often viral). In mycoplasmal pneumonia, chest x-ray may be clear.
 Fiberoptic bronchoscopy. May be both diagnostic (qualitative cultures) and therapeutic (re-expansion of lung
segment).
 ABGs/pulse oximetry. Abnormalities may be present, depending on extent of lung involvement and underlying
lung disease.
 Gram stain/cultures. Sputum collection; needle aspiration of empyema, pleural, and transtracheal or
transthoracic fluids; lung biopsies and blood cultures may be done to recover causative organism. More than one
type of organism may be present; common bacteria include Diplococcus pneumoniae, Staphylococcus aureus, a-
hemolytic streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures may not
identify all offending organisms. Blood cultures may show transient bacteremia.
 CBC. Leukocytosis usually presents, although a low white blood cell (WBC) count may be present in viral
infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte
sedimentation rate (ESR) is elevated.
 Serologic studies, e.g., viral or Legionella titers, cold agglutinins. Assist in differential diagnosis of specific
organism.
 Pulmonary function studies. Volumes may be decreased (congestion and alveolar collapse); airway pressure
may be increased and compliance decreased. Shunting is present (hypoxemia).
 Electrolytes. Sodium and chloride levels may be low.
 Bilirubin. May be increased.
 Percutaneous aspiration/open biopsy of lung tissues. May reveal typical intranuclear and cytoplasmic
inclusions (CMV), characteristic giant cells (rubeola).

Medical Management: The management of pneumonia centers is a step-by-step process that zeroes on the treatment of
the infection through identification of the causative agent.
1. Blood culture. Blood culture is performed for identification of the causal pathogen and prompt administration
of antibiotics in patients in whom CAP is strongly suspected.
2. Administration of macrolides. Macrolides are recommended for people with drug-resistant S. pneumoniae.
3. Hydration is an important part of the regimen because fever and tachypnea may result in insensible fluid losses.
4. Administration of antipyretics. Antipyretics are used to treat fever and headache.
5. Administration of antitussives. Antitussives are used for treatment of the associated cough.
6. Bed rest. Complete rest is prescribed until signs of infection are diminished.
7. Oxygen administration. Oxygen can be given if hypoxemia develops.
8. Pulse oximetry. Pulse oximetry is used to determine the need for oxygen and to evaluate the effectiveness of the
therapy.
9. Aggressive respiratory measures. Other measures include administration of high concentrations of oxygen,
endotracheal intubation, and mechanical ventilation.

Nursing Assessment is critical in detecting pneumonia. Here are some tips for your nursing assessment for pneumonia.
 Assess respiratory symptoms. Symptoms of fever, chills, or night sweats in a patient should be reported
immediately to the nurse as these can be signs of bacterial pneumonia.
 Assess clinical manifestations. Respiratory assessment should further identify clinical manifestations such as
pleuritic pain, bradycardia, tachypnea and fatigue, use of accessory muscles for breathing, coughing, and
purulent sputum.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Physical assessment. Assess the changes in temperature and pulse; amount, odor, and color of secretions;
frequency and severity of cough; degree of tachypnea or shortness of breath; and changes in the chest x-ray
findings.
 Assessment in elderly patients. Assess elderly patients for altered mental status, dehydration, unusual behavior,
excessive fatigue, and concomitant heart failure.

Diagnosis: Through the data collected during assessment, the following nursing diagnoses are made.
1. Ineffective airway clearance related to copious tracheobronchial secretions.
2. Activity intolerance related to impaired respiratory function.
3. Risk for deficient fluid volume related to fever and a rapid respiratory rate.

Nursing Care Planning & Goals is essential to establish the interventions that are appropriate for the patient’s condition.
1. Improve airway patency.
2. Rest to conserve energy.
3. Maintenance of proper fluid volume.
4. Maintenance of adequate nutrition.
5. Understanding of treatment protocol and preventive measures.
6. Absence of complications.

Nursing Priorities:
1. Maintain/improve respiratory function.
2. Prevent complications.
3. Support recuperative process.
4. Provide information about disease process, prognosis, and treatment.

Nursing Interventions: If implemented appropriately, this would result in the achievement of the goals.
To improve airway patency:
 Removal of secretions. Secretions should be removed because retained secretions interfere with gas exchange
and may slow recovery.
 Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions.
 Humidification may loosen secretions and improve ventilation.
 Coughing exercises. An effective, directed cough can also improve airway patency.
 Chest physiotherapy. Chest physiotherapy is important because it loosens and mobilizes secretions.
To promote rest and conserve energy:
 Encourage avoidance of overexertion and possible exacerbation of symptoms.
 Semi-Fowler’s position. The patient should assume a comfortable position to promote rest and breathing and
should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion.
To promote fluid intake:
 Fluid intake. Increase in fluid intake to at least 2L per day to replace insensible fluid losses.
 To maintain nutrition:
 Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
 Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also help restore proper nutrition.
To promote patient’s knowledge:
 Instruct patient and family about the cause of pneumonia, management of symptoms, signs, and symptoms, and
the need for follow-up.
 Instruct patient about the factors that may have contributed to the development of the disease.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Evaluation: Expected patient outcomes include the following

 Demonstrates improved airway patency.
 Rests and conserves energy by limiting activities and remaining in bed while symptomatic and then slowly
increasing activities.
 Maintains adequate hydration.
 Consumes adequate dietary intake.
 States explanation for management strategies.
 Complies with management strategies.
 Exhibits no complications.
 Complies with treatment protocol and prevention strategies.

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax?
A. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures.
B. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere.
C. The injury allows air into the pleural space but prevents it from escaping from the pleural space.
D. A tension pneumothorax results from a puncture of the pleura during a central line placement.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should
the nurse implement when caring for this client? Select all that apply.
A. Place the client in a low-Fowler's position.
B. Assess chest tube drainage system frequently.
C. Maintain strict bed rest for the client.
D. Secure a loop of drainage tubing to the sheet.
E. Observe the site for subcutaneous emphysema.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

3. The initial characteristics symptom of a simple pneumothorax is:

A. ARDS
B. Severe respiratory distress
C. Sudden chest pain
D. Tachypnea and chest discomfort
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

4. Clinical manifestation of related to pneumothorax includes the following except for:

A. Pleuritic pain
B. Respiratory distress
C. Acrocyanosis
D. Tachypnea
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. Which of the following should the nurse assess in patient with pneumothorax?
A. Tracheal alignment
B. Expansion of the chest
C. Breath sounds
D. All of the above
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. The pressure required in the pleural space to keep the lungs inflated is:
A. Positive
B. Negative
C. Atmospheric
D. All of the above
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. The following are types of pneumothorax except:

A. Trauma C. Tension
B. Simple D. Direct
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. On auscultation, which of the following suggest a right pneumothorax?

A. Bilateral inspiratory and expiratory crackles.
B. Absence of breath sounds in the right thorax.
C. Inspiratory wheezes in the right thorax.
D. Bilateral pleural friction rubs.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

9. Nurse Pepper is caring for a client with pneumothorax and who has had a chest tube inserted notes continues gentle
bubbling in the suction control chamber. Which action is appropriate?
A. Do nothing, because this is an expected finding.
B. Immediately clamp the chest tube and notify the physician.
C. Check for an air leak because the bubbling should be intermittent.
D. Increase the suction pressure so that the bubbling becomes vigorous.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of the
signs would indicate the presence of pneumothorax in this client?
A. A low respiratory rate
B. Diminished breath sounds
C. The presence of barrel chest
D. A sucking sound at the site of injury.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

MUDDIEST POINT
This technique will help you determine which key points have been missed in the main lesson:

In today’s session, what was least clear to you?

_________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Lesson title: PULMONARY ARTERIAL HYPERTENSION Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to: Reference:
1. Define pulmonary arterial hypertension;
2. Trace the pathophysiology of the disease condition; Hinkle, J. L., & Cheever, K. H. (2018).
3. Discuss the symptoms of pulmonary arterial hypertension; Brunner & Suddarth’s textbook of
4. Formulate nursing diagnosis of the disease; and, medical-surgical nursing (14th ed.).
5. Develop nursing care plans in the care of the client with the Philadelphia, PA: Lippincott Williams
disorder. &Wilkins.

A. LESSON PREVIEW/REVIEW

Differentiate community acquired and hospital acquired pneumonia.

B. MAIN LESSON

PULMONARY ARTERIAL HYPERTENSION

Definition
 Pulmonary arterial hypertension exists when the mean pulmonary artery pressure exceeds 25 mm Hg with a
pulmonary capillary wedge pressure of less than 15 mm Hg.

There are two types of pulmonary arterial hypertension:

 Idiopathic (or primary) pulmonary arterial hypertension.
 Pulmonary arterial hypertension due to a known cause (Badesch, et al., 2007). It occurs most often in women 20
to 40 years of age, either sporadically or in patients with a family history, and is usually fatal within 5 years of
diagnosis.

Causes
 There are several possible causes, but the exact cause is unknown.
 A common cause of pulmonary arterial hypertension is pulmonary artery constriction due to hypoxemia from
COPD

Pathophysiology
 Conditions such as collagen vascular disease, congenital heart disease, anorexigens (speciﬁc appetite
depressants), chronic use of stimulants, portal hypertension, and HIV infection increase the risk of pulmonary
arterial hypertension in susceptible patients.
 Vascular injury occurs with endothelial dysfunction and vascular smooth muscle dysfunction, which leads to
disease progression (vascular smooth muscle hypertrophy, adventitial and intimal proliferation [thickening of the
wall], and advanced vascular lesion formation).

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Normally, the pulmonary vascular bed can handle the blood volume delivered by the right ventricle. It has a low
resistance to blood flow and compensates for increased blood volume by dilation of the vessels in the pulmonary
circulation. However, if the pulmonary vascular bed is destroyed or obstructed, as in pulmonary hypertension, the
ability to handle whatever flow or volume of blood it receives is impaired, and the increased blood flow then
increases the pulmonary artery pressure.
 As the pulmonary arterial pressure increases, the pulmonary vascular resistance also increases. Both pulmonary
artery constriction (as in hypoxemia or hypercapnia) and a reduction of the pulmonary vascular bed (which occurs
with pulmonary emboli) result in increased pulmonary vascular resistance and pressure. This increased workload
affects right ventricular function.
 The myocardium ultimately cannot meet the increasing demands imposed on it, leading to right ventricular
hypertrophy (enlargement and dilation) and failure. Passive hepatic congestion may also develop.

Symptoms /Clinical Manifestation

 Dyspnea, the main symptom of pulmonary hypertension, occurs at ﬁrst with exertion and eventually at rest
 Substernal chest pain also is common.
 Other signs and symptoms include weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided
heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur).
 Anorexia and abdominal pain in the right upper quadrant may also occur.

Assessment and Diagnostic Findings

Several tests are used to determine if there is a known cause for the pulmonary hypertension. If the diagnostic tests and
thorough evaluation of the patient reveal no known cause, a diagnosis of primary pulmonary hypertension is made.
 Complete diagnostic evaluation includes a history, physical examination, chest x-ray, pulmonary function studies,
electrocardiogram (ECG), echocardiogram, ventilation–perfusion scan, sleep studies, autoantibody tests (to
identify diseases of collagen vascular origin), HIV tests, liver function testing, and cardiac catheterization.

