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NH&I -II final
study guide
| Question | Answer |
|---|---|
| PNEUMOTHORAX, definition, causes | air in plueral space occurring spontaneously or from trauma |
| PNEUMOTHORAX-s/s | diminished breath sounds, air hunger, agitation, hypotension, cyanosis, dyspnea, chest discomfort |
| PNEUMOTHORAX- interventions (achieving effective breathing pattern) | assist c emergency thoracentesis, maintain patent airway, position pt in upright position to allow for greater chest expansion, maintain patency of chest tubes, CPR if necessary, assist pt to splint when TCDB, admin meds prn, monitor O2 & ABG, provide O2 |
| PNEUMOTHORAX- nsg. diagnosis | Ineffective Breathing Pattern R/T air in plueral space, Impaired Gas Exchange R/T atelectasis and collapse of lung |
| PNEUMOTHORAX- teaching | instruct to continue use of IS, encourage to report sudden dyspnea immed. |
| CHEST TUBE-need for | to drain fluid or air from lungs. Hemothorax-blood, Pneumothorax-air |
| CHEST TUBE- after procedure assessment, intervention | assess pain at insertion site, give meds prn, assess for signs of infection, patency of drainage tubes, fluid being removed, bubbling of water in system, sutures intact |
| PLEURAVAC- what is it | consists of, collection chamber, water seal chamber, suction control chamber, want bubbling water |
| IgE triggers release of histamine, can create hypersensitivity reactions, there are 4 types | type I, II, III, IV |
| TYPE I | dust,pollen, bee stings |
| TYPE II | occurs c blood tx's or medications |
| TYPE III | causes tissue damage, autoimmune reactions, occupational diseases |
| TYPE IV | contact dermatitis, TB skin testing, transplant rejection |
| CONGESTIVE HEART FAILURE- (CHF) | occurs when cardiac output cannot meet the metabolic demands of the body |
| CHF- causes | myocarditis, cardiomyopathy, acute rheumatic fever, chronic pulmonary disease, arrhythmias, anemia, fluid overload |
| CHF- s/s | tachycardia, weak peripheral pulses, cool extremities, delayed capillary refill, pallor, pulmonary congestion, tachypnea, cyanosis, cough, edema, water wt. gain, decreased urine output, increased HR |
| CHF- chest x-ray shows | cardiomegaly, pulmonary congestion |
| CHF- meds to treat | digoxin to increase myocardial contractility, diuretics (furosemide, spironolactone) to reduce intravascular volume, ACE inhibitors to reduce workload of myocardium (captopril, enalapril, lisinopril)Beta- adrenergic blockers (metoprolol, carvedilol) |
| CHF- complications | pulmonary edema, metabolic acidosis, arrhythmia, death |
| CHF- interventions | admin. meds as prescribed, report signs of possible dig toxicity, N/V, halo's, bradycardia, ECG if ordered, daily wts., O2 if ordered, auscultate lungs, monitor for signs of infection; fever, cough, N/V, diarrhea |
| CHF- teaching | elevate HOB, teach med admin., how to check apical HR, adverse effects, monitor and report edema |
| CHF- various nrsg dx | Decreased Cardiac Output, Excess Fluid Volume, Impaired Gas Exchange, Risk for Infection |
| HYPERTENSION- (HTN) high BP | normal BP is systolic, <120, diastolic, <80, high BP is systolic, 140 and up, diastolic, 90 and up |
| HYPERTENSION- (primary) cause | unknown, could be genetic |
| HYPERTENSION- (secondary) | HTN occurs secondary to another issue, ex: Cushing's syndrome leads to an increase in adrenocortical steroids and HTN |
| HTN- s/s--- there are none, known as the silent killer. The risk factors are | age, race, obesity, family hx, smoking, sedentary lifestyle, DM |
| HTN-teaching | lose wt, limit alcohol, cut sodium, stop smoking, reduce caffeine, teach pt. to monitor BP, take meds as ordered |
