Exam II Flashcards
(212 cards)
1
Q
Inc. serum bilirubin, due to liver dysfunction, hemolysis, severe burns, pancreatic cancer, blockage of bile duct, cholecystitis
A
Jaundice
2
Q
Jaundice in light skin individuals
A
yellowing in sclera, hard palate, mucous membranes and skin LAST
3
Q
Jaundice in dark skin individuals
A
yellowing in junction of hard palate and soft palate then palms, normal for yellow deposits under eyelid
4
Q
Fissure?
A
Secondary lesion, linear crack in the skin extending to the dermis (Ex: chapped lips, hands or Tinea Pedis)
5
Q
Ulcers?
A
Secondary lesion, skin loss extending past epidermis, necrotic tissue loss (Ex: stasis ulcer, peptic ulcer, pressure ulcer)
6
Q
Erosions
A
Secondary lesion, loss of superficial epidermis only (Ex: ruptured vesicle (blicter), scratch marks )
7
Q
Steps of skin scraping
A
- Tissue is scraped from a parasitic or fungal lesion w/ scalpel that is moistened with oil so that skin sticks 2. Scraped material is transferred to the glass slide 3. Spores and hyphae of skin infection or infestation is seen (Ex: scabies)
8
Q
Tzanck Smear
A
Used on blistering skin like herpes zoster, varicella, herpes simplex, and pemphigus, Secretions from the lesion are applied on a glass slide then stained then examined
9
Q
Patch Test
A
For allergy testing purposes. You apply an occlusive patch of that allergen on the person for 48 hrs and then it s assessed after 72 hrs. (weak pos rxn: redness, fine elevation, itching) (mod positive rxn: fine blisters, papules, severe itching) (strong pos. Rxn = blistering, pain and ulceration) ALWAYS educated after about allergen trigger and avoidance
10
Q
ABCDE of Burns
A
Airway, breathing, circulatory/cardiac, disability, examine neuro deficit/environment/ exposure source.
11
Q
Top Nursing Priorities for serious burns
A
(Emergent phase: Risk for: hypovolemic shock, respiratory distress, compartment syndrome) (Acute Phase: Focus: preventing infection, alieving pain, ensuring proper nutrition, wound care) (Rehab phase: Focus: psychosocial, ADLs, PT, OT, cosmetic correction)
•ABC•Vital signs and hemodynamic status•Monitor for fluid volume deficit•Assess extent of the burn
12
Q
Why is Face, Neck and Trunk burns dangerous?
A
It affects respiratory! Especially if circumferential and can cause compartment syndrome
13
Q
S/S of smoke inhalation
A
Burn located on the face (especially mouth and nose), Carbonaceous sputum …spit has soot in it…(smoke), Hair singeing on the head and nose hairs, Soot in the mouth and nose (smoke), Skin bright red (CO poisoning), Trouble talking…voice is hoarse, Confusion, anxiety,
14
Q
Top nursing Priorities w/ smoke inhalation
A
Confusion, anxiety, Increased heart rate. Maintain oxygenation, airway clearance, fluid/electrolyte balance, body temp reg., infection prevention, dec. anxiety. Check for blistering of oropharynx. ABGs. Pulmonary function test
15
Q
1st degree burn
A
(superficial): affects the top layer of the skin “epidermis”.and there is pain and pinking of skin (sunburn), brisk cap. Refill
16
Q
2nd degree burn
A
(partial-thickness) can be superficial or deep partial-thickness affecting various areas of the dermis, hypodermis but not yet. Shiny and moist, redness and blistering, blanching present, maybe skin graft
17
Q
3rd degree burn
A
“full-thickness”: all skin layers are damaged along with the hair follicles, sweat glands, nerves down to the hypodermis and subcutaneous tissue, no pain, skin graft needed, circumferential burn full-thickness = issues with respiratory (compartment syndrome), Eschar needs to be removed
18
Q
4th degree burn
A
“deep full-thickness” : worst of all…all the layers are destroyed but it extends to the muscles, bone, ligaments …all sensation of pain is gone.
19
Q
Calculating IVF replacement
A
2 mL LR X pt weight in kg X % TBSA (if electrical burn then 4 mL LR) (½ given w/in first 8 hrs of injury and the other half over next 16 hrs) ( > 5% TBSA in children AND >10% TBSA in Adults)
20
Q
Assessment and documentation of burns
A
depth of damage to the skin, the percentage of the total surface of the skin affected (check out my video on rule of nines), patient’s age (children at most risk due to small size and elderly slower healing …usually have extensive medical history…skin is thin), medical history (diabetic already has issues with circulation already), where the burn is located (front and back of the trunk, face and neck …THINK respiratory issues or is it a circumferential burn …a burn that “circles” or surrounds an extremity or the torso?, did the patient experience an inhalation injury?
