Midterm

Question 1

Describe the pathophysiology of a deep vein thrombosis (DVT)

Answer 1

 triad - stasis of blood; vessel wall injury; increased blood coagulability
 past DVT biggest risk for future DVT after surgery: increased in the presence of impaired cardiac function (acute MI/CHF)
 venous stasis, hyperreactivity of blood coagulation and vascular trauma are all risk factors of DVT
 immobility of an extremity or the entire body causes decreased blood flow, venous pooling in the lower extremities and increased risk of DVT
 A piece of a clot becomes dislodged and travels to the lung - can cause pulmonary infarction

Question 2

 What are the signs and symptoms of a DVT?

Answer 2

 many are asymptomatic; vein not totally occluded or collateral circulation,
 pain, swelling, deep muscle tenderness (redness or warmth of leg, pain or cramp in calf, swellling of leg, areas feel hard to touch)
 fever, general malaise (chills, diaphoresis)
 elevated WBC and sedimentation rate
 any client complaining of tachypnea, dyspnea, tachycardia, especially when already receiving O2 therapy
 chest pain, hypotension, hemoptysis, dysrhythmias or HF.
 fainting, orthostatic hypotension,

Question 3

 How can you prevent DVT’s in post operative clients?

Answer 3

 Pharmacological
 anticoagulation drugs - heparin
 Non-pharmacological
 leg exercises q1-2 hrs, flex and extend all joints
 apply TEDS or AES - thrombo embolic deterrent or antiembolic stockings
 early ambulation
 avoid positioning that disrupts blood flow to extremities
 adequate fluid intake

 regular CV assessment - BP, HR, perfusion (pulses), hemorrhage, CSM

Question 4

 How do we treat a DVT?

Answer 4

 goal is to prevent further thromi, prevent extension and embolization of existing thrombi and minimize venous valve damage
 anticoagulation therapy to treat and prevent
 15-20 degree elevation of legs to prevent stasis
 footboard enables person to perform leg exercises, ankle flexion and extension while in bed
 surgical removal under selected circumstances when at risk for experiencing pulmonary emboli

Question 5

 What risk does a DVT pose?

Answer 5

 postphlebitic syndrome - damage to vessel
 Blood clot in the kidney, called renal vein thrombosis.
 Blood clot in the heart, leading to heart attack.
 Blood clot in the brain, leading to stroke.
 blood clot in the lung, leading to pulmonary embolism

Question 6

 Describe the rationale for deep breathing and coughing in the post operative patient

Answer 6

 helps to clear the anesthesia from system

 prevents atelectasis and pneumonia

Question 7

 How do you assess perfusion distal to a surgical site or area of injury?

Answer 7

 Peripheral perfusion assessment consisted of capillary refill time (CRT), peripheral perfusion index (PPI) and forearm-to-fingertip skin temperature gradient to measure the strength of the pulse as the assessment area
 collect Perfusion prior to surgery, immediately following and d1,2 & 3.

Question 8

 What findings indicate normal perfusion? What findings indicate abnormal perfusion

Answer 8

 cap refill time - 3 is delayed)
 bilateral pulse rates - normal between 60-100, gradient scale 0-4 - 0 = absent to 4= bounding, non-bilarterally equal
 forearm-to fingertip skin temperature gradient - warm, (cold and hot are abnormal)
 colour - wnr (cynotic, pale, red, flush)

Question 9

 What is your priority intervention if you notice your patient’s distal extremities to be pale and cold with decreased cap refill?

Answer 9

 place O2 on the client at .5L via NC

Question 10

 What is a paralytic ileus? How is it treated? How do you assess for it?

Answer 10

 defined as cessation of peristalsis - complaints of abdominal pain, distension, nausea, vomiting and poor appetite
 monitor for distension, auscultate all four quadrants to determine presence, frequency and characteristics of bowel sounds
 absent or diminished and abdomen sounds tympanic to percussion
 normal bowel movements are accompanied by flatus

Question 11

 Review total parenteral nutrition (TPN). What is it and how is it administered?

Answer 11

 IV administration for the delivery of 100% of a patient’s calculated nutritional requirements (carbs, fat, protein, vitamins, minerals and often fluid)

Question 12

 Review post operative care of patients following gastrointestinal surgery – Initial admission to the acute care floor and ongoing management.

