oxygenation and hematology

8/8/2019 Oxygenation and Hematology

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3.Prepare the blood and the blood recipient set.

4.Perform the venipuncture

5.Begin the infusion of blood.

6.Monitor and evaluate the patient throughout theprocedure.

7. Discontinue the infusion of blood.8. Dispose of the used blood pack IAW local SOP.9. Document the procedure and significant nursing

observations on the appropriate forms IAW local SOP.

COMPLICATIONSFluid overload

Allergic reaction

Haemolytic reaction

Graft versus host disease

ELECTROCARDIOGRAPHY Electrocardiography is a procedure by which a

physician obtains a tracing of the electrical activity of theheart. The rhythmic beating of the heart is maintained byan orderly series of discharges originating in the sinus nodeof the right atrium and proceeding through theatrioventricular node and the bundle of neuromuscularfibers (the bundle of His) to the ventricles. By attachingelectrodes to various parts of the body, a record of thiscurrent can be obtained. This record is called anelectrocardiogram, or ECG or EKG for short.

The impulse waves, recorded by the ECG machine on graphpaper, are designated by the letters P, QRS, and T . The Pwave represents depolarization of the atria. The QRScomplex represents depolarization of the ventricles. The Twave represents the polarization of the ventricles. An ECGtracing also shows the voltage of waves and the duration of both the waves and the intervals.

Normal time durations for waves and intervals are asfollows:

P wave: less than 0.11 second PR interval: 0.12 to 0.20 second QRS complex: 0.04 to 0.11 second QT interval: in women, up to 0.43 second; in men, up to

0.42 second

Indications and Contraindications The ECG is often helpful in showing the cause of an

abnormal heart rhythm or an evolving heart attack. The ECG can also detect damage from a previous heart

attack. In an exercise stress test, an ECG is recorded while a

patient is performing physical activity such as walkingon a treadmill or riding a stationary bicycle. As theintensity of exercise increases, the doctor looks forspecific changes in the ECG that indicate the heart isnot getting enough oxygen.

When a patient complains of chest pain, for instance,emergency medical professionals will likely hook thepatient up to an electronic monitor to measure heartand respiratory function, take a chest X ray, anddetermine electrical activity of the heart usingelectrocardiography.

Doctors diagnose pericarditis by using a chest X ray, anelectrocardiogram (ECG) and echocardiogram (to ruleout a heart attack), and a blood test.

Most often, arrhythmias can be diagnosed with the use

of an ECG.

Materials/ Equipment ECG machine

o This instrument consists of a recording deviceattached to electrodes that are placed at variouspoints on a persons skin. The recording devicemeasures different phases of the heartbeat andtraces these patterns as peaks and valleys in agraphic image

Graph paper

Preparation

ECG graph paper is divided into horizontal lines andvertical lines

Voltage is represented on the vertical axis of the ECGpaper.

Time is measured on the horizontal axis. By studying the duration of the waves and intervals, the

examiner can diagnose abnormal impulse formationand conduction.

The electrode sites should be rubbed with alcohol toremove skin oils and a superficial layer of skin.

If hair is present, the sites should be shaved. Electrodes are then attached to the skin and secure

electrode to skin by tape or belt. It is best if possible toavoid placing the electrode over large muscle masses.

Procedure The standard ECG has a 12- lead system, offering 12 pointsof reference for recording the electrical activity of the heart,looking in both horizontal and vertical planes.

RA electrode, below the right clavicle at MCL; LA electrode, below the left clavicle at MCL; RL electrode, right abdomen at MCL; LL electrode, left abdomen at MCL.

V1 TO V6 are the precordial or chest leads: v1, fourth ICS at right sternal border; v2, fourth ICS at left sternal border; v3, fourth ICS, midway between left sternal border and

MCL; v4, fifth ICS at left MCL; v5, fifth ICS, midway between left MCL and AAL; v6, fifth ICS at left AAL.

[AAL, anterior axillary line; ICS, intercostals space; LA, leftarm; LL, left leg; MAL, midaxillary line; MCL, midclavicularline; RA, right arm; RL, right leg.]

The standard 12-lead ECG has 6 limb leads (used to viewthe heart in a frontal or vertical plane and 6 precordial leads(used to view the heart in a horizontal plane). Together, the12-leads permit multidirectional examination of the electricevents in the heart. The location of pathologic change

within the heart, which alters electrical activity, can be pin-pointed.

ElectrocardiographAn electrocardiograph (ECG or EKG) records the electricalactivity of the heart. Preceding each contraction of theheart muscle is an electrical impulse generated in thesinoatrial node; the waves displayed in an ECG trace thepath of that impulse as it spreads through the heart.Irregularities in an ECG reflect disorders in the muscle,blood supply, or neural control of the heart.

ComplicationsSince it is a non-invasive procedure, no severe

complications have been manifested. In pregnant women, itis rarely used unless a specific heart anomaly is suspected.But, ECG with stress tests, chest angina, irregular heartrhythm, heart attack is most common.

ARTERIOGRAPHY DefinitionArteriography also called coronary angiography, is acommon procedure done by injecting a dye visible by X-rayinto the bloodstream. Then X-ray pictures are taken andstudied to see if the arteries are damaged.Arteriography is a key part in evaluating many people athigh risk of stroke.

ElectrocardiographyDefinition:


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A procedure by which a physician obtains a tracing of theelectrical activity of the heart. By attaching variouselectrodes to various parts of the body, a record of thiscurrent can be obtained. Impulse waves:- P, QRS, T

Normal time durations:- P wave: less than 0.11 second

-Pr interval: 0.12 to 0.20 second

- Qrs complex: 0.04 to 0.11 second

- Qt interval: in women, up to 0.43 second; in men, up to0.42 second

Materials/ Equipment:ECG machine

Graph paper

Procedure The Standard ECG has a 12- lead system,

offering 12 points of reference for recording the electricalactivity of the heart.

Together the 12-lead is placed on itsrespective sites, in the right and left clavicle, right and leftabdomen, chest leads, right and left sternal border, midwaythe left sternal border, midway between left MCL and AAL,left AAL.

Complications:No severe implications indicated.

Thalium 201

Definition:A soft, malleable, highly toxic metallic element, used inphotocells, infrared detectors, low-melting glass, andformerly in rodent and ant potions.Indications:

Identify clients with a decreased ejectionfraction.

Clients with diastolic dysfunction.

Clients with peripheral vascular disease.

Procedure: The heart is scanned after administration of radio

active thalium.

Dipyridamole is then given as a vasodilator.

Complications:Identification of ischemia in aged population is

important because they have more severe diseasethan the younger population and a higher surgeryrisk for cardiac and non-cardiac procedure.

A number of initial Thalium 201, defectsinduced by exercise are independent predictors of multi-vessel disease.

PHONOCARDIOGRAPHY the graphic recording of heart sounds and

murmurs; by extension, the term includes pulse tracings(carotid, apex and venous pulse).

Phonocardiography involves picking up, through ahighly sensitive microphone, sonic vibrations from the heartwhich are then converted into electrical energy and fed intoa galvanometer, where they are recorded on paper. Theprocedure is most useful when there is evidence of heartmurmurs or unusual heart sounds, such as gallops, that aredifficult to discern by the human ear. Most recordings are

made through an externally applied microphone butintracardiac recordings, made through a phonocatheter, arepossible.

ECHOCARDIOGRAPHY Echocardiography (EK-o-kar-de-OG-ra-fee), or echo,

is a painless test that uses sound waves to create picturesof your heart.

The test gives your doctor information about thesize and shape of your heart and how well your heart'schambers and valves are working. Echo also can be done todetect heart problems in infants and children.

The test also can identify areas of heart musclethat aren't contracting normally due to poor blood flow orinjury from a previous heart attack . In addition, a type of echo called Doppler ultrasound shows how well blood flowsthrough the chambers and valves of your heart.

