Exam 1 Flashcards
Normal ABG values for pH?
7.35 - 7.45
Normal ABG values for CO2?
35 - 45
Normal ABG values for HCO3?
22 - 26
If pH is less than 7.35 and CO2 is greater than 45, what is it?
Respiratory acidosis
What are causes of respiratory acidosis?
Hypoventilation = respiratory depression, airway obstruction
What are manifestations of respiratory acidosis?
hypoventilation, dyspnea, tachycardia, hypotension, weak and thready pulse, hyperkalemia (bc H+ ions move into the cell causing potassium ions to move out of the cell and into the blood stream)
Compensation that occurs with respiratory acidosis?
kidneys conserve HCO3 and excrete H+ ions
Management of respiratory acidosis?
Fowler’s, fluids, O2
Medications for respiratory acidosis?
antibiotics, smooth muscle relaxants, anti-inflammatories, Mucomyst
If pH is greater than 7.45 and CO2 is less than 35, what is it?
Respiratory alkalosis
Causes of respiratory alkalosis?
Occurs from hyperventilation (exhaling too much CO2) = CNS stimulation, anxiety, excessive mechanical ventilation
Manifestations of respiratory alkalosis?
numbness, tingling, tachycardia, rapid shallow respirations, vasoconstriction, lightheadedness, hypokalemia
Compensation of respiratory alkalosis?
kidneys conserve hydrogen ions and excrete HCO3
Management of respiratory alkalosis?
Rebreath CO2, assist to breathe slowly, anti-anxiety meds or sedatives
If pH is less than 7.35 and HCO3 is less than 22, what is it?
Metabolic acidosis
What is the cause of metabolic acidosis?
Occurs when acids accumulate = starvation, DKA, infection/fever, excess exercise. Occurs when HCO3 is lost = diarrhea
Manifestations of metabolic acidosis?
hypotension (dehydration), decreased LOC, vasodilation, warm/pink/dry skin, dysrhythmias
Compensation for metabolic acidosis?
Lungs eliminate CO2, kidneys conserve HCO3
Treatment for metabolic acidosis?
Hydration, meds, alkalitic IV solution, mechanical ventilation, antidarrheals
If pH is greater than 7.45 and HCO3 is greater than 26, what is it?
Metabolic alkalosis
Cause of metabolic alkalosis?
occurs with loss of H+ or increase of HCO3 = vomiting, gastric suction
Manifestations of metabolic alkalosis?
tachycardia, HTN, hypoventilation, dizziness, nervousness, confusion, hypereflexia, seizures
Compensation for metabolic alkalosis?
Lungs retain CO2, kidneys conserve H+ ions and excrete HCO3
Treatment for metabolic alkalosis?
IV fluids (NS), potassium, H2 receptor antagonists, antiemetics, potassium sparing diuretics
What is the calculation for anion gap?
Na - (Cl + HCO3)
What is the normal level for anion gap?
8 - 12 mEq/L
What is a high level for anion gap?
higher than 30 mEq/L
Causes of high level for anion gap?
ketoacidosis, aspirin poisoning, uremia, methanol or ethylene glycol (antifreeze) toxicity
Although low anion gap is rare, what is a cause?
Hypoproteinemia
If the anion gap is normal, but ABG is still off (acidosis), what is the cause?
diarrhea, use of diuretics, early renal insufficiency
Quick relief med for asthma, that relaxes smooth muscle and are the meds of choice for relief of acute symptoms
Short-acting beta 2 adrenergic agonists
Examples of short-acting beta 2 adrenergic agonists
Albuterol (proair, proventil, ventolin)
Xopenex
Quick relief med for asthma that reduces vagal tone of the airway
Anticholinergics
Example of anticholinergics
Ipratropium bromide (Atrovent)
Long-acting med for asthma that are used with anit-inflammatory meds to control asthma symptoms, particularly during the night. they are NOT indicated for immediate relief of symptoms, but are used long-term.
Long-acting beta 2 adrenergic agonists
Example of long-acting beta 2 adrenergic agonists
Theophylline
Serevent
Long-acting med for asthma that are the most potent and effective anti-inflammatory meds currently available. They should be used with a spacer, and pt’s mouth should be rinsed out after administration to prevent thrush.
Corticosteroids
Example of corticosteroids
Budesonide (Pulmicort) Flovent Asmanex Prednisone QVAR
Long-acting med for asthma that are potent bronchoconstrictors that also dilate blood vessels and alter permeability. They block the receptors where leukotrienes exert their action. They are tablets taken PO to help control long term symptoms of asthma.
