NR Exam I Study Guide January 2020

NR Exam I Study Guide January 2020 1. Hypovolemia (FVD - fluid volume deficit & Dehydration – urine and blood recognition of symptoms) a. Occur with abnormal loss of body fluid i. ECF volume deficit ii. Plasma to ICF fluid shift iii. Inadequate fluid intake iv. Ex: diarrhea, vomiting, hemorrhage, polyuria, severe burns v. Hypovolemia (FVD) at risk individuals ● Mostly associate w/unconscious pt ● Damage to the hypothalamus, which controls the thirst center ● ↑ Insensible water loss or perspiration (high fever, heatstroke) ● Diabetes insipidus ● Osmotic diuresis, Hemorrhage, ascites ● GI losses: vomiting, NG suction, diarrhea, fistula drainage ● Overuse of diuretics, Inadequate fluid intake ● Third-space fluid shifts: burns, pancreatitis b. Dehydration: refers to loss of pure water alone without a corresponding loss of sodium or other electrolytes. c. S/S: confusion, lethargy, drowsiness, restlessness, weakness, dizziness i. ↑ pulse, ↓Central Venous Pressure, ↓urine output, concentrated urine ii. seizure , coma w/dehydration iii. Low BP, Low perfusion , ↑ respiratory rate, postural hypotension iv. Thirst, dry mucous membranes, cold clammy skin v. Decreased skin turgor, cap refill, vi. Weight loss d. May be given Lactated Ringer’s (isotonic solution) 2. Prioritization of patients – who do you see/care for first? a. ALWAYS the most unstable patient b. ABCV 3. Hypervolemia (FVE- fluid volume excess) who is at risk? a. Excess intake of fluid i. Heart failure, renal failure, and Liver failure pt ii. Excessive isotonic or hypotonic IV fluids iii. Primary polydipsia iv. SIADH v. Cushing syndrome vi. Long use of corticosteroids vii. S/S: ● S3 heart sounds - pulmonary edema ● Headache, confusion, lethargy ● Peripheral edema ● dyspnea , crackles ● Muscle spasm, seizures, coma ● JVD ● Bounding pulse, ↑BP, ↑CVP ● Weight gain ● Polyuria (w/normal renal function) 4. Review the changes in COPD illnesses a. First symptom is usually a Chronic intermittent cough, may be present every day i. Dyspnea is progressive + pts change behaviors to avoid dyspnea (elevators> stairs) until dyspnea interferes with daily activities (groceries) ii. Then they have their first COPD exacerbation and seek medical help iii. Late stages- dyspnea occurs at rest, diaphragm flattens making the pt a chest breather using intercostal + accessory muscles, there's wheezing (from laryngeal area or not present upon auscultation) + chest tightness iv. In advanced- there's fatigue (in ADL), weight loss (with adequate caloric intake) + anorexia, paroxysm of coughing may be so severe pt may faint/ fractured ribs b. (she said this was emphysema) In COPD various processes occurs such as i. Airflow limitation ii. Air trapping iii. Gas exchange abnormalities, iv. Mucus hypersecretion c. d. e. f. g. h. i. Emphysema – is the destruction of the alveoli + is a pathologic term that explains only one of several structural abnormalities in COPD patients. Loss of lung elasticity and hyper-inflammation of lung tissue i. In severe disease, pulmonary hypertension and systemic manifestations occur. ii. COPD has an uneven distribution of pathologic changes, with severely destroyed lung areas existing together with areas of relatively normal lung. iii. As air is trapped in the lungs, the chest hyper expands and becomes barred shaped because the respiratory muscles are not able to function effectively. iv. Pt may complain of not being able to take a deep breath, heaviness in the chest, gasping, increased effort to breathe, and air hunger. v. Effective abdominal breathing is decreased because of the flattened diaphragm from the overinflated lungs. vi. The anteroposterior diameter of the chest is increased (barrel chest) from the chronic air trapping Chronic bronchitis – inflammation of the bronchioles i. development of airflow limitation ii. The presence of cough and sputum production for at least 3 months in each of 2 consecutive years. Irreversible Smoking is primary risk factors S/S i. Chronic cough/ sputum production ii. Dyspnea upon exertion, inability to speak iii. Wheezing and crackles, diminished/ bronchial breath sounds iv. Barrel chest, use of accessory muscles v. Accessory muscle use, prolonged expiratory phase vi. Clubbing - late sign vii. Hyperresonant/ dull chest sounds upon percussion – due to trapped air viii. Decreased spO2 ix. Rapid and shallow resp, pursed lip breathing x. Low level of spO2 is expected in COPD patients – not a priority if low xi. pallor/ ruddy color, poor skin turgor, thin skin, easy bruising Labs i. Increased hematocrit due to increased CO2 ii. spO2 lower than 80% iii. paCO2 greater than 45 iv. Compensated Respiratory acidosis occurs v. Chest x ray showing flattened diaphragm and hyperinflation Nursing care i. Pt in high fowler position ii. Coughing, deep breathing, spirometer use iii. Proper nutrition ● increase calories intake and increase protein intake iv. Special technique breathing ● Abdominal breathing – ask pt to take a breath from the diaphragm and lay on the back with knees bent ● Pursed lip breathing – breath into the nose and out the mouth as if blowing a candle ● Huff breathing - ask the pt to sit, inhale with mouth slowly, hold breath 2-3 sec, forcefully exhale quickly (fogging up a mirror), cough when needed to secrete mucus, rest 5-10 regular breaths, repeat 