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Nur200 Final NLN
Topics from the review guide for the comprehensive NLN final exam
| Question | Answer |
|---|---|
| What is infiltration? (IV) | Leakage of a non-vesicant IV solution or medication into the extravascular tissue. |
| What is extravasation? (IV) | Leakage of a vesicant IV solution or medication into the extravascular tissue. |
| What is phlebitis and post-infusion phlebitis? What are signs/symptoms? | Phlebitis= Inflammation of the vein. Post infusion phlebitis presents within 48 to 96 hr after the cat has been removed S&S: Pain at iv site, vein red and "cord like" |
| What is thrombosis? (IV) What are S&S? | Blood clot inside the vein. S&S? slowed or stopped infusion rate, swollen extremity |
| define: Thrombophlebitis | The presence of a blood clot and vein inflammation. |
| define: Ecchymosis and hematoma. (IV) | Ecchymosis: infiltration of blood into the surrounding tissue. Hematoma: Uncontrolled bleeding from a venipuncture site creating a painful lump. |
| S&S of iv site infection? | Site appears red, swollen, warm, client may complain of tenderness at site, exudate. |
| Venous spasm | A sudden contraction of a vein or artery. May be caused by infustion of cold fluids (blood), changes in infusion pressure... |
| What could tingling or numbness at or below the IV insertion site be a sign of? | Nerve damage from the inadvertent piercing or transection of a nerve. |
| Name 4 systemic complications of intravenous therapy. | 1.Circulatory overload 2.Speed Shock 3.Allergic reaction 4.Catheter embolism |
| What are the s&s of circulatory overload? | Client may complain of sob and cough. elevated B/P periph edema engorged neck veins |
| define Speedshock S&S of speedshock? | Systemic reaction to the rapid infusion of substance unfamiliar to the client's circulatory system. S&S: Dizziness, chest tightness, light-headedness, flushed face, irregular pulse. |
| define Catheter Embolism S&S of catheter embolism? | A shaving or piece of catheter breaks off and floats freely in the vessel. S&S: decrease in b/p and complaints of pain along the vein. Pulse becomes weak, rapid, thready and cyanosis of the nail beds. |
| What are the 4 types thorax associated with insertion of central venous catheter ? | Pneumothorax: collection of air in pleural space Hemothorax: collection of blood in pleural cavity. Chylothorax: Lymph enters pleural space Hydrothorax: Infusion of iv fluids directly into the thoracic space. |
| What are the signs and symptoms of pneumothorax, hemothorax, and chylothorax? | chest pain dyspnea apprehension cyanosis decreased breath sounds on affected side and abnormal chest x-ray |
| S&S of arterial puncture? | Pulsating of bright red blood from the introducer needle. |
| What kind of perioperative or operating room nurses are there? | Perioperative, or operating room (OR), nurses include the holding area nurse, circulating nurse, scrub nurse, and specialty nurses. |
| What is the role of the circulating nurse? | This nurse coordinates, oversees, and is involved in the client's nursing care in the OR. The circulator sets up the OR and ensures that supplies, including blood products and diagnostic support, are available as needed |
| What is the role of the scrub nurse? | The scrub nurse and/or the surgical technologist sets up the sterile field, drapes the client, and hands sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. |
| What is conscious sedation? | Conscious sedation is the IV delivery of sedative, hypnotic, and opioid drugs to reduce the level of consciousness but allow the client to maintain a patent airway and to respond to verbal commands. |
| Which drugs are most commonly used for conscious sedation? | Diazepam (Valium, Vivol , Novo-Dipam ), midazolam (Versed), meperidine (Demerol), fentanyl (Sublimaze), alfentanil (Alfenta), and morphine sulfate are the most commonly used drugs. |
| Which procedures is conscious sedation used for? | Conscious sedation is used for endoscopy, cardiac catheterization, closed fracture reduction, cardioversion, and other special but short procedures. |
| When can a patient stop being NPO following conscious sedation? | Oral intake is not permitted until 30 minutes after the client has received the sedation or according to the physician's prescription. |
| Who is responsible for the correct identification of the patient? | Correct identification of the client is the responsibility of every member of the health care team. |
| What are are the two priority nursing diagnoses for clients during surgery | 1.Risk for Perioperative Positioning Injury related to immobilization and effects of anesthesia 2.Impaired Skin Integrity and Impaired Tissue Integrity related to the surgical incision |