21
Q
Lund and Browder Method
A
recognizes % of TBSA of various anatomical parts
22
Q
Rule of Nines
A
Each arm = 9%, each leg = 18%, neck/chest/abdomen = 18%, Head = 9%, Groin = 1%, chest/abdomen = 18%, back = 18%
23
Q
Palmar Method
A
Use pts hand to measure burns on their body, each hand sized burn = 1%
24
Q
Concerning S/S of serious burns
A
Compartment syndrome w/ full thickness circumferential burns. Fluid and electrolyte imbalance, inability to thermoregulate (keep temp higher), inc. pH in kidneys, vasoconstriction, cardiac changes, immunosuppressed, edema, impaired GI motility, inability to breathe if burn on face, neck or trunk. Amputation = disabled
25
Electrolyte imbalance disturbances in acute phase injury
Fluid reenters the vascular space from the interstitial space
Hemodilution
Increased urinary output
Sodium is lost with diuresis and due to dilution as fluid enters vascular space: hyponatremia
Potassium shifts from extracellular fluid into cells: potential hypokalemia
Metabolic acidosis
26
What to do if chemical burn
Flush burn with cool water continuously, remove clothing w/ chemicals on it, bandage up the burn and then flush again if needed. Check eyes for contact lenses! Take out ASAP and call opthamologist
27
Coping with burns
Coping may include adapting to a new life with a disability, coping with body image issues, pain, needing to talk to a therapist, it all depends on the severity of the burn and the events that led up to the burn. Emergent phase = most anxiety
28
Normal BUN
7-20 mg/dL
29
Normal Creatinine
0.6-1.2 (1.4 for men) mg/dL (high if dehydrated
30
GFR
90+
31
CT
: cross sectional views of the brain, contrast used (assess kidneys prior because contrast, check for shellfish or iodine allergy). Can see tumors, masses, infarctions, hemorrhages, atrophy. Pt needs to lie still small space so claustrophobia may be an issue but sedation can happen, IV should be in and fast 4 hr prior
32
CTA
CT Angio visualizes blood vessels, radiography study w/ contrast. BUN and creatinine should be checked prior, keep pt hydrated on clear liquids, void immediately before procedure, mark all peripheral pulses, stay immobile after. Good to check aneurysms or blockages
33
MRI
w/ or w/out contrast, look for chemical brain changes and cerebral abnormalities. Can look at tumors, strokes, MS. You can see blood flow and metabolism. Absolutely NO metal. If you cannot lay flat you cannot participate, claustrophobia risk. Clearer image and no contrast needed so good for someone with kidney issues or allergies
34
Cranial nerve X testing
Sensory and motor (Pharynx, Larynx, soft palate, sensation of external ear, thoracic, abdominal organs. Ask patient to speak and say “ahhh” and see if uvula lays midline. Assess voice changes, voice paralysis and Dysphagia
35
Aging of Neuro
Visual.Auditory/taste nerve degeneration or taste bud atrophy, sleep decreases, Temp. Regulation decreases, deep tendon reflex dec., Autonomic regulatory slows down, Slower responses but change in mental status is not a normal part of aging
36
Romberg Test
balance. Slight swaying is ok but losing balance is a positive romberg test. You stand or sit for 20 second arms straight out at the side and feet together.
37
Rinne Test
Rinne is about air conduction v bone conduction, strike the tuning fork then put it on the mastoid process, once you cannot hear it vibrating anymore then you tell the physician and repeat for other ear and time both durations.
38
Weber Test
Weber is about sensorineural and air conduction, strike a tuning fork and put it in the middle of your head and then note where the sound is best heard (R/L/ Both)
39
Frontal Lobe
Frontal largest part, front of the brain and responsible for concentration, abstract thinking, memory, motor function, Broca’s area, emotional brain (judgement, affect, person)
40
Parietal Lobe
is posterior to frontal, responsible for sensory information and relays interpretations, it distinguishes between L and R, essential to awareness of body position in space and size and shape discrimination.
41
Temporal Tope
Auditory and receptive areas, play a role in memory of sounds, and understanding language and music.
42
Occipital Lobe
Responsible for visual interpretation and memory
43
How to assess mental status
Appearance, behavior, grooming, hygiene, gestures, awareness, A & O to person, place and time. Assess immediate and remote memory
44
Agnosia
Loss of ability to recognize objects through sensory system. Visual/auditory or tactile
45
Ataxia
Inability to coordinate muscle movement, difficulty walking, talking and self care
46
Spasticity
Sustained increase in tension of muscles when it is passively stretched is a condition in which certain muscles are continuously contracted. Seen with rapid movement
47
Rigidity
increase in muscle tone at rest characterized by increased resistance to passive stretch. Occurs throughout a whole movement and it does not rely on velocity
48
Lumbar Puncture (what is it, why do you do it, complications)
Empty bladder before hand because do not want to puncture, Knees to abdomen during the procedure, flat after to help avoid headaches. Hydration is very important. Usually done to remove a sample of CSF to check for bacteria or to diagnose Guillain-Barre, MS, Meningitis, Cancer. Complications: the risks include headache from a persistent spinal fluid leak, brain herniation, bleeding, and infection. Avoid sudden movement during procedure!!
49
Concussion
This is the temporary loss of consciousness w/ no apparent structural damage. Nursing Assessment includes post concussion scale, Hx, fatigue, disorientation, LOC? And avoidance of second injury.
