EXAM 1 Review Flashcards
What are the normal lab values for cholesterol?
Total Cholesterol <200mg/dL
HDL > 60mg/dL
LDL < 70mg/dL IF PT IS HIGH RISK, <100mg/dL for females, < 150mg/dL for males
TG < 135mg/dL for females, < 150mg/dL for males
What are the non-modifiable risk factors for CAD?
age, gender (men tend to develop earlier), ethnicity (African American at greater risk), family history (primary relative w/ MI before the age of 55/65), diabetes
What are the modifiable risk factors for CAD?
smoking, obesity, sedentary lifestyle, metabolic syndrome, hyperlipidemia, DM, HTN, proper management of diabetes/prediabetes, unhealthy diet, stress, sleep apnea
What are important health promotion points for CAD?
- ID at risk patients
- physical activity –> FITT(150 min/wk or 75min/wk of vigorous exercise)
- Nutritional therapy –> TLC diet: decrease sat fat/ cholesterol, increase complex carbohydrates, fat <30% daily intake, high soluble fiber
What is the pharmacological management of CAD?
statins, antiplatelets/anticoagulants, BB, CCB, nitroglycerin
What are possible procedures for treatment of CAD?
angioplasty, stent placement, CABG
What are the main patient education points for CAD?
quite smoking stay active eat healthy diet control stress manage diabetes ***drugs alone will not be effective, pt must combine pharm interventions with healthy lifestyle modifications
What is Acute Coronary Syndrome?
Occurs when a plaque breaks off and blocks the coronary artery, concern for cardiac arrest. May present as STEMI (complete blockage), NSTEMI (partial blockage), or unstable angina
How will a patient present with ACS?
chest pain (may radiate to left arm), arrhythmias, SOB (at rest or on exertion), elevated BP (which will continue causing damage to vessel walls)
What Dr orders can the nurse anticipate in treatment of the patient with ACS?
EKG, cholesterol levels, CT to check for vessel occlusion or stenosis, angiogram, stress test (walk or pharmacological using dobutamine, adenosine, dipyridamole)
What are potential complications of a stress test?
MI, HF, cardiac arrest, dysrhythmias —> have a crash cart on hand!
What is an echocardiogram used to examine?
heart size, ejection fraction, valve function, pericardial fluid, masses/thrombi
What is angina pectoris?
chest pain that occurs intermittently over a long pd w/ the same pattern of onset, duration, and intensity of symptoms, caused by decreased blood flow through coronary arteries
What can cause an episode of angina?
physical exertion, exposure to cold, eating heavy metal, stress/emotion causing release of catecholamines
What are the different types of angina and how are they characterized?
stable angina: predictable pain that occurs on exertion, relieved by rest and exertion
Unstable angina: pain that increases in frequency or intensity, NOT relieved by rest/ NG
Silent ischemia: significant myocardial ischemia w/o associated symptoms —> elderly, diabetics (diabetic neuropathy), men aged 45-65
Prinzmetal’s or Variant angina: d/t coronary spasm at rest; frequent during REM sleep, r/t hyperactivity of SNS, ST segment elevation but only DURING the episode
Intractable Angina: severe incapacitating chest pain
What are the interventions for a patient experiencing angina?
NG —> SL tablets, one every 5 minutes up to 3 doses (0.4mg)
Oxygen: 2-3L nasal cannula
Antiplatelets, anticoagulants: ASA (180-325mg), Clopidogrel [Plavix] 75mg, Heparin (therapeutic at 2-2.5x normal aPTT –> CAUTION HIT); blood thinners: enoxaparen [Lovenox], Dalteparin [Fragmin], Eptifibatide [Integrillin]; BB (metoprolol), CCB
What are the general MOA of NG, BB, and CCB?