| What are the common surgical positions? | The dorsal recumbent, prone, lithotomy, and lateral positions are most often used for surgery. Other surgical positions include jacknife and Trendelenberg, |
| What is the purpose of PACU? | The purpose of a PACU or recovery room is the ongoing evaluation and stabilization of clients, to anticipate, prevent, and treat complications after surgery. |
| What is the priority assessment when receiving a patient in PACU? | When the client is admitted to the PACU, immediately assess for a patent airway and adequate gas exchange. |
| In a post-op respiratory assessment what could snoring or stridor be a sign of? | Snoring and stridor are signs of airway obstruction resulting from tracheal or laryngeal spasm or edema, mucus in the airway, or blockage of the airway from edema or tongue relaxation. |
| PACU: you would Report blood pressure changes of more or less than _____% of values obtained before surgery | 25% |
| PACU: Decreased blood pressure, pulse pressure, and heart sounds indicate? | Decreased blood pressure, pulse pressure, and heart sounds indicate possible cardiac depression, fluid volume deficit, shock, hemorrhage, or the effects of drugs |
| PACU: A pulse deficit (a difference between the apical and peripheral pulses) could indicate a _____________ | dysrythmia |
| PACU: What are some signs of DVT? | Assess the feet and legs for redness, pain, warmth, swelling, and Homans' sign (calf pain on dorsiflexion of the foot) |
| PACU: What are some conditions regarding FLUID, ELECTROLYTE, AND ACID-BASE BALANCE that you might see? | -Fluid volume deficit or fluid volume overload -Sodium, potassium, chloride, and calcium imbalances |
| what does a "LEFT-SHIFT" or bandemia indicate? | An early indication of infection is an increase in the band cells (immature neutrophils) in the white blood cell differential count. |
| What are the priority nursing diagnoses for the client after surgery? | 1.Impaired Gas Exchange related to the effects of anesthesia, pain, opioid analgesics, and immobility 2.Impaired Skin Integrity related to surgical wounds, decreased mobility, drains and drainage, and tubes 3.Acute Pain related to the surgical incision |
| What is brachytherapy and what should you know about it? | With brachytherapy, the radiation source comes into direct, continuous contact with the tumor tissues for specific time. The radiation source is within the client. Therefore the client emits radiation for a period of time and is a hazard to others. |
| Name some side effects of chemotherapy | alopecia (hair loss), nausea and vomiting, open sores on mucous membranes (mucositis), and many skin changes. Other distressing side effects include anxiety, sleep disturbance, altered bowel elimination, and decreased mobility. |
| Clients undergoing chemotherapy often develop mucositis. What is it? | mucositis= (sores in mucous membranes) of the entire gastrointestinal (GI) tract, especially in the mouth (stomatitis). Frequent mouth assessment and oral hygiene are key in managing stomatitis and mucositis. |
| What is is the major dose-limiting side effect of cancer chemotherapy? | Immunosuppression. Because it places the client at extreme risk for infection |
| What is neutropenia? | Bone marrow suppression reduces the circulating number of leukocytes, erythrocytes, and platelets. neutropenia = Decreased leukocyte numbers, especially neutrophils causes immunosuppression. |
| What is thrombocytopenia? | Thrombocytopenia is a decreased number of circulating platelets. |
| What is a risk of thrombocytopenia? | Thrombocytopenia increases the risk for excessive bleeding. When the platelet count is less than 50,000/mm3, any small trauma can lead to prolonged bleeding. |
| What is The most definitive procedure for identification of a microorganism? | Culture After isolation of a microorganism in culture, antibiotic sensitivity testing is usually performed to determine the effects of various antibiotics on that particular microorganism. |
| Total leukocyte count is elevated when? | In most active infections, especially those caused by bacteria. Infection can also be indicated by an elevated ESR (>20 mm/hr) |
| What are priority nursing diagnoses for clients with an infection or infectious disease? | 1.Hyperthermia related to an increased metabolic state 2.Risk for Social Isolation related to altered state of wellness |
| With a tracheotomy patient, why should you Ensure that a tracheostomy tube of the same type (including an obturator) and size (or one size smaller) is at the bedside at all times, along with a tracheostomy insertion tray? | Because Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. |