Echo can detect possible blood clots inside theheart, fluid buildup in the pericardium (the sac around theheart), and problems with the aorta. The aorta is the mainartery that carries oxygen-rich blood from your heart toyour body.

Who needs echocardiography? Your doctor may recommend echocardiography

(echo) if you have signs and symptoms of heart problems.For example, shortness of breath and swelling in the legscan be due to weakness of the heart ( heart failure ), which

can be seen on an echocardiogram. Your doctor also may use echo to learn about: The size of your heart. An enlarged heart can be

the result of high blood pressure , leaky heartvalves, or heart failure.

Heart muscles that are weak and aren't moving(pumping) properly. Weakened areas of heartmuscle can be due to damage from a heart attack .Weakening also can mean that the area isn'tgetting enough blood supply, which may be dueto coronary heart disease (also called coronaryartery disease).

Problems with your heart valves. Echo can showwhether any of your heart valves don't opennormally or don't form a complete seal whenclosed.

Problems with your heart's structure. Echo candetect many structural problems, such as a hole inthe septum and other congenital heart defects . Theseptum is the wall that separates the two chamberson the left side of the heart from the two chamberson the right side. Congenital heart defects arestructural problems present at birth. Infants andchildren may have echo to detect these heartdefects.

Blood clots or tumors. If you've had a stroke, echomight be done to check for blood clots or tumorsthat may have caused it.

Your doctor also may use echo to see how well yourheart responds to certain heart treatments, such asthose used for heart failure.

Types: There are several types of echocardiography (echo)all usesound waves to create pictures of your heart. This is thesame technology that allows doctors to see an unborn babyinside a pregnant woman.Unlike x rays and some other tests, echo doesn't involveradiation.

Transthoracic Echocardiography Transthoracic (tranz-thor-AS-ik) echo is the most

common type of echocardiogram test. It's painless andnoninvasive. "Noninvasive" means that no surgery isdone and no instruments are inserted into your body.

This type of echo involves placing a device called a

transducer on your chest. The device sends specialsound waves, called ultrasound, through your chest wallto your heart. The human ear can't hear ultrasoundwaves.

As the ultrasound waves bounce off the structures of yourheart, a computer in the echo machine converts theminto pictures on a screen.

Stress EchocardiographyStress echo is done as part of a stress test . During

a stress test, you exercise or take medicine (given byyour doctor) to make your heart work hard and beatfast. A technician will take pictures of your heart usingecho before you exercise and as soon as you finish.
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Some heart problems, such as coronary heart disease , are easier to diagnose when the heart isworking hard and beating fast.

Transesophageal EchocardiographyWith standard transthoracic echo, it can be hard to

see the aorta and other parts of your heart. If yourdoctor needs a better look at these areas, he or shemay recommend transesophageal (tranz-ih-sof-uh-JEE-ul) echo (TEE).

During this test, the transducer is attached to theend of a flexible tube. The tube is guided down yourthroat and into your esophagus (the passage leadingfrom your mouth to your stomach). This allows yourdoctor to get more detailed pictures of your heart.

Fetal EchocardiographyFetal echo is used to look at an unborn baby's

heart. A doctor may recommend this test to check ababy for heart problems. Fetal echo is commonly doneduring pregnancy at about 18 to 22 weeks. For this test,the transducer is moved over the pregnant woman'sbelly.

Three-Dimensional EchocardiographyA three-dimensional (3D) echo creates 3D images

of your heart. These images provide more informationabout how your heart looks and works.

During transthoracic echo or TEE, 3D images canbe taken as part of the process used to do these typesof echo. (See above for more information on how

transthoracic echo and TEE are done.)3D echo may be used to diagnose heart problemsin children. This method also may be used for planningand monitoring heart valve surgery .

Researchers continue to study new ways to use 3D echo.

What to expect before echocardiography?Echocardiography (echo) is done in a doctor's office

or a hospital. No special preparations are needed for mosttypes of echo. Usually you can eat, drink, and take anymedicines as you normally would.

The exception is if you're having a transesophagealecho. This test usually requires that you don't eat or drinkfor 8 hours prior to the test.

If you're having a stress echo, there may be specialpreparations. Your doctor will let you know how to preparefor your echo test.

What to expect during echocardiography?Echocardiography (echo) is painless and usually

takes less than an hour to do. For some types of echo, yourdoctor will need to inject saline or a special dye into one of your veins to make your heart show up more clearly on thetest images. This special dye is different from the dye usedduring angiography (a test used to examine the body'sblood vessels).

For most types of echo, you'll be asked to removeyour clothing from the waist up. Women will be given agown to wear during the test. You'll lay on your back or leftside on an exam table or stretcher.

Soft, sticky patches called electrodes will be

attached to your chest to allow an EKG(electrocardiogram)to be done. An EKG is a test that records the heart'selectrical activity.

A doctor or sonographer (a person specially trainedto do ultrasounds) will apply gel to your chest. The gel helpsthe sound waves reach your heart. A wand-like devicecalled a transducer will then be moved around on yourchest.

The transducer transmits ultrasound waves intoyour chest. Echoes from the sound waves will be convertedinto pictures of your heart on a computer screen. During thetest, the lights in the room will be dimmed so the computerscreen is easier to see.

The sonographer will make several recordings of the pictures to show various locations in your heart. Therecordings will be put on a computer disc or videotape forthe cardiologist (heart specialist) to review.

During the test, you may be asked to changepositions or hold your breath for a short time so that thesonographer can get good pictures of your heart.

At times, the sonographer may apply a bit of pressure to your chest with the transducer. This pressurecan be a little uncomfortable, but it helps get the bestpicture of your heart. You should let the sonographer knowif you feel too uncomfortable.

This process is similar for fetal echo. However, inthat test the transducer is placed over the pregnantwoman's belly at the location of the baby's heart.Transesophageal Echocardiography

Transesophageal echo (TEE) is used when yourdoctor needs a more detailed view of your heart. For

example, TEE may be used to look for blood clots inyour heart. A doctor, not a sonographer, performs thistype of echo.

The test uses the same technology astransthoracic echo, but the transducer is attached tothe end of a flexible tube. The tube will be guided downyour throat and into your esophagus (the passageleading from your mouth to your stomach). From thisangle, your doctor can get a more detailed image of theheart and major blood vessels leading to and from theheart.

For TEE, you'll likely be given medicine to helpyou relax during the test. The medicine will be injectedinto one of your veins. Your blood pressure, the oxygencontent of your blood, and other vital signs will bechecked during the test. You'll be given oxygen througha tube in your nose. If you wear dentures or partials,you'll have to remove them.

The back of your mouth will be numbed with agel or a spray so that you don't gag when thetransducer is put down your throat. The tube with thetransducer on the end will be gently placed in yourthroat and guided down until it's in place behind theheart.

The pictures of your heart are then recorded asyour doctor moves the transducer around in youresophagus and stomach. You shouldn't feel anydiscomfort as this happens.

Although the imaging usually takes less thanan hour, you may be watched for a few hours at thedoctor's office or hospital after the test.

Stress EchocardiographyStress echo is a transthoracic echo combined

with either an exercise or pharmacological (FAR-ma-ko-LOJ-i-kal) stress test.

For an exercise stress test, you'll walk or run ona treadmill or pedal a stationary bike to make yourheart work hard and beat fast. For a pharmacologicalstress test, you'll be given medicine to make your heartwork hard and beat fast.

A technician will take pictures of your heartusing echo before you exercise and as soon as youfinish. The Diseases and Conditions Index Stress

Testing article provides more information about what toexpect during a stress test.

What you may see and hear duringechocardiography?

As the doctor or sonographer moves the transduceraround, different views of your heart can be seen on thescreen of the echo machine. The structures of the heart willappear as white objects, while any fluid or blood will appearblack on the screen.

