OXYGENATION

Thursday, August 20, 2020 2:00 PM

Perfusion

HYPERTENSION

**After-load -systolic
**Preload - diastolic

TYPES OF HTN:
1. Primary HTN
- Is most common form
- Idiopathic/No known exact cause
- CAUSE: aging, family hx, alcohol, smoking (nicotine= vasoconstrict effect), high fat diet, salty foods
(PISO = Potassium Inside Sodium Outside; attract water), caffeine, stress, DM, sedentary lifestyle

2. Secondary HTN
- Caused by underlying disease (ex. Aneurysm, kidney failure, heart attack, stroke)

S/SX OF HTN:
- HBP (>140/90 mmHg), headache, neck pain (when waking up), nuchal headache, epistaxis,
dizziness, vague discomfort, fatigue = MILD HTN
- SEVERE HTN: Retinal hemorrhage, cotton-wool spots, papilledema (redness/soreness of eye), spots,
blurred vision
- COMPLICATIONS: Coronary diseases, heart failure, renal failure, stroke, blindness

STAGES OF HTN:

**SEVERE: Check for cotton wool eyes, redness of eye

**Advanced HTN stage= Hypertensive Crisis (Urgency and Emergency)
- Target Organs: Eyes, stroke, heart attack/myocardial infarction, kidney problems

W/O TARGET ORGAN DAMAGE:

- BP 180/120 = don’t wait anymore, ask if they have maintenance meds then give it to them
immediately, otherwise it will go to emergency (w/ organ damage)
- Catapres, if no maintenance meds as it is safest med
- If 150/100 = monitor BP, take again after 15 mins CHECK REDNESS OF EYES, OTHER S/SX

140/100 BP: SEVERE

- Ano mas mataas na stage level, that’s the stage

CCH blocker = prevent calcium ion influx, prevents vasoconstriction, lowers BP Beta-blocker
=

PRIMARY SIDE EFFECT OF ANTIHYPERTENSIVE DRUG:

- Hypotension
- Dizziness, fainting, etc. = as cardiac output is lowered, blood to brain lessen also
- All cardio drugs promotes vasodilation, regardless of classification, by preventing vasoconstriction.
Relaxes smooth muscles of heart and blood vessels. Primary effect is lowers BP
- Contraindication = hypotension drugs
- Nsg. Educ =
○ avoid activities that requires mental alertness
○ Gradual change of position
- If BP is low and patient still takes antihypertensive drugs, patient will have 40/10 mmHg ORTHOSTATIC
HYPOTENSION (blurred vision, falling)

CARDIO DRUGS:
-olol = beta-blocker (metropolol, etc)
-dipine = calcium channel blocker
-pril = ace inhibitor
-zartan = adrenegic blocker / ARBS
-zosin = alpha blocker (catapres drug dito)

Decrease Cardiac Output

- Regular BP monitor
- Give antihypertensive drug as ordered
- DASH (Dietary Approaches to Stop Hypertension)diet (rich in vegetables)
- Low cholesterol
- Low fat diet
- Dietary fiber
- Dietary restriction and modification
- Low sodium diet
- HEALTH TEACH: weight reduction and control, regular exercise, alcohol restriction, smoking
cessation, relaxation techniques, stress reduction
- Avoid coffee, soda, tea, chocolate
ANGINA PECTORIS
- Paroxysm (multiple episodes) of pain and pressure in anterior chest caused by insufficient
coronary blood flow = increase metabolic demand, decrease metabolic supply
- Inner layer of heart, vascular endothelium is injured???

TYPES:
A. Stable -
- Predictable consistent chest pain during exertion; relieved by rest
- Chest pain during increased physical activities
- Let patient rest
B. Prinzmetal or variant
- Pain at rest/during sleep
C. Unstable or preinfarction
- Unpredictable, more frequent, unrelieved by rest
- Requires urgent hospital admission
D. Refractory
- Intractable incapacitating
- Severe chest pain

Diagnostic Tests:
- 12 lead ECG,
- stress test (walk or run test; 7 levels must be passed),
- Echocardiogram (see size/parts of heart, valves of heart) or 2D-echo, doppler to check heart
- Blood Chemistry: C-reactive protein (marker for inflammation of vascular endothelium)
and High homocysteine (3 parts: pericardium, middle layer that , inner layer
endothelium) C-reactive lalabas yung sa endothelium??
- 24 hr holter monitoring (ecg machine portable, record all activities at home and also the chest pain
event; so abnormal heart rhythm could be found at a certain activity or sleep time)

**Certain activities can cause chest pain even if heart is healthy at most times

CAUSE:
- Atherosclerotic (most common)
- Smoking
- Physical exertion
- Cold exposure
- Stressful situation
- Eating heavy meal
- Excess weight

