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MedSurg: Exam 2
| Question | Answer |
|---|---|
| Normal pH | 7.35-7.45 |
| Normal PaCO2 | 35-35 |
| Normal PaO2 | 80-100 |
| Normal HCO3 | 21-28 |
| Normal K+ | 3.5-5.0 |
| Normal H+ | 3.5-5.0 |
| Respiratory Acidosis: | pH- Decrease PaCO2- Increase PaO2-Decrease HCO3- Normal K+/H+- Increase |
| Respiratory Alkalosis: | pH- Increase PaCO2- Decreased PaO2- Normal HCO3- Normal K+/H+- Decreased |
| Metabolic Acidosis: | pH- Decreased PaCO2- Normal PaO2- Normal HCO3- Decreased K+/H+- Increased |
| Metabolic Alkalosis: | pH- Increased PaCO2- Normal PaO2- Normal HCO3- Increased K+/H+- Decreased |
| Compensatory Response/Additional for Respiratory Acidosis | HYPOventilation: COPD, Pneumonia, TB, Atelectasis, Asthma, PE, Opioids, Chest Trauma, Obesity, Obstruction |
| Compensatory Response/Additional for Respiratory Alkalosis | HYPERventilation: Wrong vent settings, OD, COPD exacerbation, Asthma attack, Panic attack |
| Compensatory Response/Additional for Metabolic Acidosis | Kidney failure, Pancreatitis, DKA, Diarrhea, Dehydration |
| Compensatory Response/Additional for Metabolic Alkalosis | Vomiting, NG suctioning, Alkaline, and Antacid increase |
| Perfusion | Delivering oxygen/nutrients to tissues, organs, and the brain |
| Cardiac Valves | 4 Valves: Tricuspid (AV), Mitral , Pulmonic , and Aortic Valve (TMAP) |
| Valves Malfunction Indications: | Left side failing --> Backs up to lungs, Right side failing --> Backs up to the rest of the body |
| Mean Arterial Pressure (MAP) | Must be at least 60 mm Hg to maintain adequate blood flow through coronary arteries and perfuse major organs (Brain) |
| Higher BP = | = Higher MAP (MAP should be 60 or above) |
| Systole is when the ventricle- | -contracts |
| Diastole is when the ventricle- | -relaxes and fills |
| Cardia Output (CO) | Amount (volume) of blood from the left ventricle per MINUTE CO=HR x SV |
| Heart Rate | 60-100 Normal range for an adult |
| Stroke Volume | Amount of blood from the left ventricle per CONTRACTION |
| Preload | Degree of stretch the heart muscle has at the end of diastole just before it contracts the next time |
| Afterload | Force/pressure the heart must pump against (resistance ventricles have to overcome) |
| Myocardial Contractility | Force/strength of the heart muscle contraction |
| Blood Pressure Regulation | ANS either excites or inhibits the SNS activity based on responses from our Baroreceptors or our Chemoreceptors |
| Baroreceptors are Stimulated when- | -artery walls are stretched and work to drop BP |
| Chemoreceptors are Stimulated when- | -sends an impulse to Vagus Nerve that starts VASOCONSTRICTION to raise our BP |
| Renal System with Blood Pressure Regulation | Senses a change in blood flow and activates RAS mechanism to help regulate BP and fluid balance in the body |
| Endocrine System with Blood Pressure Regulation | Certain hormones are released to stimulate Sympathetic Nervous System (SNS) at the tissue level |
| Blood Pressure Regulation: Aldosterone --> High levels = | = Increased retention, Increased BP |
| Cardiovascular System Assessment | Patient history (Modifiable and nonmodifiable), Nutritional history, Family history and genetic risk, Current health problems (Pain, Discomfort, Dyspnea, DOE, Orthopnea, PND, Fatigue, Palpitations, Edema, Syncope, Extremity pain) |
| Point to Remember: The best INDICATOR of Fluid Balance is- | -WEIGHT (2.2 lb = 1 kg = 1 L of fluid ) |
| Cardiovascular System Physical Assessment | General Appearance (cyanosis, rubor, pallor), Extremities (clubbing, edema, turgor), BP (hypo/hypertension, postural (orthostatic) hypotension), Venous and arterial pulses |
| Hypotension Range for an Adult | 90/60 |
| Hypertension Range for an Adult | 120/80 |