Answer 12

 usually NPO therefore NG tube - care for tube -
• proper placement through nose to stomach (measure from the nare to the top of ear to base of xiphoid)
• intermittent suctioning
• irrigate to avoid occlusion - flush with 30mL of water to ensure that no residual food will occlude the tube
• measure/record drainage
• monitor and record losses
 medicate for nausea
 Assess bowel sounds Q4 for paralytic ileus
 inspect for distension (tympanic/dull)
 monitor constipation

Question 13

 What is the normal range for glucose?

Answer 13

 non-diabetic is random 4.4-6.6 and fasting 4.0-6.0

Question 14

how you would interpret abnormal high BG

Answer 14

	abnormal highs means hyperglycemia 
	diabetes mellitus 
	acute stress respone
	cushing's syndrome
	pheochromocytoma
	chronic renal failure
	glucagonoma
	acute pancreatitis
	diuretic therapy
	corticosteroid therapy
	acromegaly

Question 15

how you would interpret abnormal lows BG

Answer 15

 insolinoma - no reflex feedback loop present to “turn off” production
 hypothyroidism - thyroid hormones effect glucose metabolism
 addison’s disease - cortisol affects glucose metabolism - diminished levels effect glucose to fall
 extensive liver disease
 insulin overdose
 starvation

Question 16

 What is a hemoglobin A1C and why is it measured?

Answer 16

 used to monitor diabetes treatment. accurate long-term index of the average BG levels

Question 17

Which test would you wish to have done on a patient on the medical floor who complains that they feel shaky and fatigued

Answer 17

test random BG

Question 18

Which test would you wish to have done on a patient on the medical floor who has significant weight loss and being checked to see if the patient has developed diabetes

Answer 18

hemoglobin A1C, fasting BG, urine glucose level

Question 19

Which test would you wish to have done on an outpatient who reports that they have had fairly normal blood sugar levels since their last visit 2 months ago

Answer 19

• Hemoglobin A1C

Question 20

 What labs measure kidney function and explain why

Answer 20

 Blood Urea Nitrogen (BUN) - normal 3.6-7.1 mmol/L
 measures the amount of nitrogen in blood that comes from the waste product urea - rises when the kidneys cannot remove urea from the blood
• used to evaluate and diagnose kidney function and acute or chronic kidney failure
• heart failure, dehydration or a diet high in protein can elevate BUN

Creatinine (Cr) - normal males (53-106) female (44-97)
 is a breakdown product of creatine, used in muscle contraction
 removed entirely by kidneys. increased levels means kidney function is abnormal
 good indicator of glomerular filtration and chronic renal damage

Question 21

 What labs measure liver function and why?

Answer 21

ALT - normal -4-36 u/L

 found predominantely in the liver - more specific test
for detecting hepatocellular disease

AST - normal 0-35u/L

 AST found in the liver, heart, muscle, brain and
kidney tissue - damage to any can raise levels

GGT - 8-38 u/L

 sensitive indicator of hepatobiliary disease and chronic alcohol abuse

Albumin - 3.5-5g/dL

 main protein in blood that is made by the liver.
 purpose is to maintain colloidal osmotic pressure and transport drugs, hormones and enzymes.
 in disease the liver looses its ability to synthesize albumin and so albumin decreases while dehydration can increase albumin levels

bilirubin - 0.3-1.0 mg/dl

 produced from b/d of RBC hemoglobin
 liver clears bilirubin from the body so elevated levels can indicate a disorder or blockage of the bile ducts

Question 22

Electrolytes Labs

Answer 22

Potassium
Sodium
Chloride
Calcium
Magnesium

Question 23

Liver Labs

Answer 23

ALT/AST
GGT/Albumin
Bilirubin

Question 24

Renal Labs

Answer 24

BUN

Creatinine

Question 25

Diabetic Labs

Answer 25

A1C | BG - fasting/random

Question 26

Cardiac Labs

Answer 26

Troponins CK CK-MB

Question 27

Cholesterol Labs

Answer 27

cholesterol triglycerides LDL HDL

Question 28

Discuss Anemia

Answer 28

refers to a deficiency of either erythrocytes or hemoglobin - low RBC count contributes to anemia 3 types - hypovolemic anemia - caused by blood loss - inadequate/abnormal erythrocyte production = iron deficiency, pernicious, folic acid deficiency, sickle cell anemas - hemolytic anemia - destruction of normally formed RBC

