Thallium Imaging

THALLIUM IMAGING is a very simple procedure. It is done in a resting state or after stress. The purpose of this is to know the extent of MI, also to evaluate the patency of the graft after surgery. It needs consent, and check for allergies.

The Thallium is injected to the body. 10 minutes later take a look at the heart under fluoroscopy for the areas. The thallium should be taken up by all the blood vessels. The areas of thallium which is not taken up appear a white spot and that is the area of infarcts.

CABG- Coronary Artery Bypass Graft. What we do is bypassing the occlusion of the coronary artery so they’ll do a thallium test after wards to make sure that the area that previously showed as a white spot no longer shows as a white spot.

CVP monitoring

A catheter is inserted to the right atrium of the heart to determine fluid balance. The normal functioning of the heart, all the fluids that come to the heart is pump out from the heart.

If it does not happen you’ll have Congestive Heart Failure. We try to figure out how the heart handles the volume of blood coming in.
The measuring point of the CVP is in the right atrium. What you should do is level up the right atrium with the manometer. Make sure that the manometer is the same level with the right atrium. Use a lever to balance it out.

NCLEX Q – Patient with CVP if the head of the bed is adjusted you have to adjust the manometer otherwise you will get a false reading.
Normal CVP reading 5-10 cm H20. More than 10cm is indicative of overload. Less than 5cm patient is dry or dehydrated.

Always check the level of the manometer. Check the insertion site of the catheter for bleeding and other complication like pneumothorax or hemothorax. Signs and symptoms is shortness of breath.

Cardiac catheter

CARDIAC CATHETER Is done to visualize the left side of the heart. It is an invasive procedure, needs consent, uses radio opaque dye. Doctor will obtain the consent. Nurses are just witnessing the signature.
The purpose is to look and blood supply of the heart if there are any anomalies.
The catheter is inserted in the femoral artery mostly but sometimes in the brachial all the way up into the heart passing through the abdominal and thoracic cavity. It is going to the artery. What artery is doing a whole lot? It loves to bleed.
NSG CARE:
In ER - If patient came in reporting of chest pain immediately hook up the cath. Don’t care if he is NPO or not. It is an emergency procedure now.
PRE:
In NCLEX – NPO 6 hours before the procedure.
• Check for allergies (shellfish and seafood)
• Check medication allergies
• Check if on anticoagulant therapy. Heparin is usually stop 1 day before the Coumadin 5-7 days. But still up to the doctor.
• Check baseline ECG, lab work
POST:
• compare the result to the base line
• Keep the leg straight for 6-8 hours after the procedure
• Apply pressure to the site, remember it’s an artery
• Watch allergic reaction. Rationale: reaction occur later
• Patient on bed rest 6-8 hours and head of the bed flat. The most you can raise the bed is 30 degrees.
• Force fluids. Rationale: to get rid of the dye.

Holter monitor

It records the electrical activity of the heart for 24 hours or longer as the patient is doing his routine. It is not an invasive procedure. It does not need signed consent. We simply use it because the ECG when the patient comes in, the ECG may or may not pick up the problem.

EKG is a very good tool because it records the electrical activity of the heart. The downside of it unless the problems occur like right now it will not get it or capture it. Halter Monitor also use to evaluate whether the medication like anti-arrythmic drugs is working or not. We also put the patient on H.M. who just recovered form MI to know if the medication is working.

Holter Monitor is benign, with patches like EKG, a machine like the size of a tape recorder. Nurses must tell the patient that it is important that is she/he will not take a shower while she has the H.M on. It is very important also that she will have a log or a little book. In this book she has to log down everything that she does while she has H.M. on. Like for example:
6 am – woke up, 6:30am – took a dump
6:35 am brush my teeth

You need to explain to the patient why is using H.M. Explain what the uses are and tell her not to use electrical blanket while on H.M. Rationale: it will look like the patient has a huge defib for 8 hours.

If patient sees the light comes on in the monitor/ machine or tape recorder what she needs to do is just push each electrodes right in the center because it just means something is loose.

We can detect also the causes sometimes. Let’s say she documents 6:45am taking a dump and you see 6:45am there’s a slowing of the heart, guess what she was doing?... Valsalva manuever. Bowel straining. What happen when you really strain? You are doing valsalva manuever and it slows the heart down.

Remember the vagus nerve. It slows the heart. 7am – brushing hair. Then the heart slows down guess what she does? She is also doing valsalva manuerver. If you raise your hand over your head you tend to hold your breath a little bit then when you are brushing your hair that too is valsalva manuever.

In fact, where is most MI happens? At home right? Where exactly what room in the home? In the bathroom! And what activity? Taking a shower, washing their hair that’s where most MI occurs.