| What are some indications to suction an artificial airway? | Suctioning is indicated when audible or noisy secretions, crackles or wheezes on auscultation, restlessness, increased pulse or respiratory rates, or mucus in the artificial airway is present. |
| What would you do to try and prevent hypoxia prior to suctioning client? | Prevent hypoxia by hyperoxygenating the client with 100% oxygen with a manual resuscitation bag attached to an oxygen source. |
| What are some possible effects of suctioning? | Suctioning can cause hypoxia, tissue (mucosal) trauma, infection, vagal stimulation, bronchospasm, and cardiac dysrhythmias. |
| What can vagal stimulation result in? | Vagal stimulation results in severe bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias |
| Chronic airflow limitation (CAL) is group of chronic lung diseases that includes ? | asthma, chronic bronchitis, and pulmonary emphysema. |
| Emphysema and chronic bronchitis =? | chronic obstructive pulmonary disease (COPD) |
| Is tissue damage reversible in asthma or copd? | Asthma unlike COPD, is an intermittent disease with reversible airflow obstruction and wheezing. |
| Which common drugs can trigger an asthma attack? | Some clients have asthma after taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) |
| What are five classes of chemotherapy drugs? | 1)Antimetabolites-"counterfeit" metabolites 2)Antitumor antibiotics-dmg cell DNA 3)Alkylating agents-inhibit cell division 4)Antimitotic agents-inhibits mitosis 5)Topoisomerase agents- breaks DNA |
| Is posterior nasal bleeding an emergency? | Posterior nasal bleeding is an emergency. Posterior packing or nasal pressure tubes are used to stop bleeding that originates in the posterior nasal region. |
| What is the most accurate tests for asthma ? | The most accurate tests for asthma are the pulmonary function tests (PFTs) measured using spirometry.The 3 PFTs measured are: 1.forced vital capacity (FVC) 2.forced expiratory volume in the first second (FEV1) 3.peak expiratory rate flow (PERF) |
| A decrease in either the FEV1 or the PERF of 15% to 20% below the expected value for age, gender, and size is common for the client with? | Asthma. An increase of 12% in these values after treatment with bronchodilators is diagnostic for asthma. |
| If you experience symptoms of exercise-induced asthma, use your bronchodilator inhaler when? | 30 minutes before exercise to prevent or reduce bronchospasm. |
| What kind of medications are used to treat asthma? | bronchodilators, steroidal and nonsteroidal agents to reduce inflammation, mast cell stabilizers, monoclonal antibodies, and drugs that inhibit the release or action of leukotrienes |
| What is Status Asthmaticus? | Status asthmaticus is a severe, life-threatening acute episode of airway obstruction that intensifies once it begins and often does not respond to common therapy Treated with (IV) fluids, potent systemic bronchodilators, steroids, epinephrine, and oxyge |
| The two major changes that occur with pulmonary emphysema are ____________ | The two major changes that occur with pulmonary emphysema are loss of lung elasticity and hyperinflation of the lung. |
| Describe chronic bronchitis. How does it effect gas exchange? | Bronchitis is an inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tosbacco smoke. Chronic bronchitis hinders airflow and gas exchange because of mucous plugs and infection narrowing the airways. |
| What is the most important risk factor in COPD? | Smoking. |
| What are the major complications of COPD? | hypoxemia, acidosis, respiratory infection, cardiac failure, and dysrhythmias. |
| Which kind of cardiac failure is found with COPD clients? | cor pulmonale (right-sided heart failure caused by pulmonary disease), occurs with bronchitis or emphysema. Air trapping, airway collapse, and stiff alveolar walls increase the lung tissue pressure making harder work for right side of heart. |
| What is the benefit of pursed lip breathing for COPD patients? | Breathing through pursed lips uses the mild resistance of partially closed lips to prolong exhalation and to increase airway pressure. This technique delays airway compression and reduces air trapping. |
| atelectasis | Alveolar collapse -often part of the pneumonia process |
| What are 5 common complications of pneumonia? | 1.Hypoxemia 2.Ventilatory failure-lungs unable to mechanically move gas in/out lungs 3.Atelactasis 4.Pleural effusion-fluid in pleural space 5.Pleurisy- Pain caused by friction btwn layers of pleura |