50
Pt education on concussion
do not reinjure and re concuss yourself because second impact syndrome can occur
51
S/S concussion
cannot recall immediate memory, out of it, slow, HA, N/V, dizzy, light sensitive
52
Cerebral contusion
This occurs when the brain is bruised due to damage when the brain hits the skull from an acceleration-deceleration occurrence like a car crash. Nursing assessment includes decreasing ICP via mannitol, monitoring effects since usually occurs later like 18-36 hrs post injury. MMSE, Ensure open airway, inspect scalp for wounds, neuro assessment
53
Pt education w/ cerebral contusion
includesRest, S/S identification especially of Inc. in ICP, Explain mild cognitive changes do not disappear overnight, follow up appointments are important, do not cough, sneeze or blow your nose. Observe for CSF leaks, have family do assessments on LOC
54
Subdural Hematoma (acute, subacute vs chronic)
Occurs between burs and the brain/arachnoid space. Occurs in head traumas like car accidents which are accel-decel. The cause is from rupture bridging veins, blood pools in subdural space. Pooling can take days to weeks; if acute = 24 hrs - 3 days, subacute = 3- 14 days and chronic = > 15 days
Pt in lucid state and 50% chance of coma. Venous blood. Can cause an increase in ICP, midline shift of herniations which compresses arteries which causes decrease in oxygenation
55
S/S and intervention w/ subdural hematoma
Loss of consciousness, HA, Vomiting, hyperdense CT is acute, Hypodense if Chronic. Crosses suture lines, crescent shapes, follows the shape of the brain, drained with catheter
56
Epidural Hematoma what is it and nursing action
Happens between the skull and the dura due to trauma. Nursing Action is to reduce ICP, stop the bleeding.
57
S/S of Epidural Hematoma
altered LOC, seizures, Aphasia, Vomiting, Confusion. Usually arterial
58
Skull fracture types
Linear: linear fracture, there is a break in the bone, but it does not move the bone. ,
Basilar: most serious type of skull fracture, and involves a break in the bone at the base of the skull. Patients with this type of fracture frequently have bruises around their eyes and a bruise behind their ear. They may also have clear fluid draining from their nose or ears due to a tear in part of the covering of the brain. These patients usually require close observation in the hospital.
Depressed: In this fracture, part of the skull is actually sunken in from the trauma.
Diastatic: These are fractures that occur along the suture lines in the skull. The sutures are the areas between the bones in the head that fuse when we are children
59
Subdural hematoma occurs with arteries or veins?
Veins: These can form from a tear in the veins that go from the brain to the dura, or from a cut on the brain itself. They are sometimes, but not always, associated with a skull fracture.
60
Epidural hematoma occurs with arteries or veins?
Arteries: They usually come from a tear in an artery that runs just under the skull called the middle meningeal artery. Epidural hematomas are usually associated with a skull fracture.
61
What to do when you have a pt with a skull fracture
et a CT, observe the pt, depressed skull fracture needs surgery asap w/in 24 hrs
62
Battle sign
Ecchymosis over mastoid
63
Raccoon eyes
Periorbital ecchymosis from basal fracture
64
Neuro Monitoring
Observe for altered LOC, HA, dizziness, seizures, abnormal pupil response, vomiting, irritability, slurred speech, numbness of arms or legs.
65
Glascow Coma Scale
Severe comatose = <8, Moderate = 9 - 12, Mild = 12- 15 and No damage = >15, you do it on pt
66
Normal levels of ICP
5-15 mm Hg
67
What is increase in ICP and what should a nurse do
Occurs as damaged brain swells w/ edema or blood collects. Monitor closely, if increase in ICP make sure you maintain adequate O2, Elevate HOB, maintain normal blood volume, seizure prevention important, benzos can be utilized for agitation
68
Side effects of Inc. ICP
Possible comatose, n/v, stupor, decorticate or decerebrate (worse), Hemiplegia. NO L.P. Prevent increase in ICP, Prevent hypoxia. Cheyne stokes breathing occurs (hyperventilation followed by apnea), Cushing's Triad is a late sign ( inc. BP, dec. HR, dec. RR)
69
Spinal cord injuries occur in whom
MVA, falls, violence (gunshot), sports. Occurs in males around 42 yrs of age. Can occur from concussion, contusion, laceration or compression of spinal cord
70
Dysphagia
Difficulty swallowing, speech pathologist should be consulted, thickened liquids if needed, prevent aspiration, swallow study can be done, change food consistency, tube feeds or surgery
71
CSF leak
is due to a tear or hole in the dura mater from surgery, L.P, Injury or spontaneously occurs.
72
How to assess CSF leak
pledget study (cotton pad into the nose), CT cisternogram (contrast added to spinal fluid vis L.P then the dye identifies the location of the leak, The patient is then tilted with the head down and a CT scan is performed to see where the CSF and the contrast is leaking out.). Halo sign
73
MS
Progressive immune mediated disorder. Signals are not carried on nerves of the CNS correctly or promptly due to demyelination. Conduction of CNS is affected
74
S/S of MS
trouble thinking, incontinent or inability to void, constipation or diarrhea, difficulty in coordination, loss of balance, pain, speech difficulty and visual disturbances. Exacerbative and Recurrent. fatigue, weakness, numbness.
75
Nursing care of someone w/ MS
Positive romberg sign, injury prevention, speech and swallowing, support group, exercise device, easy access to bathroom, inc. fiber, cool environment, dec. stress, Assistant devices. Lhermitte's Sign = electrical shock feeling
76
Lhermitte's Sign
sudden sensation resembling an electric shock that passes down the back of your neck and into your spine and may then radiate out into your arms and legs. It is usually triggered by bending your head forward towards your chest
77
Romberg Sign
present when a patient is able to stand with feet together and eyes open, but sways or falls with eyes closed.