| HTN- meds | avoid hormonal contraceptives, NSAID's, antihypertensives incl., (Lopressor), (Inderal), (Coreg), (Benicar), (minoxidil) also use diuretics, (Lasix), (Diuril), (HydroDIURIL)-- (minipress),(captopril) |
| CHEST PAIN- also called | angina |
| TYPES OF ANGINA- stable | 75% occlusion , pain decreases c decreased activity |
| TYPES OF ANGINA- unstable | 90% occlusion, CP increases in frequency and severity, does not decrease c rest or PO nitro |
| TYPES OF ANGINA- variant (Prinzmetal's) | pain same as stable but lasts longer and occurs at rest |
| ANGINA- s/s | elephant on chest, pressure or tightness, pain to left arm or jaw, pale, diaphoretic, SOB,N/V |
| DX TESTS FOR ANGINA- | EKG- detects changes in waveform & dysrrhythmia's, Stress Test- assesses severity of CAD by CV response to exercise, Coronary Angiography (Cardiac Cath)- checks pressures in heart chambers, assesses occlusions of coronary arteries |
| ANGINA- meds | cardiac glycosides-(lanoxin, digoxin, used in A fib, flutter, CHF, slows HR) vasodilators- (prevents and treats angina, nitroglycerin) calcium channel blockers- (used for stable angina, decreases BP, cardizem, procardia) |
| ANGINA-meds cont. | beta blockers- decreases workload on heart by decreasing CO, DO NOT stop suddenly, lopressor, inderal,tenormin)O2- 2-4L/NC to start, ASPIRIN-in low dose can actually stop heart attack |
| NITROGLYCERIN- teaching | sit dowm at onset of CP and rest, place tab under tongue, repeat q5 min x3 (maximum), if no relief call 911, keep in original glass container, SE- HA, DO NOT stop taking because of HA! |
| ANGINA- meds cont. | Analgesics-(morphine, decreases anxiety & workload on heart, next DOC for CP unresponsive to NTG) Thrombolytics- when blockage confirmed, use immed., will dissolve clots,( streptokinase), must prevent bleeding. |
| EPINEPHERIN is | emergency drug, causes vasoconstriction, increases BP, HR, & CO |
| CHEST PAIN PROTOCOL- | MONA- morphine, o2, nitro, aspirin |
| FLUID losses- | primarily urination, bowel elimination, perspiration, breathing |
| INSENSIBLE FLUID LOSS | through the skin |
| FLUID IMBALANCES-hypovolemia- causes | fluid volume deficit-inadequate fluid intake, loss c hemorrhage, V/D, burn injury, |
| HYPOVOLEMIA- s/s | EARLIEST S/S IS THIRST, wt loss, low BP, raised temp, rapid pulse, rapid resp., scant dark urine, dry stool, warm dry skin, neck veins flat, sleepy, lungs clear |
| FLUID IMBALANCES- hypervolemia- causes | fluid volume excess- excessive oral intake or rapid IV infusion of fluid, consequence of heart failure. can lead to circulatory overload, fluid retention RT kidney disease, excessive salt intake, adrenal gland dysfunct. or admin of steroid(prednisolone) |
| HYPERVOLEMIA- s/s | wt gain, high BP, normal temp, full bounding pulse, moist labored resp., cool pale moist skin, pitting edema, lungs wet, crackles,gurgles, dyspnea, orthopnea breathing, distended neck veins, anxious |
| HYPOVOLEMIA- evidence of | reflected in elevated Hct levels, and blood cell counts, urine specific gravity is high, central venous pressure is below 4cm H2O |
| HYPOVOLEMIA- NI | respond to thirst, daily wts, consume 8-10 glasses of water or more /day, avoid alcohol and caffeine, rise slowly from sitting or lying position, include moderate amts of salt in diet |
| HYPERVOLEMIA- evidence of | blood cell count and Hct levels are low, urine specific gravity is low, CVP is above 10cm H2O |
| HYPERVOLEMIA- NI | admin diuretics, modify diet to restrict salt intake, VS, daily wt, I&O, breath sounds, location & extent of edema, 2lb wt gain in 24h indicates pt is retaining 1L of fluid,limit and ration fluid intake, high fowlers to ease breathing effort |