3-5 cycles until mucus is secreted/ tired j. Complication i. Cor pulmonale, acute exacerbations, + acute respiratory failure ii. right sided heart failure ● Depending edema ● Distended neck vein ● Enlarged liver 5. What is the nursing care for clients with hypoxia? a. Inadequate oxygenation to the tissue level increasing respiratory rate- give oxygen i. Treat underlying condition ii. Measure O2 saturation (vitals), LOC + respiratory status iii. Monitor for late or early signs of hypoxia 6. Appropriate diet choices for K issues a. Avocado, bananes, cantaloupes, mushrooms, fish, potatoes, raisins, spinach, strawberries, greens, nuts, milk 7. Appropriate resp & cardiac assessment a. Auscultate i. General:The following characteristics of each symptom should be elicited and explored: ● Onset – sudden or gradual ● Location - radiation ● Duration – frequency, chronology Characteristics – quality, severity ● Aggravating and precipitating factors Relieving factors ● Current situation (improving or deteriorating) ● Effects on Activities of Daily Living (ADL) ● Previous diagnosis of similar episodes ● Previous treatments and efficacy ii. Cough ● Quality ● Severity ● Timing ● Duration: greater than 2 weeks (screen for Tuberculosis (TB) iii. Sputum ● Colour ● Amount ● Consistency ● Purulence, odour, foul taste ● Time of day, worse iv. Hemoptysis ● Amount of blood ● Frank blood or mixed with sputum ● Association with leg pain, chest pain, shortness of breath v. Shortness of Breath ● Exercise tolerance (number of stairs client can climb or distance client can walk) ● Posture – orthopnea or tripoding ● Shortness of breath at rest ● Association with Paroxysmal Nocturnal Dyspnea (PND) ● Associated swelling of ankles or recent weight gain vi. Cyanosis ● Central vs peripheral ● When does it occur ● Any recent changes in the pattern of ● Associated wheeze vii. Chest Pain ● Associated symptoms (Appendix 2) ● Relation to effort, exercise, meals, bending over ● Explore the pain carefully – include quality, radiation, severity, timing viii. Fainting or Syncope ● Weakness, light-headedness, loss of consciousness ● Relation to postural changes, vertigo or neurological symptoms ix. Extremities ● Edema: a. site b. relation of edema to activity or time of day ● Intermittent claudication (exercise-induced leg pain) a. distance client can walk before onset of pain related to claudication b. time needed to rest to relieve claudication c. temperature of affected tissue (warm, cool or cold ● Tingling ● Leg cramps or pain at rest ● Presence of varicose veins 8. Recognition of abnormal electrolytes – nursing care and what to do based on the assessment findings • Na :135-145 • K : 3.5-5.0 • Cl : 98-106 • Ca: 8.4-10.5 • Mg: 1.5-2.5 • P: 2.7-4.5 ● Hypernatremia ○ is treated based on the cause. ○ With water deficits, volume is replaced ( 0.9 sodium chloride). ● ● ● ● ● 9. ○ If sodium excess occurs, dilution is accomplished with sodium-free IV fluids (5%dextrose in water), dietary sodium intake is restricted, ○ if having seizures initiate seizure precautions Hyponatremia ○ if from water excess, fluid restriction is often the only treatment, loop diuretic may be given. ○ If fluid loss is the cause, replacement with isotonic sodium-containing solutions is indicated, oral intake is encouraged, and withhold diuretics Hyperkalemia ○ if experiencing dangerous cardiac dysrhythmias should receive IV calcium gluconate ○ With functioning kidney pts, withholding K+ intake and increase renal K+ eliminating is enough ○ Eliminate potassium intake ○ Increase elimination of potassium with loop/thiazide diuretics, dialysis, patiromer (binds to K+ in GI) and/ or kayexalate (binds to K+ in bowel) ○ Force potassium from ECF to ICF (with severe pts) ■ IV combine regular insulin and B-adrenergic agonist ■ dose inhalers and nebulizer B-adrenergic agonists (ex. Nebulized albuterol) ■ if patient is acidotic IV sodium bicarbonate ○ Stabilize cardiac membranes by giving IV calcium chloride, it reverses effects of elevated ECF potassium for life-threatening pts ■ Protects pt from dysrhythmias Hypokalemia ○ oral or IV potassium chloride and increasing dietary intake of potassium ■ Never give K+ IV push or bolus and it should always be diluted ○ Continuous ECG monitoring Hypercalcemia - mild pts ( underlying cause) ○ Treatment consists of restricting dietary calcium, increase weight-bearing activity ○ promoting urinary calcium excretion with loop diuretics ○ drink 3000 to 4000 mL to promote renal excretion + decrease chances of kidney stone formation ○ hydrating the patient with isotonic saline infusions. ○ Dialysis - life threatening situations Hypocalcemia ○ Depends on underlying cause + symptoms ○ Mild or asymptomatic involves diet, Oral or IV calcium and vitamin D supplementation ○ Symptomatic is treated with IV Calcium gluconate ○ Breathing into a paper bag/ sedation can control muscle spasm until Ca is fixed How to monitor fluid balance a. I/O b. Daily weights c. Laboratory findings d. Cardiovascular care i. Change in ● BP ● CVP ● Pulse force (bounding- FVE and rapid, weak, thready- FVD) ● Presence of JVD e. Respiratory care i. Pulmonary congestion ii. Pulmonary edema iii. Increased hydrostatic pressure iv. Rapid respirations (FVD) v. SOB (FVE) vi. moist crackles (FVE) f. Skin care i. Diminished skin turgor (FVD) ii. Cool and clammy