78
Guillain-Barre
Autoimmune disorder. Affects the PNS with rapid demyelination. GBS occurs to a prior infection like Campylobacter Jejuni or Epstein Barr and that infection attacks the MYELIN.
79
Guillain-Barre S/S
Respiratory failure can occur with progression so important to seek help! Starts in feet usually and then gradually block of sensation moves upward. No cure but you can alleviate. Can become paralzed but w/ treatment and therapy it can resolve. Respiratory and Speech are main concerns! May need feeding tubes and make sure you listen to bowels. Muscle cramping occurs which can be very painful. Risk for DVT
80
Nursing Care of Guillain-Barre
Immunoglobulin therapy and plasmapheresis can be done w/in 2 weeks of onset of symptoms to decrease the recovery time. Can do electromyography and nerve conduction study. Lumbar Puncture can be done and will result in elevated protein and normal WBC.
81
Myasthenia Gravis
Autoimmune disorder characterized by weakness (mainly in the face; eyes, throat, face, arms and legs next and then respiratory). The reason is because antibodies directed at acetylcholine at the myoneural junction impair transmission of impulses. Muscle fibers do not contract.
82
S/S Myasthenia Gravis
OB, fatigue, mask-like, ptosis, slurred speech, trouble swallowing.
83
Nursing Care of someone with Myasthenia Gravis
Administer meds 30-60 min after giving anticholinergic meds so they can better swallow meds. Best to do activities earlier in the day because that’s when pt is most rested. Check cranial nerves
84
Myasthenia Crisis and what to do
severe muscle weakness and respiratory failure due to not enough anticholinesterase medication, stress, respiratory failure or surgery. Want to give Edrophonium which is an anticholinesterase (Can do a tensilon test to see what the issue is; myasthenia or cholinergic?)
85
Cholinergic Crisis, What to do
severe muscle weakness and respiratory failure due to overmedication w/ anticholinesterase. Want to give Atropine which is an antidote. (Can do a tensilon test to see what the issue is; myasthenia or cholinergic?)
86
Meningitis
Inflammation of membranes (meninges) and fluid space surrounding the brain and spinal cord.
87
S/S meningitis
HA, fever, nuchal rigidity,positive kernig sign bilaterally (thigh cannot extend straight after bent towards abdomen), Positive Brudinski sign (flexion of the hip and knee causes flexion of the neck), photophobia, rash w/ skin lesions w. N. meningitidis infection, disorientation, inc. ICP, seizures.
88
Nursing Care of Meningitis
CT, LP, Bacterial culture, infection control, pain mgmt, rest, antipyretic and cooling blanket, hydration, close neuro monitoring, pulse ox, ABG, BP check for shock, health promotion, regular phys exams, immunization of flu and pneumococcal
89
Kernig Sign
Done for meningitis, The test for Kernig sign is done by having the person lie flat on the back, flex the thigh so that it is at a right angle to the trunk, and completely extend the leg at the knee joint. If the leg cannot be completely extended due to pain, this is Kernig sign.
90
Brudzinski Sign
physically demonstrable symptoms of meningitis is Brudzinski's sign. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed. Chin to chest causes knees and hips to flex up like in a ball
91
Trigeminal Neuralgia
Cranial nerve 5 damage characterized by paroxysms of pain in the face. Painful when washing face, oral care, eating. Nursing care: provide soft food to chew, instruct them to chew on unaffected side, ensure hygiene is taken care of, provide interventions regarding anxiety, depression and insomnia. Help w/ chronic pain and avoidance of triggers!
92
How to obtain a sputum specimen
Take 3 deep breaths, hold in for 5 seconds then cough out deeply and forcefully, 2 mL needed. May also be obtained via nasotracheal or orotracheal suctioning via sputum trap or bronchoscopy. Rinse mouth prior to decrease the amount of contamination
93
Emphysema
Destroyed and distended alveoli, decreased alveolar surface area which increases dead space, impairs oxygen perfusion and hypoxemia can occur. CO2 hangs out in alveoli because trapped. Respiratory insufficiency is a MAJOR concern
94
S/S Emphysema
Main 3: chronic cough, sputum production, and dyspnea → Early- overweight Late - underweight, pink puffers, Hypercapnia (later sign), Cor pulmonale (right-sided heart failure brought on by long-term high blood pressure in the pulmonary arteries), Barrel chest, Resp infections, inability to exercise, accessory muscle use, possible central cyanosis, Hyperinflation of lungs and flattened diaphragm.
95
Nursing Interventions of Emphysema
Spirometry test to assess airflow obstruction, Pulmonary function test, O2 monitoring, ABG CT, Perform Health History!! .
96
Pt education on Emphysema
quit smoking, use of bronchodilators, corticosteroids, oxygen therapy.