Leukotriene modifiers
Example of leukotriene modifiers
Singulair
Accolate
What is the etiology and prevention for asthma?
Exposure to allergens or irritants that initiate the inflammatory cascade. The inflammatory process results in vascular congestion, edema formation, production of thick, tenacious mucus, bronchial muscle spasm, thickening of airway walls, and increased bronchial hyperresponsiveness. Environmental Factors - pollen, animal dander, household dust, cockroaches, exhaust fumes, fireplaces, molds, perfumes or other products with aerosol sprays, smoke including cigarette or cigar smoke, and sudden weather changes. Thus, in order to prevent exacerbations, it is important to avoid exposure to these allergens or irritants.
Manifestations of ashtma exacerbation
Restlessness, wheezing or crackles, absent or diminished lung sounds, hyperresonance, use of accessory muscles for breathing, tachypnea with, diaphoresis, cyanosis, decreased SaO2, and PFT tests results that demonstrate decreased air flow rates. Upright positioning – tripod, using accessory muscles and exhibiting anxiety.Hypoxemia, restlessness, inappropriate behavior, increased pulse and blood pressure – may have pulsus paradoxus. Speech may become difficult, tachypnea, percussion of lung fields reveals hyperresonance and auscultation indicates inspiratory/expiratory wheezing
Daily monitoring for asthma, peak flow steps
Stand up or sit up straight.
- Slide the indicator to the base of the meter.
- Take in a deep breath.
- Place the mouthpiece in your mouth and seal your lips around it.
- Blow out as hard and fast as you can (one quick blow).
- Repeat that process 2 more times.
- Select the highest number of the 3 efforts.
- Record this number on your peak flow diary or on a graph.
If your peak flow is above 80% of personal best, what color is it?
Green so continue taking your maintenance meds
If your peak flow is less than 80%, what color is it?
Yellow, so take your rescue medication, then wait 20 to 30 min and check your peak flow again.
What should you do if you peak flow is not back above 80%, what should you do?
Report this to your doctor
If you peak flow is back above 80%, what should you do?
Recheck your peak flow about every 4 hours for a day or so. Call your doctor if you continue to need rescue medicine.
If you peak flow is less than 60%, what is it?
Red zone
How should you treat a peak flow in the red zone?
Consider this an emergency; take your rescue medicine and call your doctor or go to the ER right away
Risk factors for cervical cancer
high risk are women who have a hx of STI, HIV, smokers, poor nutritional status, under age 20, multiple partners, multiple pregnancies, use BC, family hx, been exposed to DES in utero
Surgical considerations for women with cervical cancer
Women need to be educated post surgery for frequent follow up bc is 35 % chance of recurrence of cancer within 2 years often occuring in upper quarter of vagina. Sign is urethra obstruction so reduced urine flow or no urine flow, weight loss, edema, pelvic pain.
Manifestations of endometrial cancer
Main manifestation is post menopausal uterine bleeding. Other sx: pelvic cramping, bleeding after intercourse or with abd pressure, enlarged lymph nodes, ascites, abd masses.
Surgical considerations for endometrial cancer
Goal of care is to provide the woman with treatment that eradicates cancer or minimizes complications. Activity restriction for 4-6 weeks postop, but don’t want to just sit bc blood can pull in abd area and increase risk of clots. So need to change position frequently and avoiding sitting for prolonged periods.
Stage 1: might do a total abd hysterectomy Stage 2 or higher: do radical hysterectomy which is removal of uterus, ovaries, fall tubes, proximal vagina, and bilateral lymph nodes done through abd incision. Lymph node biopsy if think it metastized.