Doppler ultrasound techniques often are usedduring echo tests. Doppler ultrasound is a specialultrasound that shows how blood is flowing through theblood vessels.

This test allows the sonographer to see bloodflowing at different speeds and in different directions. The

speeds and directions appear as different colors movingwithin the black and white images.

The human ear is unable to hear the sound wavesused in echo. If Doppler ultrasound is used, you may beable to hear "whooshing" sounds. Your doctor can use thesesounds to learn about blood flow through your heart.

What to expect after echocardiography? You usually can go back to your normal activities

right after having echocardiography (echo).If you have a transesophageal echo (TEE), you may

be watched for a few hours at the doctor's office or hospitalafter the test. Your throat might be sore for a few hoursafter the test.

You also may not be able to drive right after a TEE. Your doctor will let you know whether you need to arrangefor someone to take you home.

What does it shows?Echocardiography (echo) shows the size, structure,

and movement of the various parts of your heart. Thisincludes the valves, the septum (the wall separating theright and left heart chambers), and the walls of the heartchambers. Doppler ultrasound shows the movement of blood through the heart.

Echo can be used to: Diagnose heart problems Guide or determine next steps for treatment Monitor changes and improvement Determine the need for more tests
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Echo can detect many heart problems. Some maybe minor and pose no risk to you. Others can be signs of serious heart disease or other heart conditions. Your doctormay use echo to learn about:

The size of your heart. An enlarged heart canbe the result of high blood pressure , leakyheart valves, or heart failure.

Heart muscles that are weak and aren't moving(pumping) properly. Weakened areas of heartmuscle can be due to damage from a heart attack. Weakening also could mean that thearea isn't getting enough blood supply, which

may be due to coronary heart disease . Problems with your heart's valves. Echo can

show whether any of the valves of your heartdon't open normally or don't form a completeseal when closed.

Problems with your heart's structure. Echo candetect many structural problems, such asa hole in the septum and other congenital heart defects. Congenital heart defects arestructural problems present at birth.

Blood clots or tumors. If you've had a stroke,echo might be done to check for blood clots ortumors that may have caused it.

Risks Transthoracic and fetal echocardiography (echo)

have no risks. These tests are safe in adults, children, andinfants.

If you have a transesophageal echo (TEE), somerisks are associated with the medicine given to help yourelax. These include a bad reaction to the medicine,problems breathing, or nausea (feeling sick to yourstomach).

Your throat also might be sore for a few hours afterthe test. Rarely, the tube used during TEE can cause minorthroat injuries.

Stress echo has some risks, but they're related tothe exercise or medicine used to raise your heart rate, notto the echo. Serious complications from stress tests arevery uncommon. Go to the Diseases and Conditions

Index Stress Testing article for more information about therisks of that test.

Key Points Echocardiography (echo) is a painless test thatuses sound waves to create pictures of your heart. This test gives your doctor information about thesize and shape of your heart and how well your heart'schambers and valves are working. In addition, a type of echo called Doppler ultrasound shows how well blood flowsthrough the chambers and valves of your heart. Your doctor may recommend echo if you have signsand symptoms of heart problems. The test can be used toconfirm a diagnosis, determine the status of an existingproblem, or help guide treatment. There are several types of echo. Transthoracic andstress echo are standard types of the test. Transesophagealecho (TEE) is used if the standard tests don't produce clearresults. A fetal echo is used to look at an unborn baby'sheart. A three-dimensional (3D) echo may be used to helpdiagnose heart problems in children or plan andmonitor heart valve surgery . Echo is done in a doctor's office or hospital. Thetest usually takes up to an hour to do. A standard echodoesn't require any special preparations or followup. If you're having a TEE, you usually shouldn't eat or drink for 8hours prior to the test. During a standard echo, your doctor orsonographer will move a wand-like device called atransducer around on your chest to get pictures of yourheart. During a TEE, the transducer will be put down yourthroat to get a better view of your heart. A cardiologist (heart specialist) will review theresults from your echo. You usually can go back to your normal activitiesright after having echo. If you have TEE, you may bewatched for a few hours at the doctor's office or hospitalafter the test. Transthoracic and fetal echo have no risks. If youhave TEE, some risks are associated with the medicinegiven to help you relax. Rarely, the tube used in TEE cancause minor throat injuries. The risks for stress echo arerelated to the exercise or medicine used to raise your heartrate. Serious complications from stress echo are rare.

CARDIAC CATHETERIZATION

Cardiac catheterization (heart cath ) is theinsertion of a catheter into a chamber or vessel of the heart .

This is done for both investigational and interventionalpurposes. Coronary catheterization is a subset of thistechnique, involving the catheterization of the coronaryarteries .

Your doctor may perform cardiac catheterization to: Diagnose or evaluate coronary artery disease Diagnose or evaluate congenital heart defects Diagnose or evaluate problems with the heart valves Diagnose causes of heart failure or cardiomyopathy

Right Heart CatheterizationRight heart catheterization (also known as

pulmonary artery catheterization or Swan-Ganzcatheterization) is a common procedure in critically illpatients. The catheter is a long thin hollow tube that isplaced through a central venous catheter and is thenguided through the chambers of the heart and into the largeblood vessels of the lungs. The catheter is left in place in a

pulmonary (lung) artery. This catheter measures pressuresin the heart and large blood vessels and checks how wellthe heart is working.Some common situations in which doctors recommend rightheart catheterization include:

Low blood pressure (hypotension or shock) -When the blood pressure remains very low despitegiving fluids and medications to the patient.

Kidney abnormalities - When urine flow is too lowto get rid of the wastes of the body and giving fluidsand/or diuretics (medicines intended to stimulateurine output) does not increase urine output.

Lung water (pulmonary edema) - In patients witha lot of water in their lungs due to heart failure or

inflammation of the lungs, the catheter can helpmonitor treatments to prevent more water fromaccumulating in the lungs.

Specific heart abnormalities - There are someabnormalities of the heart - such as when fluidcollects around the heart or a heart valve doesn'tclose properly - in which measurements with thecatheter help to make the diagnosis and guidetreatments.

Left heart catheterizationA test that permits your doctor to inspect the inside

of your heart's left chambers, where blood is pumped out tothe rest of the body. The procedure is also called coronaryarteriography (ar-TEER-ee-og-ruh-fee) or a "left heart cath."

Retrograde ApproachCatheter maybe introduced percutaneously by

puncture of the femoral artery or by direct brachialapproach and advanced under fluoroscopic control into theaorta and into the left ventricle.Transseptal approach

Catheter is passed from the right femoral vein intothe right atrium. A long needle is passed up through thecatheter and is used to puncture the septum of the rightand left atria

Indications & Contraindications :Some of the indications for cardiac catheterization

procedure are - Unstable angina or Chest pain [uncontrolled

with medications or after a heart attack] Heart attack Before a bypass surgery Abnormal treadmill test results Determine the extent of coronary artery

disease Disease of the heart valve causing symtpoms

(syncope, shortness of breath) To monitor rejection in heart transplant

patients Syncope or loss of consiousness in patients

with aortic valve disease

Some of the relative contraindiciations forcardiac catheterization are
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Allergy to contrast (dye) medium Uncontrolled Blood Pressure (Hypertension) Problems with blood coagulation

(Coagulopathy) Kidney failure or dysfunction Severe anemia Electrolyte imbalance Fever Active systemic infection Uncontrolled rhythm disturbances

(arrhythmias) Uncompensated heart failure Transient Ischemic attack

Preparations: Patients may be required to be admitted to the hospital

the night before the procedure. For some patients,overnight stay is not required.

Nil per oral [ NPO ] or nothing to eat or drink by mouth6-8 hours before the test.

The cardiologist will explain the procedure and risksassociated with it.

