Returning after a New Phase After gaining a measure of competence in the ICU setting, I have leaped into teaching for the Buffalo Public School District. It seems this has become a personal space for posting about the transitions in a relatively transitive career. I am not sure of why I thought this would be an appropriate path; and find myself wondering today, whether upon later retrospection I will find this was a wholesome and satisfying occupation. Do my daily actions contribute to the benefit or detriment of future generations? I must suspend judgement until completing the first year of teaching, for I need that perspective to see if there were any discernible student improvement.  ¶ 12:32 PM 0 comments

  Critical Care Orientation 4NURSES is my project. None other actually became part of the team for this blog. There are however, some new grads in the "SI," where I now work, which I might enlist in a collaborative discourse on nursing and growth in the profession. The corporate and site specific orientations are over and I have had two days on the floor, and my impression rings true that this is simply the "same job, different place;" however, I am now a critical care initiate, and, while I can rely on all the med-surg experience that I have gained, my clinical ignorance is sorely smarting. I am a hemodynamic novice, green to the patients I am greeted by, fearful that my preceptors will assume me to be more advanced in my understanding and relax so as to allow me to make a potentially mortal mistake, and more. I wonder some that things are not more rigorous, but I have two preceptors and perhaps I am first with the instinctual thinker.

As for the patients, first yesterday, a terminally morbid man, who I gloss over. Today I had a man who hautily held back from any physician for most of his life, then presented with a ten year history of CP & SOB; yet this wasn't his motivation for going to see a doctor. No, he had an ear ache, which rallying after a fifty year holiday, had him seek out his primary and then a specialist, who noticed that tumor growing under his Rt Jaw (perhaps the oral hyperplasias too)--the man was an inveterate tobacconist--by trade however, he was an "inspector" for a car dealership, when he was forced into disability by being "T-boned" by a truck which struck his vehicle--squeaked by that one with only some back and rotator cuff disintegrations. In any case, when intended to do chemo and radiation, they found him to have severe CAD and the decade of doleful dolore, he was sent for a quintuple bypass. I find him the second day after this. Not to mention that he has a PEG for the eventuality of esophageal swelling, and a recent history of stroke, without major residual, but with multiple TIAs that, because ignored, went undiagnosed. Notwithstanding all this, he progressed without complications today, and advanced through a perfect second morning.

Labels: heart, hemodynamic, ignorance, inspector, new job, orientation, t-boned

  ¶ 10:32 PM 0 comments

  Written Warning--Insubordination Last night, I was delt a disciplinary admonition for my conduct one night last week on our floor. Rather than utilizing the chain of command, i.e., apprising the CN of the situation, and allowing her to deal with supervision, which if unsuccessful, I should have then proceeded to contact the NM, I asserted my unwillingness to immediately accept an assignment without delay on the grounds of policy. Moreover, when the NS appeared in obvious consternation and disbelief that an assignment was so delayed, I confronted him with the policy, but our conversation quickly devolved into assignation of blame, a refusal on my part to comply and his part to compromise, and various other verbal and non-verbal indications of animosity. It recalls the line from Bartleby the Scrivener, where the argument between Adam and Colt would not have murderously ended had there been more domestic associations in the office; hence another reason for maintaining the 4N Beautification Committee. Be that as it may, I agreed that utilization of a chain of command was more appropriate, but the outcomes are still limited, for resolution will obtain, either in:

• an effective dialogue and compromise, to varying degrees
  
• submission to dictate
• insubordination
• or surreptition by contacting a more superior authority (contacting NM, NVP, etc.)

  ¶ 6:51 PM 0 comments

  SiCKO It may seem trite and full of affect, but seeing this movie for the second time has me realizing that the work that I do was taken up for prosocial purposes, and that the absence of an ostensible contribution to the community is the source of my current discontents on our floor. I've lost sight of the forest for the trees, and even lost sight of the trees for my habitual ways of looking and doing through my shifts. Heretofore, I have been mocked for inquiring into the socio-economic status of my patients; but rather than giving some smug and self-serving answer (while laughing at the absurdity of the situation), like 'it helps me know how to deliver care to this particular person,' I should have been preaching the injustices of the health care system, and the burdens placed on our patients by preposterous and ultimately pecuniary purposes. "See here," I ought to continue, "the frail elderly removed from her home due to insolvency caused by her infirmities; do we not all care for the happiness of our elders, sick, and poor?" It does well to remind ourselves that 'It may seem strange that some of us should ring our bread from the sweat of another man's brow; but judge not that ye be not judged.' From big pharma to every orderly, we should be a conscientious nation--'saving lives, one bedpan at a time.' If there is little preventative medicine in this country, who better to provide that information than the educative nurse? If the nurse is prevented during her work day, then either she has to give more, or the system needs be more resourceful. Our hospital was notoriously in the black last year. Improvements were made, valuable ones, but there are purer purposes, i.e., ones emphasizing material patient benefit, rather than ones improving efficiency, security of information, and thorough documentation. I am almost prompted to return to school for this one, but that may not be my place, since even grassroots efforts may be effective. I simply must beware of the all too common "blatant benevolence and conspicuous consumption." I do not want to be the man by whom these offenses come. So here we have a resumption of greater conscientiousness in my practice.