97
Wheezing
Continuous high pitched sound on expiration, associated w/ bronchial wall constriction, chronic bronchitis or bronchiectasis
98
Rhonchi
Deep sonorous wheeze during expiration through a narrow tracheobronchial passage, low pitched rumble like a snoring sound. Happens with secretions in the airway or tumor
99
Crackles
soft, high pitched discontinuous popping on inspiration (may be cleared by coughing), secondary to fluid in airways or alveoli, heart failure and pulmonary fibrosis
100
Pleural Rub
Harsh crackling like leather, inspiration alone or both, coughing does not clear it but if you hold your breath then the sound disappears. Decreased lateral anterior thorax and occurs secondary to inflammation and loss of lubricating pleural fluid
101
Acute Pharyngitis
Sore throat. Due to environmental exposure to viral agents and poorly ventilated rooms, viral pharyngitis spreads fast in droplets, coughing, sneezing and unwashed hands. RADT: uses a swab that collects sputum specimen from the posterior pharynx and tonsil
102
S/S of Acute Pharyngitis
fiery-red pharyngeal membrane and tonsils, lymphoid follicles that are swollen and flecked with white-purple exudate, enlarged and tender cervical lymph nodes, and no cough
103
Nursing Interventions of Acute Pharyngitis
Cool beverages, warm liquids, and flavored frozen desserts such as ice pops are often soothing, soft or liquid diet.
104
Pt teaching on acute pharyngitis
stay in bed during febrile stage, call physician if difficulty breathing or swallowing, take AB, avoid germs and getting others sick, no smoking, do not share food or utensils.
105
PPD Mantoux Test
Take TB syringe, bevel up, under the skin, form bubble 6-10 mm. Wait to read for 48-72 hrs and if there is redness and < 4 mm induration then not significant. Induration of 5 mm + and redness = significant
106
inhaled asbestos fibers into the alveoli.
Asbestosis
107
inhaled silica dust produces nodular lesions in the lung
Silicosis
108
“black lung disease”, inhaled dust, mix of coal, Kaolin, mica and silica
Coal workers Pneumoconiosis
109
ARDS
Fluid leaks from small blood vessels and builds up in the alveoli in your lungs. Your lungs are then unable to fill up with enough air.
110
ARDS S/S
inc RR, inc HR, tired, dec. surfactant, sudden progressive pulmonary edema, Visible on chest x-ray, and absence of an elevated left atrial pressure, Rapid onset of severe dyspnea, Hypoxemia that does not respond to supplemental oxygen therapy
111
Nursing Interventions for ARDS
Fast identification and treatment of underlying cause, Intubation, mechanical ventilation with PEEP to keep alveoli open, Hypovolemia treatment, Prone positioning is best for oxygenation, frequent repositioning to safeguard integumentary system, Nutritional support, enteral feedings preferred, Reduce anxiety. VS, Lung sounds, ABG, X ray. Want PaO2 > 60 Oxygen > 90. Watch for hypotension
112
Pneumonia
Respiratory acidosis, occurs in pt w/ certain underlying disorders and diseases. Heart failure, diabetes, alcoholism, COPS, AIDS, Influenza, CF are at higher risk. Lower resp., inflammation of alveoli. arises from normal flora present in patients whose resistance has been altered or from aspiration of flora present in the oropharynx; patients often have an acute or chronic underlying disease that impairs host defenses. Affects ventilation and perfusion.
113
S/S pneumonia
Rhonchi, coarse crackles, bronchial breath sounds in peripheral, pleuritic pain, elevated PCO2 > 45, inc. WBC, fever, N/V, headache, myalgia, rash, sore throat increased HR and RR, Achy, SOB
114
Nursing Interventions w/ Pneumonia
auscultate lungs, check O2, suction if needed, sputum sample, vital signs, cyanosis check, give AB as ordered, collect sputum, ABG, Breathing treatment, hydration, HOB up Pt
115
Teaching when it comes to Pneumonia
Vaccines! Pneumovax Q5 years, incentive spirometry use, mgmt of symptoms, stop smoking
116
inflammation of both layers of the pleura. Can happen with pneumonia, TB, Trauma, pulmonary infection, PE.
Pleurisy
117
S/S pleurisy
Pleuritic pain on one side usually with taking a deep breath, coughing, or sneezing worsens the pain
118
Nursing Care of Pleurisy
Provide analgesics to enhance comfort, Sputum analysis needed, thoracentesis, chest X ray, listen to lung sounds usually show pleural friction rub
119
Pt Education on Pleurisy
Splint coughs with a pillow
120
Usually from blunt chest trauma causing free floating rib spaces. Fracture of 3+ ribs in 2 or more locations. This then creates an unstable chest wall that moves paradoxically drawing in w/ chest expansion and pushing out w/ exhalation. Respiratory distress and pain occurs
Flail chest
121
Flail chest S/S
hypoxemia, pain, respiratory acidosis potentially, decreased C.O b/c shift
122
Nursing Interventions Flail Chest
Support adequate oxygenation & ventilation, Analgesia use, prepare for endotracheal intubation & mechanical ventilation. Vent support is needed, ABG, pulse ox, bedside pulmonary. function monitoring. clearing lung secretions
123
Most common autosomal recessive disease among the caucasian population. Due to dysfunction in the protein (CFTR), which normally transports chloride ions across epithelial cell membranes. Gene mutations affect transport of these ions, leading to CF, which is characterized by thick, viscous secretions in the lungs, pancreas, liver, intestine, and reproductive tract as well as increased salt content in sweat gland secretions. Both parents w/ the gene give child ¼ chance of having
Cystic Fibrosis
124
S/S cystic Fibrosis
Starts in upper lobes and works down, bronchial mucus plugging, inflammation, and eventual bronchiectasis, productive cough, wheezing, hyperinflation of the lung fields on chest x-ray, and pulmonary function test results consistent with obstructive disease of the airways and chronic respiratory inflammation
125
Nursing Care of Cystic Fibrosis
Acute and chronic care, Airway clearance, nebulizing treatments, IV antibiotics, Pancreatic enzyme supplement w/ meals, Chest PT, Anti Inflammatory agents, CFTR modulators, adequate fluid and nutrition, remove secretions,
126
Pt Teaching o Cystic Fibrosis
coming to hospital for tune ups, do not come within 6 ft of someone with CF. Mid 40’S = LIFE EXPECTANCY
127
Simple Pneumothorax
when air enters pleural space b/c breath of pleura
128
Traumatic Pneumothorax
air escapes b/c of laceration in the lung itself
129
Tension Pneumothorax
is when the air is drawn into the pleural space from a laceration in lung or wound in chest wall.