Manifestations of ovarian cancer
General abdominal discomfort, Sense of pelvic heaviness, Loss of appetite, Feeling of fullness, Change in bowel habits, Abnormal vaginal bleeding
Nursing consideration for radiation for ovarian cancer
Must provide efficient nursing care d/t nurses are limited to 30 min/day because of the exposure to radiation
Nursing consideration for chemotherapy/surgery
Platinum and taxane agents: combo of taxol and paraplatin is most often used bc of clinical benefits with minimal toxicity. Usually do surgery in addition to chemo. Intraperitoneal chemo is used when minimum residual disease exists after surgery
Pathophysiology for COPD
Progressive, nonreversible process of airway narrowing and loss of supporting. Can be caused by emphysema and/or chronic bronchitis
Assessment for COPD
Cough, exertional dyspnea, weight, barrel chest d/t emphysema, use of accessory muscles for breathing, prolonged expiration, orthopnea, cardiac dysrhythmias, congestion and hyperinflation on chest x-ray, ABG levels indicate respiratory acidosis and hypoxemia, pulmonary function test that demonstrates decreased vital capacity
Interventions for COPD
Administer oxygen, hydration, effective cough, percussion, postural drainage, reduce intake of dairy products and salt, provide small frequent meals, assess respiratory status every 1-2 hours or as indicated - rate and pattern; cough and secretions, and breath sounds; monitor ABGS, weigh daily, monitor A&Os, assess mucous membranes and skin turgor; encourage fluid intake of at least 2,000 - 3,000 mL/day, place in Fowler’s, high-Fowlers, or orthopneic position, encourage movement and activity as tolerated; assist with coughing and deep-breathing every 2 hours while awake; provide tissues and a paper bag to dispose of expectorated sputum (infection control); refer to resp therapist as needed; provide rest periods between treatments procedures; administer medications as ordered (includes oxygen)
Education for COPD
Make sure to teach patient how to pursed-lip and diaphragmatically breath – minimizes air trapping and fatigue (maintains positive pressure longer during exhalation.
Inhale through the nose with mouth closed
Exhale slowly through pursed lips, as though whistling or blowing out a candle, making exhalation twice as long as inhalation. Pursed lip breathing helps to slow expiration, prevents collapse of small airways and helps the pt control the rate and depth of respiration. It also promotes relaxation, enabling the pt to gain control of dyspnea and reduce feelings of panic.
Abd or diaphragmatic
Place one hand on the abd et the oth on the chest
Inhale, concentrating on pushing the abd hand outward while the chest hand remains still
Exhale slowly, while the abd hand moves inward and the chest hand remains still.
Goals of oxygen therapy for COPD
Goal of supplementary oxygen is keep the PaO2 above 60mm Hg; LT oxygen therapy is usually introduced when PaO2 is below 55 mm Hg or there are s/s of tissue hypoxia or organ damage – think Cor Pulmonale, secondary polycythemia, R sided HF with edema, and/or impaired mental status.
Complications of oxygen therapy for COPD
When O2 delivered by NC during exac it is necessary to closely monitor pt – may actually increase CO2 level and/or decrease the drive to breath – leading to respiratory failure. Must monitor LOC and ABGs.
What is the teaching and side effects for a pt with COPD on Albuterol?
SE – tachycardia, muscle tremor, hypokalemia, increased lactic acid, HA et hyperglycemia. Patient needs ed. about how to use MDI, periodic cleaning of device, possible SE
What is the teaching and side effects for a pt with COPD taking anticholinergic bronchodilators, such as Atrovent?
SE – Dryness of mouth and respiratory secretions, may cause increased wheezing.
Pt. need ed. About correct use of inhaled agents, ensure adequate fluid intake, assess patient for hypersensitivity to atropine, soybeans, peanuts, glaucoma, et prostatic hypertrophy.
What is the teaching and side effects for a pt with COPD taking corticosteroids, such as Beconase?
SE – Cough, dysphonia, oral thrush (candidiasis), HA; high does systemic effects may occur – adrenal suppression, osteoporosis, skin thinning, and easy bruising.
Pt. needs ed. on correct use of MDI et use of spacer/holding chamber devices, rinse mouth p inhalation to reduce local side effects.
What is the teaching and side effects for a pt with COPD taking mucolytics?
HA, dizziness, GI upset.
Patient needs education on intake of at least 2L of fluid daily, care in sitting up, standing up and engaging in high-risk activities until response to medication is known, teach how to effectively cough (Huff).
What is hypovolemia?
Occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids, so that the ratio of serum electrolytes to water remains the same. (do not confuse with dehydration, which is when only water is lost and thus sodium levels of the body are increased).
What are the causes of hypovolemia?
vomiting, diarrhea, sweating, decreased fluid intake, third-space fluid shifts, edema formation in burns, ascites, hemorrhage, and coma.
Manifestations of hypovolemia
acute weight loss, decreased skin turgor, oliguria, concentrated urine, orthostatic hypotension, weak, rapid heart rate, flattened neck veins, increased temperature, thirst, decreased capillary refill, cool, clammy, pale skin.
What are labs for hypovolemia?
Elevated BUN out of proportion to the serum creatinine (ration greater than 20:1), increased hematocrit level due to decreased plasma volume.