Treatment/ Medical Management: The goal is to manage the underlying condition related to pulmonary hypertension of
known cause. Recommendations regarding therapy are tailored to the patient’s individual situation, functional New York
Heart Association class, and speciﬁc needs.
 Anticoagulation should be considered for patients with pulmonary hypertension and patients with an indwelling
catheter for administration of medications. Most patients with pulmonary hypertension do not have hypoxemia at
rest but require supplemental oxygen with exercise.
 Diuretics and oxygen should be added as needed.
 Different classes of medications are used to treat pulmonary hypertension; these include calcium channel
blockers, phosphodiesterase-5 inhibitors, endothelin antagonists, and proteinoids. The choice of therapeutic
agents is based on the severity of the disease

Nursing Management
 The major nursing goal is to identify patients at high risk for pulmonary arterial hypertension, such as those with
COPD, pulmonary emboli, congenital heart disease, and mitral valve disease.
 The nurse must be alert for signs and symptoms, administer oxygen therapy appropriately, and instruct the
patient and family about the use of home oxygen therapy.
 In patients treated with prostanoids (i.e., epoprostenol or treprostinil), education about the need for central venous
access (epoprostenol), subcutaneous infusion (treprostinil), and proper administration and dosing of the
medication, pain at the injection site and potential severe side effects is extremely important.
 Emotional and psychosocial aspects of this disease must be addressed.
 Formal and informal support groups for patients and families are extremely valuable.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. The physician diagnosed the patient with Class III Primary Pulmonary Hypertension. The nurse is aware that the
characteristic of this condition is:
A. No manifestation at rest and mild to moderate physical activity induces dyspnea, fatigue, chest pain, or
lightheadedness.
B. No or slight manifestation at rest and mild (less than ordinary) activity induces dyspnea, fatigue, chest pain or
lightheadedness.
C. Dyspnea and fatigue is present at rest, unable to carry out any level of physical activity without manifestations, and
manifestations of right sided heart failure apparent (engorged neck veins, dependent edema and enlarged liver).
D. Pulmonary hypertension diagnosed by pulmonary function test and right sided cardiac catheterization, no limitation
of physical activity, and moderate physical activity does not include dyspnea, fatigue, chest pain or light headedness.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. The morning weight for a client with emphysema indicates that the client has gained 5 pounds in less than a week,
even though his oral intake has been modest. The client's weight gain may reflect which associated complication of
COPD?
A. Polycythemia
B. Cor Pulmonale
C. Left Ventricular failure
D. Compensated acidosis
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

3. Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes
undetected until symptoms of other system failures occur. This may occur in the form of:
A. Cerebrovascular accident C. Myocardial infarction
B. Liver disease D. Pulmonary disease
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. A client is receiving spironolactone to treat hypertension. Which of the following instructions should the nurse provide?
A. Eat foods high in potassium C. Discontinue sodium restriction
B. Take daily potassium supplements D. Avoid salt substitute
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

5. The most important long-term goal for a client with hypertension would be to:
A. Learn how to avoid stress
B. Explore a job change or early retirement
C. Make a commitment to long term therapy
D. Control high blood pressure
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent
breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respiratory rate
38/min, temperature 38.6° C (101.4° F), and SaO2 92% on room air. Which of the following actions should the nurse
take first?
A. Obtain a chest x-ray.
B. Prepare for chest tube insertion.
C. Administer oxygen via a high-flow mask.
D. Initiate IV access.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. Which of the following regarding pulmonary hypertension is false?

A. PH has many underlying etiologies
B. The disease affects the left side of the heart
C. The hemodynamic definition of PH is a mean pulmonary arterial pressure (PAP) greater than 25 mmHg.
D. Pulmonary arterial hypertension is a subset of pulmonary hypertension.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Which of the following statement is not correct regarding pulmonary hypertension?

A. The disease affects men more than women.
B. Non- specific symptom such as fatigue and edema are present clinically.
C. Catheterization is required when PH is suspected.
D. Underlying causes are evaluated.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

9. Which of the following statement about pulmonary arterial hypertension is incorrect?

A. Vasoconstriction is an issue
B. Vascular wall re-modelling is an issue
C. There is a cure for pulmonary arterial hypertension.
D. The balance of vasoconstriction and vasodilatation may indicate PAH.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. All of the following are true regarding calcium channel blockers in pulmonary arterial hypertension.
A. Calcium channel blockers have a selective effect on vascular smooth muscles.
B. Normal physiologic doses are sufficient for treatment purposes.
C. Adverse effect must be considered.
D. Long -term clinical response is less than 10%.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

THE OUTCOME SENTENCES STRATEGY

This strategy is an excellent way to show your grasp of learning and to give you time to reflect about what you have
learned. Complete each phrase with what you have deemed to express:

 I was surprised that _____________________________________________________________________________

 I have a question about __________________________________________________________________________
 I would still like to know more about _________________________________________________________________
 I learned a great deal about _______________________________________________________________________
 Today, I understood _____________________________________________________________________________
 I am still confused about __________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Lesson title: PNEUMOTHORAX Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to:
1. Define pneumothorax; Reference:
2. Differentiate the classifications of pneumothorax;
3. Explain the pathophysiology of the disease condition; Hinkle, J. L., & Cheever, K. H. (2018).
4. Identify the causes of the disease conditions and its clinical Brunner & Suddarth’s textbook of
manifestations; and, medical-surgical nursing (14th ed.).
5. Discuss the nursing and surgical management of patients Philadelphia, PA: Lippincott Williams
with pneumothorax. &Wilkins.

A. LESSON PREVIEW/REVIEW

Enumerate and define the two types of pulmonary arterial hypertension.

B. MAIN LESSON

PNEUMOTHORAX
 Pneumothorax is one of the disorders of the chest and lower respiratory tract.
 Pneumothorax, or a collapsed lung, is the collection of air in the spaces around the lungs. The air buildup puts
pressure on the lung(s), so it cannot expand as much as it normally.
 Pneumothorax occurs when the parietal or visceral pleura are breached and the pleural space is exposed to
positive atmospheric pressure.
 The pressure in the pleural space is normally negative.
 A spontaneous pneumothorax occurs with the rupture of a bleb.
 An open pneumothorax occurs when an opening through the chest wall allows the entrance of positive
atmospheric pressure into the pleural space.
Diagnosis of pneumothorax is made by chest x-ray film.

Classification: Types of pneumothorax include simple, traumatic, and tension pneumothorax

 Simple/spontaneous pneumothorax occurs when air enters the pleural space through a breach of either the
parietal or visceral pleura.
 Traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural
space or from a wound in the chest wall.
 Tension pneumothorax occurs when air is drawn into the pleural space from a lacerated lung or through a small
opening or wound in the chest wall.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Pathophysiology of pneumothorax includes:

 Negative pressure. The negative pressure is required to maintain lung inflation.
 Breach. When either pleura is breached, air enters the pleural space.
 Collapse. When positive pressure has entered the pleural space, the lung or a portion of it collapses.

The cause leads to the identification of the type of pneumothorax:

1. Rupture of a bleb. A spontaneous pneumothorax may occur in an apparently healthy person in the absence of
trauma due to rupture of an air-filled bleb.
2. Blunt trauma. Blunt trauma like rib fractures could cause traumatic pneumothorax.
3. Invasive procedures. Traumatic pneumothorax may occur during invasive thoracic procedures in which the
pleura is inadvertently punctured.
4. Penetrating chest or abdominal trauma. Trauma such as stab wounds or gunshot wounds could cause
traumatic pneumothorax.

Clinical Manifestations: The signs and symptoms associated with pneumothorax depend on its size and cause.
 Pain is usually sudden and may be pleuritic.
 Minimal respiratory distress. The patient may have only minimal respiratory distress with slight chest discomfort
and tachypnea.
 Dyspnea. Due to pain, the patient has difficulty in breathing.
 Central cyanosis. The patient may develop central cyanosis from severe hypoxemia.
 Chest expansion. In simple and tension pneumothorax, chest expansion is decreased.
 Breath sounds are diminished or absent in both simple and tension pneumothorax.
 Tracheal alignment. In simple pneumothorax, the trachea is midline while in tension pneumothorax, the trachea
is shifted away from the affected side

Assessment and Diagnosis: Pneumothorax is assessed and diagnosed with the following
1. Thoracic CT: Studies show that CT is more sensitive than x-ray in detecting thoracic injuries, lung
contusion, hemothorax, and pneumothorax. Early CT may influence therapeutic management.
2. Chest x-ray: Reveals air and/or fluid accumulation in the pleural space; may show shift of mediastinal structures
(heart).
3. ABGs: Variable depending on the degree of compromised lung function altered breathing mechanics, and the
ability to compensate. Paco2 occasionally elevated. Pao2 may be normal or decreased; oxygen saturation usually
decreased.
4. Thoracentesis: Presence of blood/serosanguinous fluid indicates hemothorax.
5. Hb: May be decreased, indicating blood loss.

Medical management of pneumothorax depends on its cause and severity:

 Chest tube. A small chest tube is inserted near the second intercostal space to drain the fluid and air. For
patients with jeopardized gas exchange, chest tube insertion may be necessary to achieve lung re-
expansion. The priority is to maintain airway, breathing, and circulation. The most important interventions focus on
reinflation the lung by evacuating the pleural air. Patients with a primary spontaneous pneumothorax that is small
with minimal symptoms may have spontaneous sealing and lung re-expansion.
 Maintain a closed chest drainage system. Be sure to tape all connections, and secure the tube carefully at the
insertion site with adhesive bandages. Regulate suction according to the chest tube system directions; generally,
suction does not exceed 20 to 25 cm H2O negative pressure.
 Monitor a chest tube unit for any kinks or bubbling. These could indicate an air leak, but do not clamp a chest
tube without a physician’s order because clamping may lead to tension pneumothorax.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Autotransfusion involves taking the patient’s own blood that has been drained from the chest, filtering it, and
then transfusing it back into the vascular system.
 Antibiotics are usually prescribed to combat infection from contamination.
 Oxygen therapy. The patient with possible tension pneumothorax should immediately be given a high
concentration of supplemental oxygen to treat the hypoxemia.

Surgical Management
 If more than 1500 ml of blood is aspirated initially by thoracentesis, the rule is to open the chest wall surgically.
 Thoracotomy. The chest wall is opened surgically to remove the blood or air trapped in the pleural space.

Nursing Management of a patient with pneumothorax includes the following steps.

Nursing Assessment: The nurse should assess the following:

 Tracheal alignment.
 Expansion of the chest.
 Breath sounds.
 Percussion of the chest.

Nursing Diagnosis: Based on the assessment data, the major nursing diagnoses for the patient are:
 Acute pain related to the positive pressure in the pleural space.
 Ineffective breathing pattern related to respiratory distress.
 Ineffective peripheral tissue perfusion related to severe hypoxemia.
 Anxiety related to difficulty in breathing.

Nursing Care Planning and Goals: The goals for the patient include:
 Relief of pain.
 Adherence to prescribed pharmacological regimen.
 Establishment of a normal, effective respiratory pattern as evidenced by absence of cyanosis.
 Demonstration of increase in perfusion.
 Be relaxed and report anxiety is reduced to a manageable level.

Nursing Interventions:
 Re-expansion. The patient is instructed to inhale and strain against a closed glottis to re-expand the lung and
eject the air from the thorax.
 Sterile covering. The opening is plugged by sealing it with gauze impregnated with petrolatum.
 Oxygen saturation. Pulse oximetry is used to monitor oxygen saturation.

Evaluation:
 Expected patient outcomes include:
 Pain is relieved.
 Adhered to prescribed pharmacological regimen.
 Established a normal, effective respiratory pattern as evidenced by absence of cyanosis.
 Demonstrated increase in perfusion.
 Patient is relaxed and reported anxiety is reduced to a manageable level.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. An initial characteristic symptom of a simple pneumothorax is:

A. ARDS
B. Severe onset of chest pain
C. Severe respiratory distress
D. Tachypnea and chest discomfort.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. Clinical manifestations related to pneumothorax include the following except for:

3. Which of the following the nurse assesses in patient with pneumothorax?

A. Tracheal alignment
B. Expansion of the chest
C. Breath sounds
D. All of the above
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. The pressure required in the pleural space to keep the lungs inflated is:
A. Positive
B. Negative
C. Atmospheric
D. All of the above
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

5. The following are types of pneumothorax except:

A. Trauma
B. Simple
C. Tension
D. Direct
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. The healthcare provider is assisting during the insertion of a pulmonary artery catheter. Which of these, if assessed in
the patient, would indicate the patient is experiencing a complication from the catheter insertion?
A. Inspiration phase is greater than expiration
B. Diaphragmatic excursion of 3 cm
C. Tracheal deviation from normal
D. Vesicular breath sounds noted on auscultation
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. During the assessment of a 60-year-old female patient, you note the following signs: dyspnea, hypotension, reduced
chest expansion on the left side, hyper resonant percussion note and tactile fremitus on the left side, absent breath
sounds on the left side, and a tracheal shift to the right. These findings suggest which of the following?
A. A pleural effusion on the left side
B. A pneumothorax on the left side
C. Atelectasis on the left side
D. Consolidation on the left side
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. A 50-year-old male patient is intubated with a size 8 endotracheal tube and is receiving volume-controlled A/C
ventilation. Upon assessment, you note that the patient’s cuff pressure is measured at 38 cm H2O. Which of the
following would you recommend?
A. Withdraw the tube 1-2 cm and reassess the patient’s breath sounds
B. Recommend reintubation with a smaller endotracheal tube
C. Lower the cuff pressure to < 30 cm H2O
D. Recommend ventilation via a tracheostomy instead
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

9. An adult patient who is receiving mechanical ventilation suddenly started showing signs of tachypnea. Upon
assessment, you note tracheal deviation to the right and decreased breath sounds and hyperresonance on the left.
Which of the following would you recommend?
A. The patient needs suctioning.
B. The patient needs a bronchoscopy.
C. The patient needs insertion of a chest tube.
D. The patient needs a thoracentesis.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. During the assessment of a 52-year-old female patient that is receiving oxygen via nasal cannula at 4 L/min, you hear
the bubble humidifier making a whistling noise. Which of the following is the most likely cause of this finding?
A. There is an obstruction in the delivery tube.
B. The patient’s ventilation has increased.
C. There is a clogged system diffuser.
D. The flowmeter pressure is set too high.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

SUCCESS CRITERIA

You will write 3 or more statements (“I can" statements) based on the learning targets stated above. This will assess your
ability to familiarize and master this session’s topic.

