Final Exam Flashcards
PACU/Recovery Room purpose
ongoing evaluation and stabilization of patients
anticipate, prevent and manage complications after surgery
hand off report
two way verbal interaction
report between two health care professionals is required to communicate the patient’s condition and needs
Assessments in PACU
history
initial assessment- LOC and awareness, Respiratory assessment, temp, pulse, resp, BP, O2 sat, examine surgical site for bleeding and drainage
discharge from PACU
determined by health care team
criteria for discharge: stable VS, normal temp, no overt bleeding, return of swallow and gag reflux, ability to take liquids, adequate UO
places people can be discharged to
hospital unit- ICU, telemetry, med surg
home
respiratory complications of surgery
atelectasis
pneumonia
PE
laryngeal edema
ventilator dependence
pulmonary edema
cardiovascular complications of surgery
HTN
hypotension
hypovolemic shock
dysrhythmias
VTE (venous thromboembolism)
DVT
heart failure
General complications of surgery
sepsis
anemia
anaphylaxis
pressure ulcer
wound infection
wound dehiscence
wound evisceration
skin rashes or contact allergies
gastrointestional complications of surgery
paralytic ileus
gastrointestinal ulcers and bleeding
neuromuscular complications of surgery
hypothermia
hyperthermia
nerve damage/paralysis
joint contractures
kidney/urinary complications from surgery
UTI
acute urinary retention
electrolyte imbalance
AKI
stone formation
common reactions after surgery
postoperative n/v
decreased or no peristalsis for up to 24 hours
paralytic ileus
constipation
Labs for after surgery
electrolytes
CBC
ABGs
Urinanalysis
Creatinine
Priority patient problems after surgery
potential for hypoxemia
potential for wound infection and delayed healing
acute pain
interventions to prevent hypoxemia
airway maintenance
monitor O2 sat/pulse ox
positioning
oxygen therapy
breathing exercises
movement/mobility
preventions for wound infection and delayed healing
dressing changes
asses wound for infection
assess drains
drug therapy
wound complications
dehiscence- partial or complete separation
evisceration- total separation of all wound layers and protrusion of internal organs
managing pain
drug therapy
relaxation
distraction
massage
positioning
patient teachings on discharge
prevention of infection
care and assessment of surgical wound
management of drains and catheters
nutrition therapy
pain management
drug therapy
pre-operative
begins when the patient is scheduled for surgery and ends at the time of transfer to the surgical site
post-operative
starts with completion of surgery and transfer of the patient to a specialized area of monitoring such as the PACU and may continue after discharge from the hospital until all activity restrictions have been lifted
preoperative assessments
complete set of VS
focus on problem areas identified in patients history
s/s of infection
increased PT and INR
abnormal electrolytes
HCG test
psychosocial exam
lab test: UA, CBC, H/H, Clotting study, electrolyte, BUN, creatinine, ABGs
Imaging
ECG
informed consent
implies that the patient has sufficient information to understand:
nature and reason for surgery
who will be preforming surgery and other ppl present
all available options and risks
risk associated with procedure and potential outcomes
nurse’s responsibility in informed consent
that the consent form is signed, and you serve as a witness to the signature, not to the fact that patient is informed
preoperative chart review
ensure all documentation, preoperative procedures, order are complete
check consent forms
preoperative patient preparation
Hospital gown
Antiembolism stockings or pneumatic compression devices, if ordered
Give valuables to a family member or lock them in a safe place
ID band in place, bracelet indicating allergies, bracelet indicating type and screen was completed
Remove dentures (some facilities allow them in the OR)
Remove all prosthetic devices, hairpins, and clips
Remove hearing aids (some facilities allow them in the OR)
Per hospital policy, remove nail polish, artificial nails
Have the patient empty their bladder
After drug administration that can affect cognition or judgment, raise siderails, ensure call system is within easy reach of the patient, and the bed is in low position
Answer questions and offer reassurance as needed
preoperative drugs
Sedatives
Hypnotics
Anxiolytics
Opioid analgesics
Anticholinergic agents
Antibiotics
Specific – purpose drug
May be given “on call” or after the patient is
transferred to the preoperative area
Because of an unexpected emergency case, a patient
scheduled for colon surgery at 8 AM has been rescheduled
for 11 AM. What is the nurse’s best action related to
preoperative prophylactic antibiotic administration according
to the Surgical Care Improvement Project (SCIP)
guidelines?
1. Administer the preoperative antibiotic at 7 AM as originally
prescribed
2. Administer the antibiotic at the same time as the other
prescribed preoperative drugs
3. Adjust the antibiotic administration time to be within 1 hour
before the surgical incision
4. Hold the preoperative antibiotic until the patient is actually in
the operating room and has been anesthetized
3
A 75-year old patient is having an exploratory
laparotomy tomorrow. The wife tells the nurse that at
night the patient gets up and walks around his room.
What priority action does the nurse take after hearing
this information?
1. Notifies the provider
2. Develops a plan to keep the patient safe
3. Obtains an order for sleep medication
4. Tells the patient not to get out of bed at night
2
The nurse is preparing the patient for surgery. Which
common laboratory tests does the nurse anticipate to be
ordered? (Select all that apply)
1. Total cholesterol
2. Urinalysis
3. Electrolyte levels
4. Uric acid
5. Clotting studies
6. Serum creatinine
2,3,5,6
The nurse has given the ordered preoperative
medications to the patient. What actions must the
nurse take after administering these drugs?