| What are are priority nursing diagnoses for clients with pneumonia? | 1. Impaired Gas Exchange related to effects of alveolarcapillary membrane changes 2.Ineffective Airway Clearance related to effects of infection, excessive tracheobronchial secretions... primary collaborative prob=Potential for Sepsis. |
| What is the key to effective treatment of pneumonia? | The key to effective treatment of pneumonia is eradication of the organism causing the infection. |
| What should you do with a client with pneumonia every 2 hrs? | Help the client to cough and deep breathe at least every 2 hours Because of fatigue, muscle weakness, chest discomfort, and excessive secretions, the client with pneumonia often has difficulty clearing secretions. |
| When is a person infected with TB infectious? | An infected individual is not infectious to others until manifestations of disease occur. |
| When should a diagnosis of TB be considered? | A diagnosis of TB should be considered for any client with a persistent cough or other symptoms compatible with TB, such as weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. |
| For whom is the TB skin test (Mantoux) likely to show a false positive reading? | Anyone who has received BCG vaccine within the previous 10 years will have a positive skin test that can complicate interpretation. |
| Combination drug therapy is used to treat TB. How long is the average course of treatment? | 6 months |
| What is Empyema? | Empyema is a collection of pus in the pleural space. The most common cause of empyema is pulmonary infection, lung abscess, or infected pleural effusion. |
| What is A pulmonary embolism (PE) ? | A pulmonary embolism (PE) is a collection of particulate matter (solids, liquids, or gaseous substances) that enters venous circulation and lodges in the pulmonary vessels. PE is the most common acute pulmonary diseas |
| What does PE lead to? | Large emboli obstruct pulmonary blood flow, leading to decreased systemic oxygenation, pulmonary tissue hypoxia, and potential death. |
| The following are major risk factors for DVT leading to PE: | ▪ Prolonged immobilization ▪ Central venous catheters ▪ Surgery ▪ Obesity ▪ Advancing age ▪ Hypercoagulability ▪ History of thromboembolism ▪ Cancer diagnosis |
| The following are priority nursing diagnoses for clients with PE: | 1. Decreased Cardiac Output related to acute pulmonary hypertension 2. Anxiety related to hypoxemia and life-threatening illness 3. Risk for Injury (Bleeding) related to anticoagulation or fibrinolytic therapy |
| Anticoagulation therapy is used for PE clients. What is used? and for how long? | Heparin and warfarin are used. Goal for PE client is 1.5-2x the normal PTT (normal=20-30sec). The client with PE may continue anticoagulation therapy for weeks, months, or years after discharge, depending on the risks for PE. |
| Typical causes of left-sided heart (ventricular) failure ? (Formally known as CHF) | hypertensive, coronary artery, and valvular disease involving the mitral or aortic valve. Decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels indicate left ventricular failure. |
| CHF can be further divided into two subtypes: systolic heart failure and diastolic heart failure. Describe the two types. | 1.Systolic heart failure results when the hrt is unable to contract forcefully enough during systole to eject adequate amounts of blood into the circulation. 2.diastolic hrt failure occurs when left ventricle is unable to relax adequately during diastole |
| Symptoms of left sided heart failure? | blood accumulates in the pulmonary vessels. Manifestations of systolic dysfunction may include symptoms of inadequate tissue perfusion or pulmonary and systemic congestion. |
| What happens to the ejection fraction (the percentage of blood ejected from the heart during systole)during diastolic heart failure? | The ejection fraction drops from a normal of 50% to 70% to below 40%. |
| What occurs during Right-sided heart (ventricular) failure ? | In right-sided heart failure, the right ventricle is unable to empty completely. Increased volume and pressure develop in the systemic veins, and systemic venous congestion develops with peripheral edema. |
| What are common causes of Right sided heart failure? | Right-sided heart (ventricular) failure may be caused by left ventricular failure, right ventricular myocardial infarction, or pulmonary hypertension. |
| What are some compensatory mechanisms that come into play when cardiac output is insufficient to meet the demands of the body? | ▪ Sympathetic nervous system stimulation ▪ Renin-angiotensin system (RAS) activation ▪ Other neurohumoral responses ▪ Myocardial hypertrophy |
| Right-sided HF in the absence of left-sided HF is most often the result of ? | pulmonary problems, such as chronic obstructive pulmonary disease (COPD) or cystic fibrosis. |