Christopher.  ¶ 9:15 AM 0 comments

  Hemodynamic Concepts Hello to all, and thanks to anyone who continues to periodically check in to see whats going on. Finally, after turbulent personal times, I have the leisure to provide another posting.

I have made an outline of the module Hemodynamic Concepts which will be useful for all of us studying for the certification exam. If you would like a copy, please feel free to email me. Further, since I aspire to a versification of my knowledge of Myocardial Infarction; I thought I'd post a sonnet that composes part of that larger poem.

What helps in making a diagnosis?
History of atherosclerosis?
For which think “CADDISH” with CAD risk:
Increased CHOLESTEROL might make life brisk;
So AGE grown old and your face grown haggard;
DISUSE, loiter, sloth, overmuch laggard;
And DIABETES, kills by confection;
Chlamydia pneumonia INFECTION;
The SMOKER’s toxic and anoxic breath;
HYPERTENSION, lastly, or silent death.
This list leaves homocysteinemia,
But that’s the MD’s academia.
All this the world well knows; yet now better,
Since rhyme and acrostic fix each letter.


Christopher  ¶ 11:13 PM 0 comments

  Hyperkalemia I was perusing my ACLS handbook yesterday and realized that my ever operating optics spied another mnemonic in the treatments for hyperkalemia in an emergent situation. Before that we should briefly remember that the symptomatology of hyperkalemia is either cardiac, which is the most important and most frequent manifestation, or neuromuscular.

The cardiac Sx:

• Peaked T waves
• Flattened P waves
• Prolonged P-Q intervals
• Widened QRS complexes
• U waves
  
• VF
• Arrest

The neuromuscular Sx:

• Numbness
• Weakness
• Flaccid paralysis

Now, what should be done if we see these things and have hyperkalemia verified by serology? Beyond assessing prior labs, pertinent history and the previous two days I & Os, we will want to recall KALEMIA, and be prepared to administer the following:

• K-Kayexalate: 15-50g PO/PR plus sorbitol
  
• A-Amp of NaHCO3: repeat bolus in 15 minutes; then IV over next 1-2 hrs.
  
• L-Lasix: 40-80 mg bolus
  
• E-Emergency Hemodialysis/Peritoneal dialysis
  
• M-Memebrane effects (of K+) antagonised by CaCl: 5-10ml IV 10% solution (500-1000mg)
  
• I-Insulin & glucose (2unit:5g ratio) 1st bolus; then consider IV infusions
  
• A-Albuterol nebs: 10-20 mg over 15 minutes; may repeat

* Redistribution effect: facilitate intracellular shifting
** Removal: eliminate from body
*** Antagonism of toxic effects of hyperkalemia at cell membrane

Your colleague,
Christopher
  ¶ 7:10 PM 0 comments

  Adverse Reactions: Digoxin For lack of anything sexed up, I thought I'd present something more meat 'n' potatoes; i.e., mnemonics. I make these things all the time, its how I study, so if you find them tedious, well, go ahead and post something else.

The adverse reactions of digoxin are few, but made a good mnemonic. Digibind is the antidote to digoxin; so if your adverse reactions are severe, or your serum dig levels are high, not only may Digibind be indicated, but you may see DIGIBIND:

• D-delirium/depression/dizziness
• I-intestinal upsets: anorexia/diarrhea (and N/V vide infra)
  
• G-green vision
  
• I-impared platelets i.e., thrombocytopenia (rare)
  
• B-bradycardia, blocks 1st, 2nd, 3rd degree
  
• I-irregular HR: including palpitations, sinus arrhythmia to sinus arrest, ventricular ectopy, and even paradoxical tachycardia
  
• N-nausea and vomiting
  
• D-dermatological rash

So remember DIGIBIND; anecdotally, I remember an old, old woman presenting with Dig Toxicity who was tachycardic in the 110-20 range with a summation gallop. This woman was delirious on top of her dementia, with anorexia, GI distress, and curiously tremors, not related to temperature. I believe she did end up receiving digibind. Any body have any information on the summation gallop or its etiology?