Question 29

discuss INR and what abnormal value means

Answer 29

``` International Normalized Ratio - prothrombin time > 20sec for individuals not taking anticoagulants and >3.6 for those on anticoagulants - used to evaluate the adequacy of the extrinsic system and common pathway in the clotting mechanism ^ levels - liver disease - hereditary factor deficiency - vit K deficiency - bile duct obstruction - coumarin ingestion - disseminated intravascular coagulation - massive blood transfusion -salicylate intoxication ```

Question 30

WBC count

Answer 30

normal range 5-10x 109/L - used as an indicator of infection inflammation, tissue necrosis or leukemic neoplasia decreased - bone marrow failure, dietary deficiencies or autoimmune diseases

Question 31

Red blood Cell Count

Answer 31

normal findings RBC x 1012/L adult/older adult - male - 4.7-6.1 female - 4.2-5.4 closely related to hemoglobin and hematocrit levels - reps different ways of evaluating the number of RBCs in peripheral blood. ^ erythrocytosis Congenital Heart disease sever chronic obstructive pulmonary disease polycythemia vera severe dehydration ``` decreased anemia hemoglobinopathy cirrhosis hemolytic anemia hemorrhage dietary deficiency bone marrow failure prosthetic valves renal disease normal pregnancy rheumatoid/collagen-vascular diseases lymphoma multiple myeloma leukemia hodgkins disease ```

Question 32

Platelet count

Answer 32

adult - adult/older adult 150,000 /mm3 to 400,000/mm3 ^ malignant disorders polycythemia versa postplenectomy syndrome rheumatoid arthritis iron-deficiency anemia or following hemorrhagic anemia ``` decreased levels (thrombocytopenia) hypersplenism hemorrhage immune thrombocytopenia leukemia thrombotic thrombocytopenia graves disease inherited disorders dic systemic lupus erythematosus pernicious anemia hemolytic anemia cancer chemotherapy infection ```

Question 33

Potassium

Answer 33

``` adult/older adult - 3.5-5 mmol/L ^ excessive dietary intake excessive iv intake acute/chronic renal failure addison's disease hypoaldosteronism aldosterone-inhibiting diuretics crush injury hemolysis transfusion of hemolyzed blood infection acidosis dehydration ``` ``` decreased deficient dietary or iv burns GI disorders diuretics hyperaldosteronism cushing's syndrome renal tubular aidosis licorice ingestion alkalosis insulin administration glucose administration ascites renal artery stenosis cystic fibrosis trauma/surgery/burns ```

Question 34

Sodium

Answer 34

normal adult - 136-145 mmol/L hypernatremia increased sodium intake - excessive in dietary/IV decreased sodium loss - cushing's syndrome - hyperaldosteronism excessive free body water loss - GI loss - excess sweating - extensive thermal burns - diabetes insipidus - osmotic diuresis hyponatremia decreased sodium intake -iv/dietary increased sodium loss - addison's dissease - diarrhea, vomiting, nasogastric aspiration - intraluminal bowel loss (ileus, obstruction) - diuretic admin - chronic renal insufficiency - large volume aspiration of pleural or peritoneal fluids increased free body water - excessive oral water intake - oral/iv - hyperglycemia - CHF - peripheral edema - pleural effusion - intraluminal bowel loss - syndrome of inappropriate or ectopic secretion of ADH

Question 35

troponin & creatine kinase

Answer 35

- measures the levels of proteins called troponin T and troponin I in the blood which are released specifically in cardiac muscle injury - creatine raises when skeletal, neurological or heart muscle are injured

Question 36

cholesterol/triglycerides

Answer 36

two forms of lipid or fats cholesterol - normal <200 mg/dL -is associated with arteriosclerosis vascular disease - necessary for building and maintaining cells and making essential hormones triglycerides - male 40-160 mg/dL ; female 35-135 mg/dL - associated with risk of CHD in patients w/ fat metabolism disorders

Question 37

LDL/HDL Labs

Answer 37

75% of blood cholesterol bound to LDL and 25% to HDL LDL - normal 40 mg/dL - removes excess cholesterol when there are too many LDL - too much cholesterol is delivered for HDL to remove. therefore buildup of fat in arteries and veins - narrowing