NG: dilates veins, decreasing preload
BB: decreases HR, myocardial oxygen demand, thus decreasing myocardial contractility; also controls pain
CCB: decrease SA node automaticity, AV node conduction, decreasing contractility; relaxes blood vessels, increasing CA perfusion; decreased workload = decreased myocardial demand
What goals should be met when evaluating effectiveness of angina. trx?
pt reports pain relief
avoid progression to MI
pt follows self care plan, completes follow up including exercise stress test
What are the common CM of angina?
pain
mild indigestion
choking/heavy sensation upper chest
feeling of impending death
What symptoms should you be alert for when a patient is experiencing angina (i.e. what indicates it may be progressing to MI)
complaints of unusual fatigue weakness, numbness in arms and wrists SOB pallow diaphoresis anxiety dizziness N/V accompanied by pain related symptoms
What is the process of diagnosing a patient’s angina?
pt hx
12 lead ECG
bloodwork
stress test
What is a myocardial infarction?
the IRREVERSIBLE necrosis of heart muscle, secondary to prolonged ischemia
c/b damaged myocytes (which will release cardiac enzymes), loss of contractility in affected tissue, and pain for longer than 30 minutes not relieved by rest
What s/s indicate an MI?
palpitations, irregular HR, tachy or bradycardia, JVD, hypo or hypertension, S3, S4, new murmur tachypnea, SOB, crackles N/V decreased urinary. output skin cool, clammy, diaphoretic, pale anxious, light headed FEELING OF IMPENDING DOOM
What s/s may indicate an MI in women?
neck, shoulder, upper back, and abdominal discomfort; SOB; N/V; sweating; lightheadedness; unusual fatigue
A patient presents in the ED with a suspected MI. As the nurse, when should you anticipate needing to draw labs?
Labs should be drawn initially then again at 4 hours (looking for elevated troponin, CK MB, myoglobin; remember, troponin is normally almost 0)
What medical interventions should the nurse expect to provide for a patient with an MI or suspected MI?
oxygen: 2-4L
aspirin: 325mg
nitroglycerin
morphine: 2-4mg
Beta blockers (Lopressor): 5mg
continuous monitoring, labs
establish 2-3 peripheral IV’s
May need to administer a stool softener —> prevent straining and vasovagal stimulation
keep pt on bedrest
After a patient arrives to the ED with a suspected MI, how long should it be before an ECG is completed?
What does T wave inversion imply?
ST Seg elevation?
Q wave?
10 minutes from arrival (time is muscle!)
ischemia
injury
infarction
What are potential complications of an MI?
dysrhythmias, HF, cardiogenic shock, papillary muscle dysfunction, ventricular aneurysms, pericarditis/dressler’s syndrome
After education, what should the patient with angina be able to do/verbalize an understanding of?
recognize s/s of angina
participate in activities to decrease possibility of further anginal episodes
avoid activities that precipitate anginal episodes
verbalize understanding of use of OTC meds (diet pills, decongestants)
maintain a healthy lifestyle: tobacco cessation, proper diet, normal BP/chol
verbalize an understanding of use of rx med: NG, BB, ASA
What is the difference between angiography and a PCI?
angiography is strictly a diagnostic tool to obtain information about the structure and function of the heart and its vessels (including any blockages)
a PCI is therapeutic, opening blockages and potentially placing stents
Prior to an angiography, what must be considered in preparing the patient?
ASSESS: allergy to shellfish?
EDUCATE: stop glucophage 3 days prior; if unable provide ample fluids to flush out and prevent renal damage
What are pre PCI interventions the nurse must perform?
during?
post?
Pre: pt education (dye will be injected via peripheral IV, may feel. fluttering as catheter passes through heart); check for informed consent; assess allergies to idodine dye or shellfish; clipper and cleanse injection site; NPO 6-8 hours prior (Cardiac meds with sips of water ok); PIVs patent and infusions. running as ordered
During: monitor for occlusions, check pedal pulses; monitor ECG, VS; administer conscious sedation as ordered
post: maintain bedrest 4-6 hours as ordered, frequent assessment of VS including chest pain, assess color, distal pulses of affected extremity, assess site for bleeding, hematoma; if femoral must lay flat for 1-2 hours, no crossing legs; monitor I&O, assess bandage frex
What is the arrival time to ED to cath lab time?
under 60 minutes
In which situations should fibrinolytics be used?