| KEY FEATURES of Left-Sided Heart Failure decreased cardiac output? | Decreased cardiac output ▪ Fatigue ▪ Weakness ▪ Oliguria during the day ▪ Angina ▪ Confusion, restlessness ▪ Dizziness ▪ Tachycardia, palpitations ▪ Pallor ▪ Weak peripheral pulses ▪ Cool extremities |
| KEY FEATURES of Left-Sided Heart Failure pulmonary congestion? | Pulmonary Congestion ▪ Hacking cough, worse at night ▪ Dyspnea/breathlessness ▪ Crackles or wheezes in lungs ▪ Frothy, pink-tinged sputum ▪ Tachypnea ▪ S3/S4 summation gallop |
| KEY FEATURES of Right-Sided Heart Failure? | Systemic Congestion ▪ Jugular (neck vein) distention ▪ Enlarged liver and spleen ▪ Anorexia and nausea ▪ Dependent edema (legs and sacrum) ▪ Distended abdomen ▪ Swollen hands and fingers ▪ Polyuria at right ▪ Weight gain ▪ Increas |
| What is an early manifestation of Left-sided HF? | Cough As the amount of blood ejected from the left ventricle diminishes, hydrostatic pressure builds in the pulmonary venous system and results in fluid-filled alveoli and pulmonary congestion. |
| Dyspnea at rest in the recumbent (lying flat) position is known as ? | Orthopnea |
| The signs and symptoms of HF can be considered in the context of these components of the syndrome: | ▪ Failure of the left ventricle as a pump with decreased tissue perfusion and pulmonary venous congestion ▪ Failure of the right ventricle as a pump with systemic venous congestion |
| The following are priority nursing diagnoses for clients with HF: | 1. Impaired Gas Exchange related to ventilation perfusion imbalance 2. Decreased Cardiac Output related to altered contractility, preload, and afterload 3. Activity Intolerance related to an imbalance between oxygen supply and demand |
| How do ACE inhibitors work? | suppress the renin-angiotensin system (RAS), which is activated in response to decreased renal blood flow., resulting in arterial resistance, arterial dilation, and increased SV. These drugs block aldosterone, which prevents sodium and water retention. |
| What should you do when giving first dose of an ACE inhibitor? | The health care provider usually starts doses of ACE inhibitors slowly and cautiously. The first dose of an ACE inhibitor is sometimes assoc. w/ a rapid drop in BP Monitor BP for several hours after the initial dose and each time the dose is increased |
| What are the benefits of Digoxin (digitalis) use in clients with HF? | increase in contractility, a reduction in heart rate (HR), a slowing of conduction through the atrioventricular node, and an inhibition of sympathetic activity while enhancing parasympathetic activity. |
| What is the presentation of digitalis toxicity? | Digitalis toxicity is often vague and nonspecific and includes anorexia, fatigue, and changes in mental status. Carefully monitor the apical pulse rate and heart rhythm of clients receiving digoxin. |
| When monitoring a client on digitalis, what s&s should you report? | Report the development of either an irregular rhythm in a client with a previously regular rhythm or a regular rhythm in a client with a previously irregular one. Also, Monitor serum potassium levels (hypokalemia potentiates digitalis toxicity) |
| What are some symptoms of worsening HF that should be reported to physician? | ▪Rapid weight gain (3 pounds in a week or 1 to 2 pounds overnight) ▪Decrease in exercise tolerance lasting 2 to 3 days ▪Excessive awakening at night to urinate ▪Development of dyspnea or angina at rest or worsening angina ▪Increased perph edema |
| What is Mitral Stenosis? | In mitral stenosis, the valve leaflets fuse and become stiff, and the chordae tendineae contract and shorten. The valve opening narrows, preventing normal blood flow from the left atrium to the left ventricle. |
| What is the result of Mitral Stenosis? | left atrial pressure rises, the left atrium dilates, pulmonary artery pressures increase, and the right ventricle hypertrophies. Pulmonary congestion and right-sided HF occur initially |
| What is the most common cause of Mitral Stenosis? | Rheumatic fever is the most common cause of mitral stenosis. Mitral stenosis usually results from rheumatic carditis, which can cause valve thickening by fibrosis and calcification. |
| What is Rheumatic Carditis? (also called rheumatic endocarditis) | is a sensitivity response that develops after an upper respiratory tract infection with group A beta-hemolytic streptococci, which occurs in about 40% of clients with rheumatic fever and affects more than one million Americans. |