Consent form should be signed before the procedure. Any questions or doubts should be asked and clarified

with the doctor before surgery. The doctor should be informed of allergies to

medications, iodine or food . It should also bedocumented legibly in the patients chart.

Previous allergic reactions to contrast dyes must bementioned.

Catheterization procedure requires X-ray fluoroscopy.Women patients in childbearing age can undergopregnancy test to rule out pregnancy.

Medications that are taken on the day of cardiaccatheterization should be discussed with the doctor.Some medicines taken for blood thinning (e.g.,Aspirin ), erectile dysfunction (Sildenafil or Tadalafil) ordiabetic medication ( metformin ) needs to be stoppedon the day or few days before the procedure.

Kidney disease should be assessed before, ascontrast materials or dyes may not be used in patientswith abnormal kidney function.

Some blood tests and electrocardiogram (ECG) will beperformed before the procedure.

A mild sedative will be given orally or intravenously tocomfort the patient and relieve anxiety.

All personal belongings and jewellery will be removedand patient will be dressed in a hospital gown beforebeing transported to the catheterization laboratory.

Nursing patient Care considerations:Preprocedure:

Client should have X-ray, CBC with differential,urinalysis, and 12 lead ECG.

Know which approach which to be used in order toanticipate possible complications.

Withhold food and fluid 6 hours before procedure. Ascertain history of previous allergies. Mark distal pulses for easy reference after

catheterization. Explain to patient that he would lying on examination

table for a prolong period that he may experiencecertain sensations.

o Occasional thudding sensation in the chest.o Strong desire to cough may occur during contrast

medium injection.o Transient feeling of hot flushes or nausea as the

contrast medium is injected. Evaluate clients emotional status before

catheterization.o Is this patients first catheterization?o Is patient apprehensive about procedure?o Ask whether has heard stories about having a

catheterization. Dentures, glasses or hearing aids should be sent with

patient for procedure. Have patient void before procedure.

Procedure In the catheterization laboratory, the insertion area

(usually the groin, neck, or forearm) is cleansed with asterilizing solution, shaved, and covered with steriledrapes. A small-needle injection of a local anesthetic isused to numb the area.

A small incision is made and a pencil-sized plastic tube,called a sheath, is inserted into the artery (e.g., femoralartery, carotid artery) or vein. A catheter, which isusually 2 to 3 mm in diameter, is passed via the sheaththrough the artery to the heart, and into a coronary

artery. A contrast agent (dye) is injected into the catheter to

show areas of blockage and angiograms of the arteryare taken. The dye often causes a "hot-flash" sensationthroughout the body that lasts for 10 to 15 seconds.

In some cases, a catheter is passed through the sheathto the heart's left ventricle and dye injected to showhow the left ventricle is functioning.

Postprocedure1. record blood pressure measurement and apical

pulse every 15 minutes (or more frequently) until vitalsigns are stable to discern dysrrhytmias

2. Check peripheral pulses in affected extremity;

evaluate extremity temperature, color, and complaintsof pains, numbness or tingling sensation to determinesigns of arterial insufficiency.

3. Watch cutdown sites for hematoma formation.Question patient about increase in pain or tendernessat site.

4. Assess for complaints of chest pain and reportimmediately. MI (Myocardial Infarction) may occur andis serious complications of cardiac catheterization.

5. Enforce activity restrictions which are based oncoagulation status and whether avascular closuremethod was employed. (2-24 hours)

6. Evaluate complaints of back, thigh, or groin pain(may indicate) retroperitoneal bleeding.

7. Be alert of signs and symptoms of vagal reaction(nausea, diaphoresis, hypotension, bradycardia); treatas directed with atropine and fluids.

Complications: The overall risk for complications from cardiac

catheterization is about 1 in 1000 . Contrast dyes causeadverse effects in almost 1 out of 10 patients . Thecommon side effect is nausea or vomiting. Some of thecomplications due to dye allergy are

Fast heartbeat Slow heartbeat Nausea Vomiting Shock Kidney failure Epilepsy Itching Rashes

Few other complications are Bleeding at the insertion site Damage to the blood vessels used for catheter entry Infection Ventricular arrhythmias Pneumothorax [air collection between the chest wall

and the lungs] Cardiac tamponade [fluid collection around the heart] Heart attack Stroke [0.1%] Air embolism Death [0.1- 0.2%]

CENRAL VENOUS PRESSUREIndications Inability to achieve adequate peripheral venousaccess Delivery of substances not safely given viaperipheral IV (TPN, vasopressors, etc.) Hemodialysis, CVVH, plasmapheresis Measurement of cardiac filling pressures Placement of pulmonary artery catheter Placement of transvenous pacer
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Access for frequent blood sampling Remember that triple lumen catheters are lessuseful than large bore IVs for rapid volume administration unless introducer catheter placed.

Contraindications Absolute: o Operator inexperienceo Uncooperative/combative patientso Uncorrected coagulopathy in a stablepatient

Relative: o Uncorrected coagulopathy in an unstablepatiento Cellulitis over anticipated insertion siteo Injury or previous surgery to SVC (priorXRT, prior long term venous cannulation at site.o Inability to tolerate pneumothorax (femoralvein should be considered)o Ability to provide adequate care viaperipheral accesso Morbid obesity. Consider placement of linein cephalic vein on upper outer chest using ultrasoundguidance beyond the rib edges.o Vasculitiso COPD/bullous lung disease (subclavianlines)o Congenital heart disease (Glenn or Fontananastamoses). These patients have increased risk of clotting with upper body central lines. Consider a femoralapproach.o Presence of a pacemaker or ICD especially relevant for subclavian lines, pulmonary arterycatheters, and right IJ lines. The more recently placed thedevice, the more likely lead dislodgement becomes.Consider having devices interrogated followingplacement/removal of CVCs.

Risks and ComplicationsComplication Internal

Jugular

Subclavian Femoral

Arterialpuncture

6.3-9.4% 3.1-4.9% 9.0-15.0%

Hematoma


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tip is parallel to the vena cava walls. Tips that impingeagainst the vessel wall initiate venous thrombosis.

Mural/catheter related thromboses are associated withincreased risk of catheter-related infections.

Management of Complications Air Embolus:

Suspect this if a patient decompensates during yourprocedure.

Occlude any open lumen. Place patient in left lateral decubitus position &

Trendelenberg to position the RV outflow tract inferiorto the RV, thus floating air away from the outflow tract(Durants position).

Provide high FiO2 to encourage nitrogen resorption Attempt to aspirate air through your catheter. CXR in left lat decubitus may show air in heart & heart

exam may reveal mill wheel murmurArrhythmia:

Usually results from deep placement of the guidewire orline and resolves upon repositioning.

If unstable, initiate ACLS.Arterial Puncture:

With needle only: withdraw needle and apply 5-10minutes of pressure. If patient develops bradycardia

(carotid massage), release pressure.o CXR to r/o hemothoraxo Frequent vitalso Hematocrit checks

With dilator/catheter: Surgical emergency . Leaveline/dilator in place and call vascular surgery rightaway.

Catheter Infection If catheter is no longer needed, remove catheter If blood cultures are positive, remove catheter See separate Duke CVC Curriculum Website

(DICON) for more detailed discussion Catheter Knotting:

Leave catheter in place and request help from IR or

vascular service.Dysrhythmias: Usually occurs secondary to stimulation of myocardium

by catheter or guidewire Usually resolves after withdrawal of catheter or

guidewire If necessary, initiate ACLS protocols. Try to estimate distance from insertion site to SVC prior

to insertion.Guidewire Embolization:

Watch for arrhythmias and be prepared to managethem.

Obtain a CXR to check the location. Consult IR emergently for immediate removal.

Neck Hematoma: Monitor patient for airway compromise/carotid

occlusionPneumothorax:

Monitor with serial chest x-rays if small and patientspontaneously breathing without respiratory distress.