(Select all that apply)
1. Raise the side rails
2. Place the call light within the patient’s reach
3. Ask the patient to sign the consent form
4. Instruct the patient not to get out of bed
5. Place the bed in its lowest position
1,2,4,5
The nurse is assessing a postoperative patient’s
gastrointestinal system. What is the best indicator
that peristaltic activity has resumed?
1. Presence of bowel sounds
2. Patient states he is hungry
3. Passing of flatus or stool
4. Presence of abdominal cramping
3
What is the priority nursing assessment when a
patient is admitted to the PACU?
1. Level of consciousness
2. Airway and gas exchange
3. Dressing and incision status
4. Vital signs and body temperature
2
A patient who is 2 days postoperative for abdominal
surgery states, “I coughed and heard something pop.”
The nurse’s immediate assessment reveals an opened
incision with a portion of large intestine protruding.
Which statements apply to this clinical situation?
(Select all that apply)
1. Dehiscence has occurred
2. This is an emergency situation
3. The wound must be kept moist with normal saline-
soaked sterile dressings
4. This is an urgent situation
5. Evisceration has occurred
2,3,5
Which are interventions for the medical-surgical nurse
to use in preventing hypoxemia for the postoperative
patient? (Select all that apply)
1. Monitor the patient’s oxygen saturation
2. Position the patient supine
3. Encourage the patient to cough and breathe
deeply
4. Get the patient up ambulating as soon as possible
5. Instruct the patient to rest as much as possible
1,3,4
- You know that nursing care in PACU is
multifaceted and involves: (select all that apply)
A. Monitoring the patient’s physiological status
B. Intervening to ensure uneventful recovery from
anesthesia and surgery
C. Providing a safe environment for the patient
experiencing limitations in physical, mental, and
emotional function
D. Preventing or promptly treating complications in
the immediate post-anesthesia period
E. Upholding the patient’s rights to dignity, privacy,
and confidentiality
F. Utilizing high tech equipment so health care
costs will be justified
ABCDE
The nurse anesthetist gives you Mr. Potter’s
record, and prepares to give you a verbal report.
You know that her verbal report should include:
(Select all that apply)
A. Mr. Potter’s height and weight
B. The name of the surgical procedure Mr. Potter
had
C. Mr. Potter’s relevant health history
D. Anesthetic agents and other drugs that were
administered to Mr. Potter
E. Mr. Potter’s estimated blood loss during surgery
F. Mr. Potter’s religious preference
G.Mr. Potter’s fluid status and IV therapy
ABCDEG
In providing care for Mr. Potter, your first
step is to:
A. Assess your patient
B. Analyze patient data
C. Plan care
D. Intervene
E. Evaluate care
A
In PACU, many assessments and
interventions are done simultaneously.
However, the most critical, high-priority
assessment to be done with Mr. Potter is his:
A. Operative site
B. Skin integrity
C. Pulse
D. Airway
E. Blood Pressure
D
Which TWO assessments are your next
priorities?
A. Operative site
B. Skin color
C. Skin integrity
D. Pulse
E. Blood pressure
F. Orientation
DE
Since Mr. Potter is a smoker, he has
increased risk associated with surgery and
anesthesia. You are aware that smoking can
be responsible for which of the following in
the immediate postoperative period? (Select
all that apply)
A. Dehydration
B. Difficulty in clearing secretions
C. Cardiac dysrhythmias
D. Increased drowsiness
BC
Why is it important to measure arterial
oxygen saturation (SpO2) levels in
PACU?
A. Levels indicate how much oxygen is
available for use by tissues
B. Levels reflect the effectiveness of
intraoperative sedation
C. Levels reflect the ability to absorb
medications from the bloodstream
D. Levels reflect how much oxygen has
been used by tissues
A
Given Mr. Potter’s SpO2 of 97%, what
intervention is indicated?
A. Continue to monitor SpO2
B. Increase oxygen to 100%
C. Increase liter flow to 15 liters per minute
D. Remove Mr. Potter from the ventilator
A
You recognize that a number of conditions
may be responsible for Mr. Potter’s low body
temperature. These include which of the
following? (Select all that apply)
A. Surgical wound infection
B. The anesthetics Mr. Potter received
C. The environmental temperature in the OR
D. Mr. Potter’s preoperative skin prep
E. The common use of cooled irrigation
solutions during surgery
BCD
The opiate antagonist ____________
should be readily available in PACU should
reversal of respiratory depression be
necessary.
A. atropine sulfate
B. naloxone hydrochloride
C. protamine sulfate
D. aminophylline
B
You assist Mr. Potter to a sitting position
on the side of the PACU bed and allows
him to dangle his feet for ten minutes. This
will help prevent _____________ when Mr.
Potter stands.