| The following are common clinical manifestations of Rheumatic Carditis: | ▪Tachycardia ▪Cardiomegaly ▪Development of a new murmur or a change in an existing murmur Pericardial friction rub ▪Precordial pain ECG changes (prolonged PR interval) ▪Indications of heart failure (HF) ▪Evidence of an existing streptococcal infect |
| Arteriosclerosis | Arteriosclerosis is a thickening, or hardening, of the arterial wall. |
| Atherosclerosis | a type of arteriosclerosis, involves the formation of plaque within the arterial wall and is the leading contributor to coronary artery and cerebrovascular disease. |
| What is an ideal lipid profile? | Total serum cholesterol levels should be below 200 mg/dL A desirable LDL-C level is one below 100 mg/dL A desirable HDL-C level is 40 mg/dL or above |
| Malignant hypertension | Malignant hypertension is a severe type of elevated blood pressure that rapidly progresses |
| What is the difference btwn primary and secondary hypertension? | Primary has no known cause but several associated factors such as genetics.. Specific disease states and medications can increase a person's susceptibility to hypertension; a person with this type of elevation in blood pressure has secondary hypertension |
| The following are priority nursing diagnoses for clients with hypertension: | 1. Deficient Knowledge related to information misinterpretation or unfamiliarity with information resources 2. Risk for Ineffective Therapeutic Regimen Management related to noncompliance with or nonadherence to treatment |
| For the client with essential hypertension, the nurse or health care provider initially recommends the following lifestyle modifications: | ▪ Sodium restriction ▪ Weight reduction ▪ Moderation of alcohol intake ▪ Exercise ▪ Relaxation techniques ▪ Tobacco and caffeine avoidance |
| Three basic types of diuretics are used to decrease blood volume and lower blood pressure: | ▪ Thiazide (low-ceiling) diuretics, such as hydrochlorothiazide ▪ Loop (high-ceiling) diuretics, such as furosemide (Lasix) ▪ Potassium-sparing diuretics, such as spironolactone (Aldactone) |
| What is the effect of Thiazide diuretics? | prevent sodium and water reabsorption in the distal tubules while promoting potassium excretion. |
| What is the effect of Loop diuretics? | epress sodium reabsorption in the ascending loop of Henle and promote potassium excretion. |
| Calcium Channel Blocking Agents: | Calcium channel blockers, such as diltiazem (Cardizem), lower blood pressure by interfering with the transmembrane flux of calcium ions. This results in vasodilation and subsequent decrease in blood pressure. |
| aneurysm | s a permanent localized dilation of an artery, which enlarges the artery to at least two times its normal diameter. Abdominal aortic aneurysms (AAAs) account for about 75% of all aneurysms. |
| Most common causes of aneurysms? | Atherosclerosis is the most common cause of all aneurysms, with hypertension and cigarette smoking being contributing factors. Syphilis (a sexually transmitted disease), Marfan syndrome (an autoimmune disease) |
| Coronary artery disease (CAD) | CAD is a broad term that includes stable angina pectoris and acute coronary syndromes. CAD affects the arteries that provide blood, oxygen, and nutrients to the myocardium. |
| Ischemia | occurs when insufficient oxygen is supplied to meet the requirements of the myocardium |
| Infarction | necrosis, or cell death) occurs when severe ischemia is prolonged and irreversible damage to tissue results. |
| Angina pectoris | means "strangling of the chest." Angina is a temporary imbalance between the coronary arteries' ability to supply oxygen and the cardiac muscle's demand for oxygen. |
| Stable angina | is chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the client. It is usually relieved by nitroglycerin or rest and often is managed with medication |
| Unstable angina (USA) | is chest pain or discomfort that occurs at rest or with exertion and causes marked limitation of activity. An increase in the number of attacks and an increase in the intensity of the pain characterize USA. |
| Myocardial infarction (MI) | occurs when myocardial tissue is abruptly and severely deprived of oxygen. When blood flow is acutely reduced by 80% to 90%, ischemia develops. Ischemia can lead to injury and necrosis (infarction) |
| Modifiable risk factors of MI/CAD | elevated serum cholesterol levels, cigarette smoking, hypertension, impaired glucose tolerance, obesity, physical inactivity, and stress. |
| A client suffering from angina should feel relief upon taking nitroglycerin in how long? How many attempts at using nitro are allowed? | Pain relief should begin within 1 or 2 minutes and should be clearly evident in 3 to 5 minutes. a total of three doses may be administered in an attempt to relieve anginal pain. |