If hemodynamic instability, place 14-16 gaugeangiocath in the 2 nd intercostal space, midclavicularline. Remove needle, leave open to air, call foremergent chest tube placement.

If hemodynamically stable, not on positive pressureventilation, and < 20%, then can observe with oxygenadministration and serial chest x-rays

If patient on positive pressure ventilation, even small

pneumothorax may require chest tube placement.Venous Thrombosis:

If catheter is no longer needed, remove it Anticoagulation with heparin/warfarin is indicated Prevent this complication with appropriate tip

placement. Make sure the tip does not impinge againsthe vessel wall.

ARTERIAL BLOOD GAS (ABG)

Definition:An arterial blood gas (ABG) is a blood test that is performedusing blood from an artery. It involves puncturing an arterywith a thin needle and syringe and drawing a small volumeof blood. The most common puncture site is the radial

artery at the wrist, but sometimes the femoral artery in thegroin or other sites are used. The blood can also be drawnfrom an arterial catheter. An arterial blood gas (ABG) testmeasures the acidity ( pH ) and the levels of oxygen andcarbon dioxide in the blood from an artery. This test is usedto check how well your lungs are able to move oxygen intothe blood and remove carbon dioxide from the blood.

Equipment: ABG kit Ice

Indications:An ABG measures:

Partial pressure of oxygen (PaO2). Partial pressure of carbon dioxide (PaCO2). pH. Bicarbonate (HCO3) Oxygen content (O2CT) and oxygen saturation (O2Sat)

values.

Contraindications: Cellulites or other infections over the radial artery. Absence of palpable radial artery pulse. Negative results of an Allen test (collateral circulation

test), indicating that only one artery supplies the hand

and suggest to select another extremity as the site forarterial puncture. Coagulopathies or medium-to-high-dose anticoagulation

therapy (eg, heparin or coumadin, streptokinase, andtissue plasminogen activator but not necessarilyaspirin) may be a relative contraindication for arterialpuncture.

History of arterial spasms following previous punctures. Severe peripheral vascular disease. Abnormal or infectious skin processes at or near the

puncture sites. Arterial grafts. Arterial puncture should not be performed through a

lesion or through or distal to a surgical shunt (eg, as ina dialysis patient). If there is evidence of infection orperipheral vascular disease involving the selected limb,an alternate site should be selected.

Preparation: Tell your doctor if you:

o Have had bleeding problems or take blood thinners,such as aspirin or warfarin (Coumadin).

o Are taking any medicines.o Are allergic to any medicines, such as those used to

numb the skin ( anesthetics ). If you are on oxygen therapy, the oxygen may be

turned off for 20 minutes before the blood test. This iscalled a "room air" test. If you cannot breathe withoutthe oxygen, the oxygen will not be turned off.

Talk to your doctor about any concerns you haveregarding the need for the test, its risks, how it will bedone, or what the results may mean.

Procedure: A sample of blood from an artery is usually taken from

the inside of the wrist (radial artery), but it can also becollected from an artery in the groin (femoral artery) oron the inside of the arm above the elbow crease(brachial artery).

You will be seated with your arm extended and yourwrist resting on a small pillow. The health professionaldrawing the blood may rotate your hand back and forthand feel for a pulse in your wrist.

To prevent the possibility of damaging the artery of thewrist when the blood sample is taken, a procedurecalled the Allen test may be done to ensure that bloodflow to your hand is normal. An arterial blood gas (ABG)test will not be done on an arm used for dialysis or if there is an infection or inflammation in the area of thepuncture site.

The health professional taking a sample of your bloodwill:

o Clean the needle site with alcohol. You may begiven an injection of local anesthetic to numb thatarea.

o Put the needle into the artery. More than oneneedle stick may be needed.
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o Allow the blood to fill the syringe. Be sure tobreathe normally while your blood is beingcollected.

o Put a gauze pad or cotton ball over the needle siteas the needle is removed.

o Put a bandage over the puncture site and applyfirm pressure for 5 to 10 minutes (possibly longer if you take blood-thinning medicine or have bleedingproblems).

Complications There is little chance of a problem from having bloodsample taken from an artery.

You may get a small bruise at the site. You can lowerthe chance of bruising by keeping pressure on the sitefor at least 10 minutes after the needle is removed(longer if you have bleeding problems or take bloodthinners).

You may feel lightheaded, faint, dizzy, or nauseatedwhile the blood is being drawn from your artery.

Ongoing bleeding can be a problem for people withbleeding disorders. Aspirin, warfarin (Coumadin), andother blood-thinning medicines can make bleedingmore likely. If you have bleeding or clotting problems,or if you take blood-thinning medicine, tell your doctorbefore your blood sample is taken.

On rare occasions, the needle may damage a nerve orthe artery, causing the artery to become blocked.

Though problems are rare, be careful with the arm orleg that had the blood draw. Do not lift or carry objectsfor about 24 hours after you have had blood drawnfrom an artery.

HEART BYPASS SURGERY

Definition:Coronary artery bypass graft surgery is a surgical procedurein which one or more blocked coronary arteries arebypassed by a blood vessel graft to restore normal bloodflow to the heart. These grafts usually come from thepatient's own arteries and veins located in the leg, arm, orchest.

Indications:Bypass surgery may be advised to the following patients:

Has blockages in at least two to three major coronaryarteries, especially if the blockages are in arteries thatfeed the heart's left ventricle or in the left anteriordescending artery

Has angina so severe that even mild exertion causeschest pain

Has poor left ventricular function Cannot tolerate percutaneous transluminal coronary

angioplasty and do not respond well to drug therapy

Equipments/ Materials:Heart stabilizer- allows the heart to beat while reducing

movement only in the area where your surgeon is

working.Heart-lung bypass machine- used for beating heartbypass surgery. It pumps blood through the body andacts as the lungs.

Preparation: The individual should quit smoking or using tobacco

products before the surgery. Coronary artery bypass graft surgery should ideally

be postponed for three months after a heart attack.Patients should be medically stable before thesurgery, if possible.

Nurses should inform the patients on what toexpect during surgery and recovery.

If the patient develops a cold, fever, or sore throat within a few days before the surgery, he or sheshould notify the surgeon's office.

The evening before the surgery, the patientshowers with antiseptic soap provided by thesurgeon's office.

After midnight, the patient should not eat or drinkanything.

The patient is usually admitted to the hospital thesame day the surgery is scheduled. The patientshould bring a list of current medications, allergies, and appropriate medical records upon admission to the hospital. Before the surgery, the patient isgiven a blood-thinning drug usually heparin thathelps to prevent blood clots . A sedative is given the

morning of surgery. The chest and the area fromwhere the graft will be taken are shaved.

Coronary angiography will have been previouslyperformed to show the surgeon where the arteriesare blocked and where the grafts might best bepositioned. Heart monitoring is initiated. Thepatient is given general anesthesia before theprocedure.

Procedure The patient is brought to the operating room and

moved on to the operating table. An anesthetist places a variety of intravenous lines and

injects an induction agent to render the patientunconscious.

An endotracheal tube is inserted and secured by theanesthetist or assistant.

The chest is opened via a median sternotomy and theheart is examined by the surgeon.

The bypass grafts are harvested - frequent conduitsare the internal thoracic arteries , radial arteries andsaphenous veins . When harvesting is done, the patientis given heparin to prevent the blood from clotting.

In the case of " off-pump " surgery, the surgeon placesdevices to stabilize the heart.

If the case is "on-pump", the surgeon sutures cannulae into the heart and instructs the perfusionist to startcardiopulmonary bypass (CPB). Once CPB isestablished, the surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to delivercardioplegia to stop the heart.

One end of each graft is sewn on to the coronary arteries beyond the blockages and the other end isattached to the aorta .