| PRELOAD- what is it | when ventricles fill c blood |
| PULMONARY EDEMA-s/s- (left sided CHF) | requires emergency tx, accumulation of fluid in lungs, fluid escapes and fills airways, s/s- dyspnea, breathlessness, feeling of suffocation, cool, moist, cyanotic extremities, skin color is cyanotic or gray, cough c PINK FROTHY SPUTUM |
| LARYNGEAL EDEMA- | symptom of anaphylaxis |
| BONE MARROW TRANSPLANT- nsg dx | risk for infection RT compromised immunity |
| BONE MARROW TRANSPLANT-nsg management | assess pt nutritional status, monitor for signs of infection & renal insufficiency, assess for signs of graft/host; irritability, hepatitis, sepsis, enlarged spleen & lymph nodes, use protective isolation, review info RT prevent of infection, signs of rej |
| BONE MARROW TRANSPLANT- reasons for | decreased marrow in pt c cancer due to chemo, radiation, pt c leukemia, HIV/AIDS |
| MANTOUX SKIN TEST-( TB TEST) | to see if a pt's been infected, test does not differentiate between active or dormant disease |
| TB TEST admin, & results | intradermal injection on inner forearm, leaves bleb, do not rub, read test site 48-72 hrs after injection. Neg.-0-4mm induration, Questionable-5-9mm induration, (if pt aware of contact c infected person, this is seen as significant) Pos.-10mm or greater |
| TPN- what is it | hypertonic solution of nutrients designed to meet nearly all caloric & nutritional needs of severely malnourished pt's, or those who can't eat or drink for a long time. extremely concentrated, are instilled in central circulation |
| TPN- candidates for TPN incl. pt's who | have had a 10% or more loss of body wt, have anorexia nervosa, pt's c cancer of esophagus or stomach, major trauma or burns, c liver and renal failure |
| TPN- admin implications | long term admin can lead to plebitis, fluid overload, diarrhea, and rebound hypoglycemia |
| TPN- labs to monitor | protein, albumin, BUN, RBC, WBC, B12, cholesterol, Hgb |
| LAB VALUES- | glucose-70-110, k+- 3.5-5, na+ 135-145, Chloride- 100-108, WBC-4500-11000, RBC- 4.5-5.3 million, Hgb- M-13-18, F-12-16, Hct- M-35%-49%, F-36%-46%, UA- WBC, blood, glucose, nitrates-Neg., Ca+ - 4.5-5.6, pH-7.35-7.45 |
| PAIN CONTROL- all types | meds- NSAID's, analgesics, opiates, dark quiet place, distraction, no stimulus, meditation, exercise, pain scale 0-10. |
| IRREGULAR RESPIRATIONS- | ???? - normal respirations are 14-20 /min. bradypnea-<12 bpm, tachypnea->20 bpm, hyperventilation- >20 bpm deep breathing, kussmaul- rapid, deep, labored |
| PULMONARY EMBOLIS- what is it | blood clot in heart travels to lungs.,foreign particle could be blood clot, air, fat, usually forms in lower extremities |
| PE- s/s | pain, tachycardia, dyspnea, fever, cough, blood-streaked sputum, SORE CALF, increased resp rate |
| PE- medical mngmt | lovenox, heparin, EKG, x-ray, complete bed rest, O2, analgesics |
| PE- nsg interventions | best management is prevention!, test for + homans sign, IV, before shock admin vasopressors (dopamine, dobutamine) O2, VS, I&O, analgesics, DO NOT massage legs |
| SURGICAL CONSENT FORMS- | responsibility of MD, nurses role as witness, legal document, confirms pt consent for just the procedure pt is there for |
| DETERMINING APPROPRIATE NSG DX- | highest priority for disease or problem, or RISK for |
| PRIORITY SETTING- | ABC's- airway, breathing, circulation |
| MED TEACHING- basic for most | take all meds as prescribed, finish all antibiotics, inform pt of SE, inform pt when it is important to call dr., interactions c other meds, DO NOT discontinue meds s talking to dr. avoid alcohol, caffeine, stop smoking, OTC drugs |