A. Orthostatic hypotension
B. Orthostatic hypertension
C. Orthostatic paresis
D. Orthostatic paralysis
A
Before discharge, Mr. Potter is given
instructions regarding the need to: (Select
all that apply)
A. Report an elevated temperature
B. Monitor and protect his operative site
C. Avoid strenuous activity
D. Have a glass of wine at bedtime
E. Continue deep breathing exercises
F. Let someone else drive him home
G. Continue ice packs at home
ABCEFG
The nurse anesthetist reports that your patient is Mr. Potter, a 69-year-old man, who had a right inguinal hernia repair under general anesthesia. Mr. Potter smokes 1 1/2 packs of cigarettes per day and has a history of chronic bronchitis. He received no preoperative medication. During surgery, Mr. Potter received 900 mL of Lactated Ringer’s intravenously. Estimated blood loss was 20 mL. A variety of general anesthetics were administered. Mr. Potter remains intubated with a 7.5 oral endotracheal (ET) tube because he is not fully awake. Continued intubation in PACU will allow for maintenance of a patent airway until Mr. Potter is in a more alert state and can breathe and expectorate secretions on his own.
Mr. potter report… useful for practice questions
PaO2 range
80-100 mmHg
pH range
7.35-7.45
PaCO2 range
35-45 mmHg
HCO3 range
22-26 mEq/L
transtracheal oxygen
oxygen delivered through a small flexible catheter that is places in the trachea through a small incision
used for patients with long term O2 needs
avoids irritation that nasal prongs cause
typically require less O2 when delivered in this method
tracheotomy
surgical incision into trachea for purpose of establishing an airway
tracheostomy
stoma that results from tracheotomy
may be temporary or permanent
indications for a tracheostomy
stenosis of airway
obstruction of airway
laryngeal or neck trauma
neck cancer
extended need for mechanical ventilation
complications of tracheostomy
dislodgment
obstruction (mucus plugging)
SQ emphysema
skin breakdown (moisture and pressure)
infection (lung infection)
bleeding (from mucosal irritation)
features of tracheostomy tubes
single lumen and dual lumen
cuffed and un-cuffed
reusable and disposable
fenestrated and un-fenestrated
nursing care with trachs
stoma care
humification of airway
suctioning
ensure placement and patency
monitor cuff pressures
maintain extra trach and obturator at bedside
frequent oral care
aspiration precaution
complications of trach suctioning
hypoxia
tissue trauma
infection
vagal stimulation and bronchospasm
cardiac dysrhythmias
nutritional concerns with trachs
aspiration- inflated cuff can interfere with passage of food through the esophagus and weakened muscles
elevate HOB 30 min after eating
may need enteral feeding tube
weaning from trach tubes
trials of cuff deflation
gradual decrease in size of trach tube
may change from cuffed to un-cuffed
may change to fenestrated tube
cap trach with speaking valve or trach button
psychosocial considerations with trachs
communication
support for patients and families
become involved in self care activities
ABG
most accurate, invasive, obtained by arterial blood draw
A patient is receiving preoperative
teaching for a partial laryngectomy and
will have a tracheostomy. How does the
nurse define a tracheostomy to the
patient?
– A. Opening in the trachea that enables
breathing
– B. Temporary procedure that will be
reversed later
– C. Technique using positive pressure to
improve gas exchange
– D. Procedure that holds the airway open
A
A patient returns from the operating
room after a tracheostomy placement.
While assessing the patient which
observations by the nurse warrant
immediate notification to the provider?
– A. Patient is alert but unable to speak
– B. Small amount of bleeding present at
incision
– C. Skin is puffy at the neck area with a
crackling sensation
– D. Respirations are audible and noisy with
increased respiratory rate
C
To prevent accidental decannulation
of a tracheostomy tube, what does
the nurse do?
– A. Obtain an order for continuous upper
extremity restraints
– B. Secure the tube in place using ties or
fabric fasteners
– C. Allow some flexibility in motion of the
tube while coughing
– D. Instruct the patient to hold the tube
with a tissue while coughing
B
A patient has a recent tracheostomy.
What necessary equipment does the
nurse ensure is kept at the bedside?
(select all that apply)
– A. Ambu bag
– B. Pair of wire cutters
– C. Oxygen tubing
– D. Suction equipment
– E. Tracheostomy tube with obturator
ACDE
A nurse is educating a client who will be going home with a tracheostomy. When discussing suctioning frequency, what should be included in the education?
– A. The tracheostomy should be suctioned every 4 hours
– B. The tracheostomy should be suctioned when secretions can not be cleared and physical symptoms are present
– C. The tracheostomy should only be suctioned in an emergency
– D. The tracheostomy should only be suctioned at times when the home health nurse is available.
B
A patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach to the situation?
– A. Rely on the family to interpret for the patient
– B. Ask questions that can be answered with a yes or no
– C. Obtain an immediate speech consult
– D. Encourage the patient to rest rather than struggle with communication
B
steps for trach suction
- Assess the need for suctioning (routine unnecessary suctioning causes mucosal damage, bleeding, and bronchospasm).
- Wash hands. Don protective eyewear. Maintain Standard Precautions.
- Explain to the patient that sensations such as shortness of breath and coughing are to be expected but that any discomfort will be very brief.
- Check the suction source.
- Set up a sterile field.
- Preoxygenate (hyperventilate) the patient with 100% oxygen for 3 ventilations prior to suction.
- Quickly insert the suction catheter until resistance is met. Do not apply suction during insertion.
- Withdraw the catheter 1 to 2 m, and begin to apply suction. Apply suction and use a twirling motion of the catheter during withdrawal. Never suction longer than 10 to 15 seconds.