Your Colleague,
Christopher.  ¶ 4:59 PM 0 comments

  More Museful Mnemonics Hello everybody. I really do love mnemonics, so here's a new one for all of us studying for PCCN certification. What is the best, but most underprescribed, class of drugs for heart failure?? ACE inhibitors of course. According to Woods et al. in their Cardiac Nursing Textbook, "These agents are the only drugs used in the treatment of chronic HF that have been shown both to improve symptoms and prolong life." To this day, I cannot understand why my grandmother, the typical class III CHFer, has not been taking these drugs; she and others like her should take them like vitamins. Rather, these patients are simply prescribed more and more diuretics, with more and more renal impairment. So any way, if you can remember PACE for ACE inhibitor, then you've got a good start.

For the species of the ACE inhibitor family: PACE

• P-Prinivil/Zestril = lisinopril
  
• A-Accupril = quinapril
  
• C-captopril = Capoten
  
• E-enalapril = Vasotec

For the pharmacology of the class: PACE

• P-preload decrease by venodilation; or potassium levels up (both total body and circulating levels)
  
• A-afterload decrease by blocked angiotensin II
  
• C-circulation of catecholamines down; or complexity and frequency of of ventricular arrhythmias down
  
• E-enuresis (i.e., diuresis) by decreased aldosterone

For the adverse reactions: PACE INH-ibitor

• P-potassium levels high
  
• A-angioedema/aches (musculoskeletal)
  
• C-cough/congenital malformations (esp. in 1st trimester)
  
• E-elevated BUN/Creatinine
• I-insufficiency, renal
• N-neutropenia/nausea & vomiting
• H-hypotension/hepatotoxicity

Ta for now,
Christopher.  ¶ 2:44 PM 2 comments

  pharmacological fancy

How do you describe the coagulation cascade and anticoagulants to a non-medical Buffalonian? Well here's an amusing example:

Conceive an ice floe being carried down the Niagara; you see, clot coagulation is like ice condensation and confluence, and Coumadin and Heparin would then be two ways of preventing icebergs from being projected over the falls, which we may liken to a lesion, hemorrhaging or otherwise. Now, Coumadin indirectly prolongs coagulation time by deforming some vitamin K dependent clotting factors, which would be very like changing the crystic chemical compositon of the great Niagara by adding a saline substance in order to delay freezing; while, on the other hand, Heparin directly intercedes and dams off the coagulation cascade, much like lowering the ice boom in October to obstruct the brash from further navigation down stream. In other words, while Coumadin is slowly but surely modifying the chemical components (vitamin K) of the coagulation cascade, Heparin immediately stands between prothrombin and thrombin. Heparin is easily likened to reason, which would intercede for most when the urge to precipitate oneself by barrel over the falls swelled up (i.e., interceding before I thro[w]m[y]bin-over-the-falls). Further, in order for Coumadin=s powers to take effect, at least six hours and rather several days must pass until those clotting factors, which the drug is involved in the denaturation of, replace the original, unadulterated clotting factors, at which time Heparin will not be necessary.

Until the next,
Your most serious colleague,
Christopher.

  ¶ 11:04 AM 0 comments

  Update after Long Lapse I know some of you continue to stop in occasionally for the news; so you no longer have to be disappointed about not having any. The FTP server, which I spoke of before is indefinitely delayed because I don't have the tech savvy as of yet to carry through all the configurations, despite the almost universal declaration of the simplicity of the endeavour. In other matters, much enthusiasm and care has been aroused by the recent interest on our unit around the PCCN certification. While I didn't attend the review courses, I well understand the pride that this accreditation will bring us. Good luck probationers.

Here is a mnemonic I discovered in my studies of the pathogenesis of atherosclerotic lesions, for some of the most common risk factors thereto. Now you will easily incoporate these risk factors into your patient education.

"C-A-D-D-I-S-H" can stand for the risk factors for CAD or, in general, atherosclerosis.
Historical note: caddish means "of or like a cad; dishonorable; or ungentlemanly." This word comes out of the 18th century for an "ill-bred man, esp. one who behaves in a dishonorable or irresponsible way toward women."