| ATELECTASIS- what the heck is it | occurs secondary to aspiration of food, fluid, air, mucus plug, COLLAPSE OF LUNG |
| ATELECTASIS- s/s | cyanosis, fever, pain, dyspnea, O2, increased pulse & resp. rate |
| ATELECTASIS- medical, nsg mngmt | suctioning, DB & cough, bronchodilators, humidifiers, O2 admin. positioning, semi or high fowlers for comfort, TCDB, knowledge deficit, auscultate lungs, make comfortable |
| TB- what is it | infectious disease caused by bacteria, spread from person to person thru the air (airborne). usually infects the lung but can occur at virtually any site in the body. HIV infected pt's are especially at risk. spread by cough, talk, sneeze, even singing |
| TB- s/s | fatigue, anorexia, wt loss, slight non productive cough, blood tinged grayish sputum, low grade fever, night sweats |
| TB- dx tests | mantoux test, sputum smear, sputum culture, chest x-ray, |
| TB -meds | family members must take meds for 1 yr to keep from becoming infected, INH most common med, (rifampin, rifabutin, cause harmless SE of orange, red colored secretions) most common adverse effects are rash, GI intolerance, liver toxicity (from meds)antibiot |
| TB- nsg interventions | assess for symptoms of active disease, auscultate lung for crackles, assess for liver dysfunction, |
| TB- teaching | compliance is huge! if meds aren't taken infection continues to be spread, long drug therapy, up to 2 yrs, isolation is necesary, wear mask, wash hands, educate pt about disease and transmission, if had vaccine-DO NOT get TB test |
| O2 THERAPY- types | nasal cannula, can't deliver O2 concentration much higher than 40%, simple face mask, delivers O2 concentrations at 40-60%, venturi mask, mixes air and O2 to deliver constant O2 concentration, partial rebreather, inflatable bag that stores 100% O2, |
| O2 types cont. | nonrebreather mask, inflatable bag to store 100% O2 and a one way valve to prevent exhaled air from entering bag, CPAP, provides expiratory and inspiratory positive airway pressure. |
| O2 THERAPY- reason for | to treat or prevent symptoms and manifestations of hypoxia |
| O2 THERAPY- interventions | obtain ABG values, assess pt's current oxygenation, ventilation, and acid-base balances, admin O2 in the approp. concentration, MOST COMMON concentration- 2-4L, monitor response by oximetry or ABG, no smoking, explain equipment, inspect skin behind ears |
| LABS TO DETERMINE EXTENT OR PRESENCE OF CARDIAC DISEASE- | lab values, pulse oximetry, MRI, EKG, holter monitor, exercise tolerance test, stress test, echo, TEE, thallium imaging |
| SUDDEN CARDIAC DEATH - usually caused by what | v-tach, v-fib, severe bradycardia, asystole |
| lasix-furosemide- diuretic | ptomotes sodium and water excretion |
| lasix- SE | dizziness, dehydration, blurred vision, thrombocytopenia, orthostatic hypotension, hypokalemia |
| lasix- NI | weigh daily, measure I&O, monitor K+ level, advise pt to replace lost K+ c bananas, OJ, prescribed supplement |
| morphine- opiate | for anxiety, pain, post-op |
| morphine-SE | resp depression, hypotension, N/V, constipation, HA, restlessness, rash, hives |
| morphine- NI | use c caution in pt's c asthma, hepatic, renal, or seizure disorders, useful forsedation during painful procedures, may cause hypotension in pt's c acute MI |
| famotidine (pepcid)-SE | HA, dizziness, diarrhea, constipation, muscle cramps, ED |
| pepcid-NI | give c meals, and at HS, encourage reg checkups, report sore throat, fever, unusual bleeding/ bruising, dizziness, severe HA, muscle/ joint pain |