MANIFESTATION:
- Chest pain and discomfort
- Retrosternal pain
- Radiating pain
- SOB
- Dyspnea (presenting symptom for elderly)
- Weakness and numbness of arms
- Pallor
- Diaphoresis
- Undue fatigue
- Apprehension
- Dizziness

COMPLICATION:
- Myocardial ischemia = no oxygen supply/hypoxia(GIVE OXYGEN AS ORDERED, HIGH FOWLERS,
LOOSEN CLOTHES)
- Myocardial infarction = damage to heart, permanent damage
- Myocardial necrosis = nangitim na heart/dead
- Sudden death

OUTCOME FOR DECREASED CARDIAC OUTPUT FOR ANGINA:

- Absence of chest pain, 0/10 chest pain

INEFFECTIVE CARDIAC TISSUE PERFUSION:

Nursing Interventions:
- Bed rest: to decrease oxygen demand
- Semi-fowler: Lung expansion, therefore increase oxygen supply
- Oxygen therapy: Increase oxygen supply
- Monitor SpO2 = 96-100 normal
- Monitor pain of patient [P-provocation/palliation (alleviate), Q- quantity/quality (how many times
and gaanong kasakit), R-region/radiation, T-timing (when does it occur, gaano katagal), S-severity
scale (how intense)]
- ANTIANGINAL DRUGS: never ever miss this; NITRATE drugs (in name can be shown)
○ Increase o2 supply,
○ Hypotension, same reminder as HTN
○ MUST ALWAYS BE WITH PATIENT, STOP ALL ACTIVITIES/STRESSFUL SITUATION, COLD
○ Nitroglycerin (mainstay treatment) - sublingual so in 5 mins it can have effect immediately
○ ISMN / Issosorbide mononitrate (imdur) - one nitrate
○ ISDN / Isosorbide dinitrate - two nitrate, more effective

CORONARY ARTERY DISEASE (CAD)

- Also known as Ischemic Heart Disease
- Broad heart condition characterized by partial and complete obstruction of blood flow to heart
muscles
- PATHO: obstruction in coronary arteries> leading o Myocardial ischemia, infarction, and necrosis
- Atherosclerosis: local accumulation of lipid, fat deposit on arterial wall, plaques, atheromas,
and fibrous tissues along the

- Pulse Amplitude: 0+ (complete arterial obstruction); 1+ (weak and thready pulse = partial
arterial obstruction); 2+ (normal)
- Place bell at radial artery, when there’s sweeshing sounds/brewy and lubdub = brewy sound, it
means there’s arterial obstruction
S/SX:
- Chest pain, atherosclerosis

IMPAIRED CIRCULATION (nsg. Diagnosis)

-low fat diet
- Low cholesterol
- DM = low sugar, antidiabetic insulin, blood sugar monitoring
- CARDIAC REHAB PROGRAM: exercise 30 mins a day, 3-4 times a week
○ Early ambulation
○ Gradual increase in exercise
- MONITOR FOR TOTAL LIPID PROFILE!!!
HDL, good cholesterol
LDL, bad cholesterol
Triglyceride

- Prepare patient for Angioplasty (stent for vein), CABG, an open heart surgery CORONARY
ARTERY (more than 4 clot)
- DRUG OF CHOICE: Antilipemics (-statin) ex. Simvastatin
- Bile acid sequestrants - works on large intestine, binds with fats there and dissolves it then it goes
to excretioin
- Niacin, fibric acid (fenofibrate)

THREE
Deoxygenated blood>>>superior (above heart) and inferior (below heart) vena cava, coronary sinus (supply
arterial unoxygenated heart from the heart; oxygenated blood to the heart is coronary artery)>>>
RA>>>tricuspid>>>r ventricle>>> pulmonary valve>>O2 blood na> pulmonary artery>>>lungs for gas
exchange/thru process of diffusion>>> pulmonary vein>> left atrium>>bicuspid>>>left ventricle>>>aortic
valve>>>aorta>>>body from ascending aorta (upper body parts) and descending aorta (lower
parts)>>>systemic circulation is the process

5 pacemakers
1. SA (sinoatrial) node from junction at coronary sinus and right atrium (60-100 impulses)
2. AV (atrioventricular) node between atrium and ventricle (40-60 impulses) ; in case di
gumana/malfunction SA back up this para gumana
3. Bundle of HIS (30-40)
4. Right bundle branch and left bundle branch - Left and right ventricle (20-30)
5. Purkinje fibers (10/15-20); not enough so artificial pacemaker is needed

WAVES ECG
- First small wave: P-wave >>> LUB(contraction;depolarization) of atrium
- Next big wave, a complex: QRS >>> contraction of ventricles nandito din yung Atrial
repolarization???
- 3rdd wave: T wave >>> DUB (relax;repolarization) of PURKINJE FIBERS
- Pag tumaas ST, that’s heart attack