skin (FVD + Na deficit) iii. Pitting edema (FVE) 10. Monitoring F/E balance with diuretics – nsg care - Urine intake and output - Urine concentration - Edema - Lung sounds - Monitor VS - Monitor labs for evaluation 11. Safe use of MDI 12. Review all of the elderly boxes and the teaching boxes for all illnesses/ diseases we discussed. a. Fluid and electrolyte imbalance i. Structural change to the kidney and a decrease in the renal blood flow leads to decreased glomerular filtration rate and loss of the ability to concentrate urine and conserve water ii. Hormonal changes include ● Decrease in renin ● Decrease in aldosterone ● Increase in ADH and ANP iii. Loss of subcutaneous tissue and thinning of the dermis leads to ● Increase moisture loss ● Inability to respond quickly to heat or cold iv. Do not automatically attribute older patient fluid and electrolyte problem to the natural problem of aging b. Respiratory system i. c. Cardiovascular i. d. COPD 13. S&S of Hypoxia (early/late) & Hypoxemia - Hypoxemia: a. Confusion b. Cough c. Tachycardia d. Tachypnea e. SOB 14. Nursing Care of Respiratory Patient - Monitor VS - Lung sounds - O2 saturation- apply O2 prn - Monitor treatment effectiveness - Peripheral pulse sites 15. Nsg care/ considerations pre & post thoracentesis a. Pre i. Have patient sit upright, support arms with pillows or bed side table leaning over ii. Tell pt to remain totally still iii. Pt skin is clainse and a local anesthetic (lidocaine) is injected subcutaneously iv. Observe the client for signs of distress, such as dyspnea, pallor, and coughing v. The patient may receive supplemental oxygen as needed, through a face mask or nasal cannula (tube). vi. Vital signs (heart rate, blood pressure, breathing rate, and oxygen level) are to be monitored during the procedure. b. Post i. No more than 1L should be removed from the procedure ● Can cause collapsed of cardiovascular ii. Monitor pt respiratory status after the procedure iii. Observe changes in the client’s cough, sputum, respiratory depth, and breath sounds, and note complaints of chest pain. 16. S&S of Hypercapnia. 17. Acid-Base Imbalances – review the giant post-it I provided during class, it gives examples of what kind of patients would have each imbalance. 18. S&S of Tuberculosis & treatment (consider the tips given during class) - Diagnosis: - a. Skin test- tests for exposure to TB b. Chest X-ray- tests for pulmonary infiltrates c. Acid-Fast bacilli- test for active TB infection Treatment: a. Infectious for the first 2 weeks after starting Tx b. 2 month initial phase w/ these drugs (table 27-11) 19. Care of a client with pneumothorax, hemothorax, and tension pneumo… also what assessment findings would cause the nurse to suspect either of these. - Pneumothorax: a. Air in the pleural space - - b. S/S: ● Dyspnea ● Decreased movement of involved chest wall ● Diminished or absent breath sounds on affected side ● Hyperresonance to percussion c. Intervention- chest tube insertion w/ drainage system Hemothorax: a. Blood in the pleural space; can happen at the same time as pneumothorax b. S/s: ● Dyspnea ● Diminished or absent breath sounds ● Dullness to percussion ● Decreased Hgb ● Shock depending on blood volume lost c. Intervention- chest tube insertion w/ drainage system; autotransfusion of collected blood; treatment of hypovolemia as necessary Tension Pneumothorax: a. Air in pleural space that does not escape b. Increased air in the pleural space shifts organs and increases intrathoracic pressure c. S/s: ● Cyanosis ● Air hunger ● Extreme agitation ● Tracheal deviation away from affected side ● Subcutaneous emphysema ● Neck vein distention ● Hyperresonance to percussion d. Intervention- medical emergency; needle decompression followed by chest tube insertion w/ drainage system 20. Nursing care of pt w/trach & suction – the specific care and nursing consideration related to the process of safe suctioning and any concepts I emphasized during class Tracheostomy is a surgically created stoma (opening) in the anterior portion of the trachea. Cuffed/Uncuffed tracheostomy tubes are available. ● Inflated cuff (balloon) is most commonly used, particularly if pt needs mechanical ventilation or is at risk for aspiration. Prolonged can cause necrosis. ● Cuff less are used with patients with a long-term tracheostomy, making eating and talking possible. ● Fenestrated tube has an opening (a hole) on the surface of the tube. Will breathe spontaneously; this permits the patient to speak with the tracheostomy tube. - Acute care mngmt: Record V/S including HR, RR, and rhythm, BP, and spO2. Ensure an existing IV line is patent and that bedside suction is working. - Ensure obturator inside the outer cannula with its rounded tip protruding from the end of the tube to ease insertion. After insertion, immediately remove the obturator so that air can flow through the tube. - Site must be assessed every shift; observe for redness, inflammation, edema, ulceration, or signs of infection. - If tube is dislodged, immediately call for help. While waiting for HCP, a respiratory therapist, or other; obtain a hemostat to spread the opening where the tube was displaced. Insert the obturator in the replacement (spare) tracheostomy tube, lubricate with saline, and insert the tube into the stoma. 