CHRONIC OBSTRUCTIVE PUMONARY • support for alveoli and small airways,

DISEASE which makes then prone to collapse

on expiration, leading to air trapping.
• Pursed lip breathing allows
• is a condition of chronic dyspnea
maintenance of positive end
• with expiratory airflow limitation
expiratory procedure (PEEP) which
that does not significantly fluctuate. keeps the airway open. The
• It has been defined as a preventable decreased lung compliance leads to
and treatable disease with some increased work of breathing and
significantly extrapulmonary effects dyspnea.
that may significantly contribute to the • There is abnormal distention of
severity in individual patients. (The airspaces beyond the bronchioles
Global Initiative for Chronic and destruction of the walls of the
alveoli. There is impaired carbon
Obstructive Pulmonary Disease).
dioxide and oxygen exchange due to
the destruction of the walls of the
CLASSIFICATION overdistended alveoli

•CHRONIC BRONCHITIS PANLOBULAR

•EMPHYSEMA
NOTES:
• there is destruction of the respiratory
These two classifications of COPD can be bronchioles, alveolar duct and the
confusing because there are patients who have alveolus.
overlapping signs and symptoms

CHRONIC BRONCHITIS CENTRILOBULAR

• changes occur in the secondary

• is a disease of the airways that is
lobules
characterized by cough and sputum
production for at least 3 months each
of 2 consecutive years.
• -large edematous,
cyanotic, and with minimal dyspnea.
• Airway obstruction leads to hypoxia,
subsequently causing vasoconstriction
(pulmonary hypertension) further
causing reduced circulatory blood
volume and right-sided heart failure
which can lead to cor pulmonale. This
leads to hypoxemia and polycythemia
causing cyanosis.
• A wide range of viral, bacterial, and
mycoplasmal infections can produce
acute episodes of bronchitis
PATHOPHYSIOLOGY
In COPD, the airflow is both progressive and
EMPHYSEMA
associated with an abnormal inflammatory
response of the lungs to noxious gases or
• PINK PUFFER-is a thin, cathetic
person with marked shortness of particles.
breath. The blood remains oxygenated • An inflammatory response happens
because both ventilation and throughout the proximal and
perfusion are reduced. peripheral airways, lung parenchyma,
• Loss of elastin fibers reduces and pulmonary blood vessels
structural

1
 PRELIM

• Due to this chronic inflammation, 6. CT scan

changes and narrowing occur in the 7. Bronchogram
airways 8. Lung scan
• There is an increase in the number of 9. CBC
10. Blood chemistry
goblet cells and enlarged submucosal
11. Sputum cultures
glands causing increased secretions of
12. Cytology exams
mucus 13. ECGs
• Causes scar formation in the long 14. Stress test
term and narrowing of the airways.
• Wall destruction leads to loss of MEDICAL MANAGEMENT
alveolar attachments and a decrease 1. Bronchodilators
in elastic recoil 2. Corticosteroids
• This chronic inflammatory process 3. Others
affects the pulmonary •Alpha 1-antitrypsin augmentation
vessels and subsequent thickening of therapy
the vessel lining and hypertrophy of •Antibiotics
smooth muscle. •Mucolytics
•Antitussive
•Vasodilators
EPIDEMIOLOGY •narcotics
• In the United States it's the FOURTH
leading mortality cause MANAGEMENT EXACERBATIONS
• More death in WOMEN
• Bronchodilators
CLINICAL MANIFESTATION • Hospitalization
• Oxygen Therapy
The natural history of COPD is variable but is a • Antibiotics
generally progressive disease.
1. Chronic cough SURGERY
2. Sputum production
3. Dyspnea on exertion • Bullectomy
4. Dyspnea at rest • Lung volume reduction surgery
5. Weight loss • Lung transplantation
6. Barrel chest
NURSING DIAGNOSIS
PREVENTION
• Impaired gas exchange due to
1. STOP SMOKING - this is the single chronic inhalation of toxins
most cost-effective intervention • Ineffective airway clearance related
2. As nurses we can help promote the to bronchoconstriction, increased
stoppage of smoking by explaining mucus production, ineffective
the risks of smoking personally to cough, and other complications
the patient • Ineffective breathing patterns
related to shortness of breath,
mucus, bronchoconstriction, and
COMPLICATION
airway irritants
Two major life-threatening complications
• Self-care deficit related to fatigue
• Respiratory failure • Activity intolerance related to
• Respiratory insufficiency
hypoxemia and ineffective
breathing patterns
ASSESSMENT & DIAGNOSTIC FINDINGS

1. Health history NURSING MANAGEMENT

2. Pulmonary function studies • Planning and Goals
3. Spirometry • Improvement in gas exchange
4. ABG • Achievement in airway clearance
5. Chest x-ray • Improvement in breathing pattern

2
 PRELIM

ACUTE DISTRESS RESPIRATORY

• Independence in self-care activities
SYNDROME (ARDS)
• Improvement in activity intolerance
• Ventilation/oxygenation adequate
to meet self-care needs • Is a life-threatening lung
• Nutritional intake meeting caloric condition where there is a
needs failure in breathing that can
• Infection treated/prevented occur in very ill or severely
• Disease process/prognosis and injured people.
therapeutic regimen understood • This is not a specific disease
• Plan in place to meet needs after • It starts with the swelling of
discharge tissue in the lungs and buildup
of fluids in the tiny air sacs that
NURSING PRIORITIES transfer oxygen to the
bloodstream subsequently
• Airway patency leading to low blood oxygen
• Measures to facilitate gas exchange levels.
• Enhance nutritional intake • This is similar to the infant
• Prevent complications, slow respiratory distress syndrome.
progression Though they differ in the causes
• Provide information about the and the treatment. ARDS can
disease process/prognosis and occur in anyone over the age of
treatment regimen one.

NURSING INTERVENTIONS CAUSES

• Manage and monitor potential

complications DIRECT INJURY TO THE LUNGS
• Monitor cognitive changes • Chest trauma (heavy blow)
• Monitor pulse oximetry changes • Breathing vomit
• Prevent infection • Breathing smoke, chemicals, or saltwater
• Burns
EVALUATION
INDIRECT INJURY TO THE LUNGS
• Identifies the hazards of smoking
• Identifies resources for
stopping smoking • Severe infection
• Minimizes or eliminates exposure • Massive blood transfusion
• Verbalizes the need for fluids • Pneumonia
• Is free of infection • Severe inflammation of the pancreas
• Practices breathing exercises (pancreatitis)
• Performs activities with • Alcohol or drug overdose
less shortness of breath • Lung and bone transplantation

DISCHARGE & HOME CARE SYMPTOMS

• Setting goals • When shortness of breath

• Temperature control • Fast, labored breathing
• Activity moderation • Bluish skin or fingernails
• Rapid pulse
• Breathing retraining

PATHOPHYSIOLOGY
• When lung tissues are injured, the
alveoli become permeable to lung
proteins