If PCI/cath lab is unavailable
What important nursing considerations and interventions must be made in administration of fibrinolytics?
all invasive procedures done prior to administering frx eval of chest pain, VS monitor for bleeding assess heart rhythm for reperfusion DR assess neuro fx
What are ABSOLUTE CI to fibrinolytic therapy?
active bleeding, known cerebral aneurysm, known intracranial neoplasm, previous cerebral hemorrhage, recent ischemic stroke, significant closed head injury or facial trauma w/i last 3 months, suspected aortic dissection
What are the normal ABG Values?
pH: 7.35-7.45 pCO2: 35-45 mmHg pO2: 80-100mmHg O2 sat: 95-100% HCO3: 22-26mEq/L
What values are alkalotic?
pH 7.45 or >
CO2 35 or <
HCO3 > 26
What values are acidotic?
pH 7.35 or <
CO2 >45
HCO3 <22
By what organs/structures are H+ ions excreted?
bones, lungs, kidneys
What is the primary problem of respiratory alkalosis, and what are associated lab values?
alveolar hyperventilation: anxiety, pain, hypoxemia, hypermetabolic states (fever, hyperthyroidism), overzealous mechanical vent, ascites, 3rd trimester pregnancy, early stage of salicylate intox mnemonic: TACHYPNEA T- temp increase increases metabolic needs of body A- ASA tox stimulates resp center C- controlled mechanical vent H- hyperventilation hYsteria P- pain, pregnancy N-neurological injury E- embolism and edema in lungs A- asthma pH >7.45, paCO2>35
What might you find in your assessment of a pt in respiratory alkalosis?
vasoconstriction, lightheadedness, decreased calcium ionization, inability to concentrate, numbness, tingling, tinnitus
What are s/s of respiratory alkalosis?
confused, tired, fast HR; tetany; EKG changes; muscle cramps; positive Chvostek’s sign; HYPOCALCEMIA, HYPOKALEMIA
NI for a pt in respiratory alkalosis?
breathing techniques
monitor K, Ca
if pt on mechanical vent —> watch for hyperventilation
What is the primary problem of respiratory acidosis, and what are associated lab values?
alveolar hypoventilation: CNS depression (narcotics, anesthetics, barbiturates, sedatives); chronic respiratory disease (emphysema, severe asthma); pneumonia, pulmonary edema, aspiration, pneumothorax, atelectasis; NM disease: polio, MG, GB
mnemonic: DEPRESS
D- drugs, opiates
E- edema
P-pneumonia
R- respiratory center of brain damaged
E- emboli
S- spasm of bronchial tubes (think asthma)
S- sac elasticity of alveolar sac is damaged
pH <7.35, PaCO2>45
What might you find in your assessment of a patient with respiratory acidosis?
hypercapnia —> increased pulse rate, BP w/ reflex attempt to increase ventialtion
skin may be warm, flush d/t vasodilation from the CO2 increase
s/s of a patient with respiratory acidosis?
neuro changes, confused, drowsy; HA; RR <12 bpm; decreased BP
NI for the patient with respiratory acidosis?
administer O2; encourage coughing ,deep breathing; respiratory therapy and bronchodilators; watch K levels —> hyperkalemia —-> MONITOR EKG; if pneumonia antibiotics, spirometry; endotracheal intubation
What is the major causative factor of the development of metabolic acidosis, and associated lab values?
Major causative factor: increased acid or loss of bicarb creates a drop in bicarb: excessive acid intake (ASA, methanol, ethanol); GI loss of bicarb --> chronic diarrhea, biliary and pancreatic fistulas; hyperkalemia; increased acid production --> DKA or lactic acidosis; RF; starvation; shock; sepsis
mnemonic: ACIDOTIC
A- aspirin tox
C- carbs not metabolized --> lactic acid buildup
I- insuff of kidneys
D- diarrhea, DKA
O- ostomy drainage
fisTula
I- intake of high fat diet
C- carbonic anhydrase inhibitors
pH < 7.35, HCO3 <22What would you expect to find in your assessment of a ptient in respiratory acidosis?
HA, confusion, drowsiness, increased RR/depth (Kussmaul’s breathing), n/v, vasodilation –> hypotn, cool clammy skin
What nursing interventions would you expect to implement for a pt in respiratory acidosis?
watch. for respiratory distress, watch elytes/K, neuro status/seizures, if RF –> dialysis; if DKA —> insulin
What is the major causative factor of metabolic alkalosis and what are the lab values associated?
major causative factor: loss of acid and/or increase in bicarb: hypokalemia, vomiting or NG drainage/sx, increased HCO3 (e.g. from administration), potassium depletion, renal loss of H+ –> diuretics, steroid use
mnemonic: ALKALI
A-aldosterone prod
L- loop diuretics, hydrochlorothiazides
alKali ingestion
A- anticoag citrate –>. metabolized as bicarb (from
blood products, renal replacement therapy)
L- loss of fluids
I- increased sodium. bicarb admin in attempt to correct metabolic acidosis
How would a patient with metabolic alkalosis present?
tingling in fingers and toes, dizziness, h ypertonic. muscles, depressed respirations (compensatory mechanism)
NI. intervetnions of metabolic alkalosis?