21. S&S of Influenza & Pneumonia– safe administration of vaccine - Patient cannot be sick or have symptoms of illness prior to receiving the vaccine No allergies to eggs 22. Review nursing considerations for bronchoscopy, thoracentesis, chest tubes - Bronchoscopy: a. Obtain signed consent b. Instruct patient to be NPO for 6-12 hours before c. Give sedative as ordered d. Keep patient NPO until gag reflex returns e. Monitor for recovery from sedation f. Blood tinged mucus is NOT abnormal g. Monitor for hemorrhage and pneumothorax if biopsy was done Thoracentesis: a. Explain procedure to pt and obtain signed consent b. Position pt upright with elbows on elevated table and feet supported c. Tell pt not to talk/cough during procedure d. Observe for s/s of hypoxia and pneumothorax e. Verify breath sounds in all lobes f. Encourage deep breaths to expand lungs g. Send labeled specimens to lab - Chest tubes: a. Do not clamp chest tube unless looking for leaks or to change the drainage apparatus b. Complications- reexpansion pulmonary edema, symptomatic hypotension, subcutaneous emphysema (crackling felt when touching the skin) c. Sterile technique during dressing changes d. Encourage coughing, deep breathing, incentive spirometer, ROM exercises e. Monitor integrity of chest tube system f. Monitor color and amount of drainage hourly in first few hours post-op 23. Albumin and protein levels in relation to fluid balance – who might have a low albumin level or protein level….and what does the nurse do about it? (what orders would you anticipate be included in the plan of care) - Albumin Levels: a. 3.5-5.0 b. Higher- dehydration c. Lower- chronic liver disease (hepatitis, ascites), malabsorption, malnutrition, nephrotic syndrome, nutritional disorders (diarrhea, IBS) d. Indication of use = hypovolemic shock - R/t fluid balance - Serum albumin levels affect the interpretation of total calcium levels. - Total calcium values increase or decrease directly with serum albumin levels - Albumin levels do not affect ionized calcium levels. - Hypocalcemia occurs due to increased calcium binding with albumin, lowering the amount of ionized, active calcium. - ***water magnet, helps restore BP** - Anticipated orders??? - 5% = ideal for treating hypovolemic patients. - 25% Lactated Ringers = useful in treating patients with burns, hepatic failure, and ascites. 24. Care of COPD patients (emphysema, bronchitis, and asthma – treatment and nsg considerations) - Nursing Care: a. Assessment● Debilitation - ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● - Restlessness Assumption of upright position Cyanosis (bronchitis) Pallor Poor skin turgor Thin skin Digital clubbing Easy bruising Peripheral edema (cor pulmonale) Rapid, shallow breathing Inability to speak Pursed lip breathing Prolonged expiratory phase Wheezing, crackles Tachycardia Dysrhythmias JVD Right S3 (cor pulmonale) Edema Ascites Hepatomegaly (cor pulmonale) Treatment: a. Table 28-8 b. Cessation of smoking c. Airway clearance techniques- pursed lip breathing, huff cough d. O2 e. Treatment of complications f. Pulmonary rehab g. Surgical therapy h. Breathing exercises and therapy - Nursing Care: a. Health promotion- stop smoking b. Daily activities c. Inhaler use- rinse mouth afterwards d. Meds e. Causes of exacerbations f. Nutrition- lose weight if overweight, gain weight if underweight 25. Nursing care for client with CVAD/ PICC - Assessment- redness, edema, warmth, drainage, tenderness, pain; misplacement/slippage - Dressing changes and cleansing- sterile technique; change immediately if damp, loose, or soiled a. Transparent semi-permeable dressings (preferred) b. Gauze and tape (if site is bleeding) c. Cleansing skin w/ friction is important for infection prevention d. Secure lumen ports to skin above dressing site e. Document date and time of dressing changes and initial placement Injection cap changes- chlorhexidine is agent of choice a. Disinfect hubs, needleless connectors, and injection ports before accessing catheter b. Alcoholic chlorhexidine, 70% alcohol, or povidone-iodine c. Use strict sterile technique d. Tell pt to turn head opposite of insertion site during cap changes e. If you cannot clamp catheter, tell pt to lie down and do Valsalva - Maintenance of catheter patency- flushing (maintain patency and prevent med incompatibility) a. Use NaCl solution in 10mL syringe b. Do not apply force if resistance is felt c. Use the push-pause technique 26. Nsg care R/T incentive spirometer - Gives visual feedback of resp effort - Helps to prevent pneumonia - Steps: 1. Breathe in slowly through mouth as deeply as possible (try to get piston as high as possible while keeping indicator b/w arrows) 2. Hold for 10 secs 3. Once piston reaches bottom, exhale through your mouth 4. Rest 5. Repeat 10x 6. After each cycle try to cough 7. Mark level reached 27. Nursing care management of patient with upper/lower respiratory conditions - Epistaxis ● Calm sitting pt, leaning forward with head tilted forward, apply direct pressure by squeezing nostrils together for 5-15 minutes. Seek medical assistance if it doesn’t cease by then ● Packing for anterior bleeds can remain in place for 48 to 72 hours. ● Nasal packing may be left in place for 2-3 days ● Instruct pt to avoid vigorous nose blowing, engaging in strenuous activity, lifting, and straining for 4-6 weeks Allergic rhinitis ● The most important