1. I can_________________________________________________________________________________.

2. I can_________________________________________________________________________________.

3. I can_________________________________________________________________________________.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Lesson title: CORONARY ATHEROSCLEROSIS/CORONARY Materials:

ARTERIAL DISEASE (CAD) AND HEART Electronic gadget, pen, & notebook
FAILURE/CONGESTIVE HEART FAILURE (CHF)

Learning Targets:
At the end of the module, students will be able to:
1. Identify risk factors of coronary atherosclerosis and CAD;
2. Define heart failure and classify types of heart failure; Reference:
3. Explain the clinical manifestation, diagnostic finding and
identify preventive measures of the diseases; Hinkle, J. L., & Cheever, K. H. (2018).
4. Outline nursing process in caring clients experiencing the Brunner & Suddarth’s textbook of
diseases; and, medical-surgical nursing (14th ed.).
5. Illustrate nursing management of patients with the disease Philadelphia, PA: Lippincott Williams
conditions. &Wilkins.

A. LESSON PREVIEW/REVIEW

Enumerate and describe the types of pneumothorax.

B. MAIN LESSON

CORONARY ATHEROSCLEROSIS is the most common cause of cardiovascular disease in US and is characterized by
an abnormal accumulation of lipid or fatty substances and ﬁbrous tissue in the vessel wall. These substances block or
narrow the vessel, reducing blood ﬂow to the myocardium.

Atherosclerosis involves a repetitious inﬂammatory response to injury of the artery wall and subsequent alteration in the
structural and biochemical properties of the arterial walls.

Risk Factors
Modifiable Not Modifiable
 High blood cholesterol  Positive family history (a first-degree
(hyperlipidemia) relative with cardiovascular disease at
 Cigarette smoking, tobacco use age 55 years or younger for males and at
 Elevated blood pressure age 65 years or younger for females)
 Hyperglycemia (diabetes mellitus)  Age (more than 45 years for men, more
 Metabolic syndrome than 55 years for women)
 Obesity  Gender (men develop cardiovascular
 Physical inactivity disease
 Race (higher incidence in African
Americans)

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Clinical Manifestations: Symptoms and complications develop according to the location and degree of narrowing of the
arterial lumen, thrombus formation, and obstruction of blood ﬂow to the myocardium. Symptoms include the following:
 Ischemia
 Chest pain: angina pectoris
 Atypical symptoms of myocardial ischemia (shortness of breath, nausea, and weakness)
 Myocardial infarction
 Dysrhythmias, sudden death

Assessment and Diagnostic Methods

 Identiﬁcation of risk factors for coronary heart disease (CHD) primarily involves taking a thorough history,
including family history, physical examination (note blood pressure and weight)
 Laboratory work (e.g., cholesterol levels (LDL to HDL), glucose)

Prevention: The major management goal is prevention of CHD.

 Four modiﬁable risk factors—cholesterol abnormalities, tobacco use, hypertension, and diabetes mellitus—have
been cited as major risk factors for CAD and its complications. As a result, they receive much attention in health
promotion programs.

Medical Management
 The objectives of the medical management of angina are to decrease the oxygen demand of the myocardium and
to increase the oxygen supply.
 Medically, these objectives are met through pharmacologic therapy and control of risk factors. Alternatively,
reperfusion procedures may be used to restore the blood supply to the myocardium.
 These include PCI procedures (e.g., percutaneous transluminal coronary angioplasty [PTCA], intracoronary
stents, and atherectomy) and coronary artery bypass graft (CABG).

Nursing Management
A. Assessment
 Gather information about the patient’s symptoms and activities, especially those that precede and precipitate
attacks of angina pectoris. In addition, assess the patient’s risk factors for CAD, the patient’s response to angina,
the patient’s and family’s understanding of the diagnosis, and adherence to the current treatment plan.

B. Diagnosis Nursing Diagnoses

 Ineffective cardiac tissue perfusion secondary to CAD as evidenced by chest pain or other prodromal symptoms
 Death anxiety
 Deﬁcient knowledge about underlying disease and methods for avoiding complications
 Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle
changes

C. Collaborative Problems/Potential Complications

 Potential complications of angina include ACS and/or MI, dysrhythmias and cardiac arrest, heart failure, and
cardiogenic shock.

D. Planning and Goals

 Goals include immediate and appropriate treatment when angina occurs, prevention of angina, reduction of
anxiety, awareness of the disease process and understanding of the prescribed care, adherence to the self-care
program, and absence of complications.

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

E. Nursing Interventions Treating Angina

 Take immediate action if patient reports pain or if the person’s prodromal symptoms suggest anginal ischemia
 Direct the patient to stop all activities and sit or rest in bed in a semi-Fowler’s position to reduce the oxygen
requirements of the ischemic myocardium
 . Measure vital signs and observe for signs of respiratory distress.
 Administer nitroglycerin sublingually and asses the patient’s response (repeat up to three doses).
 Administer oxygen therapy if the patient’s respiratory rate is increased or if the oxygen saturation level is
decreased.
 If the pain is signiﬁcant and continues after these interventions, the patient is further evaluated for acute MI and
may be transferred to a higher-acuity nursing unit.

Teaching Patients Self-Care

 The teaching program for the patient with angina is designed so that the patient and family understand the illness,
identify the symptoms of myocardial ischemia, state the actions to take when symptoms develop, and discuss
methods to prevent chest pain and the advancement of CAD.
 The goals of education are to reduce the frequency and severity of anginal attacks, to delay the progress of the
underlying disease if possible, and to prevent complications.
 Collaborate on a self-care program with patient, family, or friends.
 Plan activities to minimize angina episodes
 Teach patient that any pain unrelieved within 15 minutes by the usual methods, including nitroglycerin, should be
treated at the closest emergency center.

F. Evaluation Expected Patient Outcomes

 Reports that pain is relieved promptly
 Reports decreased anxiety
 Understands ways to avoid complications and demonstrates freedom from complications
 Complies with self-care program

HEART FAILURE, also known as CONGESTIVE HEART FAILURE, is recognized as a clinical syndrome characterized
by signs and symptoms of fluid overload or of inadequate tissue perfusion.
 This is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.
 The term heart failure indicates myocardial disease in which there is a problem with contraction of the
heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) that may or may not cause pulmonary or
systemic congestion.
 Heart failure is most often a progressive, life-long condition that is managed with lifestyle changes and
medications to prevent episodes of acute decompensated heart failure.

Classification: Heart failure is classified into two types – left-sided heart failure and right-sided heart failure.

Left-Sided Heart Failure

 Left-sided heart failure or left ventricular failure have different manifestations with right-sided heart failure.
 Pulmonary congestion occurs when the left ventricle cannot effectively pump blood out of the ventricle into the
aorta and the systemic circulation.
 Pulmonary venous blood volume and pressure increase, forcing fluid from the pulmonary capillaries into the
pulmonary tissues and alveoli, causing pulmonary interstitial edema and impaired gas exchange.

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Right-Sided Heart Failure

 When the right ventricle fails, congestion in the peripheral tissues and the viscera predominates.
 The right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it
from the venous circulation. Increased venous pressure leads to JVD and increased capillary hydrostatic pressure
throughout the venous system.

Stages of Heart Failure:

1. Stage A. Patients at high risk for developing left ventricular dysfunction but without structural heart disease or
symptoms of heart failure.
2. Stage B. Patients with left ventricular dysfunction or structural heart disease that has not developed symptoms of
heart failure.
3. Stage C. Patients with left ventricular dysfunction or structural heart disease with current or prior symptoms of
heart failure.
4. Stage D. Patients with refractory end-stage heart failure requiring specialized interventions.

Pathophysiology
 Heart failure results from a variety of cardiovascular conditions, including chronic hypertension, coronary artery
disease, and valvular disease. As HF develops, the body activates neurohormonal compensatory mechanisms.
 Systolic HF results in decreased blood volume being ejected from the ventricle.
 The sympathetic nervous system is then stimulated to release epinephrine and norepinephrine.
 Decrease in renal perfusion causes renin release, and then promotes the formation of angiotensin I.
 Angiotensin I is converted to angiotensin II by ACE which constricts the blood vessels and stimulates aldosterone
release that causes sodium and fluid retention.
 There is a reduction in the contractility of the muscle fibers of the heart as the workload increases.

Compensation: Heart failure results from a variety of cardiovascular conditions, including

 The heart compensates for the increased workload by increasing the thickness of the heart muscle.
 Heart failure can affect both women and men, although the mortality is higher among women.

There are also racial differences; at all ages death rates are higher in African American than in non-Hispanic whites. Heart
failure is primarily a disease of older adults, affecting 6% to 10% of those older than 65. It is also the leading cause of
hospitalization in older people.

Causes: Systemic diseases are usually one of the most common causes of heart failure.
 Coronary artery disease. Atherosclerosis of the coronary arteries is the primary cause of HF, and coronary
artery disease is found in more than 60% of the patients with HF.
 Ischemia. Ischemia deprives heart cells of oxygen and leads to acidosis from the accumulation of lactic acid.
 Cardiomyopathy. HF due to cardiomyopathy is usually chronic and progressive.
 Systemic or pulmonary hypertension. Increase in afterload results from hypertension, which increases the
workload of the heart and leads to hypertrophy of myocardial muscle fibers.
 Valvular heart disease. Blood has increasing difficulty moving forward, increasing pressure within the heart and
increasing cardiac workload.

Clinical Manifestations: Left-sided HF

 Dyspnea or shortness of breath may be precipitated by minimal to moderate activity.
 Cough. The cough associated with left ventricular failure is initially dry and nonproductive.

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

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 Pulmonary crackles. Bibasilar crackles are detected earlier and as it worsens, crackles can be auscultated across
all lung fields.
 Low oxygen saturation levels. Oxygen saturation may decrease because of increased pulmonary pressures.

Clinical Manifestations: Right-sided HF

 Enlargement of the liver result from venous engorgement of the liver.
 Accumulation of fluid in the peritoneal cavity may increase pressure on the stomach and intestines and cause
gastrointestinal distress.
 Loss of appetite results from venous engorgement and venous stasis within the abdominal organs.

Prevention of heart failure mainly lies in lifestyle management.

 Healthy diet. Avoiding intake of fatty and salty foods greatly improves the cardiovascular health of an individual.
 Engaging in cardiovascular exercises 3x a week could keep the cardiovascular system up and running smoothly.
 Smoking cessation. Nicotine causes vasoconstriction that increases the pressure along the vessels.

Complications: Many potential problems associated with HF therapy relate to the use of diuretics.
 Hypokalemia. Excessive and repeated dieresis can lead to hypokalemia.
 Hyperkalemia. Hyperkalemia may occur with the use of ACE inhibitors, ARBs, or spironolactone.
 Prolonged diuretic therapy might lead to hyponatremia and result in disorientation, fatigue, apprehension,
weakness, and muscle cramps.
 Dehydration and hypotension. Volume depletion from excessive fluid loss may lead
to dehydration and hypotension.