3
 PRELIM

• Entry of more proteins, debris, and 3. Determine the presence of infection or

fluids into the lungs sepsis
• Inflammation breaks down surfactant 4. Auscultate the lung sounds
making the lungs less compliant
NURSING INTERVENTION
5P’S OF THE ARDS THERAPY • Provide supportive core
• Manage the underlying conditions
• Perfusion • Administer medications as prescribed
• Positioning • Adores the cause of sepsis
• Protective lung ventilation • Prevent complications associated with
• Protocol Weaning mechanical ventilation and ICU Day
• Preventing complications • Provide Oxygenation
• Administer oxygen as ordered
THREE STAGES • Consider mechanical ventilation
• Consider tracheostomy
1. Exudative • Turn the patient to prone position
2. Proliferative • Administer fluids with caution
3. Fibrotic • Administer nutritional support
• Promote bed rest
Initially, mild symptoms like dyspnea, cough, • Minimize sedation
tachypnea, and restlessness are observed, but as • Refer for rehab
the syndrome progresses the symptoms worsen
as fluid accumulation increases. Respiratory
muscle fatigues become evident and ABG results
PULMONARY EMBOLISM
decline.
• Refers to the obstruction of the
NURSING ASSESSMENT pulmonary artery or one its branches by
a thrombus (or thrombi) that originates
1. Review health history somewhere in the venous system or in
• Assess the patient's general symptoms the right side of the heart
(dyspnea, cough, tachypnea, • The cause is usually a blood clot in the
restlessness) leg called a deep vein thrombosis that
• Determine the underlying cause breaks, loose and travels through the
• Sepsis-most common bloodstream to the lungs.
• Multi-organ dysfunction
• It can damage part of the lungs due to
• Pneumonia
• Aspiration restricted blood flow, decrease oxygen
• Burns levels in the blood, and affect other
• Drug overdose organs as well. Large or multiple blood
• Pancreatitis clots can be fatal.
• Fractures of long bones • The blockage can be life-threatening.
2. Determine the patients' risk factors COMPLICATIONS
• Old age
• Female (in cases of trauma) Most commonly, pulmonary embolism is due to a
• Tobacco use blood clot or thrombus, but there are other types
• Alcohol use of emboli fat, air, amniotic fluid, and septic.
• Chronic lung disease
• High-risk surgeries FAT EMBOLI
• Assess the patient's environment,
occupation, or lifestyle habits • are cholesterol or fatty substances that may
clog the arteries when fatty foods are
consumed more.
PHYSICAL ASSESSMENT
1. Closely monitor the respiratory status AIR EMBOLI
2. Monitor the vital signs
• usually come from intravenous devices.

4
 PRELIM

AMNIOTIC FLUID EMBOLI amniotic fluid emboli from placental tears

occurring during labor and delivery, tumor
• are caused by amniotic fluid that has leaked
cell emboli that break away from a
towards the arteries
malignant mass, or air embolus injected
AMNIOTIC FLUID EMBOLI into a vein.
• originate from a bacterial invasion of the
thrombus. PATHOPHYSIOLOGY
• The effects of pulmonary embolism
CAUSES depend somewhat on the material but
• Blood clots can form for a variety of reasons. largely on the size and therefore on
Pulmonary embolisms are most often caused
the location of the obstruction.
by deep vein thrombosis, a condition in
which blood clots form in veins deep in the • Because lung tissue is supplied with
body. The blood clots that most often cause oxygen and nutrients by the
pulmonary embolisms begin in the legs or bronchial circulation, infarction does
pelvis. not follow obstruction of the
• Blood clots in the deep veins of the body can pulmonary circulation unless the
have several different causes, including:
general circulation is compromised
▪ Injury or damage: Injuries like bone
or there is prior lung disease.
fractures or muscle tears can cause
• Infarction usually involves a segment
damage to blood vessels, leading to
of the lung and the pleural membrane
dots.
in the area.
▪ Inactivity: During long periods of
• Small pulmonary emboli are
inactivity, gravity causes blood to
frequently "silent" or asymptomatic.
stagnate in the lowest areas of your
However, multiple small emboli ("a
body, which may lead to a blood clot.
shower") often have an effect equal
This could occur if you're sitting for
to that of a larger embolus
a lengthy trip or if you're lying in bed
• Emboli that block moderate-sized
recovering from an illness.
arteries usually causes respiratory
▪ Medical conditions: Some health
impairment because fluid and blood
conditions cause blood to clot too
fill the alveoli of the involved area.
easily, which can lead to pulmonary
Reflex vasoconstriction often occurs
embolism. Treatments for medical
in the area, further increasing the
conditions, such as surgery or
pressure in the blood vessels.
chemotherapy for cancer, can also
• Large emboli (usually those involving
cause blood clots.
more than 60% of the lung tissue)
affect the cardiovascular system,
RISK FACTOR
causing right-sided heart failure and
● Includes immobility, trauma to the legs, decreased cardiac output (shock).
childbirth, congestive heart failure, • Sudden death often results in these
dehydration, increased coagulability of the cases, which involve greatly
blood, and cancer increased resistance in the
pulmonary arteries because of the
● Thrombi tend to break off with sudden
muscle action or massage, trauma, or embolus plus reflex vasoconstriction
changes in the blood flow due to released chemical mediators
such as serotonin and histamine. This
● Post-operative risk can be reduced by
resistance to the output from the
early ambulation or the use of TEDS
right ventricle causes acute cor
(thromboembolic) stockings
pulmonale.
● Other types include fat emboli from the
• Also, there is much less blood
bone marrow resulting from fracture of a
returning from the lungs to the left
large bone, vegetations resulting from
ventricle and then to the systemic
endocarditis in the right side of the heart,

5
 PRELIM

• circulation (decreased cardiac output).

LARGER EMBOLI
• This can be appreciated by visualizing
a large embolus lying across the chest pain that increases with coughing or deep
bifurcation of the pulmonary artery breathing, tachypnea, and dyspnea develop
(a "saddle embolus") and totally suddenly. Later, hemoptysis and fever are
blocking the flow of the blood from present.
the right ventricle into the lungs. Hypoxia stimulates a sympathetic response,
with anxiety and restlessness, pallor and
A series of happenings occur inside a patient's tachycardia
body when he or she has an emboli.
MASSIVE EMBOLI
cause severe crushing chest pain, low blood
OBSTRUCTION
pressure, rapid weak pulse, and loss of
When a thrombus completely or partially
consciousness.
obstructs the pulmonary artery or its branches,
the alveolar dead space is increased
FAT EMBOLI