ECG reading
I LA -AVR
II -AVL
III - AVF

V4- mismong heart location

3 LAYERS OF HEART
Pericardium: outer layer of heart w/ pericardial sac and fluid
Myocardium: heart muscle
Endocardium: inner layer

DISEASES:
A. RHEUMATIC ENDOCARDITIS
- Causes inflammation of endocardium (inner layer)
- DIAGNOSIS: (+) throat culture, high ESR(may inflammatory process in the body; sign of
inflammation)/WBC more than 10,000(implies there’s infection)/ antistreptolysin titer (check
causative agent is streptococcus bacteria (bilog bilog))
- CAUSE: URTI and pharyngitis; acute cough and colds (most common cause),
malnutrition, overcrowd

- COMPLICATIONS: any valvular heart diseases (stenosis or narrowing, prolapse,

regurgitation tricuspid and bicuspid)
- S/SX: most common sign SORE THROAT (first sign), polyarthritis (most common),
- MOST IMPORTANT S/SX: carditis (murmur, muffled heart, cardiomegaly as heart should not be seen
on x-ray);
- Other S/SX: erythema marginatum (spot of redness at upper torso), high fever, rhinitis, precordial
pain

- NURSING THERAPEUTICS:
1. Acute Pain (joint) - strict bed rest, proper joint alignment, comfort measure, hot compress on
affected limbs, fowler, NSAID (ibuprofen) for pain, corticosteroids (prednisone) for
inflammation
- GOAL: pain control
- OUTCOME:
2. PRIORITY: Risk for infection - treat sore throat, increase OFI, proper hygiene (mouth wash, oral
care PRIORITY INTERVENTION), rest, prophylactic antibiotics ( invasive procedure), Penicillin -
antibiotic of choice
 - GOAL: control infection
- OUTCOME: body temp within normal levels, lower WBC

ANTIBIOTIC DRUGS:
-CILLIN: Penicillin group
-MYCIN: Amino-glycosides
-CYCLINE: TETRACYCLINE
-AZOLE: anti-protozoal
Starts with CE- : CEPHALOSPORIN
-FLOXACIN:FLUOROQUINOLONES
-MOXAZOLE or SULFA-: Sulfonamides

B. INFECTIVE ENDOCARDITIS
- Inflammation of the endocardium (inner layer)
- Caused by bacteria, viral, and fungal infections
- Streptococcus Viridans, staphylococcus aureus (mas common)

- DIAGNOSIS: blood culture (definitive; to determine what agent is causing endocarditis),

echocardiography (doppler to check for visible inflammation; most valuable tool)
- CAUSE: Infections (systemic, dental, and skin), IV therapy, foley, corticosteroid (bawal long term
therapy as it can make patient immunocompromised)

- CLINICAL SIGNS: febrile syndrome, petechiae (red pinpoints), osler node (check or assess through joint
alignment), Janeway lesion, murmur (main sign; blowing or sweeshing sound of heart)
- COMPLICATIONS: Heart failure (L&R sided) arterial embolization (MAJOR)

- NURSING INTERVENTIONS:
1. Risk for Infection:
- Monitor body temp
- Increase OFI, rest, adequate nutrition
- Dental care
- Hand hygiene, oral care, skin care
- Perform asepsis, avoid crowd/people
- Paracetamol (for fever)
- ANTIBIOTIC (mainstay Tx), Penicillin and Amphotericin B (antifungal if fungal in nature yung cause) -
MEDS OF CHOICE

C. MYOCARDITIS
- Inflammation of myocardium
- DIAGNOSIS: CT scan (confirmatory diagnosis), 2D echo blood test; cannot measure myocardium so CT
scan is needed (increase WBC, ESR, and C-reactive protein (kasi may heart condition))
- CAUSE: Infection (most common), rheumatic fever, immunosuppressive therapy
(corticosteroid/chemotherapy as it weakens immune system, makes pt
immunocompromised)

- MANIFESTATIONS: flulike symptoms (most common), murmur fatigue, dyspnea, SOB palpitation,
positional chest pain, gallop
- COMPLICATIONS: cardiomyopathy, HF, dysrhythmia, venous thrombosis (impaired circulation;
blood clot stays on site it started), and mural thrombi

- NURSING INTERVENTIONS:
1. RISK FOR INFECTION - immunization (flu, hepaB), check body temp, antibiotic therapy (penicillin)
2. ACTIVITY INTOLERANCE - adequate bed rest, limit sports, gradual increase in physical activity
3. IMPAIRED CIRCULATION (PRIORITY) - ANTI-EMBOLIC compression stocking, ROM exercises to
prevent thrombus formation