| What forms at the site of a bone fracture within 48-72 hours? | A hematoma forms at the site of the fracture because bone is extremely vascular |
| In young, healthy adult bone, healing takes about ____ weeks. | In young, healthy adult bone, healing takes about 6 weeks. In the older person who has reduced bone mass, healing time is lengthened; complete healing often takes 3 to 6 months. |
| What are some complications of fractures? (8 listed) | 1. Acute Compartment syndrome 2.Shock 3.Fat Embolism 4.Venous thrombus embolism 5.Infection 6.Ischemic necrosis 7.Fracture Blisters 8. DELAYED UNION, NONUNION, AND MALUNION |
| What is Acute Compartment Syndrome? (ACS) | ACS is a serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area. |
| What is Fat Embolism Syndrome? (FES) | (FES) is a serious complication, usually resulting from a fracture, in which fat globules are released from the yellow bone marrow into the bloodstream. |
| What are the earliest symptoms of Fat embolism syndrome (FES) ? | The earliest manifestation of FES is altered mental status, which is caused by a low arterial oxygen level. The client then typically experiences respiratory distress, tachycardia, tachypnea, fever, and petechiae . |
| What is the most common complication of lower extremity surgery or trauma and the most often fatal complication of musculoskeletal surgery? | Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and its complication, pulmonary embolism (PE) |
| DVT that leads to PE is more likely to develop in clients with fractures of ________ & _________? | lower extremities and pelvis. |
| Traction | Traction is the application of a pulling force to a part of the body to provide reduction, alignment, and rest. |
| Nonsurgical management of fractures typically involves closed reduction and immobilization with which 4 options? | Nonsurgical management typically involves closed reduction and immobilization with a bandage, splint, cast, or traction. |
| What is The nurse's primary concern for nonsurgical management of fractures? | The nurse's primary concern is assessment and prevention of neurovascular dysfunction or compromise |
| Gastroesophageal reflux disease (GERD) | It occurs as a result of the backward flow (reflux) of irritating gastrointestinal contents into the esophagus. |
| Barrett's epithelium | During the process of healing, the body may substitute a columnar epithelium (Barrett's epithelium) for the normal squamous cell epithelium of the lower esophagus. it is considered premalignant in clients with prolonged GERD |
| Hiatal hernia | involve the protrusion of the stomach through the esophageal hiatus of the diaphragm into the thorax. Two kinds: rolling and sliding |
| peptic ulcer | A peptic ulcer is a mucosal lesion of the stomach or duodenum. The term peptic ulcer is used to describe both gastric and duodenal ulcers. |
| Peptic ulcer disease (PUD) | Peptic ulcer disease (PUD) results when gastric mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin |
| The most common complications of PUD are : | hemorrhage, perforation, pyloric obstruction, and intractable disease |
| Peptic ulcer development is primarily associated with : | nonsteroidal anti-inflammatory drug (NSAID) use and bacterial infection with H. pylori. |
| Upper GI bleeding may require the health care provider or nurse to insert a nasogastric (NG) tube to: | ▪ Ascertain the presence or absence of blood in the stomach ▪ Assess the rate of bleeding ▪ Prevent gastric dilation ▪ Administer saline lavage |
| Irritable bowel syndrome (IBS) | is a chronic gastrointestinal (GI) disorder, characterized by the presence of chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating |
| Drug therapy for IBS includes: | The health care provider may prescribe bulk-forming laxatives, antidiarrheal agents, anticholinergic agents, tricyclic antidepressants, and 5-HT4 agonists. |
| The priority nursing diagnosis for clients with colorectal cancer (CRC) is : | Anticipatory Grieving related to the diagnosis of a potentially terminal illness, a disturbance in body image, and the possible loss of fecal continence. |
| intestinal obstructions can be partial or complete and are classified as: | Mechanical or nonmechanical obstruction |
| Mechanical intestinal obstruction | In mechanical obstruction, the bowel is physically obstructed by disorders outside the intestine (e.g., adhesions or hernias) or by blockages in the lumen of the intestine (e.g., tumors, inflammation, strictures, or fecal impactions). |
| Nonmechanical intestinal obstruction | Nonmechanical obstruction (also known as paralytic ileus does not involve a physical obstruction in or outside the intestine. Instead, peristalsis is decreased or absent, resulting in a slowing of the movement or a backup of intestinal contents. |