step in managing allergic rhinitis involves identifying and avoiding triggers of allergic reactions. Acute viral rhinitis ● To relieve symptoms ● Rest, oral fluids, antipyretics, and analgesics are recommended ● Warm salt water gargles, ice chips, lozenges, or spray to alleviate sore throat ● Petroleum jelly to soothe nose ● Saline nasal spray to reduce congestion Influenza ● Relief symptoms and prevent secondary infection ● Rest, hydration, analgesics, and antipyretics proves relief of symptoms Acute pharyngitis ● ● ibuprofen/acetaminophen for pain Gargles with salt and warm water, drink warm/cold liquids, suck on popsicles, hard candies, throat lozenges to relieve symptoms ● If given nystatin, tell patients to swish drug in their mouth before swallowing ● Treatment should continue until treatment is done ● Rinse mouth with water after using corticosteroids to prevent infection Tracheostomy ● Ensure an existing IV line is patent and that bedside suction is working ● keep the obturator at beside for emergencies of decannulation ● Tube is sutured and secured in place with cotton ties, tapes or velcro straps ● Complications: airway obstruction, bleeding, infection ● Clean around stoma with normal saline ● Apply sterile pre-cut dressing around the tube site at least once per shift or more frequently based on assessment ● Site assessed every shift ○ Observe for redness, inflammation, edema, ulceration, or signs of infection Pneumonia ● Overall goals is for clear breath sounds, normal breathing patterns, no signs of hypoxia, normal chest x-ray, normal WBC count, no pneumonia complications ● Proper handwashing, aspiration precautions TB ● Notification of public health department is required ● Assess for productive cough, night sweats, high temp, weight loss, pleuritic chest pain, abnormal lung sounds ● Preventive measure to prevent the spread of disease ● Tell pt to avoid drinking if taking Izonad, increase chances of hepatotoxicity of the drug Lung abscess ● Monitor VS, LOC, and respiratory status for signs of hypoxia, clubbing/cyanosis on fingers ● Administer O2 as needed ● IV antibiotics should be administered asap (clindamycin first line of therapy) ● Teaching on effective coughing Pulmonary embolism ● Bed rest in semi-fowlers position to facilitate breathing ● Administer O2 as ordered ● Assess cardiopulmonary status (VS, cardiac rhythm, O2 stat, ABGs, lung sounds) ● Teaching on long term anticoagulant therapy Pulmonary hypertension (results in Cor Pulmonale) ● Pulmonary artery pressure greater than 25 at rest or > 35 with exercise (Normal 12-16 m mm Hg) ● No treatment but improve the quality of life ● Drugs given to promote vasodilation of pulmonary blood vessels, reduce right ventricular, overload, + reverse remodeling ● Diuretics to manage peripheral edema ● Anticoagulants for prevent pulmonary complications related to thrombus formation ● Keep O2 at 90% or greater Cor pulmonale ● Low sodium diet ● Late sign of COPD ● O2 therapy 28. Care of patient with Chest Tubes (know what each chamber is for and how to assess it appropriately)b Collection chamber- receives fluid and air from pleural or mediastinal space; drained fluid stays in this chamber while expelled air vents to the water seal chamber - Water seal chamber- contains 2cm of water which acts as a one way valve; incoming air enters from the collection chamber and bubbles up through the water; the water prevents backflow of air into the patient a. Brisk bubbling → pneumothorax b. Intermittent bubbling → normal during exhalation, coughing, and sneezing c. No bubbling → lung re-expansion - Suction control chamber- applies suction to the chest drainage system a. Water- uses a column of water to control the amount of suction from the wall regulator; chamber typically filled with 20cm of water; when neg pressure exceeds the 20cm, air from the atmosphere enters the chamber through a vent on top of the unit and air bubbles up through the water → excess pressure/ cxccc relieved b. Dry- no water; visual alert to indicate if suction is working; uses a restrictive device or a regulator to dial the desired negative pressure 29. O2 delivery appropriateness – review the chart of each delivery type and the nursing considerations (specifically nasal cannula, face mask, and non-rebreather) - 30. Fluid and Electrolyte imbalance with N/V and Diarrhea-nursing interventions/implications HYPOnatremia - Causes: · Excessive sodium loss- diarrhea, vomiting, fistulas, NG suction, diuretics, adrenal insufficiency, Na+ wasting disease, burns, wound drainage · Inadequate sodium intake- fasting diets · Diseases- SIADH, heart failure, primary hypoaldosteronism, cirrhosis - Manifestations w/ Decreased ECF Volume: · Irritability, apprehension, confusion, dizziness, personality changes, tremors, seizures, coma · Dry mucous membranes · Postural hypertension · Decrease CVP · Decreased jugular venous filling · Increased pulse · Thready pulse · Cold and clammy skin - Manifestations w/ Normal/Increased ECF Volume: · Headache, apathy, confusion, muscle spasms, seizures, coma · Nausea, vomiting, diarrhea, abdominal cramps · Weight gain · Increased BP · Increased CVP - Nursing Implementation: · Replace fluid using isotonic sodium containing solutions, encouraging oral intake, withholding diuretics · Mild hypo caused by water excess = fluid restriction (500mL