• C-hyper-Cholesterolemia (generally dyslipidemia)
• A-Age
• D-Decreased activity
• D-Diabetes mellitus
• I-Infection (esp., chlymidia pneumoniae)
• S-Smoking
• H-Hypertension

More later, now parting, your colleague,
Christopher
  ¶ 7:26 PM 0 comments

  Keeping the A & B in ABC

Question: What's the RN's Responsibility with BiPAP/CPAP?

Import: The emphasis of our unit brings us into frequent contact with “noninvasive positive-pressure” ventilation. Recent nights and codes remind me of this. There was an article in Nursing2006, vol. 36, #5 p. 46-7, on this topic, from which much of the rest of this post is gleaned.

Fxn: improve gas exchange w/o intubation

Bilevel Positive Airway Pressure=df. 2 settings, higher on inspiration, than expiration. Can do full ventilation.

Continuous Positive Airway Pressure=df. 1 setting, same on insp. as on exp. (exhaling against pressure helps reexpand and stabilize the alveoli). Pt must be able to spontaneously breathe; cannot do full ventilation.

Whose Responsibility: RT initiates; RN educates, evaluates for, and monitors while on

And now for my newest mnemonic:

1^st and always assess mentition, vitals, ABCs, skin color (aura)

Then, what should also be noted on assessment and documented: “BiPAP”

• B breath sounds
• I inspired oxygen (FiO2)
• P pulse oximetry level
• A accessory muscle use
• P production of sputum (think ability to cough/clear secretions)

Commentary: If a recent and serious negative change has warranted placement of a patient on BiPAP for maintenance of oxygen saturation, then one wants to be particularly thorough AND PERSISTENT in assessments. This is a particularly precarious situation with potentially rapidly changing circumstances. If one has red flags going off, that things are not all well, then simply monitoring “as usual,” or less, not monitoring at all, is insufficient and negligent. This is time for Rapid Response; or you will be coding your patient.

Yours truly,
Christopher

P.S. The following link will take you to the AHRQ National Guideline Clearing House site for CPAP and BiPAP where you will find the practice parameters for the use of these devices to treat adult patients with sleep-related breathing disorders:
http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9076&nbr=&string=#s21

  ¶ 1:57 PM 1 comments

  Alittle Salt, Alittle Sage, Alittle Novel Direction

There is something new coming to our blog, an enhancement of our on-line endeavours. The next couple of weeks will find me setting up a personal FTP server in order that we may easily traffic documents amongst one another. It remains my intention, since the founding of this blog, to anchor the bulk of discussion around various readings of scientific and educational supplementation germane to the ken of telemetry and all nurses. Once I switch to DSL and establish a simple method for us all to retrieve files, we will have a convenient method of distributing reading materials. I had been reading "From Novice to Expert" by P. Benner, and unless anyone has a more apt offering, I will post her writings there for us to peruse. Once there, I'll update everyone; and we can fix on how to proceed.

In the meantime, have fun with this site; post often, post freely, post period.

Your colleague,
Christopher

  ¶ 12:14 AM 0 comments

  Bi-lateral Blood Pressures?? Just thought I would remind everyone that we are supposed to be documenting bilateral blood pressure comparisons on the admission assessment. "Two BPs!?!," you say. Well, yes; there are a few cardiovascular disease states that enter into the differential by a marked discrepancy in BP symmetry, say 20mmHg or more. I have a short mnemonic: "BP CUFF"

B - Birth defects (Congenital Heart Disease)
P - Periveral Vascular Disease
C - Coarctation of the Aorta
U - Unilateral Neuro/Muscular abnormalities
ff - Aortic Dissection (think of the "ff" as a pictogram for the aortic arch with a line through it; the line representing the dissection. Yes, I know, its a stretch.)

If anyone can improve on this, please do. This and the following bullets are from AACNs newsletter this month.

• Can't get a brachial BP, try a supine calf BP (just slightly higher reading), or a prone thigh.
• If you do a forearm BP, it should be at heart level (lower=higherBP; higher=lowerBP).
• If the cuff's too small (Higher BP) if too big (Lower BP)
• Avoid BP's over picc line sites; and only distal to a PIV

Farewell,
Christopher  ¶ 4:05 PM 0 comments

  Seminal Birthday Well, after a week into this noble enterprise, typing while prostrate on my porch, this summer solstice night, with my son crawling on my lap and we two hidden under a sheet-clad fortress, I am glad to announce that our membership is four persons strong and growing. I encourage you all to come online & post. Farewell.  ¶ 10:08 PM 0 comments

  Oxygen & COPD For those of you who couldn't make it to that recent inservice, I thought I would post a few highlights that I found particularly useful.