| inflammatory bowel disease (IBD) is used to describe two conditions of unknown etiology: | ulcerative colitis and Crohn's disease |
| Appendicitis | is acute inflammation of the vermiform appendix. Inflammation of the appendix can occur when the lumen (opening) of the appendix is obstructed. Inflammation leads to infection as bacteria invade the wall of the appendix. |
| Complications of appendicitis include: | 1. Gangrene from hypoxia or perforation can occur within 24 to 36 hours. 2. peritonitis (inflammation of the peritoneum) |
| Abdominal pain that increases with cough or movement and is relieved by flexion of the right hip or the knees suggests : | a perforated appendix with peritonitis. |
| Peritonitis | is an acute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity, or peritoneum. Peritonitis can be classified as primary or secondary, localized or generalized. Peritonitis is a life-threatening illness. |
| What is "third spacing"? | The body responds to the infectious process by shunting extra blood to the area of inflammation. Fluid is shifted from the extracellular fluid (ECF) compartment into the peritoneal cavity, connective tissues, and gastrointestinal (GI) tract |
| What complications does "third spacing" present? | This shift of fluid out of the vascular space can result in a significant decrease in circulatory volume. Severely decreased circulatory volume can result in insufficient perfusion of the kidneys, leading to renal failure with electrolyte imbalance. |
| Ulcerative colitis | is one of a group of bowel diseases of unknown etiology, characterized by remissions and exacerbations ("flare-ups"). It can result in loose stools containing blood and mucus, poor absorption of vital nutrients, and thickening of the colon wall. |
| The following are priority nursing diagnoses for clients with ulcerative colitis: | 1. Diarrhea related to inflammation of the bowel mucosa 2. Acute and Chronic Pain related to inflammation and ulceration of the bowel mucosa and accompanying skin irritation The primary collaborative problem is Potential for Gastrointestinal Bleedin |
| For a client with IBD The health care provider prescribes a combination of drugs including: | salicylate compounds, corticosteroids, immunosuppressants, and antidiarrheals. |
| cholecystitis | inflammation of the gallbladder |
| Acute cholecystitis (inflammation of the gallbladder) usually develops in association with______________? | cholelithiasis (gallstones) |
| When the concentration of bilirubin in the blood increases to greater than 2.5 mg/dL, _________ occurs | Jaundice |
| In a person with obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excessive bile salts to accumulate in the skin. This accumulation of bile salts leads to ___________ | pruritus (itching) or a burning sensation. |
| KEY FEATURES of Cholecystitis: | ▪ Episodic or vague upper abdominal pain/discomfort ▪ Pain triggered by a high-fat or high-volume meal ▪ Anorexia ▪ Nausea or vomiting ▪ Dyspepsia ▪ Eructation ▪ Flatulence ▪ Feeling of abdominal fullness ▪ Rebound tenderness (Blumberg's sign) ▪ |
| biliary colic | The severe pain of biliary colic is produced by obstruction of the cystic duct of the gallbladder. When a stone is moving through or is lodged within the duct, tissue spasm occurs in an effort to mobilize the stone through the small duct. |
| Diet therapy for the client who has undergone a cholecystectomy is based on his or her tolerance of ______ | Fats |
| Acute pancreatitis | is a serious inflammatory process of the pancreas. This process is caused by a premature activation of pancreatic enzymes that destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis of the pancreas. |
| Potential complications of acute pancreatitis: | Pancreatic infection Hypovolemia Hemorrhage Acute Renal Failure Paralytic ileus Hypovolemic/septic shock Pleural effusion Acute respiratory distress syndrome Atelectasis Pneumonia Diabetes mellitus Multiorgan system failure DIC |
| What would you see elevated on the lab report for a client with acute pancreatitis? | increased serum: amylase, lipase, trypsin, elastase. Also elevations in glucose, and WBC |
| The following are priority nursing diagnoses for clients with acute pancreatitis: | 1. Acute Pain related to biologic and injury agents (pancreatic inflammation and enzyme leakage) 2. Imbalanced Nutrition: Less Than Body Requirements related to the inability to ingest food and absorb nutrients |
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mreman
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