less than previous 24 hr output) · Acute or more serious = small amts of IV hypertonic saline solution (3% NaCl) · Pt who cannot tolerate fluid restrictions à vasopressor receptor antagonists · Monitor serum sodium levels · Levels should not increase by more than 8-12 in the first 24 hours 31. Triggers and Risk factors which contribute to a respiratory exacerbation event - Allergic Rhinitis: - Asthma: 32. Nsg care for pt with Pulm Embolism - S/s: a. May begin slowly or suddenly b. Dyspnea *most common* c. Mild-moderate hypoxemia d. Tachypnea e. Cough f. Chest pain g. Hemoptysis h. Crackles i. Wheezing j. Fever k. Tachycardia l. Accentuation of pulmonic heart sound m. Syncope n. Massive embolism- sudden change in mental status, hypotension, feelings of impending doom - Nursing Care: a. Keep pt on bed rest in semi-fowler's position b. Admin O2 therapy c. Carefully monitor VS, cardiac rhythm, pulse ox, ABG’s, and lung sounds d. Maintain and IV line e. Monitor labs to ensure therapeutic ranges of INR (warfarin), and aPTT (heparin) f. Monitor for complications of anticoagulants g. Provide fall precautions when off bed rest h. Patient education i. Patient teaching regarding long term anticoagulant therapy (3 months) 33. Care of the client with venous thrombosis and VTE - Assessment: a. Fever b. Anxiety c. Pain d. Increased extremity diameter compared to other side e. Shiny, warm skin f. Erythematous and tender g. Distention and warmth of superficial veins in affected area h. Edema and cyanosis of ext, neck, back, face (if sup, vena cava involvement) i. Increased Hct and RBC j. Leukocytosis k. Increased D-dimer 1. Nursing plans: ● Pain relief, decreased edema, increased knowledge of disorder + treatment plan, no skin ulceration, no bleeding complications and no evidence of PE ● Focus care in prevention of emboli formation + reduction of inflammation 2. Nursing actions a. Review medication reconciliation for anticoagulant interaction b. Monitor INR, aPTT, ACT, anti factor X levels, CBC, creatinine, factor x levels, Hgb, Hct, Plt, liver enzymes c. Titrate doses of UH, warfarin, and direct thrombin inhibitors d. Monitor for bleeding e. Pt receiving warfarin with an INR > 5.0 = risk of bleeding f. Early ambulation + teaching on ambulation and exercise g. Limit standing/sitting in a motionless dependent position h. Consistent diet of foods containing vitamin K and avoid vitamin K supplements i. Graduated compression stockings j. Bed rest with elevation of limbs may be prescribed with acute VTE with severe edema and limb pain k. Caring for a patient with VTE 34. Care of the client with STEMI or NSTEMI and what diagnostic test would the nurse anticipate be included in the plan of care. Also, how to recognize an active heart attack. - STEMI: a. Occlusive thrombus b. ST elevation c. Artery must be opened w/in 90 minutes d. Send to cath lab immediately e. Diagnostic Tests- ECG, biomarkers (negative) - NSTEMI: a. Non-occlusive thrombus b. No ST elevation c. Diagnostic Tests- ECG, biomarkers (positive) 35. Nursing care and considerations for PAD, PVD, hyperlipidemia, CAD and ACS. - PAD/PVD: Table 37-2 a. Assessment PAD: Table 37-4 ● Skin breakdown and arterial ulcers ● Gangrene ● Mobility/sensation impairment ● Decreased ABI ● Decreased perfusion and oxygenation of the calf b. Table 37-2 Management - cardiovascular disease risk factor modification ○ Tobacco cessation ○ Regular exercise ○ Achieve and maintain ideal body weight ○ Tight glucose and BP control ○ Hyperlipidemia treatment ○ Treatment of claudication symptoms (exercise program, structured walking) ○ nutritional/ physical therapy ○ Proper foot care Table 37-1 - - c. Nursing actions ● Assess for risk factors (33-1 and 33-2) ● Diet modification- reduce cholesterol, sat fat, refined sugars (33-3 and 33-4) ● Foot hygiene ● Avoid injuries to ext ● Check operated ext every 15 mins initially then hourly (color, temp, cap refill, peripheral pulses, sensation, movement) ● Pain management ● Complications- bleeding, hematoma, thrombosis, embolization, compartment syndrome ● Blockage of graft or stent = dramatic increase in pain, loss of pulses, extreme pallor/cyanosis, numbness/tingling, cold ext ● Avoid knee-flexed position ● Turn pt frequently w/ pillows to support incision ● Post op day 1- assist pt out of bed many times ● Discourage prolonged sitting with legs in dependent position ● Edema- position pt supine w/ legs elevated above heart ● Graduated compression stockings to control edema ● Wear clean cotton or wool socks ● Shoes with rounded toes and soft insoles ● Loose laces ● Smoking cessation education Hyperlipidemia- Monitor cholesterol levels - LDL - HDL - Risk for coronary artery disease - They might have an MI since arteries are closing with plaque - Treat with statins to lower cholesterol levels (check liver function every 6 months because of toxicity since the liver produces cholesterol) CAD: a. Risk factors: ● Nonmodifiable- age, gender, ethnicity, family history, genetics ● Modifiable- elevated serum lipids, elevated BP, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, psychologic states, elevated homocysteine level b. Nursing Actions: ● Health promotion and education about risk factors ● Lifestyle changes ● Table 33-2 - ACS: a. Assessment: ● Anxious fearful ● Restless ● Distressed ● Cool, clammy, pale skin ● Tachycardia ● Bradycardia ● Pulsus alterans ● Pulse deficit ● Dysrhythmias ● High or low BP b. Nursing Action: ● Position pt upright and apply O2 ● Assess VS ● Obtain 12-lead ECG ● ● ● ● ● ● ● Provide pain relief Auscultate heart and breath sounds ID precipitating factors for angina ID personal risk factors Encourage regular physical activity Educate on proper use of nitro Priority interventions for initial phase: 1. Pain assessment and relief 2. Physiologic monitoring- ECG and oxygenation 3. Promotion of rest and comfort 4. Alleviation of stress and anxiety 5. Understand pt emo and behavioral actions ● Cardiac rehabilitation- physiologic, psychologic, mental, spiritual, economic, and vocational 36. Care of client with either cardiac rhythm we discussed in class – refer to the giant post-its and or the discussions during class 37. Be able to identify the differences between R and L heart failure and the appropriate nursing care. 38. Review the nursing care and considerations for a pt with raynaud’s phenomenon or buerger’s disease Raynaud’s Phenomenon - - Vasospasm induced color changes of fingers, toes, ears, +nose (white, blue, +red) Decreased perfusion results in pallor, the digits then appear cyanotic (blue-purple) Diagnosis is based on persistent symptoms for at least 2 years Vasoconstrictive phase: coldness, numbness Hyperemic phase: throbbing, aching pain, swelling, tingling Exposure to cold, tobacco, emotional upsets, and caffeine bring on the symptoms Primary focus → PATIENT TEACHING and PREVENTING RECURRENT EPISODES Education: a. Wear loose, warm clothes b. Avoid temperature extremes c. Immersing hands in warm water d. Stop using tobacco products and caffeine e. Stress management Nifedipine is first drug of choice Buerger’s Disease - Occurs mostly in young men with a long Hx of tobacco or marijuana use Acute phase: inflammatory thrombus forms and blocks the vessel Chronic phase: tissue ischemia - S/s- intermittent claudications of feet/hands/arms, rest pain, ischemic ulcerations, color/temp changes of the limbs, paresthesia, superficial vein thrombosis, cold sensitivity - Primary Tx: cessation of tobacco and marijuana use - Use of nicotine replacement products is CONTRAINDICATED - Education: a. Avoid limb exposure to cold temps b. Supervised walking program c. Antibiotics for infected ulcers d. Analgesics to manage ischemia e. Avoid trauma to extremities f. Viagra and CCB’s can be used to ease the pain - Surgical option: Sympathectomy a. Improves distal blood flow b. Reduce pain c. Decrease rate of amputation d. Does NOT alter inflammatory response 39. Review all cardiac rhythms discussed in class. SINUS BRADYCARDIA SINUS TACHYCARDIA PREMATURE ATRIAL CONTRACTION (PAC) ATRIAL FLUTTER ATRIAL FIBRILLATION PREMATURE VENTRICULAR CONTRACTION VENTRICULAR TACHYCARDIA VENTRICULAR FIBRILLATION PREMATURE JUNCTIONAL CONTRACTION ASYSTOLE ARTIFACT 40. How would the nurse assess the results of the ankle-brachial index test? - ABI is a PAD screening tool using a doppler - Divides the ankle systolic BP by the higher of the left/right brachial systolic BP 41. Review the IV fluid chart from chapter 16…review the indication of use column especially Commonly Used Crystalloid Solutions - Dextrose: · 5% a. Isotonic but physiologically hypotonic b. Indications- contains free water only, no electrolytes, provides 170 cal/L, used to replace water losses and treat hypernatremia · 10% a. Hypertonic b. Indications- contains free water only, no electrolytes, provides 340 cal/L, used with parenteral nutrition - Saline: · 0.45% a. Hypotonic b. Indications- contains free water, Na+ and Cl-, no calories, used to treat hypernatremia and uncontrolled hyperglycemia, used as a maintenance solution · 0.9% a. Isotonic b. Indications- contains Na+ and Cl- in excess of plasma levels, does not contain free water or calories, used to expand intravascular volume and replace extracellular fluid losses, only solution that may be admin w/ blood products, may cause volume overload in pt w/ cardiac or renal disease · 3.0% a. Hypertonic b. Indications- contains Na+ and Cl- in excess of plasma levels, used to treat symptomatic hyponatremia and trauma pt w/ head injury, admin slowly bc it may cause volume overload and pulmonary edema - Dextrose in Saline: · 5% in 0.25% a. Isotonic b. Indications- provides Na+, Cl- and free water, used to replace hypotonic losses and treat hypernatremia, provides 170 cal/L · 5% in 0.45% a. Hypertonic b. Indications- provides Na+, Cl-, and free water, used as a maintenance solution · 5% in 0.9% a. Hypertonic b. Indications- contains Na+ and Cl- in excess of plasma levels, used to treat metabolic alkalosis and volume deficits in pt w hyponatremia - Multiple Electrolyte Solutions: · Ringer’s a. Isotonic b. Indications- similar in composition to plasma except that it has excess Cl-, no Mg2+ and no HCO3; does not provide free water or calories, used to expand the intravascular volume and replace extracellular fluid losses · Lactated Ringer’s a. Isotonic b. Indications- similar in composition to normal plasma except does not contain Mg2+; does not provide free water or calories, used to treat hypovolemia, burns, and GI fluid losses, cannot be used in pt w/ alkalosis or lactic acidosis 42. What is the difference between heart failure and fluid overload? Remember fluid may sometimes be isolated versus