EXAM 1 REVIEW MAIN POINTS Flashcards
1
Q
fluid volume deficit (hypovolemia)
onset
A
rapid
2
Q
fluid volume deficit (hypovolemia)
severity
A
depends on degree of fluid loss
3
Q
fluid volume deficit (hypovolemia)
clinical cues
first signs
A
increased pulse
increased respiratory
4
Q
fluid volume deficit (hypovolemia)
clinical cues
late sign
A
decreased BP
5
Q
fluid volume deficit (hypovolemia)
nursing management
A
monitor
- VS
- mental status
- I&O
- daily weights
6
Q
fluid volume deficit (hypovolemia)
nursing management
cautions
A
be careful when giving fluids to not push patient into fluid volume overload so make sure to monitor
7
Q
fluid volume deficit (hypovolemia)
nursing management
monitor for fluid volume overload
A
lung sounds
respiratory rate
heart rate
pulse ox
8
Q
fluid volume deficit (hypovolemia)
nursing management
maintain what priority
A
patent airway
9
Q
fluid volume excess (hypervolemia)
nursing management
A
monitor
- VS
- mental status
- I&O
- daily weights
10
Q
fluid volume excess (hypervolemia)
nursing management
cautions
A
could go too far
diuresis/restrict too much
11
Q
sodium normal
A
135-145
12
Q
sodium main _______ cation
A
ECF
13
Q
a gain or loss in sodium usually equals
A
gain or loss in water
14
Q
hyponatremia
number
A
less than 135
15
Q
hyponatremia
clinical effects
A
neurological changes
16
Q
hypernatremia
number
A
greater than 145
17
Q
hypernatremia
clinical effects
A
neurological symptoms
18
Q
potassium number
A
3.5-5
19
Q
hypokalemia
number
A
less than 3.5
20
Q
hypokalemia
causes
A
GI losses, medications, alterations of acid base balance, alkalosis, hyperaldosteronism, poor diet intake, starvation, diuretics, dig tox
21
Q
hypokalemia
manifestations
A
dysrhythmias
22
Q
hypokalemia
medical management
A
administer K over an hour IVPB
NEVER IV PUSH
23
Q
hypokalemia
nursing management
A
monitor ECG and ABG
IV assessment
24
Q
hypokalemia
clinical profile
GI
A
anorexia, N/V, decreased bowel movement, abdominal distension
25
hypokalemia
clinical profile
CV
flat T wave, dysrhythmias
26
LOW POTASSIUM
LOW T WAVES
27
hyperkalemia
number
larger than 5
28
hyperkalemia
causes
impaired renal function, metabolic acidosis, crush injury, burns, stored PRBC, ACE and NSAIDS
29
hyperkalemia
manifestations
cardiac changes and dysthymia's
30
hyperkalemia
medical management
monitor ECG
31
hyperkalemia
clinical profile
CV
tachy to brady to asystole
peaked T wave
wide QRS to sine wave
32
HIGH POTASSIUM
HIGH T WAVE
33
hyperkalemia
clinical profile
muscle
muscle weakness
34
hyperkalemia
therapy
shifter:
- NaHCO3
- insulin
- glucose
neutralizer:
- calcium
remover:
- diuretic
- kayexolate
- dialysis
35
hypocalcemia
number
less than 8.6
36
hypocalcemia
causes
alkalosis
37
hypocalcemia
manifesations
hyperactive DTR, trousseau, chovostek, seizures, abnormal clotting, increase neuromuscular excitability
38
hypocalcemia
clinical profile
CNS
anxiety, irritability, seizures
39
hypocalcemia
clinical profile
pulmonary
cardiopulmonary arrest
40
hypocalcemia
nursing management
severe hypocal is life threatening
41
hypercalcemia
number
larger than 10.2
42
hypercalcemia
manifestations
muscle weakness, ECG changes, dysrhythmias, decrease in neuromuscular excitability
43
hypercalcemia
clinical profile
CNS
depression
44
hypercalcemia
clinical profile
CV
heart block
arrthymias
arrest
45
hypercalcemia
clinical profile
pulmonary
bronchospasm
46
hypomagnesium
number
less than 1.3
47
hypomagnesium
mainfesations
neuromuscular excitability, ECG changes
48
hypomagnesium
nursing management
often accompanied by hypocalcemia
49
hypermagnesium
number
larger than 2.3
50
hypermagnesium
manifestations
lower BP, depressed respirations, ECG changes, decreased neuromuscular excitability
51
hypotonic
avoid
brain injuries
52
IV assessment of allergies
latex and medications
53
infiltration
how to avoid
ongoing close monitoring
54
infiltration
what to do
IV stopped
catheter disoncontinoued
55
infiltration
new site
started proximal to infiltration
56
extravasation
medications
chemo, vasopressors, potassium, calcium
57
extravasation
initial manifestations
pain, burning, redness
58
extravasation
later manifesations
blister, inflammation, necrosis
59
extravasation
increase risk patients
elderly, comatose, anesthesia, diabetes, peripheral vascular, cardiovascular
60
extravasation
what to do
stop infusion
notify MD
leave IV in
61
extravasation
new site
new extremity
62
phlebitis
types
chemical
mechanical
bacterial
63
phlebitis
symptoms
redness, swelling, pain, tenderness at site and along vein
64
phlebitis
what to do for new IV
discontinuous IV
restart in another site
65