IMPAIRMENT development of acute respiratory distress, a

petechial rash on the trunk, and neurologic
The area receives little to no blood flow and gas
signs such as confusion and disorientation
exchange is impaired.
DIAGNOSTIC TEST
CONSTRICTION
● Chest X-ray - usually normal but may
Various substances are released from the clot
show infiltrates, atelectasis, elevation of
and surrounding area that cause constriction
the diaphragm on the affected side, or a
of the blood vessels and result in pulmonary
pleural effusion.
resistance.
● ECG - usually shows sinus tachycardia,
PR-interval depression, and nonspecific
CONSEQUENCES T-wave changes.
● ABG analysis - ABG analysis may show
Increased pulmonary vascular resistance due
hypoxemia and hypocapnia; however, ABG
to regional vasoconstriction leading to
measurements may be normal even in the
increase in pulmonary arterial pressure and
presence of PE.
increased right ventricular workload are the
consequences that follow. ● Pulmonary angiography - allows for direct
visualization under fluoroscopy of the
arterial obstruction and accurate
FAILURE assessment of the perfusion deficit.
When the workload of the right ventricle ● Duplex venous ultrasound - This test uses
exceeds the limit, failure may occur. radio waves to visualize the flow of blood
and to check for blood clots in your legs.
SIGN AND SYMPTOMS ● Venography - This is a specialized X-ray
of the veins of your legs.
● D-dimer test - A type of blood test that is
SMALL EMBOLI used to help rule out the presence of an
a transient chest pain, cough, or dyspnea may inappropriate blood clot.
occur. Often unnoticed but can be significant ● V/Q scan (ventilation/perfusion lung scan)
because it may be a warning of more emboli evaluates the different regions of the lung
and allows comparisons of the percentage of
developing
ventilation and perfusion in each area.

6
 PRELIM

GOOD TO KNOW NURSING MANAGEMENT

● The normal range for D-dimer is • Prevent venous stasis - Encourage

500ng/mL fibrinogen equivalent units ambulation and active and passive leg
(FEU) exercises to prevent venous stasis,
• Manage pain - Turn patients frequently
● A negative D-dimer result means that
and reposition to improve ventilation-
it is most likely that the person tested perfusion ratio.
does not have an acute condition or • Manage oxygen therapy - Assess for signs
disease-causing abnormal clot of hypoxemia and monitor the pulse
formation or breakdown. oximetry values.
● A positive D-dimer result may indicate • Relieve anxiety - Encourage the patient to
the presence of an abnormally high talk about any fears or concerns related to
this frightening episode.
level of fibrin degradation products
• Monitor thrombolytic therapy -
Monitoring thrombolytic and
MEDICAL MANAGEMENT anticoagulant therapy through INR or
PTT.
● Because PE is often a medical • INR (International Normalized Ratio) and
emergency, emergency management PTT (partial thromboplastin time) - are
is of primary concern. used to monitor effectiveness of the
anticoagulant warfarin.
● Anticoagulation therapy - Heparin
• Normal range
and warfarin sodium have been o IN is a to 2
traditionally been the primary o PT is go to 45 seconds.
method for managing acute DVT and • Extended PTT times can be a result of
PE. anticoagulation therapy, liver problems,
● Thrombolytic therapy - Urokinase, lupus, and other diseases that result in
poor clotting.
streptokinase, alteplase are used in
treating PE, particularly in patients
DISCHARGE & HOME CARE GUIDELINES
who are severely compromised.
• Prevent recurrence - The nurse should
SURGICAL MANAGEMENT instruct the patient about preventing
● Removal of the emboli may recurrence and reporting signs and
symptoms.
sometimes need surgical
• Adherence - The nurse should monitor the
management. patient's adherence to the prescribed
● Surgical embolectomy - This is the management plan and enforce previous
removal of the actual clot and must be instructions.
performed by a cardiovascular surgical • Residual effects - The nurse should also
team with the patient on monitor for residual effects of the PE and
recovery.
cardiopulmonary bypass.
● Transvenous catheter embolectomy -
• Follow-up checkups - Remind the patient
about keeping up with follow-up
This is a technique in which a vacuum- appointments for coagulation tests and
cupped catheter is introduced appointments with the primary care
transvenously into the affected provider.
pulmonary artery.
● Interrupting the vena cava - This
approach prevents dislodged thrombi
from being swept into the lungs while
allowing adequate blood flow

7
 PRELIM

PNEUMONIA • Immunocompromised patients develop

pneumonia from organisms of low
• One of the most common respiratory
virulence
problems that can affect all stages of life.
• An inflammation of the lung parenchyma
that is caused by many microorganisms ASPIRATION PNEUMONIA
(Bacteria, mycobacteria, fungi, or
viruses) • Caused by the entry of endogenous or
• PNEUMONITIS- describes the exogenous substances into the lower
inflammatory process in the lung tissue airway
that can predispose and place a patient at • Most common form: Bacteria infection
risk for microbial invasion. from aspiration of bacteria in the upper
airways e
CLASSIFICATION • Most common cause: S. pneumonia, H.
influenza and S. aureus
COMMUNITY- ACQUIRED PNEUMONIA (CAP)
PATHOPHYSIOLOGY
• Occurs in the community setting or
within the 48 hours after Arises from normal flora from a patient with
hospitalization/admission altered resistance or from the aspiration of
• Usual needing admission if infectious thorax present in the oropharynx
agents are any of Streptococcus
pneumoniae (most common), H. influenza, Inflammatory reaction in the alveoli
Legionella and Pseudomonas Aeruginosa
• 50% of specific causative agent are Production of exudates that may interfere with
identified in infants or children viruses O2 and CO2 diffusion
are the causative agent
WBCs enter the alveoli and fill up air-filled
HOSPITAL- ACQUIRED PNEUMONIA (NOSOCOMIAL spaces
PNEUMONIA)
Decreased ventilation and causing obstruction
of the alveoli or bronchi
● Is defined as the onset of symptoms
more than 48 hours after admission in Mixing of oxygenated blood and poorly
patients with no evidence of infection at oxygenated blood
the time of admission
● Most lethal and leading cause of Hypoxemia
mortality in patients with pneumonia
● Most common causative agent: CAUSES
○ Enterobacter species,
○ Escherichia coli COMMUNITY-ACQUIRED PNEUMONIA
○ influenza
○ klebsiella
• Streptococcus pneumoniae- leading
○ Proteus cause
○ Serratia marcescens • H. influenza- elderly
○ S. aureus • Mycoplasma pneumonia
○ S. pneumonia
● Usual presentation: pulmonary HOSPITAL-ACQUIRED PNEUMONIA
infiltrates on x-ray and more evidence
of infection
• Staphylococcus aureus- inhaled
PNEUMONIA IN THE IMMUNOCOMPROMISED • Impaired host defenses
HOST • Comorbid conditions
• Prolonged supine position
• Includes: pneumocystis pneumonia, • Prolonged hospitalization
fungal pneumonias, and mycobacterium
tuberculosis