- Hyperoxygenate for 1 to 5 minutes or until the patient’s baseline heart rate and oxygen saturation are within normal limits.
Chronic airflow limitations (CAL)
asthma and COPD (chronic bronchitis and emphysema)
Causes of Asthma
inflammation and hyper responsiveness of airways to common stimuli
inflammation in the mucous membranes and hyper responsiveness constricts the bronchial smooth muscle
intermittent if well controlled
triggers of asthma
allergens
cold air/poor air quality
exercise
respiratory illness/ URI
general irritants
microorganisms
GERD
diagnostics on asthma
ABG (hypoxemia or acidosis)
PFTs
treatment and nursing care for asthma
goal: control and prevent episodes, improve airflow, relieve symptoms
medications: inhaled or systemic; preventative and rescue; bronchodilators and anti-inflammatory agents
avoidance of triggers, inhalers and nebulizers, oxygen therapy if extreme
status asthmaticus
severe and life threatening
treatment: oxygen, IV fluids, potent systemic bronchodilation, IV steroids, epinephrine
emergency intubation
can develop pneumothorax and cardiac respiratory arrest
absence of wheezing can indicate complete airway obstructions
COPD causes
chronic exposure to irritants, commonly smoking.
causes inflammation, congestion, mucosal edema and bronchospasm.
only effects airways, not alveoli
production of large amounts of thick mucus
EMPHYSEMA
Symptoms of COPD
dyspnea
orthopnea
cough with sputum production
use of accessory muscles
hypoxemia
chronic acidosis
weight loss
fatigue
barrel chest
cyanosis
clubbing of fingers
anxiety
diagnostics for COPD
ABG
sputum sample
CBC
chest xray
chest CT
PFTs
nursing care for COPD
attain or maintain gas exchange within the patient’s baseline and control symptoms
O2 therapy: O2 sat between 88-90
Hypoxic vasoconstriction with emphysema (blood shunting from unhealthy part of lung to healthy part… artificial O2 will mess up this process)
Positioning; elevate the HOB, tripoding
Cessation of smoking
energy conservation
breathing exercise
nutritional counseling
medications (bronchodilators, anti-inflammatories, mucolytic agents)
COPD complications
hypoxemia
acidosis
respiratory infection
cardiac failure
cardiac dysrhythmias
purpose of lung cancer chest tubes
collects air, fluid, or blood from the pleural space
allows the lung to re-expand
prevents air from re-entering the pleural space
wet drainage system
nursing care for lung cancer chest tubes
ensure dressing is tight and intact around tubing
assess SOB and breath sounds
check alignment of trachea
Palpate for puffiness or crackling
observe for signs of infection
check to see if tube ‘eyelets’ (holes indicating dislodgment) are visible
Keep drainage system lower than the level of the patient’s chest
asses for tidaling
watch for tension pneumothorax and SQ emphysema
lung cancer chest tube emergencies
tracheal deviation
sudden onset or increased intensity of dyspnea
O2 sat less than 90
Drainage greater than 70mL/hr
eyelets on the chest tube
chest tube falls out of patient’s chest
What are some most common types of
pneumonia? (Select all that apply)
A. community acquired
B. hospital acquired
C. ventilator associated
D. healthcare associated
E. dormant pneumonia
ABCD
Which clinical manifestations would the
nurse most likely see in a client
diagnosed with pneumonia? (Select all
that apply)
A. Chest discomfort
B. Dyspnea
C. Fever
D. Cough
E. Myalgia
F. Increased respiratory rate
ABCDEF
Which diagnostic tests does the nurse
initially expect to be ordered for the client
with pneumonia? (Select all that apply)
A. Pulse oximetry
B. Arterial blood gases
C. Chest X-ray
D. Chest CT
E. Sputum culture
F. Complete Blood Count (CBC)
G. Complete Metabolic Panel (CMP)
H. Coagulation panel
I. Pulmonary function test
ABCEF
When caring for a client with
pneumonia, which nursing
intervention is the highest
priority?