TREAT THE CAUSE if vomiting. --> antiemetic stop sux, watch amount stop diuretics watch ABGs. watch for signs of respiratory distress
What are the causes of FVD?
isotonic: trauma, diarrhea, vomiting, excess sweat
hypertonic: polyuria, DKA, ESRF, water deprivation
hypotonic: hyponatremia, blood has more water
third spacing
dehydration: increased sodium, LOSS OF WATER ONLY
hypovolemia: loss of water and solutes
How will a patient with FVD present?
Assessment: hypotensive, increased HR, weak pulse, concentrated urine (USG > 1.030), THIRSTY, flattened neck veins, hemoconcentrations
Therapeutic management and pt edu if FVD?
I/O should be maintained at or above 30mL/hr
daily weights
Elyte admin, IV fluid
stay hydrated and cool
remind elderly to drink
manage diabetes
What are causes of FVE?
excess intake, excess Na intake
may be caused by a disease process: RF, CHF, liver failure
What are complications of FVE?
HTN, increased hydrostatic pressure, b/u of fluid around lungs, hyponatremia
How would a pt with FVE present?
HTN, increased bounding pulse, peripheral edema, weight gain, crackles, SOB
USG < 1.010, hemodilution
Management and education for the patient in FVE?
monitor I/O; daily weight
diuretics, restrict NA, fluid, high Fowler’s, compression stockings, dialysis (last resort)
educate patient on compliance, which s/s to report and be aware of
Cause of hyponatremia (actual and relative)
Treatment
Assessment
ACtual: sweating, wound drainage, low Na diet, diuretics, hypoaldosteronism
Relative: SIADH, water intox, freshwater submersion, hypotonic fluids
SEIZURE PRECAUTIONS
increase NA intake, no free water; stop K wasting diuretics; administer 0.9% NaCl if hypovolemic, or hypertonic saline (3%), osmotic diuretics; replace slowly; avoid volume overload d/t fluid shifts; prevent neuro damage d/t overcorrection
SALT LOSS S- stupor/coma/ increased ICP A- anorexia, N/V/D L- lethargy T- tendon reflexes decrease L- limp muscles O- orthostatic hypotn S- seizures, HA S- stomach cramping
IF PT ON LITHIUM WATCH FOR TOXICITY
Na < 135
Hypernatremia causes (actual, relative), treatment, assessment, education
actual: steroids, oral ingestion, hypertonic saline, Cushing’s
relative: NPO, fever, hyperventilation, dehydration, infection
SEIZURE PRECAUTIONS
decrease levels slowly, hypotonic fluids (o.45% NS, D5W), if hypervolemic Na wasting diuretics, consult dietician
Assessment: FRIED food is salty F-flushed skin R- restlessness, irritability I- increased fluid ret, and increased BP E- edema: peripheral and pitting D- decreased urinary output, dry mouth
lethargy, confusion, drowsy, stupor; twitching, decreased DTR, muscle weakness, decreased contractility
Avoid salty foods: bacon, processed foods, lunch meats
Na > 145
Causes, treatment, assessment, and education of hypokalemia
Cause: Your body DITCHes the K
D- drugs (laxatives, diuretics, corticosteroids
I- inadequate intake
T- too much water intake
C- Cushing’s syndrome increases aldosterone
H- heavy fluid loss via NGSx, V/D, wound drainage
Treatment: treat the cause; eliminate K sparing diuretics, administer K rich foods, cardiac monitor, assess respiratory fx; replace K IV or PO SLOWLY: NO > 10MEQ/L PER HR
NEVER GIVE PUSH OR BOLUS —> CAN BE LETHAL
Assessment: the 7 L's L- lethargy, AMS, decreased LOC L- leg cramps L- limp muscles L- low shallow respiration L- lethal cardiac DR L- lots of urine L- low BP and HR hypoactive BS, N/V, constipation, depressed ST Segment [EVERYTHING IS LOW AND SLOW W/ HYPOKALEMIA]