when fluid spreads in multiple areas of the body. Fluid volume excess results from excess intake of fluids, abnormal retention of fluids (seen in heart failure & renal failure), or a shift of fluid from the intestinal fluid into plasma fluid. *Too much-circulating fluid in the blood Can cause third spacing; when excess fluid collects in nonfunctional areas between the cells · Can also have peripheral edema, bounding pulses, JVD · Daily weights are the most accurate measure of volume status · Labs; increased BUN, sodium, and hematocrit levels with increased plasma and urine osmolality. · Therapy; fluid restrictions, diuretics, and some may need sodium restrictions. · The goals of treatment in fluid imbalances are to correct the underlying cause and to restore fluid and electrolyte balance. Heart Failure is a complex clinical syndrome that results in the inability of the heart to provide sufficient blood to meet the oxygen needs of tissues and organs *fluid retention Caused by blood backing up because of ineffective pumping, in return the kidneys compromise by retaining sodium and water causing fluid overload. · Worsening of ventricular function and chronic neurohormonal activation that eventually results in hypertrophy of the ventricles. · Hypertension (modifiable) and CAD are the primary risk factors for HF. · A commonly ordered diet for a patient with HF is a 2-g sodium diet. · Edema can occur in dependent body areas; o Peripheral edema o Hepatomegaly o Ascites o Pulmonary edema/pleural effusion o Pitting edema (issues with veins in the affected area, or a systemic issue with heart, kidney, or liver fnx) o Sudden weight gain of 3 lbs or more in 2 days is a sign of ADHF 43. Complications of central lines Catheter Occlusion Causes: · Clamped or kinked catheter · Tip against wall vessel · Thrombosis · Precipitate buildup in lumen Management: · Instruct pt to change positions, raise arm, and cough · Assess for and alleviate clamping or kinking. · Flush with normal saline using 10-ml syringe. DO NOT FORCE FLUSH. · Perform fluoroscopy to determine cause and site. · Instill anticoagulant or thrombolytic agent. Embolism Causes: · Catheter breaking · Dislodgement of thrombus · Entry of air into circulation Management: · Administer O2 · Clamp catheter · Place pt on left side with head down (air emboli) · Notify the physician Catheter-related infection (local/systemic) Causes: · Contamination during insertion or use · Migration of organism along cather · Immunosuppressed pt Management: Local- · Culture drainage from cite · Apply warm, moist compresses · Remove catheter if indicated Systemic· Take blood cultures · Give antibiotic · Give antipyretic therapy · Remove catheter if indicated Pneumothorax Causes: · Perforation of visceral pleura during insertion Management: · Administer O2 · Position in semi-fowler's position · Prepare for chest tube insertion Catheter Migration Causes: · Improper suturing · Insertion site trauma · Changes in intrathoracic pressure · Forceful flushing · Spontaneous Management: · Perform fluoroscopy to verify position · Assist with removal and new CVAD placement. In Class Jeopardy 1. Stridor- crowing sound, obstruction of larynx or trachea 2. Pneumonia- pleuritic chest pain, green/yellow sputum, and fever 3. Acid-fast bacilli- sputum smear to diagnose TB 4. Standard precautions- wear gown, gloves, and any PPE necessary 5. CT scan- advanced x ray, contrast is given, used to further assess structures of lungs and diagnose PE 6. Allergic rhinitis- sneezing, itchy eyes, altered smell 7. Impaired tissue perfusion- nurse is caring for a client whose pulse ox is 92%, the upper and lower extremities are cool to touch, with sluggish capillary refill 8. Contact isolation- diagnosis of MRSA in a wound or VRE in urine 9. TB- coughing up blood, fever, night sweats 10. Empyema- purulent pleural fluid w/ bacteria related to having a pleural effusion 11. Pulmonary embolism- hemoptysis, irregular heartbeat/rhythm, dyspnea 12. Early sign of hypoxia- unexplained apprehension, tachypnea, tachycardia 13. V/Q scan- evaluates ventilation and perfusion when a pulmonary embolus is suspected 14. Airborne isolation- need for N95 mask, negative pressure room, concerned with breathing particles floating in the air 15. Droplet precaution- wear a surgical mask, positive pneumonia or flu, patient is sneezing often 16. Sinusitis- hypertrophy of the mucosa in the sinuses 17. Contact plus/enhanced contact isolation- pt has diagnosis of c.diff 18. Chest physiotherapy- tapping or clapping hands on the back of the patient to loosen mucus 19. Artificial airway- ET tube or tracheostomy 20. Pulse Oximetry- measures oxygenation to cells and tissues in the hand 21. Lung biopsy- tissue is extracted from the lungs to determine malignancy of cells 22. Ineffective airway clearance- nurse is caring for a client who has a nonproductive cough 23. Acute pain- client has pleuritic chest pain with every cough 24. Ineffective breathing pattern- nurse assess the pt breathing fast and shallow, hyperventilation 25. Risk for infection- sharing eating instruments and drinking straw from a family member who has strep Huff Coughing Sepsis - Symptoms of Sepsis (need 2+) a. Fever greater than 101 b. c. d. e. Hypothermia less than 98.6 HR greater than 100 RR greater than 20 WBC greater than 12,000 or less than 4,000