The heart is restarted; or in "off-pump" surgery, thestabilizing devices are removed. In some cases, theAorta is partially occluded by a C-shaped clamp, theheart is restarted and suturing of the grafts to theaorta is done in this partially occluded section of theaorta while the heart is beatin Protamine is given toreverse the effects of heparin.

The sternum is wired together and the incisions aresutured closed.

The patient is moved to the intensive care unit (ICU) torecover. After awakening and stabilizing in the ICU(approximately 1 day), the person is transferred to thecardiac surgery ward until ready to go home(approximately 4 days).

Complications graft closure or blockage development of blockages in other arteries damage to the aorta long-term development of atherosclerotic disease of

saphenous vein grafts abnormal heart rhythms high or low blood pressure recurrence of angina blood clots that can lead to a stroke or heart attack kidney failure depression or severe mood swings possible short-term memory loss, difficulty thinking

clearly, and problems concentrating for long periods(These effects generally subside within six months aftersurgery.)

ANGIOPLASTY

Definition:Angioplasty is the technique of mechanically widening anarrowed or obstructed blood vessel ; typically as a result of atherosclerosis. Tightly folded balloons are passed into thenarrowed locations and then inflated to a fixed size usingwater pressures some 75 to 500 times normal bloodpressure (6 to 20 atmospheres).

Indications: Improve symptoms of CAD, such as angina and

shortness of breath. Reduce damage to the heart muscle from a heart

attack . Reduce the risk of death in some patients.
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Contraindications: Absolute contraindications include

Lack of cardiac surgical support Significant obstruction of the left main coronary artery

without a nonobstructed bypass graft to the leftanterior descending or left circumflex arteries

Relative contraindications include Coagulopathy Hypercoagulable states Diffusely diseased vessels without focal stenoses A single diseased vessel providing all perfusion to the

myocardium Total occlusion of a coronary artery Stenosis < 50%

Materials balloon-tipped catheter stent - tiny mesh tube that looks like a small spring.

The stent is inserted in the area where the artery isnarrowed to keep it open

plaque remover - used to cut away plaque that narrowsin the inside of the arteries

laser - used to dissolve or vaporize plaque

Preparation Tell your doctor what drugs you are taking, even drugs

or herbs you bought without a prescription. You will usually be asked not to drink or eat anything

for 6 to 8 hours before the test. Take the drugs your doctor told you to take with a small

sip of water. Tell your doctor if you are allergic to seafood, if you

have had a bad reaction to contrast material or iodinein the past, if you are taking Viagra, or if you might bepregnant.

The nurse may check your heart rate and bloodpressure, and test your urine.

A nurse will clean (and may shave) your groin, arm orwrist where a catheter (a thin flexible tube) will beinserted during the procedure.

May have tests prior to the procedure (blood tests, ECG,and angiogram) You may be asked to wear compression stockings to

help prevent blood clots forming in the veins in yourlegs.

You may need to have an injection of an anti-clottingmedicine called heparin as well as, or instead of,stockings.

Procedure Before the angioplasty procedure begins, you will be

given some pain medicine. You may also be given bloodthinning medicines to keep a blood clot from forming.

You will lie down on a padded table. Your doctor willmake a small cut (incision) on your body, usually nearthe groin. Then your doctor will insert a catheter(flexible tube) through the incision into an artery.Sometimes the catheter will be placed in your arm orwrist. You will be awake during the procedure.

The doctor uses live x-ray pictures to carefully guidethe catheter up into your heart and arteries. Dye will beinjected into your body to highlight blood flow throughthe arteries. This helps the doctors see any blockagesin the blood vessels that lead to your heart.

A guide wire is moved into and across the blockage. Aballoon catheter is pushed over the guide wire and intothe blockage. The balloon on the end is blown up(inflated). This opens the blocked vessel and restoresproper blood flow to the heart.

A stent (wire mesh tube) may then be placed in this

blocked area. The stent is inserted along with theballoon catheter. It expands when the balloon isinflated. The stent is then left there to help keep theartery open.

Complications The main complications of balloon angioplasty and stentingare

Thrombosis Restenosis The treated arteries gradually re-narrowing. If this

happens the angioplasty may need to be repeated.Stents may help to slow down the narrowing.

Some people can have an allergic reaction to the dyeused in the angiogram. The coronary artery may

become completely blocked during or soon after theprocedure. The angioplasty may need to be repeatedstraight away or emergency coronary artery bypassgraft surgery may be needed to bypass the affectedveins.

The tip of the catheter can dislodge a clot of blood orfatty plaque from the wall of a blood vessel. It's possiblefor these to block an artery leading to the heart orbrain, causing a heart attack or stroke.

There is a risk of death but this is very rare.

PULMONARY FUNCTION TEST

Definition:Pulmonary function tests are a group of tests that measure

how well the lungs take in and release air and how well theymove oxygen into the blood. It can also diagnose problemswith the lungs, and/or determine how well treatment for alung condition is working.

Spirometry measures airflow. By measuring how muchair you exhale, and how quickly, spirometry canevaluate a broad range of lung diseases.

Lung volume measures the amount of air in the lungswithout forcibly blowing out. Some lung diseases (suchas emphysema and chronic bronchitis) can make thelungs contain too much air. Other lung diseases (such

as fibrosis of the lungs and asbestosis) make the lungsscarred and smaller so that they contain too little air. Testing the diffusion capacity allows the doctor to

estimate how well the lungs move oxygen from the airinto the bloodstream

Indications:Pulmonary function tests are done to:

Diagnose certain types of lung disease (especiallyasthma, bronchitis, and emphysema)

Find the cause of shortness of breath Measure whether exposure to contaminants at work

affects lung function

It also can be done to: Assess the effect of medication Measure progress in disease treatment

Contraindications: These tests should not be done to patients who have:

An unstable heart or lung disease Recently suffered a heart attack Active tuberculosis An acute asthma attack Respiratory distress Active bleeding from the lower respiratory tract

Equipments: Spirometer Body plethysmograph Nose clip

Preparation: Do not eat a heavy meal before the test. Do not smoke for 4 - 6 hours before the test. Wear loose-fitting clothing. Review your medications with your doctor; there may

be some that you should stop taking before testing. You'll get specific instructions if you need to stop using

bronchodilators or inhaler medications. You may have to breathe in medication before the test.

Procedure:Immediately before each PFT, the technician will explainhow each test is performed and how the PFT device beingused works. You may be asked to sit in an atmosphere-controlled booth and/or put on a nose clip. In some cases,one or more of these tests may be done during orimmediately following exercise (on a treadmill or stationarybike). If you have breathing problems, pain, or dizzinessduring testing, tell the technician right away.

The pulmonary function tests consist of: Spirometry the main measurements include: forced

expiratory volume in one second (FEV1) and forced vitalcapacity (FVC)

In a spirometry test, you breathe into a mouthpiecethat is connected to an instrument called a spirometer.

The spirometer records the amount and the rate of airthat you breathe in and out over a period of time.
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Lung volumes include total lung capacity (TLC),functional residual capacity (FRC), and residual volume(RV)

Lung volume measurement can be done in twoways:

The most accurate way is to sit in a sealed,clear box that looks like a telephone booth (bodyplethysmograph) while breathing in and out into amouthpiece. Changes in pressure inside the boxhelp determine the lung volume.

Lung volume can also be measured when youbreathe nitrogen or helium gas through a tube for a

certain period of time. The concentration of the gasin a chamber attached to the tube is measured toestimate the lung volume.

Quantification of diffusing capacity measures gasexchange

o To measure diffusion capacity, you breathe aharmless gas for a very short time, often onebreath. The concentration of the gas in the air youbreathe out then is measured. The difference in theamount of gas inhaled and exhaled can helpestimate how quickly gas can travel from the lungsinto the blood.