pt edu: dietary P- potatoes, pork O- oranges T- tomatoes A- avocados S- strawberries S- spinach f-I-sh mUshrooms M- musk melon < 3.5
Causes, treatment, assessment, pt edu of hyperkalemia
Causes: mnemonic MACHINE M- medications: K sparing diur., ace-I, NSAIDS A- acidosis C- cellular destruction: burns, tissue damage H- hypoaldosteronism (Addison's) I- intake excessive N- nephrons (RF) E- excretion impaired
if acidotic, treat this first
mnemonic for trx: AIRED
A- administer calcium gluconate
I- increase excretion via stool (kayexalate) and urine
R- remove sources of K
E- enhance K uptake into cells: insulin, glucose, sodium
bicarb, beta-adrenergic agonists
D- dialysis, EMERGENT RESPONSE FOR PTS WITH LETHAL HYPERKALEMIA
assessment: excess K can MURDER a pt M- muscle weakness, paresthesias U- urine oliguria/anuria R- respiratory distress/ failure D- drecreased cardiac contractility E- ECG changes: TALL PEAKED T WAVES R- reflexes: hyperreflexia/areflexia hyperactive bowel sounds
> 5
Hypocalcemia cause, treatment, assessment, edu
Cause: RF, hypoparathyroidism, hyperphosphatemia, malnutrition/malabsorption d/t alcoholism or VIT D def
Trx: muscle relaxants, decreases stimuli, increase nutritional intake (broccoli, coconut milk), replace calcium with Vitam D or aluminum hydroxide to promote absorption
diet high in CA: cheese, collard greens, kale, milk, soy milk, rhubarb, sardines, tofu, yogurt
<8.5
hypercalcemia cause, treatment, assessment, edu
Cause: hyperparathyroidism, malignancy, vit D tox, excess intake
Trx: IV Fluids (0.9% NaCl), cardiac monitoring, dialysis, monitor for fractures, monitor for flank or abdominal pain
Drugs: Ca+ binders, Ca+ reabsorption inhibitors, phosphorus, calcitonin, bisphosphonates, NSAIDS
Assessment: Groan (constipation), Moans (joint pain), Bones (loss of Ca), Stones (kidney stones) and Psychic Overtones (confusion, depression:)
weakness, decreased DTR, decreased LOC
decreased HR, cyanosis, DVT
decreased peristalsis
> 10.5
Hypomanesemia cause, trx, assessment
causes: alcoholism, malabsorption, diuretics, RF, diarrhea, hypoparathyroidism
Trx: replace Mg via PO Mg hydroxide, treat cause: d/c diuretics, phosphorus, or aminoglycosides; monitor EKG, DTR
assessment: numbness, tingling, tetany, seizures, increased DTR, psychosis, confusion, decreased GI Motility, constipation, anorexia
PROLONGED QT INTERVAL
Caution: treat this before hypokalemia; K cannot be processed when Mg is low!
Mg rich foods: meats, nuts, legumes, oranges, bananas
<1.5
Hypermagnesemia cause, trx, assessment
causes: RF, adrenal insuff., Mg trx for exlampsia, overcorrections w/ Mg supp
Trx: monitor CV, respirations, CNS, NM status
Assessment: severe bradycardia, cardiac arrest, vasodilation, hypotension, prolonged PR, wide QRS, drowsy/lethargic/coma, decreased DTR, slow weak muscles - WATCH RESPIRATORY MUSCLES
pt edu: avoid use of laxatives and mg containing antacids
> 2.5
What is the purpose of a bronchoscopy?
Therapeutic and Dx- removes secretions, foreign object, and/or takes tissue samples
What NI are related to bronchoscopy?
preprocedure: informed consent, NPO 4-8 hours before procedure, administer pre- procedure meds (propofol), remove dentures and store appropriately
post procedure: NPO until cough reflex returns, monitor VS/resp status, CXR, lab results w/i a week
What is the purpose of thoracentesis?
procedure to remove excess air or fluid from the pleural space- diagnostic and therapeutic
It is also an invasive procedure, so informed consent must be obtained
What is proper patient positioning for thoracentesis?