D. PERICARDITIS
- Inflammation of pericardium
- DIAGNOSE: high ESR, C-reactive protein, CT scan (CONFIRMATORY DIAGNOSIS)
- CAUSE: URTI, TB, pneumonia, HIV, cancer, MI, cardiac procedure, RF, RA (rheumatoid arthritis),
lupus

- CLINICAL SIGNS: severe chest pain, pericarditic pain, substernal precordial pain, pericardial
friction rub (hallmark sign)
- COMPLICATIONS: pericardial effusion, cardiac tamponode, right-sided HF

- NURSING THERAPEUTICS:
1. Acute Pain (GOAL: pain relief/control)
- Rest, restrict activity
- Proper positioning, comfortable position, fowler
- NSAID (ibuprofen), corticosteroids (prednisone)
2. Prepare for surgery
- Pericariocentesis (definitive treatment) is surgical excision

E. ARTERIOSCLEROSIS
- “hardening of the arteries” caused by thickening of muscle fibers and the endothelial lining of small
arterial walls
- ATHEROSCLEROSIS: Narrowing (stenosis) of the intima of large and medium sized arteries
caused by accumulation of lipids, fatty deposit, calcium, fibrous tissue, atheromas, and plaques
- ATERIOSCLEROSIS+ATHEROSCLEROSIS= CAD or systemic heart disease

- CAUSE: Age, gender, family hx, smoking (strongest risk factor), high fat diet,
hyperlipidemia, hypercholesterolemia, HRN, DM, stress, sedentary lifestyle
- CLINICAL SIGN: intermittent claudication - pain, numbness, cramp, weakness of feet/legs
(marker of developing CAD; sign of generalized athrosclerosis)
- DIAGNOSIS: Lipid profile = high LDL, cholesterol, triglyceride, BUT low HDL

- NURSING THERAPEUTICS: Peripheral Vascular Disorders)

1. Impaired circulation:
- Behavior modification, smoking cessation (HIGHLY/STRONGLY RECOMMENDED)
- Elevated feet, control exercise program, moderate walking, isometric exercises
- Warmth temperature, relaxation therapy, stress management strategies
 - Avoid cold exposure, constrictive clothing, cross legs, emotional upset, stressful situation,
avoid prolong sit/stand
- Dietary modification, low fat diet, low cholesterol diet, vitamin B3 (niacin)
- Prepare pt for vascular surgical procedure (angioplasty, PTA, stent graft)
- Medication - Bile sequestrant (cholestyramine), antilipemics (statins group)

F. ANEURYSM
- Weakness, dilatation, out pouching (lumobo), damage and distention of the tunica media (mid
layer of blood vessel) of he artery in abdomen (AAA) thoracic (TAA)
- TESTS: CT scan (standard, most accurate), chest x-ray, duplex UTZ, cardiac cath, stress test, trans
echo

- CAUSE: fam hx (CHECK BP, MONITOR BP), men, elderly, atherosclerosis (most common), aging, HRN,
smoking, alcohol, obesity, trauma
○ Remind patient if may HPN, take meds.
- CLINICAL MANIFESTATIONS:
A. Abdominal Aortic Aneurysm (AAA)
- Visible abdominal pulsating bulge/mass mid-upper abdomen (most important indication)
- DON’T PALPATE!!!
- Periumbilical mass, bruit, feel heart beating in abdomen, abdominal
pain/throbbing
B. Thoracic Aortic Aneurysm (TAA)
- Constant boring pain (most prominent), pain in supine position
- DOB, SOB, paroxysmal cough, stridor
- Hoarseness, aphonia, dysphagia

C. CEREBRAL ANEURYSM:
- Bulging>>rupture>>hemorrhage>>>bababa ang brain dahil sobrang daming
blood>>intracranial hernia>>>compress medulla oblongata (respirator center of brain)>>>
respiratory arrest/stop breathing>>>death

- COMPLICATIONS: aneurysm rupture (severe back/abdominal pain) sign of impeding rupture,

expanding enlarging aneurysm, hemorrhagic shock, stroke, AMI

- NURSING THERAPEUTICS:
1. Avoid - stimulating environment, physical exertion, HTN, caffeine, Valsalva, straining
(when pooping), palpating mass
2. Urgent surgery - aneurysmectomy (TOC, standard Tx, surgery of choice), endovascular
stent graft. But aneurysm can still develop on different arteries.

3. INEFFECTIVE TISSUE PERFUSION - control BP, antihypertensive drug (beta blocker), Propanolol
(DOC), opioid analgesic, blood products (replace loss blood due to bleeding/hemorrhage),
hydration, IV fluids, oxygen, mechanical ventilator (as condition can deteriorate anytime),
ICU/CCU care
- Opioid analgesic, like tramadol, cannot relief pain cause it’s on the weaker side of opioid. GIVE
MORPHINE SULFATE but be careful cause it’s side effect is respiratory arrest/depression.