8
 MIDTERM

CLINICAL MANIFESTATION NURSING MANAGEMENT

NURSING ASSESSMENT
• Fever-rapidly rising • Assess respiratory symptoms
• Pleuritic chest pain • Assess clinical manifestations
• Rapid and bounding pulse • Physical assessment
• Tachypnea • Assessment in elderly
• Sputum- purulent
DIAGNOSIS
PREVENTION
• Ineffective airway clearance related to
• Vaccination- pneumococcal vaccine (65- copious tracheobronchial secretions
85% effective in healthy patients) • Activity intolerance related to impaired
• Surveillance-infection and microbiologic respiratory function
• Risk for deficient fluid volume related to
COMPLICATIONS fever and a rapid respiratory rate

• Shock and respiratory failure

NURSING CARE PLANNING & GOALS
• Pleural effusion
IMPROVE AIRWAY PATENCY
ASSESSMENT & DIAGNOSTIC FINDINGS • Rest to conserve energy
• Maintenance of adequate nutrition
• History taking-recent respiratory tract • Understanding of the treatment process
infection and how to prevent
• Physical Examination-breath sounds • Absence of complications
• Chest x-ray-structural distribution
• Abscesses/infiltrates, empyema NURSING PRIORITIES
(staphylococcus).
• scattered or localized infiltration • Maintain/improve respiratory function
(bacteria) • Prevent complications
• Diffuse/extensive nodular infiltrates • Support recuperative process
(viral) • Provide information about the disease
• Clear (mycoplasma) process, prognosis, and treatment
• ABGs/pulse oximetry
• Gram stain/cultures NURSING INTERVENTIONS
• Helps identify causative organism IMPROVE AIRWAY PATENCY
• CBC-leukocytosis, ↑ ESR • Remove secretions
• Serologic studies- viral or legionella • Hydration
titers • Humidification
• Electrolytes • Coughing exercises
• Bilirubin • Chest physiotherapy
• Percutaneous aspiration/open biopsy of
lung tissue TO PROMOTE REST AND CONSERVE ENERGY
• Avoid overexertion
MEDICAL MANAGEMENT • Semi-fowler position
• Blood culture-identify To promote fluid intake
• Macrolides- for drug resistant • Fluid intake
• Hyciration • To maintain nutrition
• Antipyretics • Fluids with electrolytes
• Bed rest • Nutrition-enriched beverages
• 02 administration • To promote patient's knowledge
• Pulse oximetry • Educate the patient and family about the
• Aggressive respiratory measures- high disease
concentration oxygen, ET intubation,
mechanical ventilation

9
 MIDTERM

RESPIRATORY FAILURE RESPIRATORY FAILURE DUE TO SHOCK

• Respiratory failure is a condition where • Causes low blood pressure, pulmonary

there is not enough oxygen or too much edema and other conditions heart attacks
carbon dioxide in your body. There is a or blood loss.
sudden and life-threatening deterioration
of the gas exchange function of the lungs. PATHOPHYSIOLOGY
There is a failure to provide adequate
oxygenation or ventilation for the blood. • Impaired ventilation or perfusion
mechanisms
This is a condition where there is: • Impaired function of the CNS (e.g. drug
overdose, head trauma, infection, sleep
• Not enough oxygen in the lives in your apnea, hemorrhage)
body hype • Neuromuscular dysfunction (e.g.
• 100 much carbon dioxide is your blood Guillain-Barre Syndrome. Myasthenia
hypercapnia Gravis, AL or spinal cord trauma)
• This is a medical emergency • Musculoskeletal dysfunction (e.g. chest
• Con come on suddenly (acute) or over trauma, kyphoscoliosis, malnutrition
time (chronic) • Pulmonary dysfunction (e.g. COPD,
asthma, cystic fibrosis)
TYPES
OXYGENATION FAILURE MECHANISMS
HYPOXEMIC RESPIRATORY FAILURE
TYPE 1 • Pneumonia
• ARDS
• CHF
• Happens when you don't have enough
• COPD
oxygen in the blood hypothermia
• PE
• Also known as hypoxic respiratory failure
• Restrictive lung diseases interstitial lung
• Causes: heart and lung conditions
disease, pulmonary fibrosis, sarcoidosis

HYPERCAPNIC RESPIRATORY FAILURE POST-OPERATIVE PERIOD

TYPE 2
• major thoracic or abdominal surgery may
• Too much carbon dioxide in the blood cause inadequate ventilation and
• If your body can't get rid of carbon respiratory failure
dioxide there won’t be enough mom for • Caused by: anesthesia, analgesics or
blood cells to carry oxygen sedatives
• Causes: heart, lung, muscle and
neurological conditions (Guillain-Barre CLINICAL MANIFESTATIONS
Syndrome, Myasthenia Gravis, Early signs:
Polymyositis or Multiple Sclerosis • Impaired oxygenation
• COPD • Restlessness, fatigue, headache, dyspnea,
air hunger, tachypnea, and increased BP
PERIOPERATIVE RESPIRATORY FAILURE
As hypoxemia progresses:
• Surgery • Confusion
• Anesthesia can affect breathing could • Lethargy
lead air sacs to collapse (atelectasis and • Tachycardia, tachypnea
further lead oxygen out from the blood • Central cyanosis
• Diaphoresis
• Respiratory arrest

Physical findings:
• ARDS (increased use of accessory
muscles)

10
 MIDTERM

• Decreased breath sounds (if a patient LABORATORIES

cannot adequately ventilate
• ABG
Other related to underlying disease: • Complete blood count
• Hypotension with signs of poor perfusion • Cardiac serologic markers
suggests severe sepsis on severe • Microbiology
pulmonary embolism • Pulmonary function tests/bedside
• Hypertension with signs of poor spirometry
perfusion suggests cardiogenic • Bronchoscopy
pulmonary edema • Chest radiography
• Electrocardiogram
Symptoms depend on the cause: • Echocardiography
• Dyspnea
• Tachypnea MANAGEMENT
• Fatigue
• Heart palpitations • ABC's
• Hemoptysis • Ensure the airway is adequate
• Diaphoresis • Ensure adequate supplemental oxygen
• Restlessness and assisted ventilation, if indicated.
• Pallor Support circulation as needed
• Cyanosis
• Blurred vision TREATMENT
• Agitation, confusion
• Behavioral changes • Infection
• Antimicrobials, source control
DIAGNOSIS: HISTORY • Airway obstruction
• Bronchodilators, glucocorticoids
• Sepsis • Improve cardiac function
• Pneumonia • Positive airway pressure, diuretics
• Pulmonary embolus suggested by sudden vasodilators morphine, inotropes
onset of shortness of breath or chest pain
• COPD exacerbation suggested by the MECHANICAL VENTILATION
history of heavy smoking, cough, sputum
production
• Cardiogenic pulmonary edema suggested NON-INVASIVE
by chest pain, paroxysmal nocturnal
dyspnea, and orthopnea
• Mask usually orofacial to start
DIAGNOSIS: PHYSICAL FINDINGS INVASIVE
• Hypotension usually with signs of poor
perfusion suggests severe sepsis or • Endotracheal tube (ETT)
massive pulmonary embolus. • Tracheostomy-if upper airway is
• Hypertension usually with signs of poor obstructed
perfusion suggests cardiogenic
pulmonary edema. INDICATIONS
• Wheezing suggests airway obstruction:
• Bronchospasm • Cardiac or respiratory arrest.
• Secretions • Tachypnea or bradypnea with respiratory
• Pulmonary edema fatigue.
• Stridor suggests upper airway obstruction • Acute respiratory acidosis
• Elevated jugular venous pressure • Inability to protect the airway associated
suggests right ventricular dysfunction with a depressed level of consciousness
due to accompanying • Shock associated with excessive
• pulmonary hypertension respiratory work
• Tachycardia and arrhythmias may be the • Inability to clear secretions with Impaired
cause of cardiogenic pulmonary edema gas exchange