Pt should be upright, leaning on a table. Done from the back where pleural gutter is deepest and NV bundle is closer to the edge of the rib
Appropriate nursing interventions for thoracentesis?
Pre: Informed consent, pre procedure check and timeout including labs (INR, PTT), confirm correct side, document performing MD, personnel present, premeds administered, positioning; baseline VS including pain; administer pre procedure meds: propofol, lidocaine, low dose xanax
During: walk pt through procedure as things occur to prevent flinching
Post: pressure after needle is WD, then airtight dressing (if not airtight –> pneumothorax –> chest tube); CXR; document: fluid removed, how pt tolerated procedure, characteristics of fluid removed
Monitor: RR and symmetry, for any dyspnea, diminished BS, anxiety/restlessness, tightness in chest, uncontrolled cough, blood tinged or frothy sputum, rapid pulse
Symptoms and risk factors of Obstructive Sleep Apnea?
snoring, daytime sleepiness, significant report of sleep apnea episodes —> ask spouse
obesity, post-m women, large neck, mail gender
NANDA for OSA and upper respiratory tract disorders?
ineffective airway clearance acute pain impaired verbal communication FVD knowledge deficit r/t prevention, trx, surgical prevention, post-op care
Nursing Interventions for upper respiratory tract disorders?
elevate head ice collar for inflammation hot packs to reduce congestion analgesics for pain gargles for sore throat use alternative communication if pt struggling encourage liquids soft, bland diet and rest
What are the four classification of pneumonia?
community acquired
health-care associated
hospital acquired (develops after 48 hours from time of admit)
ventilator associated
Risk factors for developing pneumonia?
conditions that cause obstruction, interfere with lung drainage immunosuppressed smoking prolonged immobility depressed cough reflex, aspiration, dysphagia NPO, placement of tubes supine position antibiotic therapy in critically ill alcohol intox general anesthesia advanced age poor infection control practices by HCP
Nursing assessment for a pt with suspected pneumonia should include…?
VS, POX, ABG
secretions: color, thickness
cough: productive?
tachypnea, SOB
auscultate all lobes, note changes in air exchange or chest excursion
changes in MS: fatigue, edema, dehydration, concomitant HF
NANDA for pneumonia?
ineffective airway clearance activity intolerance risk for FVD imbalanced nutrition knowledge deficit
Planning care for pt with pneumonia includes?
improve airway patency increase activity maintain proper fluid volume maintain adequate nutrition pt edu in trx, prevention absence of complications
NI for pt with pneumonia?
O2 with humidificaiton to loosen secretions coughing techniques chest PT position changes, position to promote drainage by gravity IS nutrition, hydration rest activity as tolerated
What should be considered for successful interventions for pneumonia?
dyspnea not present SPO2>95 no adventitious BS clears sputum from airway reports pain control verbalizes causal factors adequate fluid, caloric intake performs ADLS
Diagnostic procedures for pneumonia?
CXR, sputum C&S, gram stain, blood cultures, ABG, CBC with diff., BMP/CMP, bronchoscopty
Compare/contrast viral and bacterial PNA
Viral: nonproductive cough, low grade fever, normal/low WBC, no consolidation, minimal change to XR, less severe, no antib
Bacterial: productive cough, higher fever, elevated WBC, consolidation, infiltrates on XR, more severe, trx antibiotics
Classification of lung cancer?
small cell
non small cell: squamous cell carcinoma, large cell carcinoma, adenocarcinoma, bronchalveolar carcinoma
lung CA RF?
tobacco smoke, secondhand smoke, environmental and occupation exposure, male gender, dietary deficits, respiratory disease: COPD, TB
CM of lung CA?
cough/change in chronic cough– OFTEN THE FIRST SIGN
dyspnea, hemoptysis, chest or shoulder pain, recurring fever, repeated and or unresolved URI, weakness, anorexia, weight loss
DX of lung CA?
CXR, chest CT, bronchoscopy, fine needle biopsy, scans for metastasis: PET, MRI, bone scan, liver ultrasound
nursing management of lung CA?
post op care manage symptoms relieve breathing problems decrease fatigue provide psych support