| Precordium Assessment | Inspection, Palpation, Auscultation (Normal heart sounds, Paradoxical splitting, Gallops and murmurs, Pericardial friction rub) |
| Serum Markers of Myocardial Damage | Troponin T and Troponin I |
| Troponin is a marker for- | -injury to the heart muscle |
| `Total Cholesterol Lab | < 200 mg/DL |
| Triglyceride Lab | 40-160 (Males, 35-135 (Females) |
| HDL Lab | >45 (Males) and 50 (Females) mg/DL (HDL goal is to be ELEVATED) |
| LDL Lab | <130; <70 mg/DL for cardiovascular patients (LDL goal is to be LOWERED) |
| Homocysteine Lab | <14 desired |
| Highly Sensitive C-Reactive Protein Lab | <1 desired; > 3 High risk for heart disease |
| Laboratory Assessments for the Heart | Microalbuminuria, Blood coagulation studies, ABG's, Fluid and electrolytes, H&H (anemia decreases), Leukocyte count (MI leads to elevation) |
| Blood Coagulation Studies | PT/INR (Warfarin): PT --> 11-12.5 / INR --> 0.8-11) PTT (heparin) (30-40 seconds) |
| Diagnostic Assessment for the Heart | Chest x-ray - PA and lateral, Angiography and arteriography, Cardiac catheterization |
| Cardiac Catheterization: Pre-Procedure | NPO, Allergies, Cannot take metformin (HOLD med), Start an IV, Educate on post-procedure, NV possible during procedure |
| Pre-Op Assessment Needs Baselines for- | -VS and Pulse (pedal) |
| It is NOT the nurses job to educate a patient about a ______ | Procedure (Simple questions can be reinforced but nothing about complications) |
| A nurses job with informed consent is to- | -make sure it is signed or be the 2nd witness of pre-op education |
| If a patient is on an anticoagulant before a Cardiac Cath, they must- | -stop taking it, helps avoid post-procedure hemorrhage |
| Cardiac Catheterization: Post-Procedure | Bedrest, 1-2 hours OR overnight stay, Observe insertion site, Post VS assessment |
| Other Diagnostic Assessments for the Heart: | ECG/EKG, Stress test, Echocardiography, CT & MRI |
| Stress Test for the Heart | Tests the heart response and checks for dysrythmias |
| Echocardiography Examples: | Pharmacologic stress echocardiogram, TEE (transesophageal echo) |
| EKG helps to- | -determine a Heart Rhythm |
| P Wave | Generated in the atrium from the SA node |
| QRS is the ____ wave | Larger |
| Sinoatrial Node (SA) | Electrical impulses 60-100 eats/min, P wave on ECG |
| Atrioventricular Junction (AV) | PR segment on ECG, Contraction known as "atrial kick" |
| 12 Lead EKG actually has- | -10 stickers but gives 12 views of heart function |
| ECG waveforms are measured in- | -amplitude (voltage) and duration (time) Multiply by 10 |
| 4 Rhythms to Know: | Normal Sinus Rhythm (NSR), Sinus Brady (SB), Sinus Tachy (ST), Sinus Arrhythmia (SA) |
| SA node controls your- | -HR |
| ECG Rhythm Analysis | 1- Determine heart rate. 2-Determine heart rhythm. 3- Analyze P waves. 4. Measure PR interval (0.12-0.2 seconds). 5- Measure QRS duration (0.04-0.1 seconds). 6- Interpret rhythm |
| ECG: Determining HR | 6 Second Stip |
| ECG: Determining Heart Rhythm | Assess for irregularities |
| ECG: Analyzing P Waves | Are they consistent? Present? Look similar? |
| ECG: Measuring PR Interval | Consistent, Measure, 0.12-0.2 |
| ECG: Measure QRS Duration | 0.04-0.10 |
| ECG: Interpreting Rhythm | Should be Normal Sinus Rhythm (NSR) |
| Normal Sinus Rhythm: RATE | 60 to 100 beats/min |
| Normal Sinus Rhythm: RHYTHM | Regular |
| Normal Sinus Rhythm: P Waves | Present, Consistent configuration, One P wave before each QRS complex |
| Normal Sinus Rhythm: PR Interval (Makes up NSR) | 0.12 to 0.20 second and constant |
| Normal Sinus Rhythm: QRS Duration | 0.04 to 0.10 second and constant |
| Sinus Arrhythmia | Variant of NSR, Results from changes in intrathoracic pressure during breathing, Can occur in normal, healthy adults |