• Flowmeters: read the CENTER of the ball; i.e., the ball's horizontal diameter should intersect the tick-marks of the meter.
• If a pt's SpO2 drops or flow rate demands increase beyond previously prescribed parameters, then an MD should be notified, since pathology may underly.
• Nasal cannula on a mouth-breather gives adequate O2, as long as nares are patent, & SpO2 is appropriate.
• Approximate FIO2 levels (q1L=approx. 4% addn'l above RA)
  
• 1 lpm: 24%
• 2 lpm: 28%
• 3 lpm: 32%
• 4 lpm: 36%
• 5 lpm: 40%
• 6 lpm: 44%
• Ventimasks:
• don't cover air entrainment ports on adaptors (too much FIO2)
  
• don't use with humidification (too little FIO2)
• Pursed Lip Breathing:
• insp./exp. ratio of at least 1:2 (the longer exp. = the better O2 exchange)
• Hypoxic Drive Review:
• small % of COPD pts actually respire perforce of Hypoxic Drive
• thus, your patient could benefit from more O2
• If in doubt, get an ABG:
• If CO2 chronically continues to rise (>60mmHg), then consider Hypoxic Driver
• Then, only low PO2 levels (<55-60mmhg)>
• But the actual Hypoxic Drive occurs ONLY in pts who are BOTH hypoxic AND hypercarbic--("the 50/50 club")
• At this point low O2 flows (1-2 lpm) and careful monitoring are recommended.
• Qualifying for home O2: Pulse Oximetry must be done NO SOONER THAN 2 DAYS BEFORE DISCHARGE.

Your Colleague,
Christopher.  ¶ 4:05 PM 0 comments

  Th'Olde Art o'Hart Hearing On Cardiac Auscultation, much pared down

On review it seems that this outline is difficult to read; it was originally a presentation to be supplemented ex tempore. But I publish it anyways, as there are still nuggets and pearls in it and it can begin a thread on this subject. I'll make a few highlights in blue. Further, if you want some websites for heart sounds, see the comment I will post.