PERIPHERAL VASCULAR DISEASES

A. ARTERIAL EMBOLISM, THROMBOSIS

- Acute vascular occlusion caused clot, embolus(traveling), thrombus (stay on one area)
- Embolus, mas grabe cause it travels, may migrate to brain
- CAUSE: latrogenic injury, invasive procedure (IABP, PTA), fracture, trauma, atrial
- Wheeshing/blowing sound on heart= murmur, blowing/wheeshing sound outside heart = bruits ; but
ALL are from occluded artery

- CLINICAL SIGNS: 6Ps=pain, pallor, pulselessness (amplitude 2+ normal, complete or grade 0 if

pulseless), parethesia, paralysis, poikilothermia (coldness) below occluded limb, pale (above limb)
- DIAGNOSIS: 2D echo (UTZ for the heart), ECG, duplex UTZ, ankle brachial index/ABI (grave
cases/massive clot)
- MI only clot in heart but same approach. Embolism/thrombosis (outside of heart)

- NSG DIAGNOSIS:
1. IMPAIRED CIRCULATION: Goal = improved circulation; Outcome = NO 6Ps
- Avoid heating and cooling pads (to prevent trauma)
- Apply sheepskin foot cradle (to protect legs from trauma)
- Leg movement, (ROM exercise), turning position (if unconscious to promote circulation)
- Embolectomy (procedure of choice), percutaneous thrombectomy

- MEDS: Heparin Anticoagulant therapy (prevent thrombus; aspirin is now also antiplatelet as it
promotes bleeding, it prevents platelet aggregation) thrombolytic therapy (-kinase,
streptokinase/TPA??, for massive/large/severe blood clot only)
- Blood clot unconscious: thrombolytic therapy (adverse effect: BLEEDING. Cerebral
hemorrhge>>intracerebral bleeding>> hernia>> bleeding>> brain bababa>>> compress medulla
oblongata>>>respi arrest); conscious: heparin

B. BEURGER’S DISEASE (Thromboangitis Obliterans)

- Inflammation of the arteries and vein of the hands and feet
- PATHO: vascular obstruction >>> ischemia >>>> nerve damage (no enough supply of o2) >>>
numbness
- CAUSE: SMOKING (primary cause), HPN, DM, CVD, peri
- MANIFESTATIONS: PAIN IN PALM & ARCH (1st sign), burning pain, pale, numbness, decrease
sensation;
- Complications: Ulcer (blackening), gangrene (dead tissues)
- **DM: Toe blackened first, going up.

- NSG. DIAGNOSIS:
- INEFFECTIVE TISSUE PERFUSION: Smoking cessation (mainstay Tx), Beurger-Allen exercises,
amputation, symphatectomy (for vasospasm)
- MEDS: Analgesic, and nifedipine (for vasodilation, prevents vasoconstriction, circulation,
CalChannelBlocker)

C. RAYNAUD’S DISEASE
 - Intermittent painful spasm/constriction of arteries in fingers & toes (digitals only)
- PATHO: arterial spasm > decrease circulation > intermittent return circulation > intermittent
return circulation
- CAUSE: unknown, cold, stress, caffeine, autoimmune (SLE, RA), occupational trauma, repetitive
hand movement, exposure to heavy metals
- SIGNS: Pale, pallor (white), cyanotic blue, cold, redness, tingling, numb, throbbing aching pain
finger
- DIAGNOSIS: Cold challenge test, hand x-ray, digital BP, plethymography
- **frostbite = directly immersed in cold only

- NSG. DIAGNOSIS:
1. INEFFECTIVE TISSUE PERFUSION:
- Warm water
- Lukewarm water bathe
- Warm clothes
- Wear mittens, gloves
- Warming device relaxation stress technique
- Career change if from job
- AVOID: colds, coffee, extreme temp, repetitive hand movement
- DRUGS: Calcium Channel Blockers (first line drug therapy)

D. Peripheral Arterial Occlusive Disease (PAOD)

- Arterial insufficiency of the extremities (legs)
- Not totally whole legs/feet; only a part
- CAUSE: men, advance age, elderly, fam hx, smoking, DM, HPN, hyperlipidema, obesity, stress,
sedentary lifestyles

- DIAGNOSIS: duplex UTZ (UTZ for the feet), ABI,

- HALLMARK SIGNS: aching, cramps, fatigue, weakness OR intermittent claudication (extremities
hurts, muscle cramp, weakness of legs)
- CLINICAL SIGNS: difficulty walking, cold and pale (feet elevated), ruddy and cyanotic (dependent)