NSG CARE:
PRE: teach about it. Should wear a loose shirt with buttons up the front. Rationanale: if you use sweater on then when you got wet it is uncomfortable to take it out. Avoid magnet or electrical blanket
POST: remove all the electrodes wrap up the H.M. And bring it back along with the book.

Action of calcitonin

Calcitonin is a hormone that produced by a thryroid that takes the calcium from your blood and put it into the bones. So if you get too much calcium or hypercalcemia that sits in your blood you take the calcium and put it on the bones. That is the action of calcitonin.

Sucralfate or Mylanta first?

If you are to give Sucralfate and Mylanta at the same time, it is confusing which one is given first.
Sucralfate does not coats the stomach. It coats the area of ulceration and it helps the area of ulceration to heal, it does not attach to the intact membranes of the gastric cavity. It only attaches to the area that has ulcer. So you always give the Sucralfate first so it can attach to the area, if you give Mylanta first- Mylanta coats everything. So if you give Mylanta first and then give the Sucralfate there is no point is there?

How Kidney failure cause hypocalcemia

The glomerulus in the kidneys have a nice membrane that generally does not permit calcium to go through what happento kidney failure, the glomerular pores get large and calcium can get through and loss it.

Normally you don’t loss a lot of calcium through the urine because the filter is intact and the membranes are intact. The glumerulus however in Renal Failure you get to end up getting holes and membranes permits a lot of calcium to go through.

The funny thing here is that because of selective filtration while it permits a large molecule of calcium to go through it does not allow the small Potassium to go through. Remember that everything in our body is selective filtration, it permits this to go through and not that to go through.

Calcium helps the heart to work

CALCUIM normal level is 8.5-10. We need calcium for bone and teeth formation. We also must have calcium for blood coagulation. If we do not have calcium we will die. The bottom line here “we will die”. I am not kidding. Calcium is used for blood coagulation if we don’t have calcium we will not clot.

Another form that calcium is very important is muscle contraction. If we don’t have calcium we will die as I said before because our muscle will not contract nerve impulses will not occur. We will die.

How the calcium helps the heart to work? In our heart we have a fiber known as actin-myosin fiber (they live one top to the other). The filament theory they slide one top to another that is why every time it happens that’s the time the heart contracts.

However, in order for the actin-myosin fiber to slide one another and the heart to contract we must have a molecule of calcium that floats through that stimulate the contraction. If we do not have the molecule of calcium floating through we don’t get the neural impulse, we don’t get the heart to contract. We will die. Very simple.

Enteral feeding nursing responsibilities

ENTERAL NUTRITION

Purpose of enteral nutrition is to supplement the oral intake not to take the place of but to supplement the oral intake and to help provide total nutritional support. There are a lot of nursing responsibilities that we should do with this one.

1.Use small bore tube when giving NGT use 10 french or less
2.Check the pH of the gastric contents
3.Check tube placement.

a. X-ray – is the best or indication for tube placement especially if using Levine tube that has little mercury at the end.

b. Aspirate the content and check the pH and put back the aspirate.
c. Inject air and auscultate over the gastric area for sounds of the air you just put in.

4.Administer tube feeding at room temperature. Rationale: too cold will cause hypothermic shock.

5.Do not give the food that is hung more than 4 hours. Rationale: it gets sour and the stool will cause sour smell.

6.If the patient is to have 60 cc per hour you just hang 240cc.

7.If patient is in continuous feeding you hang it for 4 hours if it is consumed monitor residual. If the residual is more than 100cc-150cc it indicates delayed gastric emptying and you need to tell the doctor about it.

8.If patient is on feeding every 4 hours then it is not consumed you give some more you just check the residual and also check the pump if on continuous pump feeding.

9.During the feeding position the head of the bed should be elevated 30 degrees and until 1 hour after. If the patient is on continuous feeding the bed elevation should stay on 30 degrees.

10.Feeding set should be changed every 24 hours.

11.Check residual every 4 hours and rinse the bag out. Rationale: you don’t want the ensure or osmolite that is in to sour up.

12.If the patient has 6-tube either gastrostomy or jejustomy tube you need to skin skin around for signs and symptoms of infection.

13.Do not mix medications with enteral feeding. You crush the medication, diluted in warm water.

14.When to flash the tube? NCLEX Question

• Before and after every medication administration
• Before and after change of tube feeding.
• After checking for residual volume
• Every 4 hours during continuous feeding.
Rationale: by flashing the tube you maintain the patency of the tube.

15.Give the patient water. Rationale : because the tube feeding is hyperosmolites or thick, it pulls fluid out of the cells and dehydrate the patient that will to kidney failure. The blood becomes viscous and fluid with sugar, so it is important to give patient water.

Low residue Diet

LOW RESIDUE DIET - is given for colon, perineal and rectal surgery prep before and after. The purpose is to decrease the pressure of the operative site. (NCLEX question). If the patient is given high residue diet there is a lot of residue sitting in the intestine causing pressure on the operative site. During post op low residue diet is given to decrease the pressure on that site and it is also used for prep before doing rectal or colon visualization. There will be less residue sitting in the bowel to visualize the bowel a lot better.