1. Why learn it?
1. Efficiency - around one minute per pt; with full patient load less than ten extra minutes
2. Vigilance (Early detection) – e.g. Aortic Dissection case (cf. Below @ S2)
3. Taste/Connoisseurship/Aesthetic development of the ear
4. Supremacy over the machine (as good a tool as ECG & XRay)
5. Listening qua listening is an invaluable life skill
6. Nursing Excellence: be no longer a medical minimus!
2. Method of Differentiating Heart Sounds.
1. Normal sounds
1. Ascertain S1 and S2 by one of three methods
1. if rate WNL then use "lub-dub" and longer space as diastole
2. if rate > 80 from base where S2 is louder, inch back to LLSB/Apex
3. or time with PMI pulsation or carotid pulsation (not peripherals)
2. Judge normality or abnormality of S1 & S2, esp. intensity and splitting
1. in S1 intensity is more informative
2. in S2 splitting is more informative (According to Harvey --mimicked by tapping of fingers)
3. Determine Hemodynamic rationale for sound
4. Differentiate etiology of sound
2. Extra Sounds/murmurs/etc.,
1. Ascertain “where & PQRST” of extra sound/murmur/etc., if any
2. Determine Hemodynamic rationale for sound
3. Differentiate etiology of sound
3. Normal Sounds
1. S1 =def. AV valve closure, Semilunar opening, & ejection of blood (to great vessels)
1. Semilunar valves usu. inaudible
2. Loudness, causes of:
1. Thickness of AV leaflets – leaflets like soft/hard cover books falling on hard surfaces
2. Separation of leaflets/valve position –
1. P-R intervals: in heart block, if short, leaves drop from on high; if long, then soft sounds because of time allowed for closure (1 deg. Block/Wenckebach/Rheumatic Fever)
1. NB: Wenckebach & progressive softening of S1
2. 3 deg. AV Block: SB w/ irreg., variable S1
2. AV pressure gradient (mitral stenosis) – separation of leaflets leaves longer distance for valve closure causing increased loudness
3. Rate of Rise in RV/LV pressure – (chiefly contractility affecting)
1. Fast = loud: hyperkinetic hearts (thyrotoxicosis, pregnancy, fever, AV fistulas, PDA, aortic regurgitation)
2. Slow = soft/muffled: CHF
2. S2 -- Said to be “Key to Auscultation of the Heart” (Leatham) & “ranks with electrocardiography and roentgenography as one of the most valuable routine screening test for heart disease.” (Mang. 211)
1. S2 =def. Closing of aortic (A2) and pulmonic (P2) valves (sudden deceleration of blood s/p closure of semilunar valves
1. Best heard @ pulmonic area since P2 can normally only be heard here (esp for splitting)
2. Can tell which is A2 during a split since normally only A2 is audible @ apex
1. If split @ apex then pulmonary hypertension (pathognomic until proven otherwise b/c P2 is abnormally loud); pulmonic hypertension also associated w/:
1. loud and palpable P2 @ pulmonic area
2. Rt sided (LLSB/epigastric) S4
3. pulmonic ejection sound
4. murmur of TV regurgitation
1. Loudness:
1. Increased Pulm./Systemic pressure = loud P2/A2
2. High-output states (e.g., AS defects, VS defects, thyrotoxicosis, aortic regurgitation) = loud
3. Tambour (deriv. French "Drum"
   1. usu. Dilatation of aortic root
   2. if w/ murmur of aortic regurgitation = Harvey’s Sign, as in Marfan syndrome, syphilis, or dissecting aneurysm of ascending aorta (w/ high diastolic pressures)
4. If soft (or even absent) then
1. low CO/low pressures in pulm./syst. circulation
2. reduced mobility of semilunar valves (calcific/sclerotic/stenotic)
2. Physiologic Splitting on inspiration d/t intrathoracic negative pressure gradients & pooling of blood in lungs; (I’ve only heard this w/ athletic habitus)
1. Remember!! Inspiration increases RV volume; Expiration Decreases RV and increases LV volumes
2. Best heard supine (lengthened split); sitting/standing will shorter
4. Pathological Extra Heart Sounds: consider pathological until proven otherwise
1. S3 =def. During rapid, passive filling phase (See Intracardiac pressure) in LV/RV, deceleration in rate of blood flow r/t either increased preload or poor compliance (i.e., poor contractility or low EF), and hence tension on ventricle and AV valve apparatus (usu. reflects ventricular filling pressure of >25mmHg)
1. absent if mitral stenosis, and vice versa (stenosis obstructs the rapid, passive diastolic filling)
2. at the threshold of audibility (40-50 Hz) & intensity changes w/ many variables;
1. high “index of suspicion” is needed in order to prompt aggressive search by maneuvers in pts with HF
2. gingerly allay the bell precisely @ the PMI!! Compress bell for disappearance and diagnosis of sound.
3. if pathologic, usu. lower freq. & gallop lilt
4. first clinical sign of CHF (changing position from sitting to supine may bring out, or with mild exercise as coughing or turning to Lt side or Hand grips)
1. If an S3, may predict excellent response to Digoxin.
2. Consider cardiac patients receiving parenteral fluids, who go into CHF; nurse might Dx situation by hearing this sound.
5. normal, physiologic S3 in kiddies, males<30,>45; may also occur during increased sympathetic tone and increased levels of catecholamines: tachycardia, thyrotoxicosis, anxiety, fever, anemia, pregnancy
2. S4 =def. During late active filling (“presystolic” or during “atrial kick”), increased rate of blood flow to ventricle and tension both on ventricle and AV valve apparatus (may note prominent, or notched P wave on ECG)
1. classically absent in AF & AFl
2. same as w/ S3: gingerly allay the bell @ PMI; if S4 is palpable, then definitely pathologic
3. intensified by maneuvers intensifying intracardiac blood volume and venous return: turn to Lt Lat decubitus position; Valsalva release, exhalation, Hand-Grip, leg raise
4. indicates hypertrophic, thickened, and poorly compliant ventricle
1. b/c of reduced passive diastolic filling, more of an atrial boost responds to fill the deficiency
1. as in HTN (may precede ECG evidence of LV hypertrophy)
2. aortic stenosis, coarctation of the aorta
3. hypertrophic cardiomyopathy
4. CHD (approx 90% of pts with MI)
5. prolonged P-R interval
3. S3/S4 are the substance of the descriptor “gallop”
1. S3 – ventricular gallop mnemonics:
   
1. KEN'-tuck-y;
   
2. SLOSH'-ing-in;
   
3. VENT'-ric-le;
   
4. s1---s2-s3
   
2. S4 – atrial gallop mnemonics:
   
1. Ten-ESS'-ee;
   
2. a-STIFF-wall;
   