Assessment and Diagnostic Findings

HF may go undetected until the patient presents with signs and symptoms of pulmonary and peripheral edema.
 ECG: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present.
Dysrhythmias, e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent
premature ventricular contractions (PVCs) may be present. Persistent ST-T segment abnormalities and
decreased QRS amplitude may be present.
 Chest x-ray: May show enlarged cardiac shadow, reflecting chamber dilation/hypertrophy, or changes in blood
vessels, reflecting increased pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border, may
suggest ventricular aneurysm.
 Sonograms (echocardiography, Doppler and transesophageal echocardiography): May reveal enlarged chamber
dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.
 Heart scan (multigated acquisition [MUGA]): Measures cardiac volume during both systole and diastole,
measures ejection fraction, and estimates wall motion.
 Exercise or pharmacological stress myocardial perfusion (e.g., Persantine or Thallium scan): Determines
presence of myocardial ischemia and wall motion abnormalities.
 Positron emission tomography (PET) scan: Sensitive test for evaluation of myocardial ischemia/detecting
viable myocardium.
 Cardiac catheterization: Abnormal pressures are indicative and help differentiate right- versus left-sided heart
failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected
into the ventricles reveals abnormal size and ejection fraction/altered contractility.
 Transvenous endomyocardial biopsy may be useful in some patients to determine the underlying disorder,
such as myocarditis or amyloidosis.
 Liver enzymes: Elevated in liver congestion/failure.
 Digoxin and other cardiac drug levels: Determine therapeutic range and correlate with patient response.

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Bleeding and clotting times: Determine therapeutic range; identify those at risk for excessive clot formation.
 Electrolytes: May be altered because of fluid shifts/decreased renal function, diuretic therapy.
 Pulse oximetry: Oxygen saturation may be low, especially when acute HF is imposed on chronic obstructive
pulmonary disease (COPD) or chronic HF.
 Arterial blood gases (ABGs): Left ventricular failure is characterized by mild respiratory alkalosis (early) or
hypoxemia with an increased Pco2 (late).
 BUN/creatinine: Elevated BUN suggests decreased renal perfusion. Elevation of both BUN and creatinine is
indicative of renal failure.
 Serum albumin/transferrin: May be decreased as a result of reduced protein intake or reduced protein synthesis
in congested liver.
 Complete blood count (CBC): May reveal anemia, polycythemia, or dilutional changes indicating water
retention. Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other
inflammatory or infectious states.
 ESR: May be elevated, indicating acute inflammatory reaction.
 Thyroid studies: Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF.

Medical Management
 The overall goals of management of HF are to relieve patient symptoms, to improve functional status and quality
of life, and to extend survival.

Pharmacologic Therapy
 ACE Inhibitors. ACE inhibitors slow the progression of HF, improve exercise tolerance, decrease the number of
hospitalizations for HF, and promote vasodilation and diuresis by decreasing afterload and preload.
 Angiotensin II Receptor Blockers. ARBs block the conversion of angiotensin I at the angiotensin II receptor and
cause decreased blood pressure, decreased systemic vascular resistance, and improved cardiac output.
 Beta Blockers. Beta blockers reduce the adverse effects from the constant stimulation of the sympathetic
nervous system.
 Diuretics. Diuretics are prescribed to remove excess extracellular fluid by increasing the rate of urine produced in
patients with signs and symptoms of fluid overload.
 Calcium Channel Blockers. CCBs cause vasodilation, reducing systemic vascular resistance but
contraindicated in patients with systolic HF.

Nutritional Therapy
 Sodium restriction. A low sodium diet of 2 to 3g/day reduces fluid retention and the symptoms of peripheral and
pulmonary congestion, and decrease the amount of circulating blood volume, which decreases myocardial work.
 Patient compliance. Patient compliance is important because dietary indiscretions may result in severe
exacerbations of HF requiring hospitalizations.

Additional Therapy
 Supplemental Oxygen. The need for supplemental oxygen is based on the degree of pulmonary congestion and
resulting hypoxia.
 Cardiac Resynchronization Therapy (CRT) involves the use of a biventricular pacemaker to treat electrical
conduction defects.
 Ultrafiltration is an alternative intervention for patients with severe fluid overload.
 Cardiac Transplant. For some patients with end-stage heart failure, cardiac transplant is the only option for long
term survival.

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

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Nursing Management
Despite advances in the treatment of HF, morbidity and mortality remains high. Nurses have a major impact on outcomes
for patients with HF.

A. Nursing Assessment
The nursing assessment for the patient with HF focuses on observing for the effectiveness of therapy and for the patient’s
ability to understand and implement self-management strategies.
 Health History
 Assess the signs and symptoms such as dyspnea, shortness of breath, fatigue, and edema.
 Assess for sleep disturbances, especially sleep suddenly interrupted by shortness of breath.
 Explore the patient’s understanding of HF, self-management strategies, and the ability and willingness to adhere
to those strategies.

B. Physical Examination
Auscultate the lungs for presence of crackles and wheezes.
 Auscultate the heart for the presence of an S3 heart sound.
 Assess JVD for presence of distention.
 Evaluate the sensorium and level of consciousness.
 Assess the dependent parts of the patient’s body for perfusion and edema.
 Assess the liver for hepatojugular reflux.
 Measure the urinary output carefully to establish a baseline against which to assess the effectiveness of diuretic
therapy.
 Weigh the patient daily in the hospital or at home.

C. Diagnosis
Based on the assessment data, major nursing diagnoses for the patient with HF include the following:
 Activity intolerance related to decrease CO.
 Excess fluid volume related to the HF syndrome.
 Anxiety related to breathlessness from inadequate oxygenation.
 Powerlessness related to chronic illness and hospitalizations.
 Ineffective therapeutic regimen management related to lack of knowledge.

D. Planning & Goals

The care plan necessary for HF focuses on:
 Promoting physical activities.
 Reducing fatigue.
 Relieving fluid overload symptoms.
 Decreasing anxiety.
 Increasing the patient’s ability to manage anxiety.
 Encouraging the patient to verbalize his or her ability to make decisions and influence outcome.
 Teaching the patient about self-care program.

E. Nursing Interventions
Nursing interventions for a patient with HF focuses on management of the patient’s activities and fluid intake.
 Promoting activity tolerance. A total of 30 minutes of physical activity every day should be encouraged, and
the nurse and the physician should collaborate to develop a schedule that promotes pacing and prioritization of
activities.

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Managing fluid volume. The patient’s fluid status should be monitored closely, auscultating the lungs, monitoring
daily body weight, and assisting the patient to adhere to a low sodium diet.
 Controlling anxiety. When the patient exhibits anxiety, the nurse should promote physical comfort and provide
psychological support, and begin teaching ways to control anxiety and avoid anxiety-provoking situations.
 Minimizing powerlessness. Encourage the patient to verbalize their concerns and provide the patient with
decision-making opportunities.

Nursing Priorities
1. Improve myocardial contractility/systemic perfusion.
2. Reduce fluid volume overload.
3. Prevent complications.
4. Provide information about disease/prognosis, therapy needs, and prevention of recurrences.

F. Evaluation
For the expected patient outcomes, the following are evaluated:
 Demonstration of tolerance for increased activity.
 Maintenance of fluid balance.
 Less anxiety.
 Decides soundly regarding care and treatment.
 Adherence to self-care regimen.

G. Discharge and Home Care Guidelines

 The nurse should provide education and involve the patient in the therapeutic regimen.
 Patient education. Teach the patient and their families about medication management, low-sodium diets, activity
and exercise recommendations, smoking cessation, and learning to recognize the signs and symptoms of
worsening HF.
 Encourage the patient and their families to ask questions so that information can be clarified and understanding
enhanced.

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates
to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders
include oxygen by NC at 4L/minute, blood work, chest x-ray, an ECG, and 2 mg of morphine given intravenously. The
nurse should first:
A. Administer morphine
B. Obtain 12 leads ECG
C. Obtain laboratory work
D. Order chest X-ray
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

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2. Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the
drug when chest pain occurs?
A. Take one tablet every 2-5 minutes until pain stops.
B. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes.
C. Take one tablet, then an additional tablet every 5 minutes for a total of 3 tablets. Call the physician if pain persists
after 3 tablets.
D. Take one tablet. If pain persists, after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the
physician.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

3. A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the
physician’s office. The nurse would plan on having which of the following medications readily available for use?
A. Diltiazem ( Cardizem
B. Digoxin ( Lanoxin)
C. Propranolol ( Inderal)
D. Metoprolol ( Lopressor)
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. A nurse is conducting a health history with a client with a primary diagnosis of heart failure. Which of the following
disorders reported by the client is unlikely to play a role in exacerbating the heart failure?
A. Recent URI
B. Nutritional anemia
C. Peptic ulcer disease
D. A-fib
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram
complexes on the screen. The first action of the nurse is to:
A. Check the client status and lead placement.
B. Press the recorder button on the electrocardiogram console.
C. Call the physician.
D. Call a code blue
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

6. Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?
A. Heart failure
B. Diabetes
C. MI
D. Pericardial effusion
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that
apply.
A. Reflects electrical impulse beginning at the SA node
B. Indicated electrical impulse beginning at the AV node.
C. Reflects atrial muscle depolarization
D. Identifies ventricular muscle depolarization
E. Has duration normally of 0.11 seconds or less.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Which of the following arteries primarily feeds the anterior wall of the heart?
A. Circumflex artery
B. Internal mammary artery
C. Left anterior descending artery
D. Right coronary artery
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. With which of the following disorders is jugular vein distention most prominent?
A. Abdominal aortic aneurysm
B. Heart failure
C. MI
D. Pneumothorax
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

10. Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following
conditions?
A. Pericarditis
B. Hypertension
C. MI
D. Heart Failure
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

11. Which of the following factors can cause blood pressure to drop to normal levels?
A. Kidney’s excretion of sodium only
B. Kidney’s retention of sodium and water
C. Kidney’s excretion of sodium and water
D. Kidney’s retention of sodium and excretion of water.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

12. The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that
this procedure is being used in this specific case to:
A. Open and dilate the blocked coronary arteries.
B. Assess the extent of arterial blockage
C. Bypass obstructed vessels
D. Assess the functional adequacy of the valves and heart muscles.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

13. As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given
sublingually. This drug’s principal effects are produced by:
A. Antispasmodic effect on the pericardium
B. Causing an increased myocardial oxygen demand
C. Vasodilation of peripheral vasculature
D. Improved conducting in the myocardium.
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #6 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

14. Furosemide is administered intravenously to a client with HF. How soon after administration should the nurse begin to
see evidence of the drugs desired effect?
A. 5 to 10 minutes
B. 30 to 60 minutes
C. 2-4 hours
D. 6-8 hours
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

15. Which of the following symptoms is most commonly associated with left-sided heart failure?
A. Crackles
B. Arrhythmias
C. Hepatic engorgement
D. Hypotension
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

1. What was the most useful or the most meaningful thing you have learned this session?

2. What question(s) do you have as we end this session?

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #7 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Lesson title: CARDIOGENIC SHOCK Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to:
1. Define cardiogenic shock and classify according to its
causes;
2. Trace the pathophysiology of the disease; Reference:
3. Discuss its causes, clinical manifestations and diagnostic
findings; Hinkle, J. L., & Cheever, K. H. (2018).
4. Illustrate nursing management in the care of client with Brunner & Suddarth’s textbook of
cardiogenic shock; and, medical-surgical nursing (14th ed.).
5. Describe home care guidelines and documentation Philadelphia, PA: Lippincott Williams
guidelines. &Wilkins.

A. LESSON PREVIEW/REVIEW

List the signs and symptoms associated to the following conditions.

Left-Sided Right-sided
Heart Failure Heart Failure

B. MAIN LESSON

CARDIOGENIC SHOCK
This is also sometimes called “pump failure”. It is a condition of diminished cardiac output that severely impairs cardiac
perfusion. It reflects severe left-sided heart failure.

Pathophysiology
1. Inability to contract. When the myocardium can’t contract sufficiently to maintain adequate cardiac
output, stroke volume decreases and the heart can’t eject an adequate volume of blood with each contraction.
2. Pulmonary congestion. The blood backs up behind the weakened left ventricle, increasing preload and causing
pulmonary congestion.
3. Compensation. In addition, to compensate for the drop in stroke volume, the heart rate increases in an attempt to
maintain cardiac output.