It is also used for Crohn’s and Ulcerative Disease both will have 20-50x bowels a day. So to promote or increase absorption of nutrients Low residue diet is needed because the residue sitting a little longer and pass slower in the small intestine where more absorption occurs. Patient should avoid high fiber food like nuts, seeds, food with skin, milk and milk products.

Purine Diet

PURINE DIET – is used for gout, increased uric acid and kidney stones. The purpose of it is to decrease the amount of purine. Purine is the precursor of uric acid. Purine is found in lobster, organ meats, lintels, dry peas, nuts, oat meals and whole wheat. We should do health teachings to them and avoid the food stated above.

PKU DIET

PKU DIET – The purpose of this diet is control the intake of Phenylalanine. Phenylalanine is found in nutri-sweet products like diet soda. It is one example of NCLEX question. Food that needs to be avoided: bread, meat, poultry products, legumes, cheese nuts, and eggs.All babies born should have PKU test. It is mandated that all babies should have Newborn Screening and that includes PKU. Babies should not leave in the hospital with out the result usually 24-48 hours after.

If the baby is positive for PKU he/she should on PKU diet until 6 years old otherwise if not having that diet it could cause mental retardation. They can be given with Lofenalac drugs it will help. We should teach the family to use low protein flour and avoid all nutri-sweet products.

GLUTEN-FREE DIET

GLUTEN-FREE DIET – It is the diet for patients who have Celiac Disease. What happens in this is there is inability to digest gluten. It is our responsibility as nurses to teach them to avoid things that contain gluten. Gluten is a protein that can’t be digested by the body. They need to avoid food like barley, rye, oats and wheat (BROW). Bread is okay unless it is made of corn, rice or soya or flour. Nursing interventions: we should teach the patient to read all the labels of prepared food. We might be over powered how many food contains gluten because we use gluten as a filler.

Diabetic Diet

There are many people around the globe who are diabetic. It is really necessary to know about their diet.

DIABETIC DIET – The purpose of it is to maintain the normal ideal body weight and to get that plasma glucose level close to normal as possible. According to the ADA (American diet Association) come up with little change in this. This one maintains normal plasma glucose level. The reality of getting it close normal is impossible with diabetes. What the ADA recommends now is not normal but steady. We don’t want 110 today and 300 tomorrow. Steady if it end up 150, 160 but steady is much better than 110 today and 180 tomorrow.

The principle is to avoid sweets, avoid food high in simple sugars like jams, jelly, and cakes, cream, cookies and pies.
Complex carbohydrates like rice, pasta, bread are good but cake is not good. As nurses it is our responsibility to teach diabetic patients to use he exchange list (the normal to make their lives the more compliant they will be).

FAT SOLUBLE VITAMINS

FAT SOLUBLE VITAMINS
Small amounts of vitamins A, D, E and K are needed to maintain good health. Foods that contain these vitamins will not lose them when cooked.

VITAMIN A - also known as Retinol. It is found in carrots, green and yellow vegetables, milk, butter, cheese and fortified margarine, according to Feuer margarine is only one molecule away from plastic, it also contain in fish liver oil.

Vitamin A is necessary for the sight specifically “night sight” to see things at night. It is also needed for the maintenance of epithelial tissue and for the basic growth of the body and bone development. Vitamin C and vitamin A is very important for the matrix. If you are deficit of it you will have night blindness, bones and teeth do not develop properly.

VITAMIN K – It is important for clotting mechanism. It is found green leafy vegetables, alfalfa, cabbage and in liver. It has a major body function in blood clotting mechanism. If you have not vitamin K you will have prolong clotting time or bleeding tendencies.

Vitamin K is made in the intestines and made by the bacteria that lives in the intestines that is why we give vitamin K when babies are born because their bowels are sterile, don't have the bacteria in the bowel yet to make vitamin K.

VITAMIN C

VITAMIC C - before many years ago as nursing students we were taught that it can only be found in oranges and grape fruits but now it is found in peppers, broccoli, and strawberries. If you do not have Vitamin C, you are in trouble because it is very essential for the maintenance of the matrix of our cartilage maintenance of bones and dentine.

It is very important for the collagen synthesis and wound healing. Matrix according to Feuer it is the surrounding, we are the matrix of air and nitrogen. It means that before our body can sit together or fit together we got to have vitamin C, before our wound can heal we got to have vitamin C.

VITAMIN B COMPLEX

All of the B Vitamins are water soluble with exception of Vitamins B6 and B12.