Gerontologic considerations for hypovolemia
assessment of skin turgor is not as valid in the elderly because the skin has lost some of its elasticity. Therefore it is best to use other assessments such as slowness in filling of veins in the hands and feet. Skin turgor is best tested over the forehead or the sternum in elderly patients.
Medical management for hypovolemia
Isotonic electrolyte solutions (lactated Ringer’s solution and 0.9% NS) are used because they expand plasma volume.
Nursing management for hypovolemia
monitor I/Os, encourage fluids, monitor for weak, rapid pulse and orthostatic hypotension, administer antidiarrheal and antiemetics as needed.
What is hypervolemia?
Occurs when there is an abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF. It is always secondary to an increase in the total body sodium content, which in turn leads to an increase in totaly body water.
Causes of hypervolemia
heart failure, renal failure, cirrhosis, and consumption of excessive amounts of table salt.
Manifestations of hypervolemia
edema, distended neck veins, crackles, tachycardia, increased blood pressure, increased weight, increased urine output, shortness of breath, and wheezing.
Lab values for hypervolemia?
BUN and hematocrit levels are decreased because of plasma dilution.
Medical management for hypervolemia?
Restrict fluids and sodium and administer diuretics. Thiazide diuretics (hydrochlorothiazide, metolazone) are prescribed for mild to moderate hypervolemia, and loop diuretics (lasix, bumex) for severe hypervolemia. Pt will be on a dietary restriction of sodium. Lemon juice, onions, and garlic are good substitute flavorings. Some patient’s prefer salt substitutes, but they generally contain potassium and must therefore be used cautiously by patients taking potassium-sparing diuretics (spironolactone, triamterene).
Nursing management for hypervolemia
I/O, daily weight, monitor degree of edema, promote rest, restrict sodium intake, monitor parenteral fluid therapy, administer diuretics. If dyspnea occurs, place pt in semi-Fowler’s position to promote lunch expansion. Reposition at regular intervals bc edematous tissue is more prone to skin breakdown than normal tissue.
What do hypotonic fluids do?
• Sodium concentration is less than the body so they dilute the ECF and thus cause water to go into the ICF (cells), causing the cells to swell.
What are hypotonic fluids used to treat?
Hypernatremia and other hyperosmolar conditions
Example of hypotonic fluid
half strength saline (0.45%)
What do hypertonic fluids do?
Sodium concentration is higher than the body, so they put lots of salt into the ECF and thus draw water out of the ICF (cells) and into the ECF (bc water follows salt), causing cells to shrink.
What are hypertonic fluids used to treat?
Used to treat hyponatremia but must be used with extreme caution
Examples of hypertonic fluids
3% sodium saline
50% dextrose in water
What are isotonic fluids?
Fluids that are classified as isotonic have a total osmolality (sodium concentration) close to that of the ECF and do not cause red blood cells to shrink or swell. However, they do still expand the ECF volume. Thus, patient’s with hypertension and heart failure should be carefully monitored for signs of fluid overload.
Examples of isotonic fluids
D5W
Normal saline (0.9%)
Lactated Ringer’s
What is isotonic fluid used ofr?
given to burn victims and hemorrhaging pts
amount of blood presented to the ventricle just prior to systole determined by venous return.
Preload
amount of resistance to the ejection of blood from the ventricle
Afterload
force of contraction, directly related to the status of the myocardium.
Contractility
Symptoms of right sided heart failure:
- Systemic manifestations because the heart can’t pump blood out of the right ventricle and into the lungs so the blood backs up into the body.
- Dependent edema
- increased BP (if fluid overload is causing problem)
- decreased BP (if decreasing CO is causing problem)
- hepatomegaly
- Weight gain
- JVD - measured by laying bed flat and then bringing the bed up to 30-40 degree angle. If have JVD, the veins will pop out at this angle.
- Swelling of the fingers and hands
- Splenomegaly
- Abdominal distention
- Nocturnal diuresis - urinate more than 1 time at night because excess fluid is reabsorbed by kidneys when lying supine.
- Orthopnea - SOB when supine
- A weight gain of 2 lb in 24 hours or 5lb in one week is considered a sign of worsening failure.
- Cor pulmonale - compression of heart by the excess fluid, very severe
What are symptoms of left-sided heart failure?
- Heart can’t pump blood out of left ventricle to the body, so blood gets backed up in the lungs. This causes decreased cardiac output and decreased blood flow to the body.