| Sinus Arrhythmia has ALL characteristics of NSR except for its- | -irregularity |
| Heart Failure | Also called pump failure; inability of heart to work effectively as a pump |
| Major Types of Heart Failure | Left-sided, Right-sided, and High-output (3) |
| Left-Sided Heart Failure: Formerly known as- | -Congestive heart failure, Not all cases involve fluid accumulation |
| Left-Sided Heart Failure: Typical Causes: | Hypertension, Coronary artery disease, Valvular disease |
| Left-Sided Heart Failure: Type Types: | Systolic and Diastolic |
| Right-Sided Heart Failure: Causes- | Left ventricular failure, Right ventricular MI, Pulmonary hypertension |
| Right-Sided Heart Failure: Right ventricle cannot- | -empty completely |
| Right-Sided Heart Failure: Increased volume and pressure in- | -venous system and peripheral edema |
| When cardiac output is insufficient to meet the body's demands, these mechanisms operate to increase cardiac output: | Sympathetic nervous system stimulation, Renin-angiotensin system activation, B-type natriuretic peptide (BNP), Myocardial hypertrophy (thickening of muscle) |
| Left-Sided Heart Failure Clinical Manifestations: | Dyspnea, Weakness, Fatigue, Chest discomfort, Palpitations, Dizziness, Acute confusion, Pulmonary congestion, Breathlessness, Oliguria (little to no urine) |
| Right-Sided Heart Failure Clinical Manifestations: | Jugular vein distention, Increased abdominal girth (ACITES), Dependent edema, Hepatomegaly, Hepatojugular reflux, WEIGHT is the most reliable indicator of fluid gain/loss |
| (L)eft Sided Heart Failure = | = (L)ungs (L + L) |
| Acronym for Left-Sided Heart Failure: DYSPNEA | D-yspnea, Y-ellow secretions, S-tridor (dec O2), P-ulmonary crackles, N-asal flaring, grunting, retracting, E-levation in the RR, A-ctivity intolerance |
| (R)ight Sided Heart Failure = | = (R)est of Body (R + R) |
| Acronym for Right-Sided Heart Failure: EDEMA | E-nlarged liver (hepatomegaly), D-istended neck veins, E-nlarged spleen, M-ost edema in LE, A-scites, anorexia |
| Assessment of Heart Failure: Labs | Electrolytes, H&H, BNP, Urinalysis, ABG's |
| Assessment of Heart Failure: Imaging | CXR. Echocardiography (BEST diagnostic tool), ECG |
| Valvular Heart Disaeses | Mitral stenosis, Mitral regurgitation (insufficiency), Mitral valve prolapse, Aortic stenosis, Aortic regurgitation (insufficiency) |
| Volume and pressure will build in the left atrium along with pulmonary congestion because of- | -Valvular Heart Disease |
| Aortic stenosis | Hardening/thickening of valve/flow as it leaves the left ventricle (backflow into the left side) |
| Mitral regurgitation | Insufficient blood flow through the valves, and goes backwards through the valve |
| Mitral valve prolapse | Leaflets not closing effectively, Prolapsed into the wrong direction (Mostly asymptomatic depending on how much backflow) |
| Analysis of Heart Failure: Priority problems | Impaired gas exchange, Decreased perfusion, Risk for pulmonary edema |
| Improving Gas Exchange: Promoting Oxygenation and Gas Exchange | Ventilation assistance, Monitor respiratory rate, Auscultate breath sounds, Position in high Fowler's if patient dyspneic, Maintain O2 saturation of 90% |
| Improving Cardiac Output/Perfusion | Improve/increase cardiac pump effectiveness- Reduce PRELOAD--> Nutrition Therapy, Diuretics (caution with Renal patients), Venous vasodilators Reduce AFTERLOAD --> ACE Inhibiotrs, ARBs, ARNI's |
| Drugs that Enhance Contractility | Digoxin (Cardiac glycosides) --> Increase contractility, Reduce HR, Slows conduction through atrioventricular node, Inhibits sympathetic activity Inotropic drugs (beta adrenergic agonist) |
| Additional Drug Therapy for HF | Beta-adrenergic blockers (-OLOL) --> HCN channel blocker if contraindicated to beta blocker Aldosterone antagonist, Morphine sulfate |