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
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Module #7 Student Activity Sheet

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Section: Schedule: _________ Date: _

4. Diminished stroke volume. As a result of the diminished stroke volume, coronary artery perfusion and collateral
blood flow is decreased.
5. Increased workload. All of these mechanisms increase the heart’s workload and enhance left-sided heart failure.
6. End result. The result is myocardial hypoxia, further decreased cardiac output, and a triggering of compensatory
mechanisms to prevent decompensation and death.

Classification: The causes of cardiogenic shock are known as either coronary or non-coronary.
 Coronary cardiogenic shock is more common than noncoronary cardiogenic shock and is seen most often in
patients with acute myocardial infarction.
 Noncoronary cardiogenic shock is related to conditions that stress the myocardium as well as conditions that
result in an ineffective myocardial function.

Causes: Cardiogenic shock can result from any condition that causes significant left ventricular dysfunction with reduced
cardiac output.
 Myocardial infarction (MI). Regardless of the underlying cause, left ventricular dysfunction sets in motion a
series of compensatory mechanisms that attempt to increase cardiac output, but later on leads to deterioration.
 Myocardial ischemia. Compensatory mechanisms may initially stabilize the patient but later on would cause
deterioration with the rising demands of oxygen of the already compromised myocardium.
 End-stage cardiomyopathy. The inability of the heart to pump enough blood for the systems causes cardiogenic
shock.

Statistics and Incidences

 Cardiogenic shock could be fatal if left untreated.
 Cardiogenic shock occurs as a serious complication in 5% to 10% of patients hospitalized with acute myocardial
infarction.
 Historically, mortality for cardiogenic shock had been 80% to 90%, but recent studies indicate that the rate has
dropped to 56% to 67% due to the advent of thrombolytic, improved interventional procedures, and better
therapies.
 Incidence of cardiogenic shock is more common in men than in women because of their higher incidence of
coronary artery disease.

Clinical Manifestations: Cardiogenic shock produces symptoms of poor tissue perfusion.

 Clammy skin. The patient experiences cool, clammy skin as the blood could not circulate properly to the
peripheries.
 Decreased systolic blood pressure. The systolic blood pressure decreases to 30 mmHg below baseline.
 Tachycardia. Tachycardia occurs because the heart pumps faster than normal to compensate for the decreased
output all over the body.
 Rapid respirations. The patient experiences rapid, shallow respirations because there is not enough oxygen
circulating in the body.
 Oliguria. An output of less than 20ml/hour is indicative of oliguria.
 Mental confusion. Insufficient oxygenated blood in the brain could gradually cause mental confusion and
obtundation.
 Cyanosis. Cyanosis occurs because there is insufficient oxygenated blood that is being distributed to all body
systems.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Assessment and Diagnostic Findings

Diagnosis of cardiogenic shock may include the following diagnostic tests:
 Auscultation. Auscultation may detect gallop rhythm, faint heart sounds and, possibly, if the shock results from
rupture of the ventricular septum or papillary muscles, a holosystolic murmur.
 Pulmonary artery pressure (PAP).PAP monitoring may show increase in PAP, reflecting a rise in left ventricular
end-diastolic pressure and increased resistance to the afterload.
 Arterial pressure monitoring. Invasive arterial pressure monitoring may indicate hypotension due to impaired
ventricular ejection.
 ABG analysis. Arterial blood gas analysis may show metabolic acidosis and hypoxia.
 Electrocardiography. Electrocardiography may show possible evidence of acute MI, ischemia, or
ventricular aneurysm.
 Echocardiography. Echocardiography can determine left ventricular function and reveal valvular abnormalities.
 Enzyme levels. Enzyme levels such as lactic dehydrogenase, creatine kinase. Aspartate aminotransferase and
alanine aminotransferase may confirm MI.

Medical Management: The aim of treatment is to enhance cardiovascular status by

 Oxygen is prescribed to minimize damage to muscles and organs.
 Angioplasty and stenting. A catheter is inserted into the blocked artery to open it up.
 Balloon pump is inserted into the aorta to help blood flow and reduce workload of the heart.
 Pain control. In a patient that experiences chest pain, IV morphine is administered for pain relief.
 Hemodynamic monitoring. An arterial line is inserted to enable accurate and continuous monitoring of BP and
provides a port from which to obtain frequent arterial blood samples.
 Fluid therapy. Administration of fluids must be monitored closely to detect signs of fluid overload.

Pharmacologic Therapy
 IV Dopamine, a vasopressor, increases cardiac output, blood pressure, and renal blood flow.
 IV Dobutamine is an inotropic agent that increases myocardial contractility.
 Norepinephrine is a more potent vasoconstrictor that is taken when necessary.
 IV Nitroprusside is a vasodilator that may be used with a vasopressor to further improve cardiac output by
decreasing peripheral vascular resistance and reducing preload.

Surgical Management: When the drug therapy and medical procedures don’t work, then this is the last option.
 Intra-aortic balloon pump (IABP). The IABP is a mechanical-assist device that attempts to improve the coronary
artery perfusion and decrease cardiac workload through an inflatable balloon pump which is percutaneously or
surgically inserted through the femoral artery into the descending thoracic aorta.

Nursing Management: Cardiogenic shock needs rapid, accurate nursing management.

A. Nursing Assessment
 Vital signs. Assess the patient’s vital signs, especially the blood pressure.
 Fluid overload. The ventricles of the heart cannot fully eject the volume of blood at systole, so fluid may
accumulate in the lungs.

B. Nursing Diagnosis
 Decreased cardiac output related to changes in myocardial contractility/inotropic changes
 Impaired gas exchange related to changes in alveolar-capillary membrane.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Excess fluid volume related to a decrease in renal organ perfusion, increased sodium and water, hydrostatic
pressure increase, or decrease plasma protein.
 Ineffective tissue perfusion related to reduction/cessation of blood flow.
 Acute pain related to ischemic tissues secondary to blockage or narrowing of coronary arteries.
 Activity intolerance related to imbalance between the oxygen supply and needs.

C. Nursing Care Planning & Goals: The major goals for the patient are
 Prevent recurrence of cardiogenic shock.
 Monitor hemodynamic status.
 Administer medications and intravenous fluids.
 Maintain intra-aortic balloon counter pulsation.

D. Nursing Interventions: The appropriate nursing interventions for a patient with cardiogenic shock include
 Prevent recurrence. Identifying at-risk patients early, promoting adequate oxygenation of the heart muscle, and
decreasing cardiac workload can prevent cardiogenic shock.
 Hemodynamic status. Arterial lines and ECG monitoring equipment must be well maintained and functioning;
changes in hemodynamic, cardiac, and pulmonary status and laboratory values are documented and reported;
and adventitious breath sounds, changes in cardiac rhythm, and other abnormal physical assessment findings are
reported immediately.
 Fluids. IV infusions must be observed closely because tissue necrosis and sloughing may occur if vasopressor
medications infiltrate the tissues, and it is also necessary to monitor the intake and output.
 Intra-aortic balloon counter pulsation. The nurse makes ongoing timing adjustments of the balloon pump to
maximize its effectiveness by synchronizing it with the cardiac cycle.
 Enhance safety and comfort. Administering of medication to relieve chest pain, preventing infection at the
multiple arterial and venous line insertion sites, protecting the skin, and monitoring respiratory and renal functions
help in safeguarding and enhancing the comfort of the patient.
 Arterial blood gas. Monitor ABG values to measure oxygenation and detect acidosis from poor tissue perfusion.
 Positioning. If the patient is on the IABP, reposition him often and perform passive range of motion exercises to
prevent skin breakdown, but don’t flex the patient’s “ballooned” leg at the hip because this may displace
or fracture the catheter.

E. Evaluation
 Prevented recurrence of cardiogenic shock.
 Monitored hemodynamic status.
 Administered medications and intravenous fluids.
 Maintained intra-aortic balloon counter pulsation.

F. Discharge and Home Care Guidelines: Lifestyle changes must be made to avoid recurrence of cardiogenic shock.
 Control hypertension. Exercise, manage stress, maintain a healthy weight, and limit salt and alcohol intake.
 Avoid smoking. The risk of stroke is the same for smokers and non -smokers’ years after you stop smoking
 Maintain a healthy weight. Losing those extra pounds would be helpful in lowering the cholesterol and blood
pressure.
 Diet. Eat less saturated fat and cholesterol to reduce heart disease.
 Exercise. Exercise daily to lower blood pressure, increase high-density lipoproteins, and improve the overall
health of the blood vessels and the heart.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

G. Documentation Guidelines
The focus of documentation includes:
 Baseline and subsequent findings and individual hemodynamic parameters, heart and breath sounds, ECG
pattern, presence/strength of peripheral pulses, skin/tissue status, renal output, and mentation.
 Respiratory rate, character of breath sounds, frequency, amount, and appearance of secretions, presence of
cyanosis, laboratory findings, and mentation level.
 Conditions that may interfere with oxygen supply.
 Conditions contributing to the degree of fluid retention.
 I&O, fluid balance.
 Pulses and BP.
 Client’s description of response to pain.
 Acceptable level of pain.
 Specifics of pain inventory.
 Prior medication use.
 Plan of care.
 Teaching plan.
 Client’s responses to interventions, teaching, and actions performed.
 Status and disposition at discharge.
 Attainment or progress toward desired outcomes.

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. A patient is being treated for cardiogenic shock. Which statement below best describes this condition? Select all that
apply:
A. “The patient will experience an increase in cardiac output due to an increase in preload and afterload.”
B. “A patient with this condition will experience decreased cardiac output and decreased tissue perfusion.”
C. “This condition occurs because the heart has an inadequate blood volume to pump.”
D. “Cardiogenic shock leads to pulmonary edema.”
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Cardiac output is very important for determining if a patient is in cardiogenic shock. What is a normal cardiac output in
an adult?
A. 2-5 liters/minute
B. 1-3 liters/minute
C. 4-8 liters/minute
D. 8-10 liters/minute
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

3. Which patient below is at MOST risk for developing cardiogenic shock?

A. A 52-year-old male who is experiencing a severe allergic reaction from shellfish.
B. A 25-year-old female who has experienced an upper thoracic spinal cord injury.
C. A 72-year-old male who is post-op from a liver transplant.
D. A 49-year-old female who is experiencing an acute myocardial infarction.
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

4. You’re caring for a patient with cardiogenic shock. Which finding below suggests the patient’s condition is worsening?
Select all that apply:
A. Blood pressure 95/68
B. Urinary output 20 mL/hr
C. Cardiac Index 3.2 L/min/m2
D. Pulmonary artery wedge pressure 30 mmHg
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

5. You’re precepting a new nurse. You ask the new nurse to list the purpose of why a patient with cardiogenic shock may
benefit from an intra-aortic balloon pump. What responses below indicate the new nurse understands the purpose of an
intra-aortic balloon pump? Select all that apply:
A. “This device increases the cardiac afterload, which will increase cardiac output.”
B. “This device will help increase blood flow to the coronary arteries.”
C. “The balloon pump will help remove extra fluid from the heart and lungs.”
D. “The balloon pump will help increase cardiac output.”
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

6. A patient is receiving treatment for an acute myocardial infarction. The nurse is closely monitoring the patient for signs
and symptoms associated with cardiogenic shock. Which value below is associated with cardiogenic shock?
A. Cardiac index 1.5 L/min/m2
B. Pulmonary capillary wedge pressure (PCWP) 10 mmHg
C. Central venous pressure (CVP) 4 mmHg
D. Troponin <0.01 ng/mL
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

7. A patient who has cardiogenic shock is experiencing labored breathing and low oxygen levels. A STAT chest x-ray is
ordered. The x-ray results show pulmonary edema. The physician orders Furosemide IV. What finding would require
immediate nursing action?
A. Blood pressure 98/54
B. Urinary output 45 mL/hr
C. Potassium 1.8 mEq/L
D. Heart rate 110 bpm
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

8. They physician orders a Dobutamine IV drip on a patient in cardiogenic shock. After starting the IV drip, the nurse
would make it priority to monitor for?
A. Rebound hypertension
B. Ringing in the ears
C. Worsening hypotension
D. severe headache
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

9. Which medications below are used in cardiogenic shock that provide a positive inotropic effect on the heart? Select all
that apply:
A. Nitroglycerin
B. Sodium Nitroprusside
C. Dobutamine
D. Norepinephrine
E. Dopamine
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

10. A patient with cardiogenic shock has an intra-aortic balloon pump. As the nurse you know that during ________ the
balloon deflates and during _____ the balloon inflates in a section of the aorta.
A. systole, diastole
B. diastole, systole
C. inspiration, expiration
D. expiration, inspiration
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

C. LESSON WRAP-UP

Thinking about Learning

CAT 3-2-1

This strategy provides a structure for you to record your own comprehension and summarize your learning. Let us see
your progress in this chapter!