- Pulmonary edema - crackles, pink frothy sputum, feel like suffocating
- Dyspnea, tachypnea
- Cough
- Paroxysmal nocturnal dyspnea - awakened at night with SOB
- Ventricular gallop - S3 sound present
- Increased blood pressure
- cyanosis in fingers and toes
- anxious
What are medications to reduce preload?
diuretic and fluid restriction (to get rid of excess fluid and thus make blood thinner and easier to pump)
What are medications to reduce afterload?
ACE inhibitor, ARBs, calcium channel blocker, digoxin (to make the heart pump more effectively and get the blood pumped to the body better)
What do ACE inhibitors do?
angiotensin converting enzyme inhibitors; inhibit production of angiotension II, reducing afterload, improving CO et renal function. Also, ACE inhibitors reduce pulmonary congestion and et peripheral edema, suppress myocyte growth et reduce ventricular remodeling in HF (hypertrophy). Can cause hyperkalemia. May also cause a chronic cough.
What do ARBs do?
angiotensin receptor blockers – work in much the same manner as ACE inhibitors, but block the action of angiotensin II at the receptor rather than interfering with its production. Reduces afterload
What can both ACE inhibors and ARBS cause?
Neutropenia (low WBC)
What do beta blockers do?
reduce the adverse effects from the constant stimulation of the sympathetic nervous system (such as increased heart rate that happens since body is trying to compensate for decreased CO). This medication slows the heart down, and reduces anxiety so that the heart doesn’t get too tired. SE: hypotension, bradycardia
What do diuretics do?
remove excess extracellular fluid by increasing the rate of urine produced in pt with s/s of FVE.
What should you know about Lasix?
can be ototoxic do not adm concurrently with aminoglycoside antibiotics (gentamicin) which are also ototoxic. Never IVP Lasix faster than 20mg/min
Bumex also popular loop diuretic.
What are examples of potassium sparing diuretic?
Spironolactone, triamterene, et Midamor are K+ sparing. Spironolactone (Aldactone) blocks aldosterone receptor et reduces symptom of HF and slows progression of HF. Need to monitor for hyperkalemia (bananas, raisins, spinach, potassium supplements, salt substitues bc they usually have potassium in them).
What does Digoxin (Lanoxin) do?
Positive inotropic - helps heart contract more effectively
What s/s of Digoxin toxicity?
anorexia, nausea et vomiting, HA, altered vision (yellowish green halos), et confusion. Rhythms assoc with dig toxicity include Sinus arrest, supraventricular and ventricular tachycardias, and high levels of AV block. Low potassium (hypokalemia) assoc. with increased risk for dig toxicity (as well as hypomagnesemia and hypercalcemia).
What must the apical pulse be to administer digoxin?
above 60 bpm
What is the normal therapeutic level of digoxin ?
0.5 - 2.0 mg/mL
What is the antidote for Digoxin?
Digibind
What are calcium channel blockers?
Cardizem and amlodipine used with diastolic HF – not with systolic HF. They cause vasodilation and decrease systemic vascular resistance SVR.
What do Dopamine (Inotropin) and Dobutamine (Dobutrex) do?
sympathomimetic; increase the force of cardiac contraction. Dobutamine is preferred for HF because it does not increase heart rate as much as Dopamine. Route is IV et must be titrated
How does nitroglycerin work?
vasodilator that relaxes smooth muscle in blood vessels, causing dilation. Arterial dilation reduces peripheral vascular resistance (PVR) and afterload thus reducing myocardial work. Venous dilation reduces venous return and preload. Pulmonary vascular relaxation reduces pulmonary capillary pressure and allows for reabsorption of fluid from interstitial tissues et the alveoli. Nitrites dilate both venous and arterial vessels.
What vasodilator is used in African Americans because it is more effective?
BiDil
What is education for pts with heart failure?
Lifestyle changes include restriction of dietary sodium, avoidance of excessive fluid intake, alcohol, and smoking; weight reduction when indicated, and perform regular exercise. Weigh self daily and if more than 2 lb per 24 hours or 5 lb per week is gained, contact physician.
What are the classifications for pleural effusions?
collection of excess fluid in the pleural space as a result of systemic (heart failure, liver or renal disease, and connective tissue disorders) or local disease (pneumonia, atelectasis, TB, lung CA, and trauma).
high capillary pressure/low plasma protein level, clear fluid, usually results from heart failure.