VIT. B1 (Thiamine) is found in meat and meat products. Thiamine is found in pork, organ meat, beans legumes, cereal and nuts. It is essential for good neurological functioning. It is also important in respiratory cycle in the removal of carbon dioxide. If it is deficit it can cause : Beri-beri- it occurs due to starvation in peripheral nerve. A Patient becomes less sensitive of their peripheral part on their fingers and toes or can be hypersensitive or hyposensitive. It cause Edema and in sever cases it will lead to heart failure.

VITAMIN B2 (Riboflavin) is a more friendly vitamin. It is more friendly because it can be found in pretty everything that we eat. For example it is found in big Mac. So when you are teased by eating big mac you can make an excuse that you are needing Vitamin B2. Isn’t it great? This vitamin involve in energy metabolism. So if you have no energy or feeling slow you need this vitamins or vitamin B complex. If it is deficit you will have lip crack, white face and red lips in (child) she may look very cute with those red lips but it is already a manifestation of vitamin B2 insufficiency, eye lesions, or lots of sties. If you are nurse working in a nursing home if you observe that the residents are starting to have crack in their mouth or sties in their eyes, recommended to the doctor to prescribed vitamin B2 or B supplement.

VITAMIN B6 (Pyridoxine) is found in meat, vegetables and whole grains. It is very important in metabolisms of amino acid and glycogen.
Amino Acid – is a protein, a foundation or a building block of muscles, the protein molecule.

Glycogen - is the energy stored in the liver. 300 grams of glycogen stored in the liver. To understand this more here is a scenario. If you are running the first hour or 30 minutes your body is using all the sugars that is stored in your blood. Once it is already consumed the body will now use your glycogen that is stored in your liver. Then once it is dissipated it breaks to fats and so on. So, if you do not have Vitamin B6 your glycogen stored will never get replenished or never get replaced. If Vitamin B6 is deficit it can cause irritability and convulsions, muscle twisting, dermatitis and kidney stones. Have you ever experience being irritable when you are hungry? I guess you do because it spares no one.

VITAMIN B12 - is found in meat, eggs, and dairy products. Vitamin B complex is expensive because they are primarily found in meat. But only one found in legumes that is why Vitamin B problems are more prevalent on the third world country due to starvation. It is very important for the formation of maturation of RBC and synthesis of RNA and DNA. It very expensive both to get in to our body and it is very expensive if we loss it we can’t replicate. Our entire body changes every six months to one year. If we have no Vitamin B12 our cells will die and it can’t be replaced it will result to pernicious anemia and nuerological diseases.

There are two ways of being Vitamin B12 deficient. It is by not eating enough or lack of intrinsic factor. If there is no intrinsic factor, no matter how much you eat you won’t get it. You need to have a vitamin B12 shots for the rest of your life. * This is an NCLEX question.

ABOUT VITAMINS

We now talk about Vitamins. This does not sound very interesting but as nurses we really need to know what vitamins our patients are lacking. If you have no idea with these how can you do health teachings? There are 2 aspects of Vitamins, the water soluble vitamins and fat soluble vitamins. Water soluble vitamins are not stored in the body. They are readily excreted in urine and must be replaced each day. While the fat soluble vitamins are absorbed through the intestinal tract with the help of lipids or fats. In humans there are 13 vitamins: 4 fat-soluble (A, D, E and K) and 9 water-soluble (8 B vitamins and vitamin C).

Contact Isolation

CONTACT ISOLATION – this is prevention of diseases transmission through skin to skin contact. The nurse who are caring for these patients should use gloves upon entering the room. There is no need to use mask or gown. Then remove the gloves and wash hands before leaving the room.

Good handwashing

GOOD HANDWASHING is the best preventive method of transmitting diseases. A nurse should be experts on this and know how to use gloves and change gloves appropriately.

Just like when opening patient’s door, you enter the room, before you touch or care for the patient you should wash your hands. Then put on your gloves and you take care of the patient. After doing all the nursing care necessary you should change your gloves while you are still in the room. Then wash your hands before you exit.

Do it all over again in caring for other patients. This is so simple yet very effective in prevention of transmitting diseases but I am so sad to know that most nurses forgot this. As good nurse we should already master this very basic procedure.

Airborne Transmission Precaution

It is the prevention of the transmission of small particle residue 5 micron or smaller. It can be prevented by using a mask. You have to remember that even you are more than 3 feet away from the patient you still can get it.

Airborne diseases like meningitis, Tuberculosis, and chicken pox are spread when droplets of pathogens are expelled into the air due to coughing, sneezing or talking. Patients with airborne diseases should be isolated and not to be shared with other patients in the room.

The equipment should be used exclusively for the particular patient. Use particulate filter mask when you are caring for a TB patients. You wear a mask if you are 3 feet away from the patient but if you are just opening the patient’s room no need to wear a mask. But all the visitors should wear mask even they only plan to be 3 feet away from the patient. It is not reliable, the tend to forget it.