Three things you learned:

1. _______________________________________________________________________________________

2. _______________________________________________________________________________________

3. _______________________________________________________________________________________

Two things that you’d like to learn more about:

1. __________________________________________________________________________________________

2. __________________________________________________________________________________________

One question you still have:

1. __________________________________________________________________________________________

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #8 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Lesson title: HYPERTENSIVE EMERGENCY AND URGENCY Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to: Reference:
1. Differentiate hypertensive emergency from hypertensive
urgency; Hinkle, J. L., & Cheever, K. H. (2018).
2. Identify conditions associated with hypertensive emergency Brunner & Suddarth’s textbook of
and urgency; and, medical-surgical nursing (14th ed.).
3. Enumerate drug of choice for the management of the Philadelphia, PA: Lippincott Williams
conditions. &Wilkins.

A. LESSON PREVIEW/REVIEW

Differentiate coronary cardiogenic shock and non-coronary cardiogenic shock.

B. MAIN LESSON

HYPERTENSIVE EMERGENCIES AND URGENCIES may occur in patients whose hypertension has been poorly
controlled, whose hypertension has been undiagnosed, or in those who have abruptly discontinued their medications.
 The current recommendations for management of both hypertensive emergencies and urgencies are based on
expert opinions because there are not clinical trial data comparing treatment options or identifying the impact of
treatment on morbidity and mortality.
 Hypertensive emergency is a situation in which blood pressure is extremely elevated (more than 180/120 mm
Hg) and must be lowered immediately (not necessarily to less than 140/90 mm Hg) to halt or prevent damage to
the target organs. Assessment will reveal actual or developing clinical dysfunction of the target organ.

Conditions associated with a hypertensive emergency include:

 hypertension of pregnancy  dissecting aortic aneurysm
 acute myocardial infarction  intracranial hemorrhage

Hypertensive emergencies are acute, life-threatening blood pressure elevations that require prompt treatment in an
intensive care setting because of the serious target organ damage that may occur.

The therapeutic goals are:

 reduction of the mean blood pressure by up to 25% within the ﬁrst hour of treatment
 a further reduction to a goal pressure of about 160/100 mm Hg over a period of up to 6 hours
 more gradual reduction in pressure over a period of days

The medications of choice in hypertensive emergencies are those that have an immediate effect.
 Intravenous vasodilators, including sodium nitroprusside (Nitropress), nicardipine hydrochloride (Cardene),
fenoldopam mesylate (Corlopam), and enalaprilat.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Nitroglycerin has immediate actions that are short lived (minutes to 4 hours), and they are therefore used for initial
treatment.

Experts also recommend assessing the individual’s ﬂuid volume status. If there is volume depletion secondary to
natriures, this is caused by the elevated blood pressure, and then volume replacement with normal saline can prevent
large sudden drops in blood pressure when antihypertensive medications are administered.

Hypertensive urgency describes a situation in which blood pressure is very elevated but there is no evidence of
impending or progressive target organ damage.
 Elevated BP associated with severe headaches, nosebleeds, or anxiety is classiﬁed as urgencies.
 In these situations, oral agents can be administered with goal of normalizing blood pressure within 24 to 48 hours.

The medication of choice for hypertensive urgencies:

 Oral doses of fast-acting agents such as beta-adrenergic blocking agents (e.g., labetalol [Trandate]), ACE
inhibitors (e.g., captopril Capoten), or alpha2agonists (e.g., clonidine [Catapres]) are recommended for the
treatment of hypertensive urgencies.
 Extremely close hemodynamic monitoring of the patient’s blood pressure and cardiovascular status is required
during treatment of hypertensive emergencies and urgencies.
 The exact frequency of monitoring is a matter of clinical judgment and varies with the patient’s condition.

Taking vital signs every 5 minutes is appropriate if the blood pressure is changing rapidly; taking vital signs at 15- or 30-
minute intervals in a more stable situation may be sufﬁcient. A precipitous drop in blood pressure can occur that would
require immediate action to restore blood pressure to an acceptable level.

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. The client is admitted to the hospital with a hypertensive crisis. Diazoxide (Hyperstat) is ordered. During administration
the nurse should:
A. Utilize an infusion pump C. Place the patient in Trendelenburg position
B. Check the blood glucose level D. Cover the solution with foil
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

2. A 52-year-old patient who has no previous history of hypertension or other health problems suddenly develops a BP of
188/106 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that
A. a BP recheck should be scheduled in a few weeks.
B. the dietary sodium and fat content should be decreased.
C. there is an immediate danger of a stroke and hospitalization will be required.
D. more diagnostic testing may be needed to determine the cause of the hypertension.
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

3. Which action will be included in the plan of care when the nurse is caring for a patient who is receiving sodium
nitroprusside (Nipride) to treat a hypertensive emergency?
A. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night.
B. Assist the patient up in the chair for meals to avoid complications associated with immobility.
C. Use an automated noninvasive blood pressure machine to obtain frequent BP measurements.
D. Place the patient on NPO status to prevent aspiration caused by nausea and the associated vomiting.
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

4. The nurse has just finished teaching a hypertensive patient about the newly prescribed quinapril (Accupril). Which
patient statement indicates that more teaching is needed?
A. "The medication may not work as well if I take any aspirin."
B. "The doctor may order a blood potassium level occasionally."
C. "I will call the doctor if I notice that I have a frequent cough."
D. "I won't worry if I have a little swelling around my lips and face."
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

5. During change-of-shift report, the nurse obtains this information about a hypertensive patient who received the first
dose of propranolol (Inderal) during the previous shift. Which information indicates that the patient needs immediate
intervention?
A. The patient's most recent BP reading is 156/94 mm Hg.
B. The patient's pulse has dropped from 64 to 58 beats/minute.
C. The patient has developed wheezes throughout the lung fields.
D. The patient complains that the fingers and toes feel quite cold.
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline BP for a new patient?
A. Obtain a BP reading in each arm and average the results.
B. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
C. Have the patient sit in a chair with the feet flat on the floor.
D. Assist the patient to the supine position for BP measurements.
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

7. The nurse obtains this information from a patient with prehypertension. Which finding is most important to address?
A. Low dietary fiber intake C. Weight 5 pounds above ideal weight
B. No regular aerobic exercise D. Drinks wine with dinner once a week

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

8. Your patient's blood pressure is 172/98 mmHg. Is this a hypertensive emergency?

A. Yes - it is. C. No - this is considered pre-HTN.
B. No - it would be considered Stage 2 HTN. D. No - it would be considered Stage 1 HTN.
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

9. Why HTN is considered a silent killer?

A. Because symptoms don't usually present until end organ damage occurs
B. It is not; myocardial infarctions are considered the silent killer
C. Because at no point in the disease progression does symptoms ever present
D. Because it never progresses slowly, it occurs suddenly and immediately
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

10. You are taking care of a patient in the hospital and the CNA reports to you that their blood pressure is 198/101. They
have been running 140's/80's throughout their stay. What will you do first?
A. Check the cuff size to make sure it’s appropriate and recheck blood pressure
B. STAT page the physician
C. Ensure the recording has been appropriately documented & continue to monitor with their next BP reading in 4 hours
D. Check the chart, obtain any PRN antihypertensive and immediately administer them
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

MUDDIEST POINT
This technique will help you determine which key points have been missed in the main lesson:
In today’s session, what was least clear to you?

_________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Lesson title: CARDIOMYOPATHY Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to: Reference:
1. Define cardiomyopathy; Hinkle, J. L., & Cheever, K. H. (2018).
2. List the classifications of cardiomyopathies; and, Brunner & Suddarth’s textbook of
3. Explain the process in the development of the disease medical-surgical nursing (14th ed.).
condition. Philadelphia, PA: Lippincott Williams
&Wilkins.

A. LESSON PREVIEW/REVIEW

List down conditions associated with hypertensive emergency and hypertensive urgency.

Hypertensive Emergency Hypertensive Urgency

B. MAIN LESSON

CARDIOMYOPATHY is a heart muscle disease associated with cardiac dysfunction. It is classiﬁed according to the
structural and functional abnormalities of the heart muscle:
a. Dilated Cardiomyopathy (DCM) (most common),
b. Hypertrophic Cardiomyopathy (HCM) (rare autosomal dominant condition),
c. Restrictive / Constrictive Cardiomyopathy (RCM),
d. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC), and
e. Unclassiﬁed Cardiomyopathies (different from or have characteristics of more than one of the other types).

A patient may have pathology representing more than one of these classiﬁcations, such as a patient with HCM developing
dilation and symptoms of DCM. Ischemic cardiomyopathy is a term frequently used to describe an enlarged heart caused
by coronary artery disease (CAD), which is usually accompanied by heart failure.

Pathophysiology
 The pathophysiology of all cardiomyopathies is a series of events that culminate in impaired cardiac output
 Decreased stroke volume stimulates the sympathetic nervous system and the renin–angiotensin–aldosterone
response, resulting in increased systemic vascular resistance and increased sodium and ﬂuid retention, which
places an increased workload on the heart.
 These alterations can lead to heart failure.

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Clinical Manifestations
 Presents initially with signs and symptoms of heart failure (shortness of breath on exertion, fatigue).
 May also report paroxysmal nocturnal dyspnea (PND), cough, and orthopnea.
 Other symptoms include ﬂuid retention, peripheral edema, nausea, chest pain, palpitations, dizziness, and
syncope with exertion.
 With HCM, cardiac arrest (i.e., sudden cardiac death) may be the initial manifestation in young people.
 Systemic venous congestion, jugular vein distention, pitting edema of dependent body parts, hepatic
engorgement, tachycardia, and extra heart sounds on physical examination.

Assessment and Diagnostic Methods

 Patient history; rule out other causes of failure
 Echocardiogram, cardiac MRI, electrocardiogram (ECG), chest x-ray, cardiac catheterization, and possibly an
endomyocardial biopsy

Medical Management is directed toward identifying and managing possible underlying or precipitating causes; correcting
the heart failure with medications, a low-sodium diet, and an exercise/rest regimen; and controlling dysrhythmias with
antiarrhythmic medications and possibly with an implanted electronic device, such as an implantable cardioverter
deﬁbrillator.
 Surgical intervention (e.g., myectomy, heart transplantation) is considered when heart failure has progressed and
treatment is no longer effective. In some cases, ventricular assist devices (eg, a left ventricular assist device
[LVAD]) are necessary to support the failing heart until a suitable donor becomes available.

Assessment
 Take detailed history of presenting signs and symptoms and possible etiologic factors.
 Careful psychosocial history:
 Identify family support system and involve family in patient management.
 Physical assessment directed toward signs and symptoms of heart failure.
 Evaluate vital signs (pulse pressure), weight and any gain/loss, palpation for a shift to the left of the point of
maximum impulse, auscultation for a systolic murmur and S3 and S4 heart sounds, pulmonary auscultation for
crackles, measurement of jugular vein distention, and edema.

Nursing Diagnoses
 Decreased cardiac output related to structural disorders secondary to cardiomyopathy or dysrhythmia
 Ineffective cardiopulmonary, cerebral, peripheral, and renal tissue perfusion related to decreased peripheral
blood ﬂow
 Impaired gas exchange related to pulmonary congestion secondary to myocardial failure
 Activity intolerance related to decreased cardiac output or excessive ﬂuid volume, or both
 Anxiety related to the change in health status and in role functioning
 Powerlessness related to disease process
 Noncompliance with medication and diet therapies

Collaborative Problems/Potential Complications

 Heart failure
 Ventricular and atrial dysrhythmias
 Cardiac conduction defects
 Pulmonary or cerebral embolism
 Valvular dysfunction

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Planning and Goals

 The major goals for patients include improvement or maintenance of cardiac output, increased activity tolerance,
reduction of anxiety, adherence to the self-care program, increased sense of power with decision making, and
absence of complications.

Nursing Interventions:

Improving Cardiac Output

 Assist patient into a resting position (usually sitting with legs down) during a symptomatic episode.
 Administer oxygen if indicated.
 Administer prescribed medications on time.
 Promote low-sodium meals and adequate ﬂuid intake.
 Keep patient warm, and change positions frequently to stimulate circulation and reduce skin breakdown.