130
S/S of Pneumothorax
sudden pleuritic pain, minimal resp. Distress, chest discomfort, tachypnea, Pneumothorax, acute resp. Distress if pneumothorax is large, anxious, dyspnea, air hunger, accessory muscle use, central cyanosis.
131
Nursing interventions w/ Pneumothorax
assess tracheal alignment, expansion of chest, breath sounds, O2 stats and percussion of chest, in traumatic open pneumothorax - emergency treatment is to stop airflow through the opening (b/c w/ each breath the mediastinum shifts, pushing heart)
132
pH
pH = 7.35 - 7.45,
133
PaCO2
PaCO2 = 45 - 35,
134
HCO3
HCO3 = 22-26.
135
Empyema
thick purulent fluid in the pleural space due to bac. Pneumonia or lung abscess. Decreased or absent lung sounds over the affected area.
136
S/S Empyema
fever, night sweats, pleural pain, cough, dyspnea, anorexia, weight loss.
137
Teaching when it comes to Empyema
cope with the condition and instructs the patient in lung-expanding breathing exercises to restore normal respiratory function, chest tube care at home and drainage (chest tube in until pus is gone)
138
Nursing Care w/ Empyema
Chest CT and thoracentesis(needle aspiration), drain fluid and give AB 4-6 weeks. Chest tube is needed
139
Pulmonary HTN
This high pressure in the pulmonary arteries and right ventricle lead to back up of blood in the venous system, resulting in dependent edema, distended neck veins, or pain in the region of the liver.
140
S/S pulmonary Hypertension
SOV, dizziness, substernal pain, weakness, fatigue, syncope, hemoptysis, rt sided heart failure s/s (edema, ascites, distended neck vein), crackles, heart murmur, liver engorgement
141
Nursing of Pulmonary HTN
obtain Hx, provide diuretics, vasodilators, O2 therapy, ECG, pulmonary function test, X ray, hypoxia risk. (COPD, PE, Congestive heart failure mitral valve disease higher risk)
142
Pt education on Pulmonary HTN
home oxygen therapy
143
COPD
Chronic bronchitis and emphysema. Preventable and treatable but not reversible. Involves airways, pulmonary parenchyma or both. Airflow limitation, inflammation, scar tissue in parenchyma so dec. elastic recoil and pulmonary HTN from thickened vessel linins
144
S/S COPD
Chronic cough, sputum production, Dyspnea, weight loss, barrel chest
145
Nursing care of someone w/ COPD
pulmonary function tests, spirometry, ABG, X-Ray, obtain Hx, review diagnostic tests, achieve airway clearance, inc breathing and activity tolerance, acute respiratory failure, bronchodilator, corticosteroids nebulizer treatment, limit infection, improve breathing pattern
146
Pt teaching with COPD
quit smoking, MDI education, exercise, living in climate w/ minimal shifts. Pulmonary rehab, managing exacerbations
147
TB
is an infectious disease that primarily affects the lung parenchyma. S/S low fever, cough (Non productive or mucopurulent),hemoptysis, night sweats, fatigue, weight loss.
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Nursing care w/ TB
Hx and physical, mantoux ppd, X ray (lesions in upper lobes) , Sputum testing, give isoniazid and rifampin, promote airway clearance, advocate med adherence, promote activity and nutrition, prevent transmission
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Conduction
SA → AV → Bundle of His → R & L bundle branches to Purkinje Fibers → Up ventricles (depolarization (systole) followed by repolarization (diastole))
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Types of Vasopressors
Norepinephrine, Dopamine, Phenylephrine, Vasopressin, Epinephrine
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Purpose of Vasopressors
increases Bp via vasoconstriction
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Disadvantage of Vasopressors
increase afterload and cardiac workload, compromises perfusion to skin, kidney, lungs, GI, can cause trouble breathing and can cause arrhythmias. Cyanosis, numbness/cool feeling, Anaphylaxis CHECK BP!
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Flatline, CPR!, Intubate, IV access
Asystole
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SOB, Palpitations, irregular pulse, rapid pulse, fatigue, cheat pain, increased chance of blood clots and stroke
Disorganized and uncoordinated twitching with no P wave, increased risk of heart failure, M.I, Stroke and pulse deficit. No P wave just little waves
AFib: Common, due to abnormal impulse formation that occurs when structural or electrophysical abnormalities alter the atrial tissue.