11
 MIDTERM

• Short-term adjunct in the management

of acutely increased intracranial pressure PRIMARY SPONTANEOUS PNEUMOTHORAX
ICP
• occurs without an evident
Consider non-invasive ventilation,
particularly in the following settings SECONDARY SPONTANEOUS PNEUMOTHORAX
• COPD exacerbation
• Cardiogenic pulmonary edema
• occurs due to an underlying illness
• Obesity hypoventilation syndrome
(COPD, asthma, tuberculosis, cystic
fibrosis and other lung disease)
NURSING MANAGEMENT
IATROGENIC PNEUMOTHORAX
• Assess the patient's tissue oxygenation
status regularly
• Evaluate ABG results • occurs due to puncture or laceration of
• To enhance V/Q matching, turn the the lungs during a medical procedure
patient on a regular and timely basis to (lung biopsy, tracheostomy or catheter
rotate and maximize lung zones. insertion!
• Regular, effective use of incentive
spirometry TENSION PNEUMOTHORAX
• Regular patient turning and repositioning
enhances diffusion by promoting a • occurs when the air enters the pleural
healthy, well-perfused alveolar surface. space and cannot escape due to trauma
• These actions, as well as suctioning, help (stab wound, gunshot wound, fractured
mobilize sputum or secretions. rib)
• Regular, effective use of incentive
spirometry NURSING PROCESS
• Regular patient turning and repositioning
enhances diffusion by promoting a Check patient’s ABC’s and hemodynamic
healthy, well-perfused alveolar surface. stability
• These actions, as well as suctioning, help
mobilize sputum of secretions • if the patient is stable and has minimal air
or fluid accumulation in the pleural space,
no treatment may be necessary as it may
PNEUMOTHORAX resolve spontaneously.
• But severe immediate medical care is
• is a collection of air outside the lung but needed
within the pleural cavity.
• It occurs when air accumulates between NURSING ASSESSMENT
the parietal and visceral pleura inside the
chest Review health history
• In a normal lung, negative pressure exists
b/n the visceral and parietal pleural 1. Determine cause
(pleural space) • Chest trauma/injury
• This pleural space contains minimal fluid • Ruptured blebs or bullae (collection of air or
that serves as lubricant when the tissues fluid)
move. • Underlying lung disease
• When air enters the space, pressure • Recent surgery or invasive procedures
changes will cause the lungs lo collapse
(partial or complete) 2. Obtain past medical history. Note existing
TYPES lung disease
• COPD
SPONTANEOUS PNEUMOTHORAX • Cystic fibrosis
• Lung cancer
• Sarcoidosis
• rupture of air-filled sacs on the lung
• Tuberculosis
surface
• HIV/AIDS with pneumonia

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 MIDTERM

3. Risk Factors Inspection: respiratory discomfort, airway

• Gender- Male patency, tracheal deviation
• Age- 20 to 30 years old Palpitation: 1 tactile fremitus, asymmetrical
• Tall, thin expansion
• Smoking
Percussion: hyper resonance
• Pregnancy
• Maran syndrome Auscultation: lor absent breath sounds
• Family history of pneumothorax
ASSESS THE CARDIOVASCULAR STATUS
4. Genetics • ⬆HR
• patients with Marfan syndrome, • ⬇BP
homocystinuria, and Brad-Hogg- • Jugular vein distention
Dube syndrome are linked with • Cyanosis
spontaneous pneumothorax, • Cardiac arrest

5. Previous Hx of Pneumothorax DIAGNOSTIC PROCEDURES

• Smoker
• Younger 1. Chest x-ray
• Taller and thinner 2. Imaging scans
• Hx of COPD, AlDs, and pulmonary 3. ABGS
fibrosis
• May recur within the first 6 months to NURSING INTERVENTIONS
3 years
Administer medications
6. Review past medical procedures • Prophylactic antibiotics prior to chest
• Transthoracic needle aspiration (main tube insertion
factor in iatrogenic pneumothorax) • Analgesics or nerve block
• CVP insertion
• Tracheostomy Prepare for decompression
• CPR • Inserting a large bore catheter into the
• ARDS chest wall to draw out excess air
• NGT placement
Assist in tracheostomy tube insertion
7. Patient lifestyle and occupation
• Placing a chest tube following needle
• Drug use (inhaled) marijuana or cocaine
decompression
• Flying, scuba or deep-sea diving (can
• Heimlich valves are one-way valves that
cause drastic air pressure changes)
allow air to escape without using suction
• SSP typically requires suction
PHYSICAL ASSESSMENT
Watchful approach to small pneumothoraxes
SYMPTOMS • For small asymptomatic, observation is
• Sudden chest pain - sharp, severe and advised with 02 therapy because it will
becomes worse with inspiration that likely resolve on its own
radiates to the ipsilateral shoulder
• Dyspnea - becomes more severe with
Oxygen Therapy
secondary pneumothorax
• 3 Ipm via a cannula or higher to treat
hypoxemia
MONITOR VITAL SIGNS
• RR and PR Surgical Intervention
• BP & 02 saturation • Thoracoscopy
• Closely monitor changes for
• Electrocautery
hemodynamic instability
• Laser treatment
• Resection of blebs or pleura
ASSESS RESPIRATORY STATUS
• IPPA (inspection, palpation, percussion,
• Open thoracotomy
• VATS
and auscultation)

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 MIDTERM

Decrease pneumothorax recurrence

• Pleurodesis (sclerotherapy) - creates scar
tissue b/n layers of the pleura causing the.
sticking them together to prevent the
reaccumulating of fluid or air in the
pleural space

PREVENTIONS

• Stop smoking
• Avoid activities with drastic changes in
air pressure
• Limit air travel
• Treat lung infection

Although you've been diagnosed with pulmonary

hypertension, you have no symptoms with normal
activity.

CLASS TWO

You don't have symptoms at rest, but you

experience symptoms such as fatigue, shortness
of breath or chest pain with normal activity.

CLASS THREE

You're comfortable at rest, but have symptoms

when you're physically active.

CLASS FOUR

You have symptoms with physical activity and

while at rest.