Additional pulmonary function tests that are used incertain situations include:

Oxygen saturation test A small probe ispainlessly strapped or clipped to one of your fingersor toes to measure the amount of oxygen beingcarried in the blood.

Allergen challenge tests You are exposed tospecific allergens during pulmonary functiontesting. This is only done in limited situations,under close and careful supervision.

Bronchoprovocation testing: Methacholine provocation testPeople with asthma

will experience a mild constriction of the airwayswhen the drug methacholine is inhaled. This testmay be done in situations where asthma issuspected but other pulmonary function tests havenot shown a clear diagnosis of asthma.

Possible Complications Slight risk of collapsed lung in some patients with lung

disease. Allergen challenge tests can pose dangers Since the test involves some forced breathing and rapid

breathing, you may have some temporary shortness of breath or light-headedness.

PULSE OXIMETRY

DEFINITIONPulse oximetry is a non-invasive method allowing themonitoring of the oxygenation of a patient's hemoglobin.

INDICATION Whenever a patient's oxygenation is unstable, including

intensive care, critical care, and emergency departmentareas of a hospital.

The need to monitor the adequacy of arterialoxyhemoglobin saturation

CONTRAINDICATION The presence of an ongoing need for measurement of

pH, PaCO2, total hemoglobin, and abnormalhemoglobins may be a relative contraindication to pulseoximetry.

EQUIPMENTS Pulse oximeter

PROCEDURE Plug the pulse oximeter in to an electrical socket, if

available, to recharge the batteries. Turn the pulse oximeter on and wait for it to go through

its calibration and check tests. Select the probe you require with particular attention to

correct sizing and where it is going to go. The digitshould be clean (remove nail varnish).

Position the probe on the chosen digit, avoiding excessforce.

Allow several seconds for the pulse oximeter to detectthe pulse and calculate the oxygen saturation.

Read off the displayed oxygen saturation and pulserate.

Be cautious interpreting figures where there has beenan instantaneous change in saturation - for example99% falling suddenly to 85%. This is physiologically notpossible.

If in doubt, rely on your clinical judgement, rather thanthe value the machine gives.

COMPLICATIONS Pulse oximetry is considered a safe procedure, but

because of device limitations, false-negative results forhypoxemia and/or false-positive results for normoxemiaor hyperoxemia may lead to inappropriate treatment of the patient.

Tissue injury may occur at the measuring site as aresult of probe misuse.

SPIROMETRY Spirometry is a quick, painless test in which measures

how much air a person's lungs can hold (air volume) and the speed of inhalations and exhalations

during breathing (flow rate). This test is used in children older than 5 years.

Spirometric values FVC - Forced vital capacity; the total volume of air that

can be exhaled during a maximal force expiration.effort.

FEV1 - Forced expiratory volume in one second; thevolume of air exhaled in the first second under forceafter a maximal inhalation.

FEV1/FVC ratio -The percentage of the FVC expired inone second.

Lung volumes ERV -Expiratory reserve volume; the maximal volume of

air exhaled from end-expiration. IRV -Inspiratory reserve volume; the maximal volume of

air inhaled from end-inspiration. RV -Residual volume; the volume of air remaining in the

lungs after a maximal exhalation. VT -Tidal volume; the volume of air inhaled or exhaled

during each respiratory cycle.

Lung capacities FRC -Functional residual capacity; the volume of air in

the lungs at resting end-expiration. TLC -Total lung capacity; the volume of air in the lungs

at maximal inflation. VC -Vital capacity; the largest volume measured on

complete exhalation after full inspiration.

FVC

80% to 120%

Absolute FEV1/FVC ratio

Within 5% of the predicted ratio

TLC

80% to 120%Pulmonary function test Normal value (95

percent confidenceinterval)

FEV1 80% to 120%FVC 80% to 120%

Absolute FEV1/FVC ratio Within 5% of thepredicted ratio

TLC 80% to 120%FRC 75% to 120%RV 75% to 120%


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FRC

75% to 120%

RV

75% to 120%INDICATION

spirometry tells health care professionals how well thelungs are working. It's used to help diagnose and monitordiseases that affect the lungs and make breathingdifficult, such as asthma and cystic fibrosis. It can also beused to:

o find the cause of shortness of breath, coughing orwheezingo monitor treatment of respiratory problemso evaluate lung functioning before surgery.

-find the cause of shortness of breath, coughing or wheezi

-monitor treatment of respiratory problems

-evaluate lung functioning CONTRAINDICATIONS hemoptysis of unknown origin (forced expiratory

maneuver may aggravate the underlying condition); unstable cardiovascular status (forced expiratory

maneuver may worsen angina or cause changes inblood pressure) or recent myocardial infarction orpulmonary embolus;

thoracic, abdominal, or cerebral aneurysms (danger of

rupture due to increased thoracic pressure); presence of an acute disease process that mightinterfere with test performance (eg, nausea,vomiting);

recent surgery of thorax or abdomen.

EQUIPMENT Spirometer

PREPARATION The patient should avoid eating a big meal before the

test. If the patient is taking any medications, the doctor

might have the patient stop taking them for a certainamount of time before the test.

make sure that the patient doesn't wear tight clothingthat could interfere with the ability to breath in and outdeeply.

PROCEDURE Patient might have to wear soft nose clips during the

procedure to prevent air from escaping. Patient may be asked to stand during the test. If while

the test is performed, the patient should not leanforward because this can affect breathing.

Patient will be asked to take a very deep breath, placethe device in his or her mouth with the lips sealedsecurely around the mouthpiece, and then exhale asfast and hard as possible for as long as possible.

The test may be repeated several times to confirm theaccuracy of the results.

Spirometry is often performed before and after aninhaled asthma medication called a bronchodilator isadministered. Use of this type of medication indicateswhether a lung problem can be treated with specificmedications.

Spirometry usually takes 5-30 minutes, depending onthe number of times the test must be done.

The results are expressed as percentages and aregenerally considered abnormal if they're less than80% of the normal value based on the patients age,gender, height, and weight.

Normal lungs can empty more than 80% of theirvolume in 6 seconds or less.

CONTRAINDICATIONS

Spirometry is considered a safe procedure with little risk.Because the test requires patients to breathe quickly anddeeply, some experience temporary shortness of breath orlightheadedness. This test shouldn't be performed onpatients who have chest pain, a recent history of eye orabdominal surgery, or serious heart disease.

CHEST X-RAY

Definition -A chest radiograph, commonly called a chest x-ray (CXR), is a projection radiograph of the chest used todiagnose conditions affecting the chest, its contents, andnearby structures.-Chest radiographs are among the most common filmstaken, being diagnostic of many conditions.-Like all methods of radiography, chest radiographyemploys ionizing radiation in the form of x-rays to generateimages of the chest. The typical radiation dose to an adultfrom a chest radiograph is around 0.06 mSv.

Indications and contraindicationsA chest x-ray is typically the first imaging test used to helpdiagnose symptoms such as:

Shortness of breath. A bad or persistent cough. Chest pain or injury. Fever.

Physicians use the examination to help diagnose or monitortreatment for conditions such as:

Pneumonia. Heart failure and other heart problems. Emphysema. Lung cancer. Other medical conditions.

Contraindicated for pregnant women

Equipment The equipment typically used for chest x-rays consists

of a wall-mounted, box-like apparatus containing the x-ray film or a special plate that records the imagedigitally and an x-ray producing tube, that is usuallypositioned about six feet away.

The equipment may also be arranged with the x-raytube suspended over a table on which the patient lies.A drawer under the table holds the x-ray film or digitalrecording plate.

A portable x-ray machine is a compact apparatus thatcan be taken to the patient in a hospital bed or theemergency room.

The x-ray tube is connected to a flexible arm that isextended over the patient while an x-ray film holder orimage recording plate is placed beneath the patient.