| Increase in Aldosterone leads to- | -Increase in fluids retention, Increases Na+ |
| Nonsurgical Options for HF | Continuous Positive Airway Pressure (CPAP), Cardiac Resynchronization Therapy (CRT), and CardioMEMS implantable monitoring system (even though CRT and CardioMEMS are implants, still considered noninvasive) |
| Surgical Management of HF | Heart transplantation, VADs (or LVAD), Other surgical therapies |
| Preventing or Managing Pulmonary Edema | Assess for early signs (crackles in bases, Dyspnea at rest, Disorientation, Confusion), High Fowler's, O2 Therapy, Nitro, Rapid-acting diuretics, IV morphine sulfate |
| Continual Assessment for Preventing or Managing Pulmonary Edema | Home Care; Healthcare resources, MAWDS (Medications, Activity, Weight, Diet, Symptoms) |
| MAWDS- (M) Self Care Teaching | Medications: Take medications as prescribed and do not run out, Know the purpose and side effects of each drug, Avoid NSAIDs to prevent sodium and fluid retention |
| MAWDS- (A) Self Care Teaching | Activity: Stay as active as possible but DON'T overdo it, Know limits, Be able to carry on a conversation while exercising |
| MAWDS- (W) Self Care Teaching | Weight: Weigh each day at the same time on the same scale to monitor for fluid retention |
| MAWDS- (D) Self Care Teaching | Diet: Limit daily sodium intake to 2-3 g as prescribed, Limit daily fluid intake to 2 L |
| MAWDS- (S) Self Care Teaching | Symptoms: Note any new or worsening symptoms and notify the health care provider immediately |
| Indications for Worsening or Recurrent HF | Rapid weight gain, Decrease in exercise tolerance, Cold symptoms, Development of dyspnea/angina at rest, Increased edema in feet, ankles and hands |
| Nursing Considerations with Valvular Heart Disease | Sudden illness or slowly developing symptoms over many years, Family history and symptoms, Ask about possibility of IV drug abuse |
| Diagnostics for Valvular Heart Disease | Chest X-ray, ECG, Stress test, and Cardiac catheterization |
| Nonsurgical Management of Valvular Heart Disease | Rest, Drug therapy (Diuretics, Beta-blockers, ACE inhibitors, Digoxin, Oxygen, Anticoagulants (warfarin***), Education (Home Care and Self-Management) |
| Pericarditis | Inflammation of the Pericardium (can be caused virally/bacterially) |
| Assessment of Pericarditis | Substernal Percoidial Pain (Radiating to the left side of neck, shoulder, or back -- Grating, oppressive pain, aggravated by breathing, coughing, swallowing -- Pain worsened by supine position; relieved by sitting up and leaning forward) |
| Interventions for Pericarditis | Pain management (NSAIDs, Corticosteroids, Antibiotics for bacterial form), Pericardiectomy- for chronic constrictive pericarditis |
| Desired BP | 120/80 |
| Why is it important to manage BP? | BP, whether high or low, can lead to complications |
| Essential Hypertension: | Not caused by an existing health problem but contributes to other health problems |
| Common Risk Factors for Essential Hypertension | Obesity, Smoking, Stress, Family history |
| Secondary Hypertension: | HTN caused by a specific condition such as: Renal disease, Primary aldosteronism, Pheochromocytoma, Cushing's syndrome, Medications |
| Assessments for Vascular Problems | Patient history- What are risk factors for HTN? Physical assessment- Does HTN cause symptoms? Psychological assessment- How could this be linked to HTN? |
| Lifestyle Modification for Vascular Problems | Diet, Weight reduction, Reduce alcohol intake, Exercise, Decrease stress levels, Avoid smoking |
| Drug Therapy for Hypertension | Diuretics, Calcium channel blockers, ACE inhibitors, Angiotensin II receptor antagonist, Beta-adrenergic blockers |
| Loop Diuretics | furosemide - Fast, Decrease K+, K+ rich foods |