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SHOCK, 3+ PVCs in a row w/ HR above 100. Emergency b/c pt s usually unresponsive and pulseless. Abnormal QRS, P wave hard to even see if there. More QRS than P. Give Amiodarone
VTach
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SHOCK common in cardiac arrest. Rapid disorganization of Ventricular rhythm, quivering ventricles, ventricular rate is greater than 300 bpm. Everything irregular. No recognizable QRS Give Amiodarone No P wave
VFib
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Defibrillate
to stop dysrhythmia, emergency treatment, no cardiac output, start w/ 200 joules and max 360, pt unconscious and EKG on, Given in Vtach or Vfib only
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Cardioversion
Synchronized w/ QRS complex, pt awake and sedated will need breathing tube , 50-200 joules, consent needed, EKG monitoring, for arrhythmias. Given for afib when pt does not respond to meds after 48hrs. warfarin is indicated for at least 4 weeks after the procedure. Use of a synchronizer
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congestion in the peripheral tissues and the viscera predominates. This occurs because the right side of the heart cannot eject blood effectively and cannot accommodate all of the blood that normally returns to it from the venous circulation
Rt sided heart failure
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S/S rt sided heart failure
Viscera and peripheral congestion, JVD, Dependent edema, Hepatomegaly, Ascites, Weight gain.
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Lt sided heart failure
Pulmonary congestion occurs when the left ventricle cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation.
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S/S left sided heart failure
Pulmonary congestion, crackles, S3 ventricular gallop, DOE, Low O2, Dry unproductive cough, Oliguria, Crackles that do not clear with cough, as failure worsen crackles are heard everywhere.
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Pt teaching w/ heart failure
Low sodium diet, healthier eating habits, exercise, quit smoking, medication adherence, stress management, daily weights, follow-up visits, include fam in education
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Assessment with heart failure
Echo, 12 lead, X-Ray, BNP
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S/S: altered digestion, dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow. As anxiety increases, so does dyspnea, increasing anxiety and creating a vicious cycle. Stimulation of the sympathetic system also causes the peripheral blood vessels to constrict, so the skin appears pale or ashen and feels cool and clammy.
In chronic HF
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CPR
30:1 ratio or 100-120 bpm, press down on chest 2 inches, rescue breaths if patient isn't breathing
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Hallmark symptom - intermittent claudication (achining, cramping, fatigue, weakness) ← occurs with exercise, which is relieved with rest, pain also associated with ischemia which is worse at night and when pt wakes up. Elevation of limb causes pain, feels better when limb is lower
PAD
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Intervention of PAD
Antiplatelet therapy (aspirin, plavix, trental, statins). Take note of Hx, meds risk factors, S/S of arterial insufficiency, claudication, color changes, weak/absent pulses, skin changes.
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Nursing Goal of PAD
decrease venous congestion,encourage vasodilation instead of compression, increase blood supply, relieve pain, maintain tissue integrity.
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Arterial insufficiency in mostly men, aching, cramping, fatigue, weakness when doing activities only relieved with rest. Pain in muscle groups distal to the area of occlusion. Sensation of coldness or numbness in the extremity may accompany intermittent claudication and is a result of reduced arterial blood flow.
PVD
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How to ease PVD
Exercise! The pain of peripheral vascular disease is typically chronic and often disabling. Analgesic agents may be taken before scheduled activities to help the patient participate more comfortably.
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Coumadin
an anticoagulant medication, commonly used to treat and prevent thrombosis Nursing Assessment: monitor INR and platelet count
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Adverse Effects and Pt teaching on Coumadin
Adverse effects: Risk for bleeding, Pt Education do not abruptly stop taking medication, do not eat green leafy vegetables, oral contraceptives, ginseng and st john's wort work against, Do not take NSAIDs or call doctor prior (ibuprofen or aspirin)
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Heparin
Anticoagulant: prevents the formation of new blood clots
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Nursing assessments, teaching and adverse effects of Heparin
Nursing Assessment: monitor aPTT Adverse effects: increased risk for bleeding, Pt Education do not abruptly stop taking medication, take dose at the same time each day and do not double the dose if you forget one day. Keep up with doctor appt. Do not take NSAIDs or call doctor prior (ibuprofen or aspirin)
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Lovenox
Prevention of thrombus formation and treatment for current VTE
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Nursing assessments, teaching and adverse effects of Lovenox
ursing Assessment: Usually given when someone has a heart attack, hip replacement or knee replacement, anti factor Xa is monitored NOT PT or aPTT Adverse effects: increased risk for bleeding, Pt Education do not abruptly stop taking medication, take dose at the same time each day and do not double the dose if you forget one day. Keep up with doctor appt. Do not take NSAIDs or call doctor prior (ibuprofen or aspirin)
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Feeling of a heart beating in abdomen when lying down
Abdominal Aortic Aneurysm
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S/S Abd. Aortic Aneurysm
Cyanosis can occur, Abdominalpain localized , low back pain may be present, (intense pain w/ falling BP and decreasing hematocrit can be a sign of ruptured aneurysm)
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Assessment of Abd. Aortic Aneurysm
palpable aneurysm, bruit, abdominal girth, ultrasonography or CTA. Monitor BP, Give antihypertensive meds. At high risk of hemorrhaging. Check temp!
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Percutaneous Transluminal Balloon Angioplasty (PTA)
a type of percutaneous coronary intervention in which a balloon is inflated within a coronary artery to break an atheroma and open the vessel lumen, improving coronary artery blood flow.