Increasing Activity Tolerance

 Plan nursing care so that activities occur in cycles, alternating rest with activity.
 Ensure that the patient recognizes the symptoms indicating the need for rest and actions to take when the
symptoms occur.

Reducing Anxiety
 Spiritual, psychological, and emotional support may be indicated for patients, families, and signiﬁcant others.
 Provide patient with appropriate information about signs and symptoms.
 Provide an atmosphere in which the patient feels free to verbalize concerns and receive assurance that their
concerns are legitimate.
 Assist patient to accomplish a goal, no matter how small, to enhance a sense of well-being.
 Provide time for the patient to discuss concerns if facing death or awaiting transplantation; provide realistic hope
 Help the patient, family, and signiﬁcant others with anticipatory grieving.

Decreasing Sense of Powerlessness

 Assist patient in identifying things he or she has lost (e.g., foods enjoyed)
 Assist patient in identifying emotional responses to the loss (e.g., anger and depression).
 Assist patient in identifying the amount of control that he or she still has (e.g., selecting food choices).

Promoting Home- and Community-Based Care:

Teaching Patients Self-Care

 Teaching patients about the medication regimen, symptom monitoring, and symptom management.
 Help patient balance lifestyle and work while accomplishing therapeutic activities.
 Help patient cope with their disease status; helps them to adjust their lifestyles and implement a self-care
program at home.

Continuing Care
 Reinforce previous teaching and perform ongoing assessment of the patient’s symptoms and progress.
 Assist in review of lifestyle, and suggest strategies to incorporate therapeutic activities to balance lifestyle and
work.
 Stress the signs and symptoms that should be reported to the physician; teach the patient’s family CPR if
necessary

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Assess the psychosocial needs of the patient and family on an ongoing basis.
 Establish trust with patient, and provide support during end-of-life decision making.
 Refer patient for home care and support if necessary.

Evaluation Expected Patient Outcomes

 Maintains or improves cardiac function
 Maintains or increases activity tolerance
 Experiences reduction of anxiety
 Decreases sense of powerlessness
 Adheres to self-care program

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. Which of the following heart muscle diseases is unrelated to other cardiovascular diseases?
A. Cardiomyopathy
B. Coronary artery disease
C. Myocardial infarction
D. Pericardial effusion
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Which of the following types of cardiomyopathy can be associated with childbirth?

A. Dilated
B. Hypertrophic
C. Myocarditis
D. Restrictive
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Septal involvement occurs in which type of cardiomyopathy?

A. Congestive
B. Dilated
C. Hypertrophic
D. Restrictive
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

4. Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?
A. Heart failure
B. DM
C. MI
D. Pericardial effusion
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

5. What is the term used to describe an enlargement of the heart muscle?

A. Cardiomegaly
B. Cardiomyopathy
C. Myocarditis
D. Pericarditis
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

6. Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following
conditions?
A. Pericarditis
B. Hypertension
C. Obliterative
D. Restricted
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Which of the following types of cardiomyopathy does not affect cardiac output?
A. Dilated
B. Hypertrophic
C. Restrictive
D. Obliterative
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

8. Which of the following cardiac conditions does a fourth heart sound (S4) indicate?
A. Dilated aorta
B. Normally functioning heart
C. Decreased myocardial contractility
D. Failure of the ventricle to eject all the blood during systole
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

9. Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy?
A. Antihypertensive
B. Beta-adrenergic blockers
C. Calcium channel blockers
D. Nitrates
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

10. Which of the following blood tests is most indicative of cardiac damage?
A. Lactic dehydrogenase
B. Complete blood count
C. Troponin I
D. Creatine kinase
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

THE OUTCOME SENTENCES STRATEGY

This strategy is an excellent way to show your grasp of learning and to give you time to reflect about what you have
learned. Complete each phrase with what you have deemed to express:

 I was surprised that _____________________________________________________________________________

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Lesson title: DYSRHYTHMIAS Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to: Reference:
1. Differentiate the types of dysrhythmias; Hinkle, J. L., & Cheever, K. H. (2018).
2. State the causes of dysrhythmias; and, Brunner & Suddarth’s textbook of
3. Explain the management of each type of dysrhythmias. medical-surgical nursing (14th ed.).
Philadelphia, PA: Lippincott Williams
&Wilkins.

A. LESSON PREVIEW/REVIEW

Illustrate the mechanism of each cardiomyopathy.

B. MAIN LESSON

DYSRHYTHMIAS are disorders of the formation or conduction (or both) of the electrical impulse within the heart. These
disorders can cause disturbances of the heart rate, the heart rhythm, or both.
 Dysrhythmias may initially be evidenced by the hemodynamic effect they cause (e.g., a change in conduction may
change the pumping action of the heart and cause decreased blood pressure).
 Dysrhythmias are diagnosed by analyzing the electrocardiographic (ECG) waveform. Their treatment is based on
frequency and severity of symptoms produced.
 Dysrhythmias are named according to the site of origin of the impulse and the mechanism of formation or
conduction involved.

The Electrocardiogram (ECG)

The electrical impulse that travels through the heart can be viewed by means of electrocardiography, the end product of
which is an ECG. Each phase of the cardiac cycle is reflected by specific waveforms on the screen of a cardiac monitor or
on a strip of ECG graph paper. An ECG is obtained by slightly abrading the skin with a clean dry gauze pad and placing
electrodes on the body at speciﬁc areas.

Electrodes come in various shapes and sizes, but they all have two components: (1) an adhesive substance that attaches
to the skin to secure the electrode in place and (2) a substance that reduces the skin’s electrical impedance and promotes
detection of the electrical current. The number and placement of the electrodes depend on the type of ECG needed. Most
continuous monitors use two to ﬁve electrodes, usually placed on the limbs and the chest. These electrodes create an
imaginary line, called a lead.

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #10 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Types of Dysrhythmias: Dysrhythmias include sinus, atrial, junctional, and ventricular dysrhythmias and their various
subcategories.

Sinus Tachycardia is a heart rate greater than 100 beats per minute that originated from the sinus node.
 Rate: 100 to 180 beats per minute
 P Waves precede each QRS complex
 PR interval is normal
 QRS complex is normal
 Conduction is normal
 Rhythm is regular

Causes of sinus tachycardia may include exercise, anxiety, fever, drugs, anemia, heart failure, hypovolemia and shock.
Sinus tachycardia is often asymptomatic.

Management however is directed at the treatment of the primary cause. Carotid sinus pressure (carotid massage) or a
beta blocker may be used to reduce heart rate.

Sinus bradycardia is a heart rate less than 60 beats per minute and originates from the sinus node (as the term “sinus”
refers to sinoatrial node). It has the following characteristics
 Rate is less than 60 beats per minute
 P Waves precede each QRS complex
 PR interval is normal
 QRS complex is normal
 Conduction is normal
 Rhythm is regular
Causes may include drugs, vagal stimulation, hypoendocrine states, hypothermia, or sinus node involvement in MI. This
arrhythmia may be normal in athletes as they have quality stroke volume. It is often asymptomatic but manifestations may
include: syncope, fatigue, dizziness.

Management includes treating the underlying cause and administering anticholinergic drugs like atropine sulfate as
prescribed.

Premature Atrial Contraction is ectopic beats that originates from the atria and they are not rhythms. Cells in the heart
start to fire or go off before the normal heartbeat is supposed to occur. These are called heart palpitations and have the
following characteristics:
 Premature and abnormal-looking P waves that differ in configuration from normal P waves
 QRS complex after P waves except in very early or blocked PACs
 P waves often buried in the preceding T wave or identified in the preceding T wave.

Causes include coronary or valvular heart diseases, atrial ischemia, coronary artery atherosclerosis, heart failure,
COPD, electrolyte imbalance and hypoxia.

Usually there is no treatment needed but may include procainamide and quinidine administration (antidysrhythmic drugs)
and carotid sinus massage.

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #10 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Atrial flutter is an abnormal rhythm that occurs in the atria of the heart. Atrial flutter has an atrial rhythm that is regular but
has an atrial rate of 250 to 400 beats/minute. It has saw-tooth appearance. QRS complexes are uniform in shape but
often irregular in rate.
 Normal atrial rhythm
 Abnormal atrial rate: 250 to 400 beats/minute
 Saw-tooth P wave configuration
 QRS complexes uniform in shape but irregular in rate

Causes include heart failure, tricuspid valve or mitral valve diseases, pulmonary embolism, cor pulmonale, inferior wall MI,
carditis, and digoxin toxicity.

Management if the patient is unstable with ventricular rate of greater than 150 bpm, prepare for immediate cardioversion.
If patient is stable, drug therapy may include calcium channel blocker, beta-adrenergic blockers, or anti-arrhythmics.
Anticoagulation may be necessary as there would be pooling of blood in the atria.

Atrial fibrillation is disorganized and uncoordinated twitching of atrial musculature caused by overly rapid production of
atrial impulses. This arrhythmia has the following characteristics:
 Atrial Rate: 350 to 600 bpm
 Ventricular Rate: 120 to 200 bpm
 P wave is not discernible with an irregular baseline
 PR interval is not measurable
 QRS complex is normal
 Rhythm is irregular and usually rapid unless controlled.

Causes include atherosclerosis, heart failure, congenital heart disease, chronic obstructive pulmonary
disease, hypothyroidism and thyrotoxicosis. Atrial fibrillation may be asymptomatic but clinical manifestation may include
palpitations, dyspnea, and pulmonary edema.

Nursing goal is towards administration of prescribed treatment to decrease ventricular response, decrease atrial irritability
and eliminate the cause.

Premature Junctional Contraction (PJC) occurs when some regions of the heart become excitable than normal. It has
the following characteristics.
 PR interval less than 0.12 seconds if P wave precedes QRS complex
 QRS complex configuration and duration is normal
 P wave is inverted
 Atrial and ventricular rhythms irregular

Causes of PJC may include myocardial infarction or ischemia, digoxin toxicity, excessive caffeine or amphetamine use.
Management includes correction of underlying cause, discontinuation of digoxin if appropriate.

Atrioventricular Blocks
AV blocks are conduction defects within the AV junction that impairs conduction of atrial impulses to ventricular pathways.
The three types are first degree, second degree and third degree.

First Degree AV Block

 Rate is usually 60 to 100 bpm

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Module #10 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 PR intervals are prolonged for usually 0.20 seconds

 QRS complex is usually normal
 Rhythm is regular

First degree AV block is asymptomatic and may be caused by inferior wall MI or ischemia, hyperkalemia, hypokalemia,
digoxin toxicity, calcium channel blockers, amiodarone and use of antidysrhythmic.

Management includes correction of underlying cause. Administer atropine if PR interval exceeds 0.26 second or
symptomatic bradycardia develops.

Second Degree AV Block Mobitz I (Wenckebach)

 Atrial rhythm is regular
 Ventricular rhythm is irregular
 Atrial rate exceeds ventricular rate
 PR interval progressively but only slightly, longer with each cycle until QRS complex disappears (dropped beat)
 PR Interval shorter after dropped beat.

Clinical manifestations include vertigo, weakness, and an irregular pulse. This may be caused by Inferior wall MI,
cardiac surgery, acute rheumatic fever, vagal stimulation.

Treatment includes correction of underlying cause, atropine or temporary pacemaker for symptomatic bradycardia and
discontinuation of digoxin if appropriate.

Third Degree AV Block (Complete Heart Block)

 Atrial rhythm regular
 Ventricular rhythm regular and rate slower than atrial rate
 No relation between P waves and QRS complexes
 NO constant PR interval
 QRS interval normal or wide and bizarre

Manifestations include: hypotension, angina and heart failure. This may be caused by congenital abnormalities, rheumatic
fever, hypoxia, MI, LEv’s disease, Lenegre’s disease and digoxin toxicity.

Management includes atropine, epinephrine, and dopamine for bradycardia. Installation of pacemaker may also be
considered.

Premature Ventricular Contractions (PVC) is caused by increased automaticity of ventricular muscle cells. PVCs
usually are not considered harmful but are of concern if more than six occur in 1 minute, if they occur in pairs or triplets if
they are multifocal or if they occur or near a T wave.
 Atrial rhythm is regular
 Ventricular rhythm is irregular
 QRS complex premature, usually followed by a complete compensatory pause
 QRS complex is also wide and distorted, usually >0.14 second.
 Premature QRS complexes occurring singly, in pairs, or in threes

Clinical manifestations include palpitations, weakness, lightheadedness but it is most of the time asymptomatic.