phlebitis
treatment
warm moist compress to affected site
66
phlebitis
what is key
prevention
67
clotting or obstruction
what to do
discontinue
new site
68
clotting or obstruction
what not to do
do not raise infusion site or solution container
do not aspirate clot
69
cough is a symptom of
bronchospasm
70
chest pain
bronchospasm, PE
71
wheezing
PE
72
crackles
fluid volume overload, PE
73
hemoptysis
PE, bronchospasm, fluid volume overload
74
FVC
forced vital capacity
max forced expiratory
(unable to assess on COPD)
75
FEV1
forced expiratory volume
volume of air exhaled in 1 second
if unable to do=airway obstruction
76
arterial blood gas
accurate measurement of oxygen in blood
77
sputum is obtained
in the morning before the patient ate or drank
78
imaging studies
assess for what prior
allergies to contrast, shellfish
monitor BUN and creatinine
79
MRI
remove metal
80
broncoscopy
postprocedure monitoring
81
oxygen toxicity main symptom
substernal discomfort
82
venturi mask
most reliable and accurate/precise
83
care of patient with trache
gold standard
bilateral breath sounds followed by xray
84
care of patient with trache
monitor/check cuff pressure every
6-8 hours
85
prevention of complications in postop
improving gas exchange
improving airway clearance
relieving pain
promoting mobility and shoulder exercises
maintain fluid and nutrition
86
most common cause of upper respiratory tract disorders are
viruses
87
epistaxis
treatment
topical vasoconstrictors
packing of nasal cavity
88
laryngeal obstruction
use of ACEI
history of NG tube
89
laryngeal cancer
early symptoms
hoarseness, persistent cough, weight loss
90
laryngeal cancer
later symptoms
dysphagia
dyspnea
persistent hoarsness
91
care of patient post op laryngectomy
pre and post op care
self care of airway
methods of communication
pain control medications
nutritional support
92
care of patient post op laryngectomy
nursing assessment
airway patency
montior for hemorrhage and repertory distress
airway obstruction
93
care of patient post op laryngectomy
nursing assessment
prevention of aspiration
elevate head of bead
gastric residual
rehab for swallowing
diet adjustment
94
care of patient post op laryngectomy
disturbed body image
realistic goals
involving client in self care
communication methods
95
allergy
hypersensitive reaction to an allergen initiated by an imununologic mechanisms that is usually mediated by IgE antibodies
96
patients at risk for allergies
peanuts, shellfish, penicillin, sulfa antibiotics, contrast, NSAIDS, stings, latex, ACEI
97
severe allergic reaction/anaphylaxis
abrupt onset
progress to bronchospasm
laryngeal edema
severe dyspnea
cyanosis
hypotension
cardiac arrest
98
allergic reaction
medical and nursing management strategies
treat respiratory problems
o2
intubation and CPR
epi 1:1000 subq
99
atelectasis
prevention
early mobilization
deep breathing
pain meds
incentive spiro
suction
positioning
100
pneumonia
risk factors
long term care
compromised defense mechanisms
immunosupresion
smoking
prolonged immobility
depressed cough reflex
supine position
transmission from healthcare providers
101
pneumonia
manifestations elderly
mental status
fatigue
102
pneumonia
interventions
hydration (2-3L)
humidification
cough and deep breath
provide nutritional enriched foods
103
PPD placed
intradermally forearm
104
PPD
exposure in healthy patient
10mm
105
PPD exposure in immunocompsorimsed
5mm
106
tuberculosis
patient education
follow drug regimen
107
pulmonary emboli
risk factors
venous status
heart disease
trauma
postop/partum
diabetes
COPD
108
pulmonary emboli
preventive
leg exercises
ambulation
SCD
subq heparin
109
pulmonary emboli
emergency
VOMIT
110
pulmonary emboli
anticoagulant therapy
prevent reoccurrence
111
pulmonary emboli
thrombolytic
high risk of bleeding
112
tension pneumothorax
Signs and symptoms
weak and rapid pulse
pallor
JVD
anxiety
assymetrical chest wall movement
shortness of breath
dercreased/abseent breath sounds over lung
trachea deviation
113
COPD
bronchitis
blue bloater
dusky to cyanotic
recurrent cough
increased sputum
hypoxemia
respiratory acidosis
increased H&H
increase RR
dyspnea
Digital clubing
use of accessory musclesC
114
COPD
emphysema
smoking or recurrent inflamations
pink puffer
increased co2 retention, no cyanosis, purse lip breathing, ineffective cough, bronchi collapse on expiration, orthopenic, barrel chest
115
COPD
diagnostic tests
pulmonary function: FEV1
sputum samples
oxygenation assessment
- ABGS: resp acidosis
pulse ox 88-92
116
COPD
treatment strategies
airway management
oxygen therapy
patient education
- smoking
- vaccinations