- NSG DIAGNOSIS:
1. Impaired circulation
- Feet exercises, leg elevation
- Avoid cross leg and prolong feet dependency (to prevent thrombosis)
- Elastic compression stocking
- Adequate hydration, weight reduction, smoking cessation
- Endarterectomy or vascular graft (treatment of choice)
- MEDS: Pentoxiylylline (reduce blood viscosity), Antiplatelet (Ciloztazol, Aspirin, Clopidogrel)
to prevent blood clot

E. CELLULITIS
- Limb swelling associated w/ bacterial infection
- CAUSE: Leg cracks, fissures, contusions, abrasions, ulcerations, ingrown toenails, and hangnails
- CLINICAL SIGNS: swelling, localized redness, pain affected, febrile sign (fever, chills, sweating,
palpable lymph nodes)

- NSG. DIAGNOSIS:
1. Infection - Antibiotic therapy, clean wound
2. Acute Pain - elevate affected legs, apply warm moist pack, analgesics

F. VARICOSE VEINS
- Dilated, weak, incompetent, defective, distending, bulging, protruded, prominent, visible,
tortuous veins in legs
- DIAGNOSE: duplex UTZ
- PATHO: vein = (pumps deoxygenated blood back to heart) incompetent vein > increase venous
pressure > venous reflux > decrease venous return to heart > venous stasis

- CAUSE: prolong sit, standing, cross sit, obesity, pregnancy, CVD, constrictive cloth, high impact,
exercises, heavy physical activities, thromboplebitis
- CLINICAL SIGNS: heavy aching leg pain (most common), spider vein (telangiectasis), burning pain,
paresthesia (numbness AND tingling - tusoktusok), leg fullness, leg cramps
- COMPLICATION: DVT (deep vein thrombosis), SVT (most common)

- NSG. DIAGNOSIS:
1. IMPAIRED CIRCULATION
- Turning q2h, frequent, position change (promote circulation)
- Anti-embolic elastic compression stockings (due to venous stasis > stagnant blood flow > impaired
circulation > clot (DVT))
- Ankle-flexion-leg exercise, feet elevation
- Warm compress
- Prepare patient for surgical ligation (procedure of choice), sclerotherapy, radiation ablation
- MEDS: anticoagulant (for blood clot), NSAIDS (ibuprofen, alaxan), ASA (for leg discomfort;
paracetamol)

G. Deep Vein Thrombosis

- Blood clot formation due to Virchow Triad (endovascular damage, venous stasis,
hypercoagulability)
- Deep vein usually on calf, back part of leg
- DIAGNOSE: duplex UTZ (confirmatory) laboratory (slow PT, PTT, APTT, INR)
- CAUSE: Prolong sit, bed rest, standing, cross sit, immobility, travel, trip, smoking, surgery (hip, knee),
obesity, pregnancy, pills, restrictive clothes

- CLINICAL SIGNS: +Homan sign (calf pain during feet dorsiflexion; may also hurt while walking), leg
edema, swelling, tenderness, pain, hot/warmth, redness, discomfort
- COMPLICATION: pulmonary embolism (most serious) - report for severe dyspnea and chest pain
- Dislodge thrombus on deep vein > Pulmonary artery/vein > pulmonary embolism
- MEDICAL INTERVENTION:
- Anticoagulant (for blood clot), throbolytic therapy (report immediately bleeding)
- Venous thrombectomy (remove thrombus in veins) procedure of choice

- NSG. DIAGNOSIS:
 1. IMPAIRED CIRCULATION:
- Increase OFI (2-3 L), hydration, prevent dehydration (prevent hypercoagulation)
- Early ambulation/mobilization (most cost efficient), turning q2h
- Anti-embolic elastic compression stockings (prevent clot), leg exercise
- Avoid prolong sitting/standing

2. ALTERED COMFORT:
- Mild analgesic NSAIDS, ASA (for leg discomfort), bed rest, warm compress, walking, bed exercises,
elevate legs above heart level

HEMATOLOGIC DISEASES:
Hematocrit: total count o hemoglobin in blood
Hemoglobin: oxygen carrying capacity of blood

TYPES OF ANEMIA
1. MEGALOBLASTIC ANEMIA
- Abnormal large RBC, macrocytic, stem
- Due to defective DNA synthesis
- Leading to lower RBC production in bone marrow
- CAUSE: alcohol, deficiencies (folic acid, cobalamin & VIT B12)
- MANAGEMENT: Solve the cause (alcohol, deficiencies)

2. HEMOLYTIC ANEMIA
- RBC reduction
- CAUSE: autoimmune, radiation, blood transfusion rejection (wrong blood; dissolve RBC), arsenic, drug
- MANAGEMENT: corticosteroid, splenectomy (RBC producer is spleen, liver, kidney, bone marrow;
hemolysis automatically so it must be cut), erythocytapheresis (remove abnormal RBC; phresis is like a
catheter; machine that remove antibodies/abnormal RBC/ toxic waste; this machine filters blood > it
returns blood then again but w/o abnormal RBC)