Transudate
increased capillary permeability, clear fluid, usually results from inflammation by bacteria or tumors
Exudate
thick, purulent fluid usually from pneumonia or lung abscess
Empyema
Blood in pleural space
Hemothorax
Combination of blood and pleural fluid in pleural space
Hemorrhagic pleural effusion
Lymph fluid in pleural cavity
Chylothorax
How is pleural effusion treated?
Objectives of tx are to discover the underlying cause of the pleural effusion, to prevent reaccumulation of fluid, and to relieve discomfort, dyspnea, and respiratory compromise. Thoracentesis is performed to remove fluid. If the underlying cause is a malignancy, the effusion tends to recur within a few days or weeks. Pleurectomy may be performed for recurring pleural effusions. It is surgically stripping the pareital pleura away from the visceral pleura, resulting in intense inflammatory reaction that promotes adhesion formation between the two layers during healing.
Nursing management of pleural effusion
Frequent turning and movement are important to facilitate adequate spreading of the talc over the pleural surface. Monitor chest tube function and drainage, pain management.
Manifestations of pleurisy
Taking a deep breath, coughing, or sneezing worsens the pain. Pain usually occurs only on one side. Pain may become minimal or absent when the breath is held. Later as pleural fluid develops, the pain decreases.
Treatment of pleurisy
The objectives of tx are to discover the underlying condition causing the pleurisy and to relieve the pain. Prescribed analgesic agents and topical applications of heat or cold provide symptomatic relief. Indocin is a NSAID often given. If the pain is severe, an intercostal nerve block may be required.
Nursing management of pleurisy
Keep pt comfortable, turn frequently onto the affected side to splint the chest wall and reduce the stretching of the pleurae. Teach pt to use hands or a pillow to splint the rib cage while coughing.
Manifestations of pulmonary edema
Crackles, SOB, dyspnea
What is priority nursing care for pulmonary edema?
Administer oxygen to correct hypoxemia, intubation or mechanical vent may be necessary. If problem is fluid overload, administer diuretics and restrict fluids.
What type of medications are used for anticoagulant therapy for pulmonary embolism?
heparin, warfarin (takes 4-5 days to take effect, monitor labs q 2-3 weeks), lovenox (low-molecular-weight heparin, check morning platelet labs), and heparinoids (fondaparinux, dalteparin, inzaparin, lepirudin, and argatroban). Lepirudin et argatroban are contraindicated in pts with overt major bleeding et pt who are hypersensitive to these meds or high risk for bleeding, anomaly of vessels/organs, recent major surgery, recent puncture of large vessels/organ biopsy All pts continue anticoagulation therapy for at least 3-6 months p the event.
What type of medications are used for thrombolytic therapy for pulmonary embolism?
urokinase, streptokinase, alteplase) for pts who are severely compromised (hypotensive with significant hypoxemia). Dissolves emboli et restores normal hemodynamic fx of the pulmonary circulation et reduces pulmonary hypertension et improves perfusion, oxygenation et cardiac output. Contraindication for thrombolytic therapy include CVA in past 2 mths, oth active intracranial processes, active bleeding, surgery within 10 day of the event, recent labor/delivery, trauma or severe hypertension.
Nursing measures to prevent pulmonary embolism
Reduce risk of PE – , preventing thrombus formation, assessing potential for pulmonary embolism , monitor thrombolytic therapy (only essential arterial punctures or venipuncture performed with manual pressure applied to site for at least 30 minutes, managing pain, managing oxygen therapy, relieving anxiety, monitoring for complications, postoperative care – pulm arterial pressure, UO, insertion site of catheter, elevation of feet with isometric exercises, anti-embolism stockings, walking when permitted, sitting discouraged because hip flexion compresses the lg veins in the legs.
What are nursing interventions for pulmonary embolism?
Notify rapid response team, reassure client and elevate HOB, prepare to administer oxygen, obtain vital signs and check lung sounds, prepare to obtain an ABG, prepare for the administration of heparin therapy or other therapies. Document the event, interventions taken, and the pts responses to the interventions
Pathology of pulmonary hypertension
changes in the pulmonary artery leading to abnormal growth and modeling of pulmonary vessels. That leads to abnormal vasoconstriction and fibrosis of pulmonary vessels.
What is the etiology of primary pulmonary hypertension?
Unknown etiology, can be related to a BMPR2 gene. PPH occurs most often in women 20-40 years of age. After diagnosis, survival is about 3 years.
What is the etiology of secondary pulmonary hypertension?