| Thiazide Diuretics | HCTZ - Self limiting, Dec K+ |
| K+ Sparing Diuretics | Spironolactone, Inc K+, Foods low in K+ |
| Calcium Channel Blockers | Decreased HR (verapamil, amlodipine, diltiazem), Avoid grapefruit juice |
| ACE Inhibitors | (PRIL), Block the angiotensin conversion 1-2, Common side effect is a dry, hacking cough, Incr K+ |
| ARBS | (ARTAN), Angiotensin II Block, Incr. K+ |
| Beta-Blockers | (OLOL), Decr. HR, Don't give if HR is less than 50-60, SBP of 90-100 |
| Arteriosclerosis | Thickening or hardening of arterial wall, Often associated with aging |
| Atherosclerosis | Type of arteriosclerosis involving formation of plaque within arterial wall |
| Causes of Arteriosclerosis & Atherosclerosis | Genetic predisposition, DM< HLD (hyper lipidemia) --> HDL Low, LDL High |
| Triglyceride Range | Below 150 |
| Assessment & Interventions of Arteriosclerosis & Atherosclerosis | Assess labs (Cholesterol, HDL and LDL, Triglycerides), Nutrition therapy, Smoking cessation, Exercise, Drug therapy (HMG-CoA reductase inhibitors (statins- MOST COMMON), Ezetimibe |
| Peripheral Vascular/Arterial Disease | Alters natural flow of blood through arteries and veins of peripheral circulation due to partial or total arterial occlusion, Result of systemic atherosclerosis |
| Key Features of PVD/PAD (Peripheral Vascular/Arterial Disease) | (4 Stages) 1. Asymptomatic 2. Claudication (Reproducible, pain with activity) 3. Rest pain (Pain that occurs even while at rest; numbness and burning, NEVER prop legs up against the heart) 4. Necrosis/Gangrene (NO bloodflow) |
| Inflow Disease | Discomfort in lower back, buttocks, thighs (Inguinal) |
| Overflow Disease | Burning or cramping in calves, ankles, feet, toes |
| Physical Assessment of PVD/PAD | Hair loss and dry, scaly, pale or mottled skin, thickened toenails, Severe arterial disease (Extremity is cold and gray-blue or darkened, Pallor may occur with extremity elevation, Dependent rubor, Muscle atrophy, Gangrene/necrosis, Ulcers) |
| Diagnostic Assessments for PVD/PAD | Imaging assessment - Magnetic Resonance Angiography, Ankle-brachial index (ABI), Exercise tolerance testing |
| Nonsurgical Management for PVD/PAD | Exercise and position, Promote vasodilation, Avoid stress, caffeine, nicotine, Drug therapy (antiplatelet agents), Percutaneous vascular intervention. Atherectomy , Avoid extreme temp |
| Venous Thromboembolism (VTE) | Term including Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) |
| Thrombus | A blood clot |
| Virchow's Triad | Stasis of blood flow, Endothelial injury, Hypercoagulability |
| DVT Risk --> | --> Pulmonary Embolism (DVT is most common Thromboembolism) |
| VTE Assessment - DVT's (Deep Vein Thrombosis) | Calf or groin tenderness or pain, Sudden onset of unilateral swelling of leg, Localized edema, warmth of affected area |
| VTE Imaging | Venous duplex ultrasound, MRI, D-Dimer (Marker of clot breakdown) |
| Nonsurgical VTW Management | Rest, Preventative measures (Exercise, Movement, Early ambulation, Hydration) |
| VTE Drug Therapy | Unfractionated heparin, Low-molecular-weight heparin, Warfarin, DOAC's, Thrombolytics |
| Surgical VTE Management | Imports/Clot traps |
| Arterial Vs. Venous - Arterial System | Dangling legs down (Dependent position) Elevation.. makes pain worse |
| Arterial Vs. Venous - Venous System | Elevation of legs.. decreases swelling & helps with blood flow. Dangling legs or standing for long periods.. makes pain & edema worse |
| Arterial Vs. Venous - Skin - Arterial System | Cool to touch, Think, dry/scaly skin, Hairless, Thick toenails "DR. EP" --> Dangle legs = Rubor Elevate legs = Pale |
| Arterial Vs. Venous -Skin - Venous System | Warm to touch, Thick, tough skin, Brownish color |
Created by:
AdrianMtz42
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