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 MIDTERM

TYPES
PULMONARY HYPERTENSION

A severe, rare lung disease characterized by high GROUP 1 PAH

blood pressure in the pulmonary arteries, which
• Pulmonary hypertension is associated with
deliver blood from the heart to the lungs
the narrowing of the small blood vessels in
● The increased pressure in the blood the lungs.
vessels of the lungs means that your • It also is called Pulmonary Arterial
heart has to work harder to pump blood Hypertension (PAH) and Includes cases
into the lungs. where the underlying cause of the narrowing
● Is a serious health condition that is not known (idiopathic pulmonary
results when the arteries carrying hypertension).
blood from the right side of the heart
There are multiple other subgroups in group 1,
to the lungs are constricted, disrupting including:
blood flow • Familial or Heritable Pulmonary
● Blood must travel through the lungs for Hypertension (FPAH) or (HPH)
air exchange in order to pick up oxygen • PAH caused by certain drugs or toxins
that it delivers to all the organs, including some recreational drugs and diet
medications
muscles, and tissue in the body.
• PAH associated with other conditions such as
● When the arteries between the heart connective tissue diseases like:
and lungs become narrowed and flow 1. Scleroderma or lupus (connective tissue
is constricted, the heart has to work diseases certain autoimmune diseases)
extra hard to pump blood to the lungs. 2. Congenital heart problems
● Over time, the heart can grow weak and 3. High blood pressure in the liver
4. HIV
proper circulation can diminish
5. Schistosomiasis (a type of parasitic
throughout the body.
infection)
6. Sickle cell anemia
CLASSIFICATIONS 7. Liver disease

CLASS ONE GROUP 2 PH

Although you've been diagnosed with pulmonary
hypertension, you have no symptoms with • Group 2 refers to pulmonary
hypertension caused by left heart disease.
normal activity.
• Long-term problems with the left side of
the heart can lead to changes in the
CLASS TWO pulmonary arteries and cause pulmonary
You don't have symptoms at rest, but you hypertension.
experience symptoms such as fatigue, shortness This may include:
of breath or chest pain with normal activity. 1. Left ventricular systolic dysfunction:
when the heart cannot pump blood
effectively
CLASS THREE 2. Left ventricular diastolic dysfunction:
when the heart cannot properly relax to
You're comfortable at rest, but have symptoms allow enough blood to flow in
when you're physically active. 3. Valvular disease: when the valves of the
left side of the heart are allowing blood to
leak
CLASS FOUR 4. Congenital heart defects (heart defects
You have symptoms with physical activity and from birth): which can lead to problems
while at rest. with blood flowing in or out of the heart

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 MIDTERM

GROUP 3 PH PREDISPOSING FACTORS

• Family history & Genetics
• Group 3 includes: pulmonary 1. Certain genetic disorders, such as
hypertension resting from lung diseases Down syndrome, congenital heart
or shortage of oxygen in the body disease, and Gaucher disease, can
(hypoxia). increase your risk of developing
The common diseases associated are: pulmonary hypertension.
1. Chronic obstructive pulmonary disease 2. A family history of blood clots or
(COPD) pulmonary embolism also increases
2. Interstitial lung disease (such as your risk of developing Pulmonary
pulmonary fibrosis), which can cause hypertension.
scorning on lung tissue
3. Sleep-disordered breathing, a group of • Age
diseases that affect breathing during 1. Risk goes up as you get older,
sleep like obstructive sleep apnea (OSA) although it may occur at any age.
4. Chronic high-altitude exposure 2. Typically diagnosed between ages 30
5. Lung developmental abnormalities and 60.
6. Alveolar hypoventilation disorders
• Sex
1. Common in women than in men.
GROUP 4 PH
2. Pulmonary hypertension with
certain types of heart failure is also
• Refers to pulmonary hypertension caused more common in women.
by blood clots obstructing the pulmonary
arteries. • Lifestyle Habits
• This also can be referred to as chronic 1. Unhealthy lifestyle habits can
thromboembolic pulmonary increase the risk of pulmonary
hypertension (CTEPH). hypertension.
• Clots are the body's response to bleeding
and injuries but can harm the heart and • Illegal Drugs
lungs when they occur without an 1. Such as cocaine and amphetamines
apparent cause. Pulmonary emboli are
blood clots that travel to the lungs, and • Smoking
pulmonary thrombosis are clots that are • Overweight
formed in the lungs, which can block the • Appetite suppressant medications
pulmonary arteries.
CLINICAL MANIFESTATIONS
GROUP 5 PH (MULTIFACTORIAL)
• Early symptoms include:
1. Shortness of breath during routine
• The last category and includes other less- activity and eventually while at rest
common causes that do not fit in early of 2. Fatigue
the other four groups. 3. Chest pain (angina)
4. Racing heartbeat
These are widely split into four categories: 5. Pain in upper right side of abdomen
1. Blood Disorders: such as some types of 6. Decreased appetite
anemia (polycythemia vera and
thrombocythemia • Later symptoms include:
2. Systemic Disorders: such as Sarcoidosis 1. Feeling light-headed, especially
(a condition that results in inflammation during physical activity
of different organs like the lungs and 2. Dizziness or fainting (syncope)
lymph nodes) and Histiocytosis (a rare 3. Swelling in the ankles or legs
disorder that causes scarring) 4. Bluish color to lips or skin (cyanosis)
3. Metabolic Disorders: such as glycogen
storage diseases and thyroid disorders
4. Other Disorders: such as chronic kidney
failure or tumors obstructing pulmonary
arteries