Develops most often from chronic hypoxemia – chronic lung diseases, sleep apnea, and hypoventilation d/t obesity or neuromuscular disease. Also can result from HIV, Lupus, and Scleroderma.
Manifestations of pulmonary hypertension
progressive dyspnea, fatigue, angina, and syncope with exertion
Complication of pulmonary hypertension
Cor Pulmonale
Interdisciplinary care for pulmonary hypertension
CBC, ABGs, CXR, ECG, Doppler ultrasound
Treatment of pulmonary hypertension
phlebotomy, oxygen prevent thrombus formation, calcium channel blockers to reduce pulmonary vascular resistance and improve cardiac output, coumadin, bilateral lung transplant, cor pulmonale – salt/water restriction and diuretics.
What is hyponatremia?
Serum sodium level less than 135 mEq/L
Causes of hyponatremia
Adrenal insufficiency, water intoxication, SIADH, vomiting, diarrhea, sweating, diuretics
Manifestations of hyponatremia
poor skin turgor, dry mucosa, headache, decreased salivation, fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes: altered mental status, status epilepticus, lethargy, confusion, muscle twitching, coma, death.
Lab values of hyponatremia
Decreased serum and urine sodium, decreased urine specific gravity and osmolarity
Medical management of hyponatremia
Most common treatment is careful administration of sodium by mouth, NG tube, or parenteral route. In a patient with normal or excess fluid volume, hyponatremia can be treated by restricting fluid rather than administering sodium and it is far safer.
Nursing management of hyponatremia
I/O, daily weight, monitor for GI manifestations and central nervous system changes. Encourage foods and fluids with high sodium content or encourage fluid restriction if the primary problem is fluid retention
What is hypernatremia?
Serum sodium greater than 145 mEq/L
What causes hypernatremia?
excess water loss, fluid deprivation, excess sodium intake, diabetes, heat stroke, and near drowning in sea water.
Manifestations of hypernatremia
Thirst, increased temperature, dry swollen tongue, sticky mucosa, weight gain, restlessness, weakness, disorientation, delusions, hallucinations
Lab values of hypernatremia
increased hematocrit and BUN, increased specific gravity
Medical management of hypernatremia
Infusion of hypotonic solution (0,3% sodium chloride) or an isotonic nonsaline solution (D5W). Diuretics may also be prescribed to treat the sodium gain.
Nursing management of hypernatremia
I/O, daily weight, monitor ingestion of OTC meds that may have a high sodium content (Alka-Seltzer), monitor for changes in behavior, provide fluids at regular intervals.
What is hypokalemia?
Potassium less than 3.5 mEq/L
Causes of hypokalemia
Poor diet, potassium-losing diuretics (loop and thiazide diuretics), vomiting and gastric suctioning, diarrhea, acid/base imbalances.
Manifestations of hypokalemia
Fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility ,paresthesias, dysrythmias (flat T waves and elevated U wave).
Medical management of hypokalemia
Increased intake in the daily diet or oral potassium supplements. For severe give IV replacement potassium (40-30 mEq/day is adequate). Foods high in potassium include most fruits and vegetables, lgumes, whole grains, milk, and meat.
Nursing management of hypokalemia
Encourage foods rich in potassium, I/O, daily weight, monitor ECG for changes and arterial blood gas. Potassium is NEVER administered IV push or IM to avoid replacing potassium too quickly and can cause cardiac arrest!!
What is hyperkalemia?
Potassium level greater than 5.0 mEq/L
Causes of hyperkalemia
Decreased renal excretion of potassium rapid administration of potassium, untreated renal failure, Addison’s disease, and potassium sparing diuretics (aldactone, triamterene).
Manifestations of hyperkalemia
Peaked T waves, widening of the QRS complex, ventricular dysrhythmias, cardiac arrest, skeletal muscle weakness, and paralysis.
Medical management of hyperkalemia
ECG to detect peaked T wave, restriction of dietary potassium and potassium-containing medication, administration of loop diuretics. If severe administration of Kayexalate either orally or by retention enema, or IV calcium gluconate.
Nursing management of hyperkalemia
Observe for signs of muscle weakness and dysrhythmias, avoid potassium rich foods such as fruits and vegetables, legumes, whole grain breads, meat, milk, eggs, coffee tea, and cocoa. Never give potassium supplements or salt substitutes to patients with renal dysfunction.
What is hypocalcemia?