Question 38

Isotonic Solutions

Answer 38

o.9% NaCL (NS) Ringer's Lactated used to expand vascular volume watch for signs of bounding pulse and SO D5W - 5% dextrose in water - dextrose is rapidly metabolized providing only free water to expand extra in intracellular spaces

Question 39

Hypotonic Solutions

Answer 39

o.45% NaCl - (1/2 NS) 0.33% NaCl - (1/3 NS) used to provide free water and treat cellular dehydration - promote waste elimination by the kidneys

Question 40

Hypertonic solutions

Answer 40

``` 5% dextrose in NS (d5NS) 5% dextrose in o.45% NaCl (d5 1/2 NS) 5% dextrose in Lactated Ringers used to draw fluid out of intracellular and intrastitial compartements into vascular - expand vascular volume - do not use iwth kidney/hd patients - watch for signs of hypervolemia ```

Question 41

respiration

Answer 41

process by which bodies cells are supplied o2 and co2 is eliminated external respiration - movement of gases across alveolar-capillary membrane internal respiration - movement of gasses across systemic capillary membranes - cell membranes

Question 42

ventilation

Answer 42

mechanical movement of airflow to and from the atmosphere and the alveoli - actual work of breathing and requires adequate functioning of the lungs and airways, thorax, ventilatroy muscles and nervous system control.

Question 43

inspiration

Answer 43

air moves because intrathoracic pressure changes. contraction of diaphragm increases chest dimensions

Question 44

expiration

Answer 44

passive - elastic recoil of chest wall and lungs

Question 45

Compliance

Answer 45

measure of elasticity of lungs and thorax when decreased, lungs are more difficult to inflate can be altered due to any condition that affects lung tissues - emphysema, pulmonary fibrosis, pulmonary edema, pleural effusion

Question 46

Diffusion

Answer 46

O2 & CO2 move across the alveolar capillary membrane by diffusion; area of high to low pressure ability of lungs to axygenate arterial blood adequately determined by looking at PaO2 and SaO2

Question 47

O2-Hemaglobin Curve

Answer 47

Oxygen transport - O2 carried in blood in 2 ways - bound to hemoglobin or dissolved in plasma PaO2 - arterial blood o2 tension - represents the amount of O2 dissolved in the plasma - expressed in mmHg SaO2 - arterial blood oxygen satruation - measue of te % of Hgb in arterial blood sample that is occupied by O2 molecules- expressed as a percentage if Sa)2 is 0% than 90% of the hemoglobin attachments have oxygen bound to them Affinity of hemoglobin for O2 Large changes in PaO2 result in small changes in SaO2 as hemoglobin becomes desatruarted, SaO2 levels will fall rapidly

Question 48

80-100 PaO2 mmHg means....

Answer 48

> 95% SaO2 (normal)

Question 49

60 PaO2 mmHg means....

Answer 49

90% SaO2 adequate

Question 50

55 PaO2 mmHg means....

Answer 50

88% SaO2 problematic - may need continuours O2 therapy

Question 51

<40 PaO2 mmHg means....

Answer 51

<75% SaO2 - tissue hypoxia, cardiac arrhythmia - when you get to this point your patient will die.

Question 52

Arterial Blood Gases

Answer 52

- measured to determine oxygenation status and acid-base balance measures PaO2, PaCO2, PpH, bicarbonate (HCO3) in arterial blood CO2 is very acidic if retained in the blood.

Question 53

Spirometry Studies - Pulse Oximetry SpO2

Answer 53

probe on finger, toe, ear to measure light waves - oxygenated blood absorbes light differently tissue in the tissues have only 60 receoptros so if probe is below 95% then critical issues as only about 40 receptors have O2

Question 54

s/s Pneumonia

Answer 54

inspection - tachypnea - use of accessory muscles, cyanosis palpation - unequal movement with lobar in involvement; fremitus over infected area ``` percussion - dull over affected areas auscultation - early bronchial sounds - later - crackles; wheezes ```

Question 55

s/s & possible complications bronchitis

Answer 55

viral persistant cough following an acute upper airway infection - rhinitis, phayngitis cough accompanied by production of clear, mucoid sputum, sometimes purulent fever, headace, malaise, sob on exertion elevated pulse, RR, either normal breath sounds or expiratory weezing. no radiographic evidence of congestion. - usually self-limiting COPD patients may be prescribed antibiotics to deal wit bacterial infections that develop with broncitis