A. Increase fluid intake
B. Encourage deep breathing exercises
and controlled coughing
C. Ambulate as much as possible
E. Maintain a nothing-by-mouth (NPO)
B
What should the nurse include in
discharge teaching for a client to
prevent further pneumonia? (Select all
that apply)
A. Continue IV antibiotics
B. Continue breathing exercises
C. Healthy balanced diet
D. Decrease fluid intake
E. Avoid crowded public areas
F. Annual flu vaccine
G. Pneumococcal vaccine
BCEFG
pneumonia
excess fluid in the lungs resulting from an inflammatory process
inflammation triggered by many infectious organisms and inhalation of irritating agents
develops when the immune system cannot overcome the invading organisms
pneumonia types
community acquired CAP
hospital acquired HAP
health care associated HCAP
ventilator associated VAP
community acquired pneumonia CAP
acquired in community
hospital acquired pneumonia HAP
diagnosis less than 48 hours after admission to hospital
health care associated pneumonia HCAP
diagnosis greater than 48 hours after admission to a hospital and has had recent treatment at a health care facility (inpatient or outpatient)
ventilator associated pneumonia VAP
diagnosis within 48-72 hours of intubation
pneumonia risk factors
older adult
not vaccinated for flu or pneumococcal
Chronic health problems
limited mobility
uses tobacco or alcohol
altered LOC
aspiration
poor nutritional status
immunocompromised status
mechanical ventilation
pneumonia prevention
avoid risk factors
annual influenza vaccine
pneumococcal vaccine
avoid crowded areas during flu season
hand washing
cough, turn, and move if you have impaired mobility
Clean respiratory equipment
avoid indoor pollutants
stop smoking
drink 3L of fluid each day as recommended with diet
CM of pneumonia
increased RR or dyspnea
hypoxemia
cough
purulent, blood tinged, or rust colored sputum
fever with or without chills
pleuritic chest discomfort
acute confusion from hypoxia
pneumonia lab results
sputum by gram stain, culture, and sensitivity testing
CBC to assess elevated WBC
blood culture
ABGs
serum lactate level
procalcitonin
BUN and electrolytes
pneumonia imaging assessment
chest x ray
pulse ox
invasive tests: transtracheal aspiration, bronchoscopy, direct needle aspiration of the lung
Priority nursing diagnosis for pneumonia
impaired gas exchange related to decrease diffusion at the alveolar- capillary membrane
pneumonia nursing interventions
O2 therapy
monitor pulse ox
cough and deep breath every 2 hours
incentive spirometry
adequate hydration
assess fluid status
drug therapy
diabetes definition
chronic metabolic disease resulting from either a deficiency in insulin secretion, resistance of insulin action at the cellular level or both
resulting in hyperglycemia and inability to regulate blood glucose.
what happens in the absence of insulin?
body breaks down other sources for energy (fats and proteins)
counter-regulatory hormone levels are increased (glucagon, epinephrine, GH, and cortisol)
why is insulin important?
key that moves glucose into cells
a decrease can cause hyperglycemia
the cells don’t get the glucose they need
symptoms of DM
polyuria, polydipsia, polyphagia, metabolic acidosis, Kussmaul respirations, dehydration and electrolyte imbalance
polyuria
frequent and excessive urination
caused by osmotic diuresis secondary to excess glucose
polydipsia
excessive thirst
caused by dehydration
polyphagia
excessive eating
cause by cell starvation
types of diabetes
type 1, type 2, gestational
type 1 diabetes
no insulin is produces
autoimmune disorder
beta cells of the pancreas are destroyed by antibodies
onset usually occurs less than 30 yo
abrupt onset
weight loss
requires insulin
could be viral in etiology
Type 2 diabetes
reduction of the cells to respond to insulin and decreased secretion of insulin from beta cells
onset usually occurs greater than 50 yo
could have no symptoms or polydipsia, fatigue, blurred vision, vascular and neural comlications
gestational diabetes
glucose intolerance during pregnancy
Acute complications of DM
Diabetic Ketoacidosis
Hyperglycemic- Hyperosmolar state
Hypoglycemia
all considered medical emergencies
DKA
insulin deficiency and acidosis
HHS
insulin deficiency and severe dehydration
hypoglycemia
too much insulin or too little glucose
What are chronic complications of DM caused by
changes in blood vessels in tissue and organs (poor tissue perfusion, cell damage and death)
vascular changes result from:
hyperglycemia thickening basement membranes and causing organ damage.
hyperglycemia affects cell integrity
What are the two types of chronic complications in DM
macro vascular
microvascular
Macrovascular examples
cardiovascular disease- MI
cerebral vascular disease- stroke
peripheral vascular disease- PAD/PVD
pulmonary embolism- PE
risk factors for macrovascular diseases
HTN
obesity
dyslipidemia
sedentary lifestyle
nursing implication for DM
decreasing modifiable risk factors
microvascular examples
retinopathy
neuropathy
nephropathy
retinopathy
caused by damage to the retinal vessels causing leaking and retinal hypoxia
neuropathy
progressive deterioration of nerves
loss in sensation or muscle weakness
blood vessel changes that lead to nerve hypoxia
can affect multiple body systems (extremities, GI, cardiac, urinary)
nephropathy
change in kidney that decreases function and causes kidney failure
chronic high blood glucose: causes leaking and hypoxia of nephrotic vessels
increase in filtration of large particles, damaging kidneys further
Fasting blood glucose range
70-100
above 126 on at least 2 occasions is diagnostic for DM
Glucose tolerance test
less than 140
Hemoglobin A1C
4-6%
levels greater than 6.5% are diagnostic for DM
Planning and Priorities for DM
injury related to hyperglycemia
impaired wound healing
injury related to diabetic neuropathy
acute and chronic pain related to diabetic neuropathy
injury related to retinopathy (reduced vision)
potential for kidney disease
potential l hypoglycemia
potential DKA
potential HHS
expected outcome for DM