| cironolactone- (aldactone, spirotone) | K+ sparing diuretic, promotes excretion of Na+, and water particularly in cases of ascites |
| aldactone-SE | HA, drowsiness, confusion, ataxia, gastric bleeding, hyperkalemia, dehydration, hirsutism, agranulocytosis |
| aldactone- NI | to enhance absorption, give c meals, protect drug from light, monitor electrolytes, I&O, wt, admin in AM, avoid K+ supplements and salt substitutes |
| beta blockers- propranolol (inderol) | prevent or inhibit sympathetic stimulation, used to prevent anginal attacks, and to reduce symptoms of hyperthyroidism(tachycardia, tremors, nervousness) |
| inderol- SE | bradycardia, hypoglycemia, ED, CHF, dysrhythmias |
| inderol-NI | monitor cardiac function, blood glucose in pt's c diabetes, monitor for fliud retention, rash, difficulty breathing, do not DC abruptly, admin c meals |
| antidysrrhythmias- vasopressor | used in cardiac emergencies- epinephrine(adrenalin)- increases HR, force of contraction, and BP, used in asystole |
| antidysrrhythmic - SE | hypertension, dysrhythmia, pallor, oliguria |
| antidysrhythmia-NI | admin q5 min during cardiac resuscitation, monitor VS, cardiac rhythm |
| cholinergic antagonist (atropine) | increses HR, used for bradydysrhythmias, |
| atropine-SE | palpitations, tachycardia, urinary retention |
| atropine- NI | monitor for therapeutic and adverse effects, document HR before and after admin |
| class 1 antidysrhythmic-lidocaine | used for ventricular dysrhythmias, decreases ventricular excitability |
| lidocaine- SE | dizziness, fatigue, drowsiness, vomiting, vision changes, seizures, hypotension |
| lidocaine- NI | monitor cardiac rhythm, VS, keep life support equip available |
| cardiac glycosides-aka, digitalis glycosides | benefit failing heart, also help control ventricular response to A-fib, or flutter |
| most commonly used positive inotropic drug | digoxin |
| antihypertensives- minipress | relax vascular smooth muscle |
| minipress- SE | orthostatic hypotension, drowsiness, dizziness, nausea, palpitations |
| minipress- NI | admin before HS, monitor for postural hypotension, caution pt to change positions slowly |
| antihypertensives-ACE inhibitors -captopril (capoten) | promotes fluid and Na+ loss, and decreases peripheral vascular resistance |
| captopril-SE | tachycardia, hypotension, GI irritation, pancytopenia, proteinuria, dry mouth, dry cough, hyperkalemia |
| captopril-NI | hypotension is common in older adults, admin 1 hr before or 2 hrs after meals, monitor K+ blood urea, nitrogen and creatinine |
| hypoglycemia- s/s | confusion, irritability, sweating, nervousness |
| hyperglycemia= s/s | fruity/ acetone smell to breath, incresed pulse, abdominal breathing |
| digoxin (lanoxin) teaching | take med same time qday, never double dose or skip dose, TAKE APICAL PULSE 1 FULL MIN BEFORE GIVING, if <60, do nottake! before taking other meds, or OTC meds ask MD |
| drugs that increase dig toxicity | adrenergics, furosemide, laxatives, steroids, thiazide diuretics. ANOREXIA is early sign of toxicity |
| signs of dig tox | colored vision, halos, flickering lights |
| drugs that reduce therapeutic effects of dig | antacids, antidiarrheals, anticholinergics, barbituates |
| heparin- anticoagulant (lovenox) | inhibits thrombus and clot formation |
| heparin- SE | hemorrhage, bruising, fever, local irritation |
| heparin- NI | have protamine sulfate available in case of OD, avoid vit k foods, use electric razor, soft toothbrush to protect agaist bleeding |
| coumadin-warfarin | interferes c vit k dependent clotting factors |
| coumadin-SE | nausea, alopecia, prolonged bleeding |