3. a-TRI'-al;
   
4. s4-s1---s2;
   
3. quadruple rhythm and summation gallop – overlap on rate changes
1. I-can't--keep-up
2. s4-s1---s2-s3
1. in CHF & severe myocardial diseases
2. esp, in pts tacycardic c hypertensive heart failure
3. or in 1st deg. AV block, where prolonged PR interval causes s4 to move backward in diastole
1. Acrostic for the sounds near S2 that may confuse the Auscultator: P-L-O-P-P-S
1. Paradoxical Splitting (A2 is delayed until after P2 on exhalation) – (persistent on standing) LV dysfunction or acute decompensation: (volume/pressure loads on LV [aoritc stenosis, etc]); acute, unstable MI & Conduction defects)
2. Late Systolic Clicks – prolapse and backward ballooning of leaflets
   
3. Opening Snap (diastolic) – high pitched “sail suddenly filling under wind, with ballooning and bellowing and a final snap due to the tight grip of the chordae tendinae”
   1. consider also the opening sound of an atrial myxoma (i.e., a tumor plop) peculiar b/c of its intermittency and cycle to cycle variability of intensity
   1. tumours are pedunculated and attached to the atria by a stalk, and sometimes prolapse through the open valve
   2. pt may also have drops in BP and syncope s/p change in position d/c of transient obstruction of diastolic ventricular flow by the tumor
4. Pericardial Knock sharp, loud, medium to high pitched ventricular filling sound: a peculiar form of the S3 (caveat: if hearing a Gallop, this is more Zebra than Horse) r/t calcific constrictive pericarditis 2nd to old TB processes
5. Pulmonary Hypertension – abnormally intense S2 at the apex (distinguish from relative softening of S1, as in MI)
6. S3 =def. During rapid, passive filling phase in LV/RV, deceleration in rate of blood flow r/t either increased preload or poor compliance
4. Early systolic click (ejection sound) =def. the usu. inaudible component of S1: louder over base; consider indicative of semi-lunar valve or great vessel pathology unless proven otherwise
1. Differentiate origin A2/P2 and note intensity which in stenosis reflects mobility of the valve
1. softening of sounds in fibrosis and disappearance in calcification
2. if seeking P2, and increase in intensity during inspiration is noted then source of click is valvular
1. if intensity is static through inspiration and expiration then think vasculature: pulmonary HTN/dilatation of pulmonary artery.
5. Means-Lerman scratch of hyperthyroidism raspy pulmonic ejection sound with a pulmonic murmur r/t hyperkinetic heart syndrome (also anemia/fever)
6. Pericardial Friction Rub scratching, scraping, leathery, crackling, and oft fleeting on inflammation 2 pericardial layers; one systolic sound (ventricular contraction) and two diastolic sounds (passive and active filling) loudest @ LLSB
1. Dressler’s Syndrome – both pericardial and pleural friction rub.
1. One complication of MI (usu. after 1st 24hrs.) is pericardial effusion and pericarditis, with or without pleurisy; if with then Dressler’s
7. Pleural Friction Rub – holding breath differentiates from pericardium
5. Murmurs =def. occur whenever blood flow becomes turbulent enough to cause auditory vibrations in the cardiac structures (notably concentric narrowing of a vessel or valve, or sudden change in the diameter of a vessel), which causes high pressure gradients and abnormal velocities of blood flow
1. Classification:
1. Most systolic murmurs are benign, i.e., innocent and functional murmurs
1. Most benign murmurs are never more intense than a 3/6 (see below), i.e., never palpable with thrill or thrust
1. further classificaton:
1. ejection – early or mid systole (usually benign ejection through semilunar valves, but may be forward flow across stenotic semilunar valves)
1. regurgitant – holo- or pan-systolic or late systole (will most often extend into and touch S2); if so, probably pathologic (when late may be MV prolapse & papillary muscle disorders; when holosystolic may be MV or TV regurgitation or VSD)
2. Most diastolic are pathological: must ascertain origin, hemodynamic cause, and severity
1. variations by timing:
1. early – aortic or pulmonic regurgitation
1. if aortic and heard at base right, may also hear above Erb’s point Lt 3rd/4th ICS
1. If this is heard in a pt with preexistent diastolic hypertension (i.e., loud, tambour S2), then may be aortic aneurysm or dissection, or both
2. mid – mitral/tricuspid stenosis (low in frq. & rumbling)
3. late – mitral/tricuspid stenosis
1. can bring out with some coughing or maneuvers
4. holo – PDA
1. Continuous murmurs have no pause reflecting cardiac cycling: e.g., to-fro, machine like murmur of Patent Ductus Arteriosus
2. Mangione’s two golden and three silver rules
1. Golden
1. “Always judge murmurs like people–by the company they keep”
1. extra sounds, abnormal pulses, abnormal ECG, abnormal CXR, or any CV symptom
2. Thus, if they’re on our floor, its probably pathologic
2. “A diminished or absent second sound usually indicates a poorly moving and abnormal semilunar valve. . . the hallmark of pathology” & vice versa
2. Silver
1. “All diastolic murmurs are pathologic,” until proven otherwise
2. “All holosystolic or late systolic murmurs are pathologic”
3. “All continuous murmurs are pathologic”
3. Murmur Characteristics: “Where and PQRST” Or The Six S’s
1. P - Pitch Site
2. Q - Quality Single or Multiple
3. R - Radiation Spread (conduction) and these sites
4. S - Severity/intensity Systolic and/or diastolic timing
5. T - Timing Soft/loud, harsh, rumbling (Qual.) Standing, sitting, lying, leaning, (Special Maneuvers) relation to exercise, Valsalva, Respiration, Hand-Grip, Amyl Nitrate (& NTG, etc?)
1. 6. Keep in mind that murmurs on the Rt generally increase w/inspiration, on Lt, decrease
4. Mnemonic for Cause of Systolic Murmur at apex: MACHINE (shipman, 243)
1. Mitral Valve incompetence
2. Anemia: esp., in Pregnancy
3. Coronary thrombosis: papillary muscle involvement with rupture of Chordae tendineae
4. Hypertension with LV enlargement
5. Innocent
6. Narrowing of Aortic Valve (stenosis)
7. Enlarged heart from any cause, e.g. cardiomyopathy
   