maintaining blood glucose in expected range and preventing acute and chronic complications of DM are the primary outcomes
interventions for DM
proper nutrition- decrease alcohol, carb counting, watch saturated fats and cholesterol
exercise- watch for injury
blood glucose monitoring- accurate samples, clean technique, adequate supplies
medications- DM T1 will require insulin, DM T2 may require medication
ways to reduce risk for peripheral neuropathy by proper footcare
cleanse and inspect feet daily
wear properly fitting shoes
avoid walking with bare feet
wear clean, dry socks daily
trim toenails properly
report non healing breaks in the skin of the feet
s/s of neuropathy
tingling/numbness
burning
muscle cramps
piercing or stabbing pain
metatarsalgia (walking on marbles)
allodynia (pain from normal non-painful stimuli)
hyperalgesia (exaggerated pain response)
reducing injury from impaired vision
regular eye exams
appropriate eyewear
reading aids
adaptive devices for insulin administration/ BG monitoring
reducing injury for diabetic nephropathy
control HTN
control hyperlipidemia
assess kidney function annually
smoking cessation
hypoglycemia features
skin is cool and clammy
absent dehydration
no change in respirations
anxious, nervous, irritable mental status
seizure and coma
weakness, double vision, blurred vision, hunger tachycardia, palpitations
glucose is less than 70
negative ketones
hyperglycemia features
Skin is warm and moist
Dehydration is present
Kussmaul respirations- fruit odor
Mental status varies
No specific symptoms- acidosis and dehydration
Glucose greater than 250
Positive ketones
Laboratory findings for DKA
glucose greater than 300
variable osmolarity
positive serum ketones
pH less than 7.35
HCO3 less than 15
variable serum Na
BUN greater than 30
Creatinine greater than 1.5
positive urine ketones
Laboratory findings for HHS
glucose greater than 600
osmolarity greater than 320
negative serum ketones
pH greater than 7.4
HCO3 greater than 20
normal or low serum Na
elevated BUN and creatinine
negative urine ketones
60 yo woman is one day post op from a knee replacement; she is a type 2 diabetic on a new insulin regimen; the nurse gave took her BG and gave her short acting insulin knowing she ordered her lunch; one hour later she is pale, confused, and clammy; her lunch tray is on her table and appears totally untouched. Is her condition consistent with hyperglycemia or hypoglycemia? Explain why…
Hypoglycemia especially because she received her insulin about an hour ago and has not replenished her glucose supply.
60 yo woman is one day post op from a knee replacement; she is a type 2 diabetic on a new insulin regimen; the nurse gave took her BG and gave her short acting insulin knowing she ordered her lunch; one hour later she is pale, confused, and clammy; her lunch tray is on her table and appears totally untouched. What is your first action? Explain why…
Check her blood glucose level immediately because the methods to increase her blood glucose level are dependent on how the current level is.
60 yo woman is one day post op from a knee replacement; she is a type 2 diabetic on a new insulin regimen; the nurse gave took her BG and gave her short acting insulin knowing she ordered her lunch; one hour later she is pale, confused, and clammy; her lunch tray is on her table and appears totally untouched. What is the most likely cause leading to this problem?
Clearly, there was a delay in eating after receiving the insulin. Moreover, it is possible because of her recent change to insulin, she was not aware of the necessity of eating soon after receiving insulin.
60 yo woman is one day post op from a knee replacement; she is a type 2 diabetic on a new insulin regimen; the nurse gave took her BG and gave her short acting insulin knowing she ordered her lunch; one hour later she is pale, confused, and clammy; her lunch tray is on her table and appears totally untouched. What should happen to prevent this from happening again in the future?
More education to the patient about the relationship between insulin and eating. The nurse should also evaluate the patient 20 min after administering short acting insulin.
21 yo college student brought to the ED by his roommate. ABD pain, polyuria for the last 2 days, vomiting and extreme thirst. He is flushed, lips and mucus membranes are dry and cracked, skin turgor is poor. Rapid respirations, fruity odor, and may have skipped a few doses of insulin. He is alert but struggling to answer questions. O2 sat is 99, BP 110/60, pulse is 110/min, Resp. are 32/min, glucose 485 mg/dL . Should you apply oxygen at this time? Why or why not?
No. Applying oxygen would serve no useful purpose. His respiratory symptoms are a result of compensation for the metabolic acidosis.
21 yo college student brought to the ED by his roommate. ABD pain, polyuria for the last 2 days, vomiting and extreme thirst. He is flushed, lips and mucus membranes are dry and cracked, skin turgor is poor. Rapid respirations, fruity odor, and may have skipped a few doses of insulin. He is alert but struggling to answer questions. What is going on with this patient?
DKA
21 yo college student brought to the ED by his roommate. ABD pain, polyuria for the last 2 days, vomiting and extreme thirst. He is flushed, lips and mucus membranes are dry and cracked, skin turgor is poor. Rapid respirations, fruity odor, and may have skipped a few doses of insulin. He is alert but struggling to answer questions. What is the immediate intervention the Dr. would prescribe?
IV drip because SQ wont absorb fast enough and is inappropriate for emergency situations.
patient could also get IV fluids to correct fluid deficit.
21 yo college student brought to the ED by his roommate. ABD pain, polyuria for the last 2 days, vomiting and extreme thirst. He is flushed, lips and mucus membranes are dry and cracked, skin turgor is poor. Rapid respirations, fruity odor, and may have skipped a few doses of insulin. He is alert but struggling to answer questions. What is another acute complication of DM resulting from elevated glucose?