- Autoimmune disorder: corticosteroid to avoid destroying of itself

- Check blood first before giving blood

3. APLASTIC ANEMIA (or hypoplastic anemia)

- Low RBC, WBC, platelet count = pancytopenia all component of blood is lowered
- CAUSE:
1. Virus, radiation, diseases (cancer/metastastasis)
2. Chemicals (benzene, insecticide, arsenic)
3. Medications (methotrexate, ankylating, antimetabolites)

- CLINICAL SIGNS: pancytopenia (low RBC, WBC, platelet count)

- Others: neutropenia, fever, infection, septic shock

- NSG. INTERVENTIONS:
- Blood transfusion
- Antibiotic (low WBC to fight; bactericidal and bacteriostatic)
- Bone marrow transplant
- Ciclosporin (suppress immune cell to prevent attack of bone marrow)
- Steroid

4. PERNICIOUS ANEMIA
- Parietal cell: only on stomach mucosa; absorbs vitamin B12
- Autoimmune disease; antibodies destruct gastric parietal cells (secretion protein intrinsic
factor to absorb vit b12 - cobalamin)
- Leading to vit b12 (cobalamin deficiency)

- CAUSE: gastrectomy (part of stomach is removed > no parietal cells), jejunostomy, gastric
carcinoma, malabsorption syndrome, crohn, alcohol
- ** 80% is lost from the stomach as it is cut = bariatric surgery
- CLINICAL SIGNS: sore red beefy smooth tongue, abdominal pain, jaundice (RBC breakdown
in liver)

- NSG. INTERVENTIONS: Vit B12, Cobalamin, Cyanocobafamin injection, blood transfusion, eat red meats,
& dairy products

5. SICKLE CELL ANEMIA

- Genetic disorder RBC becomes sickled
- RISK FACTOR: infection
- CLINICAL SIGNS: severe pain (primary symptom) of body
- COMPLICATIONS: acute respiratory failure (most common cause of death), infec

6. IRON-DEFICIENCY ANEMIA (IDA)

- Or microcytic < Decrease RBC, hemoglobin production < decrease oxygen-carrying capacity
- CAUSE: decrease dietary intake of iron, hemorrhage, gastrectomy, pregnancy, alcoholic
- NSG. INTERVENTIONS: Advice patient to eat iron-rich foods (red meat, egg yolk, green leafy
vegetables), vit c/ascorbic acid (Can help for absorption of iron),

- IMBALANCED NUTRITION: less than body requirements

- Food diary, nutritional counseling, calorie count, good nutrition, adequate ditary intake
- Administer iron supplement (ferrous sulfate, gluconate, fumarate) with vit c diet (promote
iron absorption) and avoid giving with milk (interfere iron absorption)
- Eat iron rich foods/ folic acid/ vit B12 rich foods (red meat, raisin, dried foods, eggs, dark
green leafy vegetables, organ meat, whole grain)

ANEMIA:
Signs = fatigue, muscle weakness, pale, pallor, weakness, pale, pallor, loss of apetite, poor concentration,
tachycardia, hypotension

DIAGNOSTIC: Decrease RBC, Low Hgb, Low Hct, Low serum iron (IDA)

INTERVENTIONS: ACTIVITY INTOLERANCE

1. Adequate rest period
2. Balanced rest and activity (after every intervention, rest)
3. Energy conserving measures
 4. Assist in ADL

INEFFECTIVE TISSUE PERFUSION

1. Administer o2 therapy
2. Blood products, packed RBC
3. Blood transfusion
4. IV fluid therapy
5. Folic acid

POLYCYTHEMIA VERA
- Increase production of RBC
- DIAGNOSTIC: blood test = >6M RBC,
- CAUSE: unknown,
- CLINICAL SIGNS: Ruddy/reddish skin, reddish purple lips, petechiae, bruises, paresthesia, splenomegaly,
hepatomegaly, Erythromelalgia (red and pain in hands and feet)
- Others: headache, dizziness, vertigo, epistaxis, tinnitus

- COMPLICATIONS: hypercoagulability,
- NSG. DIAGNOSIS:
1. INEFFECTIVE TISSUE PERFUSION
- MANAGEMENT: Phlebotomy (500 mL/every other day) - mainstay treatment
- Prevent coagulation = adequate hydration (at least 3L fluids to dilute hypercoagulation of blood),
high OFI, hydration
- High caloric, high protein diet
- Bed rest
- Avoid iron supplements
- MEDS:
- Antineoplastic (stops RBC production in bone marrow)
- Radiation therapy (stops RBC production in marrow)
- Radioactive phosphorus