Bibliography:
See Comments.  ¶ 11:26 AM 3 comments

  From the Desk of J. Rutowski, RN, BSN, CVN I like the idea of a blog site as an informal forum for the nursing staff and would like to help out. As I mentioned before a link to the PEARLS REVIEW site may be helpful and now that we are in the process of reviewing for the Certification exam this may be a good place to link review in formation as well. Thanks for your stick-to-itiveness and ongoing efforts at uniting our staff!

Here is the link to the Pearls review site that I mentioned

http://pearlsreview.com/

I need to get the login info from Lisa Nelson at Mary Dillon’s office. To access it for free as an employee of Sisters you need specific log in codes and I can’t remember them off hand.


Jerry  ¶ 4:19 PM 0 comments

  The Opening Agenda You may remember aways back I circulated a bill with much of the following information on it. Since it has been a great challenge to bring several members of the nursing staff of 4N together at one time, this blog has been created to foster discussions and research bearing on aspects of patient care here at SOCH, esp. on 4N. This is intended as a non-formal meeting place for continuing education and professional comradery. I welcome suggestions regarding the establishment of any guidelines and selection of topics for future discussion. Some topics earlier recommended for discussion were:

1. Basic Cardiac Assessment Review
2. Advanced and Emergent Cardiac Assessment
3. Thoracic and Cardiac Auscultation
4. Clinical Pathways for MI, CHF, Arrhythmias
5. Current Issues in Cardiac Pharmacology
6. Interpretation of Haematology, Chemistry, Labs, etc.
7. Cardiological Genetics
8. The Philosophical Ethics of Nursing: Care and Responsibility
9. The Buisness of Nursing: Management, Staffing, and Salaries
10. Beautification of our environment
11. Maths and Medicine

The possibilites abound. Please leave your contact information (Name/Email) with my email address at christopher.cataldi@gmail.com so that I can begin to draft a members list for this forum, and so you can begin to post your own threads.  ¶ 8:34 AM 1 comments

  How to Post First, you'll need to be invited. This is easy. Email your contact information, i.e., your name and email address, to me at the email I gave you at the bottom of the flyer. When I receive your information, I can invite you. Just follow the instructioins in the email which will be sent to you.  ¶ 8:10 AM 0 comments

  The Pristine Posting This is the first example of the epehemera to be electronically scrawled around the association known as the 4North United Review of Scientific and Educational Supplements, or 4N.U.R.S.E.S., a group established and moderated by Mr. CC, RN, staff nurse at the a Hospital in Buffalo, NY.  ¶ 4:57 PM 0 comments