Serum calcium level below 8.5 mg/dL
Causes of hypocalcemia
Hypoparathyroidism, thyroid and parathyroid surgery (because the parathyroid regulates serum calcium levels), pancreatitis, renal failure, inadequate vitamin D consumption, magnesium deficiency, loop diuretics.
Manifestations of hypocalcemia
Tetany, sensations of tingling around the mouth, spasms of the muscles, hyperactive DTR’s, trousseau’s sign, Chvostek’s sign, dypsnea and laryngospasm, seizures, hyperactive bowel sounds, dry and brittle hair and nails.
Medical management of hypocalcemia
IV treatment with calcium salt such as calcium gluconate diluted in D5W and administered slow IV bolus or slow IV infusion. Vitamin D therapy to increase calcium absorption from the GI tract. Foods rich in calcium such as: green leafy vegetables, canned salmon, milk, sardines, fresh oysters.
Nursing management of hypocalcemia
seizure precautions, monitor airway, teach pt’s which foods are rich in calcium, observe IV site often for evidence of infiltration, administer calcium supplements with food, avoid overuse of laxatives and antacids.
What is hypercalcemia?
Serum calcium greater than 10.5 mg/dL
Causes of hypercalcemia
malignancies and hyperparathyroidism, immobility, tiazide diuretics, vitamin A and D intox, chronic lithium use. (calcium levels are inversely related to phosphorus levels)
Manifestations of hypercalcemia
Hypercalcemia reduces neuromuscular excitability so muscle weakness, incoordination, and constipation occur. Abdominal and bone pain, severe thirst, confusion, impaired memory, slurred speech, lethargy, bradycardia, coma.
Medical management of hypercalcemia
administer fluids, mobilize patient, restrict dietary calcium intake, loop diuretics, calcitonin. For patient’s with cancer: surgery, chemo, radiation.
Nursing management of hypercalcemia
increase pt mobility and encourage fluids (3-4 quarts daily), adequate fiber in diet to reduce constipation.
What is hypomagnesemia?
Serum magnesium lower than 1.8 mg/dL
Causes of hypomagnesemia
alcoholism, GI loss, DKA, sepsis, burns, hypothermia
Manifestations of hypomagnesemia
muscle weakness, tremors, cardiac dysrhythmias, nystagmus, tetany, chvostek’s and trousseau’s signs, marked alterations in mood.
Medical management of hypomagnesemia
magnesium diet: green vegetables, seafood, milk, bananas, citrus, chocolate, magnesium supplements,
Nursing management of hypomagnesemia
observe for signs and symptoms, give foods rich in magnesium, adm mag supplements
What is hypermagnesemia?
Serum magnesium greater than 2.7 mg/dL
Causes of hypermagnesemia
Renal failure, DKA
Manifestations of hypermagnesemia
Depresses the CNS and peripheral neuromuscular junction. Facial flushing, lethary, difficulty speaking, diminished DTR’s, muscle weakness and paralysis, depressed respiratory center, cardiac arrest, coma.
Medical management of hypermagnesemia
Avoid administration of magnesium to pts with renal failure. IV calcium gluconate, loop diuretics, IV NS, hemodialysis
Nursing management of hypermagnesemia
Monitor VS, observe for decreased DTR’s and changes in LOC
What is hypophosphatemia?
Serum phosphorus level below 2.5 mg/dL
Causes of hypophosphatemia?
Overzealous refeeding of malnourished pt’s receiving parenteral nutrition, alcoholism, vit D deficiency.
Manifestations of hypophosphatemia
wide range of neurologic manifestations such as irritability, fatigue, weakness, numbness, diplopia, confusion, seizures, coma.
Medical management of hypophosphatemia
Neutra-phos PO, IV for severe
Nursing management of hypophosphatemia
gradually introduce refeeding, prevent infection, encourage foods such as: milk, organ meats, nuts, fish, poultry, and whole grains.
What is hyperphosphatemia?
Serum phosphorus greater than 4.5 mg/dL
Causes of hyperphosphatemia
Renal failure, excessive vitamin D, chemo
Manifestations of hyperphosphatemia
Few symptoms, soft-tissue calcification, tetany (because of the reciprocal relationship between phosphorus and calcium, a high serum phosphorus level tends to cause a low serum calcium level, so may have tingling around mouth, tetany etc).
Medical management of hyperphosphatemia
Calcium-binding antacids, restriction of dietary phosphate, loop diuretic, phosphate binding gels.
Nursing management of hyperphosphatemia
Encourage pts to avoid foods rich in phosphorus, avoid phosphate-containing substances such as laxatives and enemas