| coumadin-NI | evaluate pt for signs of blood loss, petechiae, dark stools and urine, bruises, bleeding gums, vit k for OD, monitor WBC to assess for neutropenia |
| AZT- HIV drug (antiviral)-SE | anemia, nausea, GI pain, diarrhea, myositis, HA, fever, rash |
| AZT- NI | monitor T4 cell counts, admin drug q4h ATC, tell pt to report extreme fatigue, N/V, rash, |
| neupogen- ??? | ??? increases production of neutrophils, used for cancers, leukemia, HIV ??? |
| epogen- (procrit, epoeiten alpha) | increases production of RBC, used for cancers, leukemia, HIV |
| chemo, antineoplastics cause- | bone marrow suppression, N/V, alopecia |
| chemo- NI | monitor closely for extravasation, to prevent drug from leaking into tissue, causing blistering and necrosis |
| tx of exravasation | stop admin of drug, leave needle in place, aspirate gently residual drug and blood, inject neutralizing solution (sodium bicarb) to reduce tissue damage |
| chemo- SE | neutropenia, stomatitis, bone marrow suppression . wkly monitoring of CBC |
| neutropenia-SE | fever |
| surgical drains- | penrose- flat tubing, jackson-pratt- bulb on end, hemo vac- portable wound suction device |
| protease inhibitors (crixivan), HIV drug, SE | GI intolerance, HA, blurred vision, metallic taste, thrombocytopenia, hyperglycemia |
| crixivan-NI | monitor for kidney stones, increase fluid intake, give med 1 hr before or 2 hrs after meal c skim or lowfat milk, give hard candy for metallic taste, check glucose reg., observe for signs of bruising, warn drug causes redistribution of fat |
| inhaled meds (primatene mist)-SE | nevousness, tremors, HA, hypertension, palpitations, dysrhythmias, |
| inhaled meds-NI | monitor BP, HR, teach proper technique for using inhaler, show how to check when nearly empty, always carry spare |
| look at chpt 32 for | EKG strips |
| PVC - premature ventricular contraction | flip flop sensation in chest, described as fluttering |
| PVC- s/s | pallor, nervousness, sweating, faintness, may be RT stress, fatigue, alcohol w/d, or tobacco, normally not associated c specific heart disorder |
| electrolyte imbalances- Na+, hyponatremia, causes | profuse diaphoresis, exceessive ingestion of water, or IV fluids, prolonged vomiting, GI suctioning |
| hyponatremia-s/s | mental confusion, muscle weakness, anorexia, restlessness, N/V, personality changes |
| TX -hyponatremia | treat underlying cause, oral admin of sodium, foods high in Na+, salt water,etc |
| hypernatremia- excess sodium in the blood-causes | profuse watery diarrhea, excessive salt intake, s sufficient water intake, high fever |
| hypernatremia- s/s | THIRST, dry sticky mucous membranes, decreased urine output, fever, rough dry tongue |
| hypernatremia-TX | depends on cause, admin of plain water, or IV of hypotonic solution |
| NI | early detection, oral fluids, maintain accurate I&O, assess VS, q4h, closely monitor IV fluids |
| hypokaemia- s/s | fatigue, cardiac dysrhythmias, parasthesias,muscle weakness, |
| tx- hypokalemia | substitute potassium- sparing diuretic, increase K+ or admin of K+ chloride |
| hyperkalemia- can occur c severe renal failure, severe burns, overuse of K+ supplements, addisons disease- s/s | diarrhea, nausea, muscle weakness, parasthesias, cardiac dysrhythmias |
| tx - hyperkalemia | decrease intake of K+ rich foods, severe--admin kayexalate |
| NI- hyperkalemia | meds, food sources, oral K+ |
| sorry, i'm exhausted, finish c hypercalcemia,hypocalcemia, hypo and hypermagnesemia | on pages 216, 217, 218.....hope this has helped, sorry it took so long |
Created by:
echilders
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