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 MIDTERM

LABORATORY & DIAGNOSTIC TEST NURSING MANAGEMENT

• Echocardiogram Although medical treatment can't cure
• Chest X-ray pulmonary hypertension, it can lessen
• Electrocardiogram symptoms.
• Right heart catheterization
• Blood tests Lifestyle changes also can help improve your
• Cardiac MRI condition such as:
• Get plenty of rest: Resting can reduce the
COMPLICATIONS fatigue that might come from having
pulmonary hypertension.
• Right-sided Heart Enlargement and Heart
Failure (cor pulmonale) • stay as active as possible: Even the mildest
1. In cor pulmonale: your heart's right forms of activity might be too exhausting for
ventricle becomes enlarged and has to some people who have pulmonary
pump harder than usual to move blood hypertension. For others, moderate exercise
through narrowed or blocked pulmonary such as walking might be beneficial —
arteries. especially when done with oxygen. Discuss
2. At first, the heart tries to compensate by the level of activity with your doctor about
thickening its walls and expanding the specific exercise restrictions. Avoid straining
chamber of the right ventricle to increase or lifting heavy weights. Rest when you need
the amount of blood it can hold. But this to.
thickening and enlarging works only
temporarily, and eventually the right • Don't smoke: If you smoke, the most
ventricle fails from the extra strain. important thing you can do for your heart
and lungs is to stop. If you can't stop smoking
• Blood Clots by yourself, ask your doctor to prescribe a
1. Clots help stop bleeding after you've been treatment plan to help you quit. Also, avoid
injured. But sometimes clots form where secondhand smoke if possible.
theyre not needed. A number of small
clots or just a few large ones dislodge • Avoid pregnancy and birth control pills: If
from these veins and travel to the lungs, you're a woman of childbearing age, avoid
leading to a form of pulmonary pregnancy. Pregnancy can be life-
hypertension that can generally be threatening for both you and your baby. Also
reversible with time and treatment. avoid using birth control pills, which can
2. Having pulmonary hypertension makes it increase your risk of blood clots. Talk to your
more likely you'll develop clots in the doctor about alternative forms of birth
small arteries in your lungs, which is control. If you do become pregnant, it's
dangerous if you already have narrowed important to consult with your doctor as
or blocked blood vessels. pulmonary hypertension can cause serious
complications to both you and the fetus.
• Arrhythmia
1. Irregular heartbeats (arrhythmias) from • Avoid travelling to or living at high altitudes:
the upper or lower chambers of the heart High altitudes can worsen the symptoms of
are complications of pulmonary pulmonary hypertension. If you live at an
hypertensión. These can lead to altitude of 8,000 feet (2,438 meters) or
palpitations, dizziness or fainting and can higher, your doctor might recommend that
be fatal. you move to a lower altitude. Be cautious
about air travel or high-latitude locales. You
• Bleeding may need to travel with extra oxygen.
2. Pulmonary hypertension can lead to
bleeding into the lungs and coughing up • Get vaccines: Your doctor may recommend
blood (hemoptysis. This is another getting influenza and pneumonia vaccines. as
potentially fatal complication. these conditions can cause serious issues for
people with pulmonary hypertension.

• Get support: If you're feeling stressed or

worried due to your condition, get support
from family or friends. Or, consider joining a

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 MIDTERM

support group with others who have o Major risks of any type of
pulmonary hypertension transplantation include rejection of
the transplanted organ and serious
• Heart-healthy eating: which includes eating infection, and you must take
less salt, to lower blood pressure or immunosuppressive drugs for life. to
cholesterol. High levels of these contributed help reduce the chance of rejection.
to the cause of your pulmonary hypertension.
Eating less salt will help control your body • Oxygen therapy if oxygen levels in the blood
fluids and may improve heart function. Aim are too low.
to eat a healthy diet of whole grains, a variety
of fruits and vegetables, jean meats and low- • Balloon atrial septostomy to decrease
fat dairy [Link] saturated fat, trans pressure in the right heart chambers and
fat and cholesterol. Aim to maintain a healthy improve the output of the left heart and
weight. oxygenation of the blood. In this procedure, a
small hole is made in the wall between the
• Physical rehabilitation: to improve your right and left atria to allow blood to flow
ability to exercise and also boost your quality from the right. to the left atrium.
of life
• Balloon pulmonary angioplasty to lower the
• Ask your doctor about medications: Take all blood pressure in your. pulmonary artery and
your medications as prescribed. Ask your improve heart function in people who cannot
doctor about any other medications before have a pulmonary endarterectomy.
taking them, as some can interfere with your
medication or worsen your condition. • Pulmonary endarterectomy surgery to
remove blood clots from the inside of the
• Watch your weight: A daily record of your blood vessels of the lungs.
weight can help you be aware of rapid weight
gain, which may be a sign that your • Blood pressure medicines such as
pulmonary hypertension is worsening. angiotensin-converting enzymes inhibitors,
beta blockers; or calcium channel blockers
• Anticoagulation or blood thinners: to prevent when left heart disease is the cause
blood clots in people whose pulmonary
hypertension is caused by chronic blood clots • Blood transfusions or Hydroxyurea to treat
in the lungs. These thinners also can help sickle cell disease
some people who have. pulmonary arterial
hypertension, heart failure, or other risk • Heart valve repair
factors for blood clots.

• Digitalis or digoxin: to control the rate blood

is pumped throughout the body.

SURGICAL MANAGEMENT

• Atrial septostomy: If medications don't

control your pulmonary hypertension, this
open-heart surgery might be an option. In an
atrial septostomy, a surgeon will create an
opening between the upper left and right
chambers of your heart (atria) to relieve the
pressure on the right side of your heart.
o Atrial septostomy can have serious
complications, including heart
rhythm abnormalities (arrhythmias).

• Transplantation: In some cases, a lung or

heart-lung transplant might be an option,
especially for younger people who have
idiopathic pulmonary arterial hypertension.

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 MIDTERM

o Obesity
CORONARY ARTERY DISEASE o Uncontrolled stress and anger
o Unhealthy diet
Is the narrowing or blockage of the coronary,
In the Philippines:
usually caused by atherosclerosis.
In 2017, coronary heart disease (CHD) deaths
reached 122,950 or 19.86% of total deaths. The
ARTHEROSCLEROSIS - the hardening or
age adjusted rate is 11.82 per 100,000 of
clogging of the arteries is the build-up of
population ranks Philippines 116th in the world.
cholesterol and fatty deposits (plaques) on the
inner walls of the arteries. These plaques can
restrict the blood flow to the head muscle by SYMPTOMS
physically clogging the artery or by causing
abnormal artery tone function. This can also lead • Chest pain (Angina Pectoris) it may also
to chest pain, angina, or heart attack. be felt in the left shoulder, arms, neck,
back or jaw.
• Overtime, CAD can also weaken the heart • Chest discomfort, heaviness, tightness,
muscle and contribute, to heart failure and pressure, aching, burning, numbness,
arrhythmias; fullness, or squeezing
• Shortness of breath
• Heart Failure means the heart can't pump • Irregular heartbeats or rapid heart beats
blood well to the rest of the body. • Dizziness
• Sweating
• Arrhythmias are changes in the normal • Fatigue
rhythm of the heart. • Nausea
• Palpitation
• CVDs are the number 1 cause of death
globally; more people die annually from CVDs DIAGNOSTIC EXAM
than from any other cause.
ECG or EKG
• An estimated 17.9 million people died from • Measures the electrical activity rate
CVDs in 2016, representing 31% of all global and regularity of your heartbeat
deaths. Of these deaths 85% are due to heart
attack and stroke. Echocardiogram
• Uses ultrasound to assess cardiac
• Over three quarters of CVD deaths take place structure and mobility
in low- and middle-income countries.
Exercise stress test
• Out of 17 million premature deaths (under 70 • Measures heart rate while walking
years old) due to non-communicable on a treadmill. Helps to determine how well the
diseases in. 2015, 82% are in low and middle- heart functions while it has to pump more blood
income countries, and 37% are caused by
CVDs Heart CT Scan
• To see calcium deposits in arteries
RISK FACTORS that can narrow arteries.