HHS
how long is each segment of a monitor strip
6 second strip
P wave
represents atrial depolarization (atrial contraction)
present, consistent, configuration, one P wave before each QRS complex
PR interval
represents the time required for atrial depolarization as well as impulse travel through the conduction system
QRS complex
is measured from the beginning of the Q (or R) wave to the end if of the S wave (ventricular contraction)
ST segment
represents early ventricular repolarization- ventricular returning to resting state. indication of MI
QT interval
total time required for ventricular depolarization and repolarization
Steps to ECG Rhythm Analysis
determine HR, Heart rhythm, analyze P waves, measure PR interval, QRS duration, examine the ST segment.
normal PR interval duration
0.12- 0.20 and constant
normal QRS duration
0.06-0.12 and constant
Elevations in ST segment
may indicate myocardial infarction, pericarditis, hyperkalemia
depression in ST segment
is associated with hypokalemia, myocardial infarction, ventricular hypertrophy.
normal sinus rhythm
rate 60-100 bpm
rhythm: atrial and ventricular rhythms are regular
sinus arrhythmia (SA)
variant of normal sinus rhythm, results from changes in intrathoracic pressure during breathing, has all the characteristics if normal sinus rhythm except for its irregularity. The PP and RR intervals vary, with the difference between the shortest and the longest intervals being greater than 0.12 second
Dysrhythmias
Any disorder of the heartbeat
Tachydysrhythmias
Heart rate greater than 100 beats per minute
Bradydysrhythmias
Heart rate less than 60 bpm
Premature complexes
Early rhythm complexes; if they become more frequent, especially those that are ventricular, the patient may experience symptoms of decreased cardiac output.
Repetitive rhythm complexes
Bigeminy, trigeminy, quadrigeminy
Etiology for dsyrhythmias
May occur for many reasons. Can be classified by their site of origins in the heart (sinus, atrial, ventricular). Managed with antidysrhythmic drug therapy.
Care of patients with dysrhythmias
Asses VS every 4 hours
Monitor for cardiac dysrhythmias
Evaluate and document patients response
Encourage patient to notify nurse if chest pain occurs
Asses for chest pain and respiratory difficulty
Asses peripheral circulation
Administer medication and monitor response
Monitor lab values
Monitor activity tolerance and schedule exercise/rest periods, avoid fatigue
Promote stress reduction
Offer spiritual support
Atrial Dysrhythmia-Supra-ventricular Tachycardia
Rapid stimulation of atrial tissue occurs at rate of 100-280 bpm in adults. P waves may not be visible, because they are embedded in the preceding T wave.
Atrial Fibrillation
Most common dysrhythmia. Associated with atrial fibrosis and loss of muscle mass. Common in heart disease such as HTN, heart failure, CAD. Many other risk factors. Cardiac output can decrease by as much as 20-30%
Assessment for A Fib
Assess for fatigue, weakness, SOB, dizziness, anxiety, syncope, palpitations, chest discomfort or pain, hypotension. High risk for PE, VTE, stroke
Drug Therapy for A fib
Calcium channel blocker, aminodarone, beta blockers, digoxin, anticoagulants, antiplatelet
Other treatments for A fib
Cardio version, per cutaneous radio frequency catheter ablation, bi-ventricular pacing, surgical maze procedure
Ventricular dysrhythmias
More life threatening than atrial dysrhythmias. Left ventricle pumps oxygenated blood throughout the body to perfume vital organs and other tissues. Most common or life threatening: PVC, VT, VF, VA
Ventricular dysrhythmia- ventricular tachycardia
Also called v tach- repetitive firing of an irritable ventricular ectopic focus, usually 140-180 bpm or more.
Stable VT
Treatment: oxygen amiodarone, lidocaine, or magnesium sulfate, elective cardio version radio frequency catheter ablation, implantable cardioverter debrillation.
Oral antidysrhythmic agent: mexiletine or sotalol
To prevent further occurrences.
Unstable VT
Can cause cardiac arrest, unstable VT without a pulse is treated the same way as v fib. Assess patient’s airway, breathing, circulation, LOC, and oxygenation level
Treatment for V Fib
Life threatening… no cardiac output or pulse, blood is no longer being pumped out of the heart and brain not receiving blood. May be the first manifestation of CAD. First priority: patient immediately. Continue high quality CPR, provide airway management, follow ACLS protocol.
Ventricular dysrhythmia- ventricular fibrillation
Called v fib. Result of electrical chaos in ventricles
Ventricular dysrhythmia-ventricular asystole
Called ventricular standstill- complete absence of any ventricular rhythm.
Treatment for ventricular asystole
Full cardiac arrest- no cardiac output or perfusion to the rest of the body. Prognosis is poor. Manage airway. Administer CPR- compressions, airway, breathing. DO NOT DEFIBRILLATE… no electrical activity to shock. Follow ACLS protocols
Patient teachings with dysrhythmias
Prevention, early, recognition, and management. Lifestyle, modifications, (avoid caffeinated beverages, stop, drinking, drink, alcohol in moderation, follow prescribe diet). Drug therapy instructions. Teach the patient and family how to take pulse and or blood pressure and report any changes. Keep follow up appointments. Provide oral and written instruction for pacemaker, ICDS, cardiac exercise programs, support groups as applicable.
A client who had open abdominal surgery 4
hours ago reports feeling weak and dizzy.
The client’s current blood pressure has
decreased to 98/50, and pulse rate is 120.
What is the nurse’s best action at this time?
–A. Document the vital signs, and continue to
monitor the client.