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #10 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Management includes assessment of the cause and treat as indicated. Treatment is indicated if the client has underlying
disease because PVCs may precipitate ventricular tachycardia or fibrillation. Assess for life threatening PVCs. Administer
antiarrhythmic medication as prescribed.

Ventricular tachycardia (VT) is three or more consecutive PVCs. it is considered a medical emergency because cardiac
output (CO) cannot be maintained because of decreased diastolic filling (preload).
 Rate is 100 to 250 beats per minute
 P wave is blurred in the QRS complex but the QRS complex has no associate with P wave.
 PR Interval is not present
 QRS complex is wide and bizarre; T wave is in the opposite direction
 Rhythm is usually regular
 May start and stop suddenly

Clinical manifestations of VT include lightheadedness, weakness, dyspnea and unconsciousness.

Causes include MI, aneurysm, CAD, rheumatic heart diseases, mitral valve prolapse, hypokalemia, hyperkalemia,
and pulmonary embolism. Anxiety may also cause VT.

Pulseless Ventricular Tachycardia

Management for Pulseless VT: Initiate cardiopulmonary resuscitation; follow ACLS protocol for defibrillation, ET intubation
and administration of epinephrine or vasopressin.

Ventricular Tachycardia with Pulse

Management with Pulse VT: If hemodynamically stable, follow ACLS protocol for administration of amiodarone, if
ineffective, initiate synchronized cardioversion.

Ventricular Fibrillation is rapid, ineffective quivering of ventricles that may be rapidly fatal.
 Rate is rapid and uncoordinated, with ineffective contractions
 Rhythm is chaotic
 QRS complexes wide and irregular
 P wave is not seen
 PR interval is not seen

Causes of ventricular fibrillation are most commonly myocardial ischemia or infarction. It may result from untreated
ventricular tachycardia, electrolyte imbalances, digoxin or quinine toxicity, or hypothermia.

Clinical manifestations may include loss of consciousness, pulselessness, and loss of blood pressure, cessation of
respirations, possible seizures and sudden death.

Start CPR is pulseless. Follow ACLS protocol for defibrillation, ET intubation and administration of epinephrine or
vasopressin.

Other Arrhythmias:
 Atrial Tachycardia
 2nd Degree AV Block Type 1, Mobitz I
 Torsade de Pointes
 Pulseless Ventricular Tachycardia

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #10 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 Supraventricular Tachycardia
 ST Depression

NURSING CARE MANAGEMENT OF PATIENT WITH A DYSRHYTHMIA

Assessment
 Major areas of assessment include possible causes of the dysrhythmia, contributing factors, and the
dysrhythmia’s effect on the heart’s ability to pump an adequate blood volume. When cardiac output is reduced,
the amount of oxygen reaching the tissues and vital organs is diminished. This diminished oxygenation produces
the signs and symptoms associated with dysrhythmias. If these signs and symptoms are severe or if they occur
frequently, the patient may experience signiﬁcant distress and disruption of daily life.
 A health history is obtained to identify any previous occurrences of decreased cardiac output, such as syncope
(fainting), lightheadedness, dizziness, fatigue, chest discomfort, and palpitations.
 Coexisting conditions that could be possible causes of the dysrhythmia (eg, heart disease, chronic obstructive
pulmonary disease) may also be identiﬁed.
 All medications, prescribed and over-the-counter (including herbs and nutritional supplements), as well as the
route of administration, are reviewed. If a patient is taking an antiarrhythmic medication, assessment for side
effects, adverse reactions, and potential contraindications is necessary.
 Laboratory results are reviewed to assess levels of medications as well as factors that could contribute to the
dysrhythmia (e.g., anemia).

Nursing Diagnosis
Based on assessment data, major nursing diagnoses of the patient may include:
 Decreased cardiac output
 Anxiety related to fear of the unknown
 Deﬁcient knowledge about the dysrhythmia and its treatment

Collaborative Problems/Potential Complications

Potential complications that may develop include the following:
 Cardiac arrest
 Heart failure
 Thromboembolic event, especially with atrial ﬁbrillation

Planning and Goals

The major goals for the patient may include eliminating or decreasing the occurrence of the dysrhythmia (by decreasing
contributory factors) to maintain cardiac output, minimizing anxiety, and acquiring knowledge about the dysrhythmia, tests
used to diagnose the problem, and its treatment.

Nursing Interventions
1. Monitoring and Managing the Dysrhythmia
 The nurse regularly evaluates the patient’s blood pressure, pulse rate and rhythm, rate and depth of respirations,
and breath sounds to determine the dysrhythmia’s hemodynamic effect.
 The nurse also asks the patient about episodes of lightheadedness, dizziness, or fainting as part of the ongoing
assessment.
 The nurse assesses and observes for the beneﬁts and adverse effects of each medication.
 The nurse, in collaboration with the physician, also manages medication administration carefully so that a
constant serum level of the medication is maintained.

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #10 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

 The nurse may also conduct a 6-minute walk test as prescribed, which is used to identify the patient’s ventricular
rate in response to exercise. The patient is asked to walk for 6 minutes, covering as much distance as possible.
 The nurse monitors the patient for symptoms.
 At the end, the nurse records the distance covered and the pre exercise and post exercise heart rate as well as
the patient’s response.
 The nurse assesses for factors that contribute to the dysrhythmia (e.g., oxygen deficits, acid-base and electrolyte
imbalances, caffeine, or nonadherence to the medication regimen). The nurse also monitors for ECG changes
(e.g., widening of the QRS, prolongation of the QT interval, increased heart rate) that increase the risk of a
dysrhythmic event.
2. Minimizing Anxiety
 When the patient experiences episodes of dysrhythmia, the nurse stays with the patient and provides assurance
of safety and security while maintaining a calm and reassuring attitude. This assists in reducing anxiety (reducing
the sympathetic response) and fosters a trusting relationship with the patient.
 The nurse seeks the patient’s view of the events and discusses the emotional response to the dysrhythmia,
encouraging verbalization of feelings and fears, providing supportive or empathetic statements, and assisting the
patient to recognize feelings of anxiety, anger, or sadness.
 The nurse emphasizes successes with the patient to promote a sense of self-management of the dysrhythmia
 In addition, the nurse can help the patient develop a system to identify possible causative, inﬂuencing, and
alleviating factors (eg, keeping a diary). The nursing goal is to maximize the patient’s control and to make the
episode less threatening.

Promoting Home and Community-Based Care

When teaching patients about dysrhythmias, the nurse ﬁrst assesses the patient’s understanding, clarifies misinformation,
and then shares needed information in terms that are understandable and in a manner that is not frightening or
threatening.

CONTINUING CARE
A referral for home care usually is not necessary for the patient with a dysrhythmia unless the patient is hemodynamically
unstable and has significant symptoms of decreased cardiac output.
Home care may be warranted if the patient has signiﬁcant comorbidities, socioeconomic issues, or limited self-
management skills that could increase the risk of nonadherence to the therapeutic regimen.

Evaluation Expected Patient Outcomes Expected patient outcomes may include:

1. Maintains cardiac output
 Demonstrates heart rate, blood pressure, respiratory rate, and level of consciousness within normal ranges
 . Demonstrates no or decreased episodes of dysrhythmia
2. Experiences reduced anxiety
 Expresses a positive attitude about living with the dysrhythmia
 Expresses conﬁdence in ability to take appropriate actions in an emergency
3. Expresses understanding of the dysrhythmia and its treatment
 Explains the dysrhythmia and its effects
 Describes the medication regimen and its rationale
 Explains the need to maintain a therapeutic serum level of the medication
 Describes a plan to eliminate or limit factors that contribute to the dysrhythmia
 States actions to take in the event of an emergency

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #10 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse
responds that this procedure may stimulate the:
A. Vagus nerve to slow the heart rate
B. Vagus nerve to increase the heart rate; overdriving the rhythm
C. Diaphragmatic nerve to slow the heart rate
D. Diaphragmatic nerve to overdrive the rhythm
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

2. A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS
complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing:
A. Premature ventricular contractions
B. Ventricular tachycardia
C. Ventricular fibrillation
D. Sinus tachycardia
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

3. A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at
the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be
responsible for the artifact?
A. Frequent movement of the client
B. Tightly secured cable connections
C. Leads applied over hairy areas
D. Leads applied to the limbs
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

4. A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the
following, if prescribed, during an episode of ventricular tachycardia?
A. Breathe deeply, regularly, and easily
B. Inhale deeply and cough forcefully every 1 to 3 seconds
C. Lie down flat in bed
D. Remove any metal jewelry
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #10 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

5. When ventricular fibrillation occurs in a CCU, the first person reaching the client should:
A. Administer oxygen
B. Defibrillate the client
C. Initiate CPR
D. Administer sodium bicarbonate intravenously
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

6. A nurse is watching the cardiac monitor, and a client’s rhythm suddenly changes. There are no P waves; instead there
are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The
nurse interprets this rhythm as:
A. Sinus tachycardia
B. Atrial fibrillation
C. Ventricular tachycardia
D. Ventricular fibrillation
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

7. A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the
preceding beat. The client’s rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead there
are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be:
A. Ventricular tachycardia
B. Ventricular fibrillation
C. Atrial fibrillation
D. Asystole
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

8. When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is
characterized by:
A. The presence of occasional coupled beats
B. Long pauses in otherwise regular rhythm
C. A continuous and totally unpredictable irregularity
D. Slow but strong and regular beats
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #10 Student Activity Sheet

Name: ___________________________________________________ Class number: _

Section: Schedule: _________ Date: _

9. A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of
the following items?
A. Blood pressure and peripheral perfusion
B. Sensation of palpitation
C. Causative factor such as caffeine
D. Precipitating factors such as infections
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

10. A client with a bundle branch block is on a cardiac monitor. The nurse should expect to observe:
A. Sagging ST segment
B. Absence of P wave configurations
C. Inverted T waves following each QRS complex
D. Widening of QRS complexes to 0.12 seconds or greater
Answer: ________
Rationale:
________________________________________________________________________________________________
________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

SUCCESS CRITERIA

You will write 3 or more statements (“I can" statements) based on the learning targets stated above. This will assess your
ability to familiarize and master this session’s topic.

1. I can_________________________________________________________________________________.

2. I can_________________________________________________________________________________.

3. I can_________________________________________________________________________________.

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COPD Nursing Care Overview

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COPD Nursing Care Overview

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Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ

Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Lesson title: CHRONIC OBSTRUCTIVE PULMONARY DISEASE Materials:

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Complications: There are two major life-threatening complications of COPD

Assessment and Diagnostic Findings

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Medical Management: Pharmacologic Therapy

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Emphysema Chronic Bronchitis

Elastic recoil Alveolar detachment

Cyanosis Activation JVP Loud

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Discharge and Home Care Guidelines

Check for Understanding

2. The underlying pathophysiology of COPD is:

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

3. The abnormal inflammatory response in the lungs occurs primarily in the:

4. Two diseases common to the etiology of COPD are:

5. The term “blue bloater” refers to which of the following conditions?

6. The most important environmental risk factor for emphysema is:

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Thinking about Learning

2. What question(s) do you have as we end this session?

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Lesson title: PULMONARY EMBOLISM (PE) AND ACUTE Materials:

Learning Targets: Reference:

Differentiate emphysema and chronic Bronchitis. State at least five characteristics.

This document is the property of PHINMA EDUCATION

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Assessment and Diagnostic Findings

This document is the property of PHINMA EDUCATION

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Nursing Care Planning and Goals

This document is the property of PHINMA EDUCATION

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

 Displayed hemodynamic stability.

ACUTE RESPIRATORY DISTRESS SYNDROME

This document is the property of PHINMA EDUCATION

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

PATHOPHYSIOLOGY OF ACURE RESPIRATORY DISTRESS SYNDROME

Acute Lung Injury

Increase work of Decreased cardiac

This document is the property of PHINMA EDUCATION

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Check for Understanding

This document is the property of PHINMA EDUCATION

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

This document is the property of PHINMA EDUCATION

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

This document is the property of PHINMA EDUCATION

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

This document is the property of PHINMA EDUCATION

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

15. Which of the following is a type of embolism?

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