• NON-MODIFIABLE Cardiac Catheterization

o Gender • To assess O2 levels, blood flow, CO, heart
o Age structures, and coronary artery
o Family History visualization.
o Race
Angiogram
• MODIFIABLE • Involves introduction of contrast
o Cigarette Smoking medium into the vascular arteries to outline the
o High Blood cholesterol, high heart and blood vessels.
triglycerides
o Hypertension
o Uncontrolled Diabetes
o Sedentary Lifestyle

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 MIDTERM

LABORATORY TEST Right Coronary Artery

The right coronary artery supplies blood to the
Hemoglobin right ventricle, the right atrium, and the SA
• decreased hgb increases the risk of (sinoatrial) and AV (atrioventricular) nodes,
oxygen deficit in the tissues when which regulate the heart rhythm.
cardiovascular disease is present.
The right coronary artery divides into smaller
Total cholesterol branches:
• high level can increase risk of heart
disease. • Right Posterior Descending Artery and the
Acute Marginal Artery.
LDL o Together with the left anterior
• too much LDL in the blood descending artery, the right coronary
causes accumulation of fatty artery helps supply blood to the middle or
deposits in arteries, which reduces septum of the heart.
blood flow.
MEDICAL MANAGEMENT
HDL
Pharmacologic Therapy
• the good cholesterol.
Cholesterol-modifying Medications
by decreasing the amount of cholesterol in the
Triglycerides
blood, especially LDL, these drugs decrease the
• high levels of these can increase the risk
primary material that deposits on the coronary
of heart disease
arteries.
Lipoprotein
Platelet Aggregation Inhibitors
• is an LDL. High level of this
class of drug that decreases platelet aggregation
increase the risk of heart attack, stroke,
and inhibits thrombus formation.
blood clots, and fatty build-up.
Beta-adrenergic Blockers
Creatinine-Kinase CK-MB
It decreases blood pressure and heart rate: It
• is a cardiac muscle cells that therefore
reduces the risk for future heart attacks
increase when there is damage to these
cells
Calcium-channel Blockers
Inhibits tile transport calcium into myocardial
DIFFERENT TYPES OF CORANARY ARTERIES and vascular smooth muscle cells, resulting in
inhibition of excitationcontraction coupling and
subsequent contraction it has systemic
Left Main Coronary Artery (LMCA) vasodilation effect resulting in decreased BP
The left main coronary artery supplies blood to Coronary vasodilation in decreased frequency
the left side of the heart muscle (the left and severity of attacks of angina.
ventricle and left atrium).
The left main coronary divides into branches: Nitroglycerin
increases blood flow by dilating coronary
• Left Anterior Descending Artery arteries and improving collateral flow to
o branches off the left coronary artery and ischemic regions. Decreases blood pressure
supplies blood to the front of the left side
of the heart. ACE Inhibitors and ARBs
These similar drugs decrease blood pressure
• Circumflex Artery and help in preventing the progression
o branches off the left coronary artery and of coronary artery disease.
encircles the heart muscle. This artery
supplies blood to the outer side and back Analgesic-Morphine sulfate
of the heart. may be used in acute onset because of is several
beneficial effects, e.g., causes peripheral
vasodilation and reduces myocardial workload,
has sedative effect to produce relaxation.

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 MIDTERM

MEDICAL PROCEDURE Calcium-channel Blockers

Angioplasty and Stent Replacement • Assess HR and BP
(Percutaneous coronary revascularization) • Monitor hepatic and renal function
mechanical dilation of the coronary vessel wall • Administer 1 hour before or 2 hours after
by compressing the atheromatous plaque meals.
• Food delays absorption and decreases
• A special designed balloon tipped catheter plasma levels of the drug.
inserted under fluoroscopic guidance and
• The antidote for calcium-channel blocker
advanced to the site of the coronary
obstruction. poisoning is Glucagon
• Stent helps prevent the artery from closing
up again, A drug the eluting stent has a
medicine embedded in it that helps prevent NURSING INTERVENTION
the artery from closing in the long term. • Instruct patient and watchers to notify
nurse immediately when chest pain
NURSING INTERVENTION occurs.
(DRUG THERAPY)
• Identify precipitating event, if any:
Nitroglycerin therapy
frequency, duration, intensity and
• Assume sitting or reclining position when
location of pain
taking the drug
• Assess and document patient's response
• Caution, patient to change positions slowly
to medication.
• It to be taken sublingually over sips of water
• Observe for associated symptoms;
before administration because dryness
dyspnea, nausea and vomiting; dizziness
• amount may inhibit drug absorption instruct
palpitations, desire to urinate.
client to avoid drinking alcohol to avoid
• Evaluate reports of pain in jaw, neck,
• hypotension, weakness, and faintness
shoulder, arm or hand usually in left side.
• Inform patient, dizziness,
• Obtain results of cardiac markers
• faintness, or common side
creatinine, CK-MB, Total Cholesterol,
• effect during first few doses
LDL, HDL, Lipoprotein, hemoglobin and
• Transderm nitro patch applied OD in the
triglycerides as ordered.
morning
• Place patient at complete rest during
• Evaluate the effectiveness relief of chest pain anginal episodes.
• Position patient to moderate high back
Beta-adrenergic Blockers
rest to improve chest expansion and
• Assess pulse rate before administration of
oxygenation
the drug, withhold bradycardia is present
• Monitor patient vital signs with pain and,
• Administer after meals to prevent GI
02 saturation, Note heart’s rhythm.
upset.
• Monitor and obtain ECG results to note
• Do not administer propranolol to asthma
abnormal tracings.
patients because it causes
• Provide oxygen as needed or as ordered.
bronchoconstriction.
• Administer vasodilators, beta-blockers,
• Do not give propranolol to patients with
calcium-channel blockers and platelet
DM because it causes hypoglycemia.
aggregation inhibitors as ordered.
• Give with extreme caution to patients
• Monitor patient’s vital signs every 15
with heart failure.
minutes during the initial angina attack.
• Observe for side effects: nausea, vomiting
• Maintain a quiet, comfortable
mental
environment. Restrict visitors as
• depression, mild diarrhea, fatigue and
necessary.
impotence.
• Advise patient to minimize emotional
• Antidote for beta blocker poisoning is
outbursts, worry, and tension because
Glucagon
angina pain is often precipitated by
emotional stress.

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 MIDTERM

• Assist with the activities of a patient to

avoid overexertion.
• Stay with a patient who is experiencing
pain or appears anxious.
• Provide light meals or small frequent
feedings. Have the patient rest for 1hr
after meals.

HOME TEACHING
• Daily management of hypertension.
• Take medicines on a regular basis.
• Stop smoking. Smoking reduces
available oxygen to the heart and can
precipitate angina. It also increases
heart rate and blood pressure.
• Follow a heart-healthy diet - Low
sodium, low fat, low cholesterol and
high fiber diet, Avoid saturated fats.
• If obese or overweight, lose weight.
• Reduce stress because stress stimulates
the increase of norepinephrine that
causes vasoconstriction and tachycardia.
Stress also causes anginal pain.
• Allow adequate time for rest and
relaxation

22