Preparation A chest x-ray requires no special preparation. You may be asked to remove some or all of your clothes

and to wear a gown during the exam. You may also be asked to remove jewelry, eyeglasses

and any metal objects or clothing that might interferewith the x-ray images.

Women should always inform their physician or x-raytechnologist if there is any possibility that they arepregnant. Many imaging tests are not performed duringpregnancy so as not to expose the fetus to radiation.

If an x-ray is necessary, precautions will be taken tominimize radiation exposure to the baby.

Procedure You will be asked to remove any clothing, jewelry, or

other objects that may interfere with the procedure. You will be given a gown to wear. The particular view that the physician orders will

determine how you are positioned for the x-ray such aslying, sitting, or standing. You will be positionedcarefully so that the desired view of the chest isobtained. The physician will also specify the number of films to be made.

For a standing or sitting film, you will stand or sit infront of the x-ray plate.

You will be asked to roll your shoulders forward, take ina deep breath, and hold it until the x-ray exposure ismade. For patients who are unable to hold their breath,the radiologic technologist will take the picture at theappropriate time by watching the breathing pattern.

It will be important for you to remain still during theexposure, as any movement will blur the film.


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For a side-angle view of the chest, you will be asked toturn to your side and raise your arms above your head.

You will be instructed to take in a deep breath and holdit as the x-ray exposure is made.

The radiologic technologist will step behind a protectivewindow while the images are being made.

BRONCHOSCOPY

DEFINITION:Bronchoscopy is a technique of visualizing the inside of theairways for diagnostic and therapeutic purposes. Aninstrument (bronchoscope) is inserted into the airways,usually through the nose or mouth, or occasionally througha tracheostomy

INDICATIONDiagnostic

To view abnormalities of the airway To obtain tissue specimens of the lung in a variety of

disorders To evaluate a person who has bleeding in the lungs ,

possible lung cancer, a chronic cough , or a collapsed lung

Therapeutic To remove secretions, blood, or foreign objects

lodged in the airway Laser resection of tumors or benign tracheal and

bronchial strictures Stent insertion to palliate extrinsic compression of the

tracheobronchial lumen from either malignant orbenign disease processes

Bronchoscopy is also employed in percutaneoustracheostomy

Surgical procedures on the airways, such as trachealreconstruction, often require the use of bronchoscopy

CONTRAINDICATION Uncooperative Patient Acute Myocardial Infarction Tracheal Stenosis Asthma

PREPARATION: You will be asked to sign a consent form before a

bronchoscopy. Before you have a bronchoscopy, tell your doctor if you: Are taking any medicines. Are allergic to any medicines, including anesthetics. Have had bleeding problems or take blood-thinners,

such as aspirin, clopidogrel (Plavix), or warfarin(Coumadin).

Are or might be pregnant.

Your doctor may order other tests before yourbronchoscopy, such as a complete blood count (CBC), bleeding factors, arterial blood gas (ABG) , or lung function tests .

Do not eat or drink for at least 8 to 10 hours before theprocedure.

Arrange to have someone drive you home after theprocedure.

Procedure:

The patient will often be given antianxiety and antisecretorymedications (to prevent oral secretions from obstructing theview), generally atropine , and sometimes an analgesic suchas morphine. The patient is monitored during theprocedure with periodic blood pressure checks, continuousECG monitoring of the heart, and pulse oximetry .A flexible bronchoscope is inserted with the patient in asitting or supine position. Once the bronchoscope isinserted into the upper airway , the vocal cords areinspected. The instrument is advanced to the trachea andfurther down into the bronchial system and each area isinspected as the bronchoscope passes. If an abnormality isdiscovered, it may be sampled , using a brush, a needle, orforceps. Specimen of lung tissue (transbronchial biopsy )may be sampled using a real-time x-ray (fluoroscopy ).Flexible bronchoscopy can also be performed on intubatedpatients, such as patients in intensive care. In this case, theinstrument is inserted through an adapter connected to thetracheal tube.

Complications and Risks:

can scratch or tear airways or damage the vocal cords. Excessive bleeding following biopsy. laryngospasms is a rare complication but may

sometimes require intubation. Patients with tumors or significant bleeding may

experience increased difficulty breathing after abronchoscopic procedure, sometimes due to swelling of the mucous membranes of the airways.

THORACOTOMY

DEFINITION:

Thoracotomy is an incision into the pleural space of thechest.[1] It is performed by a surgeon, and, rarely, byemergency physicians, to gain access to the thoracicorgans, most commonly the heart, the lungs, the esophagusor thoracic aorta, or for access to the anterior spine such asis necessary for access to tumors in the spine.

INDICATION:A physician gains access to the chest cavity (called the

thorax) by cutting through the chest wall. Reasons for theentry are varied. Thoracotomy allows for study of thecondition of the lungs; removal of a lung or part of a lung;removal of a rib; and examination, treatment, or removal of any organs in the chest cavity

Contraindications:

Contraindications are those general to surgery and includecoagulopathy that cannot be corrected, acute cardiacischemia, and instability or insufficiency of major organsystems. vascular structures, a separate laparotomy isrecommended after the thoracotomy h as been completed.

Diagnosis/PreparationPatients are told not to eat after midnight the night beforesurgery. The advice is important because vomiting duringsurgery can cause serious complications or death. Forsurgery in which a general anesthetic is used, the gag reflexis often lost for several hours or longer, making it muchmore likely that food will enter the lungs if vomiting occurs.Patients must tell their physicians about all known allergies

so that the safest anesthetics can be selected. Olderpatients must be evaluated for heart ailments beforesurgery because of the additional strain on that organ.

Procedure:Three basic approaches are used .

Limited anterior or lateral thoracotomy: A 6- to 8-cmintercostal incision is made to approach the anteriorstructures.

Posterolateral thoracotomy: The posterolateralapproach gives access to pleurae, hilum,mediastinum, and the entire lung.

Sternal splitting incision (median sternotomy): Whenaccess to both lungs is desired, as in lung volumereduction surgery, a sternal splitting incision is used.

Patients undergoing limited thoracotomy require a chesttube for 1 to 2 days and in many cases can leave thehospital in 3 to 4 days. The principal indications forthoracotomy are lobectomy and pneumonectomy (eg, lungcancer surgery). Video-assisted thoracoscopic surgery hasreplaced thoracotomy for open pleural and lung biopsies.

Complications:In addition to pneumothorax , complications fromthoracotomy include air leaks, infection , bleeding andrespiratory failure . Postoperative pain is universal andintense, generally requiring opioids , and does interfere withthe recovery of respiratory function.Hemorrhage, infection, pneumothorax, bronchopleuralfistula, and reactions to anesthetics are the greatesthazards.
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SPUTUM COLLECTION

DEFINITION:Sputum specimen collection is a procedure designed tocollect expectorated secretions from a patient respiratorytract.

PREPARATIONIf there is any difficulty in expectorating, the physician maysuggest the use of an inhalation, an expectorant, orphysiotherapy to aid in producing sputum for collection. Thesputum should be transferred to the laboratory within twohours for analysis.

INDICATION:Sputum induction is indicated on patients with suspecttuberculosis who are unable to cough and produce anadequate sputum sample.

CONTRAINDICATION:Hypertonic saline will provoke cough in some patients. It is

harsh on the airways and may trigger severebronchospasm. It will not be used on patients with knownairway hypersensitivity such as asthma or on patientsactively wheezing at the time of the request. Patients whoexperience severe bronchospasm after a sputum inductionmay be candidates for bronchodilator or aerosol therapy torelieve induced bronchospasm (0.5 ml albuterol in

treatment cup).

EQUIPMENTS NEEDED: Sterile specimen container with cover Clean disposable gloves Facial tissues Emesis basin (optional) Toothbrush (optional) Completed identification labels Completed labora

oxygenation and hematology

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