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Complications and nursing care of PTA
Complications coronary artery dissection, perforation, abrupt closure, vasospasm, MI, Serious dysrhythmias (VTach) and cardiac arrest Nursing monitor for signs of bleeding, give prescribed IV heparin or a thrombin inhibitor
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s/s VTE
nonspecific but it can be warmth, pain, swelling, tissue ischemia.
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Prevention of VTE
compression stockings, early ambulation, leg exercises, weight loss, quit smoking, low molecular weight heparin.
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Complication of VTE
chronic venous occlusion, pulmonary emboli from dislodged thrombus, valvular destruction (venous insufficiency, varicosities, venous ulcers) or venous obstructions (increased distal pressure, fluid stasis, edema, venous gangrene). You can do a risk assessment
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Arterial Ulcer
Inadequate exchange of O2 and other nutrients in the tissue. Chronic arterial disease is characterized by intermittent claudication, which is pain caused by activity and relieved by rest. Complaints of foot pain is common. Arterial ulcers are small, circular, deep ulcerations on the tips of toes or in between toes. Ulcers form on the medial side of the hallux due to ischemia and pressure.
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Assessment and nursing intervention of arterial ulcer
Pulses examined. Patients with ulcers can be effectively managed by advanced practice nurses or wound-ostomy-continence nurses in collaboration with the patients’ primary provider. All ulcers have the potential to become infected. Nurses want to improve mobility, ensure adequate nutrition and restore skin integrity.
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Common thrombolytics
Alteplase (Activase, t-PA), Reteplase (Retavase), Tenecteplase (TNKase), Urokinase (Abbokinase)
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Indication for thrombolytic
chest pain lasting more than 20 min, ST segment elevation, Stroke, MI, dissolve DVT
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Contraindication for thrombolytic
Active bleeding, bleeding disorder, Hx of hemorrhagic stroke, Hx of intracranial vessel malformation, Major surgery recently, Uncontrolled HTN, pregnancy.
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Assessment after giving thrombolytic
S/S of bleeding, decrease in hematocrit and hemoglobin, decrease in BP, back pain, increased HR, muscle weakness, changes in LOC, HA complaints. PERSON CAN BLEED OUT
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Risk factors for DVT and PE
Flying frequently, pregnancy, immobilization post surgery, Oral contraceptives, Overweight, Hypercoagulation, Immobilization
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Topical agents on burns
Topical agents such as silver sulfadiazine cream, mafenide acetate cream, nanocrystalline silver dressings, and hypochlorous antiseptic solutions are recommended for deep second- and third-degree burns prior to early surgical excision and closure. Decrease infection!!
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T or F: Prevention of shock and respiratory distress are two immediate priorities of care during the emergent/resuscitative phase of burn injury.
T
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Mortality associated with burns is greater in younger patients than in older adult patients when comparing injuries with similar severity.
F
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During burn care fluid resuscitation the patients’ response to fluid therapy is assessed every hour.
T
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Burns more than 40% of TBSA produce a local and systemic response and are considered major burns.
T
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The goal of nutritional support for a burn injury is to promote a state of _________ balance and match __________ utilization.
electrolyte, fluid?
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The initial systemic event, after a major burn injury, is a shift of fluid, sodium, and protein resulting in ______________ shock.
Burn Shock
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A major part of the nurse’s role during the acute phase of burn care is detection and prevention of ____________.
Infection
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Methods used to determine total body surface area burned include __________, Lund and Browder method and Palmer method.
Rule of Nines
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A seizure may be the first obvious sign of a brain lesion.
T
203
A person with tactile agnosia most likely has a brain lesion in the __________ lobe.
Parietal
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A pathologic reflex indicative of central nervous system disease affecting the corticospinal tract is known as the _____________ reflex.
Babinski
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The major cause of death in ARDS is nonpulmonary multiple organ dysfunction syndrome, often with sepsis.
F it is shock
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Antibiotics are the initial medical treatment of choice in viral upper respiratory tract infections and pneumonia.
T
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Tachypnea, dyspnea, and mild-to-moderate hypoxemia are hallmarks of the severity of atelectasis.
T
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When caring for a patient who has had a pulmonary embolism, the nurse must be alert for the potential complication of right ventricular failure or ______________ shock.
Obstructive shock
| Tachypnea is most common sign of Pulmonary Embolism
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. The main symptom of pulmonary hypertension is ____________, which occurs at first with exertion and eventually at rest.
SOB "Dyspnea"
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On the scene care of burns
Prevent injury to rescuer•Stop injury: extinguish flames, cool the burn, irrigate chemical burns •ABCs: Establish airway, breathing, and circulation•Start oxygen and large-bore IVs•Remove restrictive objects and cover the wound•Do assessment surveying all body systems and obtain a history of the incident and pertinent patient history •Note: Treat patient with falls and electrical injuries as for potential cervical spine injury
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Care during emergent phase
Patient is transported to emergency department•Fluid resuscitation is begun•Foley catheter is inserted•Patient with burns exceeding 20% to 25% should have an NG tube inserted and placed to suction•Patient is stabilized and condition is continually monitored•Patients with electrical burns should have ECG•Address pain; only IV medication should be administered•Psychosocial consideration and emotional support should be given to patient and family
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Issues that can occur in emergent phase of burns
•Acute respiratory failure•Distributive shock•Acute kidney injury•Compartment syndrome•Paralytic ileus•Curling ulcer