–B. Remind the client to stay in bed if feeling
weak and dizzy.
–C. Call the health care provider immediately.
–D. Increase the client’s IV rate to restore fluid
volume.
C
A client in the telemetry unit is on a
cardiac monitor. The monitor technician
notices there are no ECG complexes and
the alarm sounds. What is the first action
by the nurse?
–A. Begin CPR immediately.
–B. Call the emergency response team.
–C. Press the record button to get an ECG
strip.
–D. Assess the client and check lead
placement
D
Hypertension
most common health problem seen in primary settings. AHA 2017 guidelines above 130/80
desired BP in 60 yo and older
below 150/90
desired BP in younger than 60 yo
below 140/90
desired BP in patients with DM and heart disease
below 130/90
BP elevations…
results in damage to organs, causes thickening of the arterioles, as the blood vessels thicken, perfusion decreases and body organs are damaged
HTN is a major risk for…
stroke, myocardial infarction, kidney failure, death
Classifications of HTN
primary and secondary
primary classification of HTN
most common type, not caused by an existing health problem: can develop when a patient has any one or more of the risk factors: family history, African American ethnicity, hyperlipidemia, smoking, older than 60 or postmenopausal, excessive sodium and caffeine intake, overweight/obesity, physical inactivity, excessive alcohol intake, low potassium, calcium or magnesium intake, excessive and continuous stress.
secondary classification of HTN
results from specific diseases and some drugs. kidney disease is one of the most common causes of secondary HTN
physical assessment/clinical manifestations of HTN
most people have no symptoms, some patients experience headaches, facial flushing (redness), dizziness, fainting, blood pressure screenings (take in both arms, two or more readings at a visit, use appropriate size cuff)
orthostatic hypotension
decrease in BP with changes in position, 20 mmHg for systolic and or 10 mmHg for diastolic
psychosocial considerations for HTN
assess for stressors that can worsen HTN
Diagnostic assessment for HTN
no specific lab or x-rays are diagnostic of primary hypertension. secondary hypertension can be screened with labs specific to the underlying disease
ex: kidney disease
interventions for HTN
lifestyle changes, complementary and alternative therapies, drug therapy, avoid OTC medications (NSAIDS, decongestants)
lifestyle changes for HTN
dietary sodium restriction to less than 2g per day, reduce weight, use alcohol sparingly, exercise 3-4 times a week for 40 min, use relaxation techniques to decrease stress, avoid tobacco and caffeine
complementary and alternative therapies for HTN
biofeedback and meditation
Drug therapies for HTN
diuretics, calcium channel blocker, angiotensin converting enzyme (ACE) inhibitor, angiotensin II recpetor blockers (ARBs), Aldosterone receptors antagonists, beta adrenergic blockers,
Venous Thromboembolism VTE
includes deep vein thrombosis DVT and pulmonary embolism PE
Risk factors for VTE
stasis of blood, vessel wall injury, altered blood coagulation
VIRCHOW’S TRIAD
VTE prevention
prevention is key to address this challenge in health care: patient education, leg exercises, early ambulation, adequate hydration, graduated compression stockings, intermittent pneumatic compression, such as SCDs, venous plexus foot pump, avoid oral contraceptive, anticoagulant therapy
Unfractionated Heparin Therapy (UFH)
Baseline PT, aPTT, INR, CBC with platelet count
antidote: protamine sulfate
heparin-induced thrombocytopenia (HIT)- life threatening complication
Low Molecular Weight Heparin (LMWH)
Preferred for prevention and treatment of VTE
antidote: protamine sulfate
May see an overlap of enoxaparin and warfarin given for treatment of DVT or PE
Warfarin
given PO
monitor PT and INR
Assess for bleeding
antidote: vitamin K
teach patients to avoid foods with high concentrations of vitamin K
It is shift change. The oncoming nurse
enters the room and notices observable
hematuria in Mrs. Adam’s urinary
catheter.
- What action should the nurse initiate
first?
–1. Obtain a stat aPTT
–2. Stop the heparin infusion
–3. Assess vital signs
–4. Observe the surgical site for bleeding
2
After consulting with the HCP, the
nurse is to administer a heparin
antagonist.
*
* Which medication will be
administered?
–1. Vitamin K
–2. Protamine Sulfate
–3. Enoxaparin (Lovenox)
–4. Ticlopidine (Ticlid)
2
To which nursing diagnosis should
the nurse give the highest priority
when planning care for Mrs. Adams?
– 1. Pain related to decreased venous flow
– 2. Risk for injury (bleeding) related to
anticoagulant therapy
– 3. Impaired physical mobility related to
prescribed bedrest
– 4. Knowledge deficit related to lack of
discharge teaching
2
Mrs. Adams is transitioned to warfarin
by mouth. Mrs. Adams should receive
additional teaching about foods
- Which food should the nurse instruct
Mrs. Adams to avoid?
–1. Apple products
–2. Red meats
–3. Green leafy vegetables
–4. Nuts
3
heart failure statistics
leading cause of hospital admission for patients over 65. major cause of disability and death. Readmission an important quality measure in acute care. CMS core measure.
heart failure
chronic inability of heart to work effectively as a pump. Heart not able to maintain adequate cardiac output to meet the metabolic needs of the body.