Question 56

s/s & possible complications acute asthma attack

Answer 56

s/s - wheezing, breathlessness, sensation of chest tightness, coughing, combination of these prolonged expiration - instead of 1:2 - 1:3, 1:4 wheezing, air trapping and hyperinflation due to mucous plugs silent chest is an ominous sound usually sit upright or bent forward, intercostal pulling, pursed lips, anxiety/panic moderate/severe - hypoxemia behaviour - increased pulse, bp and a drop in systolic pressure during inspiratory cycle of more than 10 mm Hg. significantly increased resp rate >30bpm difficult completing sentences hyperresonence on purcussion

Question 57

ss COPD

Answer 57

subjective: anorexia, weight loss or gain, early satiety, difficulty eating decreased level of activity and ability to perform ADLs or exercise dyspnea, palpitations, recurrent cough, use of sitting-up position for sleeping, paroxysmal nocturnal dyspnea, ortopnea, swelling of feet constipation, gas, bloating headace, loss of memory, inability to concentrate fatigue, insomnia, depression, anxiety , panic Objective: general - weight weigh BMI distress, increased work of breathing, use of compensatroy mechanisms for breating, anxiety, depression, restlessness integumentary cynosis, bronchitis, pallor or ruddy colour, poor skin turgor, thin skin, easy bruising, peripheral edema (cor pulmonale), respiratory - rapid, shallow, accessory muscle use, inability to speak at al, prolonged expiratory phase, pursed-lip breating, wheezing, crackles, diminished breath sounds, decreased chest excursion and diaphramatic movements, hyper resonant or dull chest sounds on percussion cardio - tachycardia, dysrythmias, jugular vein distension right-sided third heart sound (cor pulmonale), edema GI - ascites, hepatomegaly (cor pulmonale) MS - muscle atropy, increased anteroposterior diameter barrel-chest)

Question 58

ss & possible complications atelectasis

Answer 58

collapsed airless alveoli - results from retained exudates and secretions - postoperative deep breathing exercises prescribed

Question 59

ss & possible complications emphysema

Answer 59

x

Question 60

assessment and care associated with respiratory disorders - specifically asthma & COPD

Answer 60

x

Question 61

understand bronchodilators, corticosteroids & differences

Answer 61

bronchodialators - cause the relaxation of the bronchial smoot muscle - rescue therapy corticosteroids - anti-inflammatory medication to reduce bronchial hyper-responsiveness by blocking the late-phase reaction that inhibits migration of inflammatory cells - long-term therapy

Question 62

peritonsillar abscess - risks

Answer 62

treat to airway patency - s/s hig fever, leukocytosis, chills iv therapy of antibiotics needle aspiration or incision and drainage of abscess either an emergency tonsillectomy or scheduled once infection has subsided

Question 63

sleep apnea

Answer 63

complete or partial upper airway obstruction during sleep

Question 64

nursing considerations for tracheostomy

Answer 64

provide care - suction, clean around stoma, change ties, inner cannula cleaning

Question 65

tidal volume, capacity and residual volume

Answer 65

volume of air inspired or expired during normal breathing (0.5L) vital capacity - volume of air exhaled after maximal inspiration (3L) residual capacity - volume of air left in eac lung after maximal exhalation - 1.2 L

Question 66

IPPA review for a patient presenting with a respiratory complaint

Answer 66

I - inspect, P - palpate, P- percuss, A-auscultate

Question 67

possible complications Pneumonia

Answer 67

complications - pleurisy - inflammation of te pleura pleural effusion - may require aspiration via thoracentesis atelectsis - collapsed airless alveoli delayed resolution - persistent infection lung abscess - not common empyema - accumulation of purulent exudate in pleural cavity pericarditis - infection spreads to sac around heart bacteremia - meningitis - patient disoriented, confussed should have lumbar puncture endocarditis - attacks the endocardium and/or valves of heart

Question 68

possible complications COPD

Answer 68

cor pulmonale | emphysema