THROMBOCYTOPENIA
- Decrease in platelet count (80, 000???)
- Normal platelet count: 150,000 - 400,000
- CAUSE: sepsis (infection on the bone)
- Petechiae (pinpoint dot - may indicate low platelet), ecchymosis (bruising), bleeding tendencies
(platelet is responsible for blood clot)
- Usually in back of hipbone (pelvis) for bone marrow extraction
- NSG. INTERVENTIONS:
1. Risk for bleeding: careful handling, assist in turning, getting out of bed, Vit K (dark green leafy vegies),
fluid balance
- AVOID: physical activities, vigorous exercise, weight lifting, forceful blow nose, bowel straining,
aspirin (promotes bleeding), hard-bristle toothbrush, use of blades
2. RISK FOR INJURY: Plasmapheresis (remove autoantibodies) is the most commonly used treatment
modality, platelet transfusion (prevent , platelet transfusion, splenectomy (remove spleen),
- MEDS: (not sure yet, sir will check again)

THROMBOCYTHEMIA
- Thrombocytosis: stem cell disorder within the bone marrow characterized by marked increase in
platelet production (>600,000/mm3)
- DIAGNOSIS: increase platelet, WBC, RBC; bone marrow analysis (increase precursor megakaryote;
ginagawa bago magawa platelet)
- CAUSE: hereditary, smoking, peripheral vascular disease, atherosclerosis,
thromboticevents
- COMPLICATION: Thrombotic event (visual change, numb, tingling, weakness)

- SYMPTOM: hemorrhage (>1M/mm3), bleeding tendency, headache, erythromelalgia (pain and red
hand and feet)
- AFFECTED EXTREMITY: painful burn, redness, warmth, numbness, tingling

- NSG. INTERVENTIONS:
1. RISK FOR BLEEDING:
- Low-dose aspirin (relieve headache, erythromelalgia, and thrombotic events) > Interferon
alfa 2b (for infection, to prevent)
- Hydroxyurea (chemotherapy owers platelet count) < platelet pheresis (machine to reduce
circulating platelets)

HEMOPHILIA
- Bleeding disorder caused by lack/absent/deficiency of clotting
- Mas grabe sa thrombocythemia and thrombocytopenia, even pingpong ball can cause bleeding
- VII (Type A), and IX (Type B; Christmas factor)
- DIAGNOSIS: Prolong Partial Thromboplastin (PTT)
- CAUSE: Hereditary (defective h. Gene), minor surgery
- SYMPTOM: Bleeding (main sign), ecchymosis, hemarthrosis (bleeding into the joint), melaena
(black tarry stool)
- Before surgery, give anti-bleeding meds

- COMPLICATION: Intracranial Hemorrhage (major, most common)

- NSG. THERAPEUTICS:
1. Risk for bleeding: ice compress (vasoconstrict), safe home environment, fresh frozen plasma,
cryoprecipitate, blood products, clotting factors (8 & 9) replacement
- AVOID: razor, aspirin, skin cut, contact sport, physical activity, chores, sharps
- MEDS: antifibrinolytic (Tranexamic acid, aminocaproic acid) promotes clotting stability
- Fibrin one of components for blood clot (lytic means nega)

VON WILLEBRAND
- Common bleeding disorder caused by deficiency of vW factor (essential for factor VIII and for
platelet adhesion during vascular injury)
- DIAGNOSIS: prolong partial thromboplastin time (PTT), normal platelet count
- SYMPTOM: excess bleeding (main sign), nose bleeding, heavy mense
- CAUSE: hereditary
- NSG. THERAPEUTICS:
1. RISK FOR BLEEDING: cryoprecipitate (factor 8, fibrinogen), fresh frozen plasma (factor 13), vasopressin
(desmopressin) prevents bleeding, limit dental and surgical procedures
DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
- Fatal condition due to: (1) over-action of coagulation and fibrinolytic pathway; (2) alternate
bleeding (hemorrhagic) & clotting (thrombotic)
- DIAGNOSIS: high D dimer (confirmatory), high PT, PTT, TT, low platelet, fibrinogen
- CAUSE: burns, leukemia, cancer, P. Vera, shock, sepsis, hepatic disease, transfusion reaction/ BT
rejection, cytotoxic treatment

- COMPLICATION: renal impairment ( low UO), organ necrosis/infarction

- SIGNS: Purpura (first sign), petechiae, bleeding tendency, low bp, high PR, oliguria (less than 500 mL),
P. Embolism (severe chest pain, DOB), P. Ileus (severe abdominal pain)

- NSG> THERAPEUTICS:
- Administer whole blood products (PRBC, platelet, fresh, frozen plasma)
- Cryoprecipitate
- Avoid venipuncture
- Anticoagulant (antithrombin and aminocaproic acid), Heparin (for bleeding episodes)