Exam 2 Flashcards
with HTN which organs are we most concerned about effects?
brain
heart
kidneys
describe the patho of HTN
vessel remodeling –> arterioles thicken –> blood flow can’t get to organs –> tissues damaged due to lack of O2
what is the most common type of HTN? and what’s the definition?
primary / essential
not caused by existing health problem
modifiable risk factors for HTN
diet, exercise, weight, substance use, stress
non modifiable risk factors for HTN
age, genetics, family hx
what is most common cause of secondary HTN?
kidney disease
what BP measurement indicates malignant hypertensive crisis?
> 200/130-150
!!!
symptoms of hypertensive crisis
HA, blurred vision, uremia, dyspnea, nose bleed
what can happen if hypertensive crisis is not treated?
stroke
kidney failure
heart failure
(the 3 organs we’re mostly concerned with HTN affecting)
priority interventions for hypertensive crisis (3)
- cardiac monitor (12 lead)
- IV access
- administer IV antihypertensives (to SLOWLY reduce BP)
re: JNC8, what should BP be for adults > or = 60
less than 150/90
re: JNC8, what should BP be for adults 30-59?
less than 140/90
re: JNC8, what should BP be for adults 18+ w/CKD or DM?
less than 140/90
re: JNC8, what should BP be for adults 19-29?
based on expert / provider opinion
why is JNC8 scale for BP considered more holistic?
takes a person’s age into account + existing conditions
what about HTN makes “buy in” challenging for tx, meds, lifestyle changes?
usually no symptoms
silent killer
what is priority intervention for pt with HTN?
plan of care adherence –> following drug therapy + lifestyle changes
what’s the overall broad goal of HTN interventions?
lifestyle changes
low sodium, exercise, nutrient dense foods, quit smoking + drinking
what are the parameters for diagnosing orthostatic hypotension?
drop in systolic: 20
OR
drop in diastolic: 10
WITH increase HR: 10%-20%
1. A patient is prescribed a new medication for the treatment of hypertension. While supine, the patient’s blood pressure is 112/70 mmHg and the heart rate is 80 beats/minute. The healthcare provider assesses the patient when the patient changes to a sitting position. Which of the following indicates the patient is experiencing orthostatic hypotension? A) BP 88/62, HR 100 B) BP 98/60, HR 68 C)BP 100/66, HR 90 D)BP 120/84, HR 82
A
systolic drop: 20+ OR diastolic drop: 10+ WITH HR increase of 10-20%
what is angina defined as?
O2 supply not meeting demand –> ischemia –> prolonged leads to cell death
+ anaerobic metabolism –> lactic acid buildup = pain
person admitted to hospital for 1st time chest pain - would you label this stable or unstable angina? why?
CANNOT be called stable; no baseline to compare it to; need further assessment
what is stable angina? when does this cause pain?
stable plaque not moving that’s blocking blood flow - limited amt of blood can get to heart
pain with activity
what type of angina is relieved with nitroglycerin + rest?
chronic stable
when should pt call 911 with chest pain? (4 scenarios)
- when pain isn’t within normal pattern
- NGL isn’t helping
- rest isn’t heping
- pain lasting >15 mins
= this is considered unstable at this point
per Messer: call 911 based on provider’s recommendation for this pt
does chronic stable angina cause permanent damage to heart?
nope - as long as they’re managing it :)
which type of angina causes pain at rest or with exertion (no pattern)?
unstable angina
pt presents to ED with unstable angina. what are your priority interventions? (3)
- 12 lead
- VS
- pain assessment
what is HF?
pump failure + heart cannot work effectively (cannot meet O2 demands of body)
why would anemia be a risk factor for HF?
this person has low RBCs, which means they have a low O2 carrying capacity –> causes heart to work harder
what is most common cause of LEFT sided HF? why?
HTN
Left ventricle must overcome increased vascular resistance + has to constantly work harder –> leads to hypertrophy of LV –> HF
systolic LEFT sided HF is defined as….
left ventricle PUMP failure
systolic LEFT sided HF most commonly caused by what?
HTN
what is normal EF? (amt of blood pushed out of L ventricle)
50-70%
with systolic left sided HF, what would EF be?
<40%
diastolic LEFT sided HF is defined as….
left ventricle doesn’t relax during diastole + can’t fill with as much blood
most common cause of diastolic left sided HF?
aging
what would you see re: EF with diastolic left sided HF?
“preserved EF” - misleading because it can look normal but really, the heart hasn’t filled with as much blood as normal
what 2 things are happening with LEFT sided HF? (broad)
- tissues not getting enough O2 (perfusion)
2. blood backing up into lungs (oxygenation)
what measurement is a great indicator of cardiac output?
urinary output
kidneys take the hit first if CO is decreased. if they’re not being perfused, body isn’t producing urine
s+s of left sided HF
- dyspnea
- breathlessness
- pulmonary congestion
- oliguria
- confusion
- weakness
- fatigue
= perfusion + oxygenation problems
RIGHT sided HF most commonly caused by what?
left sided HF (LHF increases pulmonary pressure + causes R ventricle to work harder / hypertrophy –> eventually fail
s+s of RIGHT sided HF
- edema
- weight gain
- JVD
what is the most reliable indicator of HF?
a patient’s weight
weight gain in HF that would warrant a call to the provider
1-2 lbs/day
or
3lbs/week
what’s the best way to diagnose HF?
ECG (EF)
EF normal is 50-70%; anything below could be indicative of HF; aside from diastolic left sided as this EF can appear normal)
BNP is also helpful but not best choice
what is BNP? and what’s normal level?
hormone secreted by heart overstretching
<100
what electrolyte imbalance could we see with HF?
hyponatremia (dilutional r/t FVO)
knowing the manifestations of HF, what are the overall broad goals for interventions?
improve cardiac output + improve gas exchange
w/HF patients, what interventions can we use to improve gas exchange? (3)
- elevate HOB (high fowlers)
- O2 therapy (>90%)
- ventilation assistance
what intervention is strongly indicated for acute episodes of HF? why?
ventilation assistance: this increases pressure in thoracic cavity so less blood can come into heart + it opens alveoli
(ex: CPAP, BiPAP)
mnemonic for treating left sided HF
hint: non pharm and pharm
UNLOAD FAST
upright, nitrates, lasix, O2, ACE, dig
fluids (dec), afterload (dec), sodium (dec), test
what are the fluid and sodium restrictions for HF patients?
KNOW THIS
fluid: 2L/day
sodium: 2-3g/day
HF pt presents to ED with rapid onset of dyspnea, crackles in lungs, pink/frothy sputum and complaints of feeling anxious. what are you primary interventions?
- high fowlers
2. O2 therapy
what is the best way we can educate pts to monitor for disease progression of HF?
rapid weight gain
anemia is defined as what? (broad)
not enough RBCs to carry adequate O2 to tissues
2 ways to diagnosis anemia
- reticulocyte count: # of “baby” RBCs (0.5-2%)
2. mean corpuscle volume (MCV): size of RBC (80-95)
low number of reticulocytes =
production problem
high number of reticulocytes =
destruction problem (hemolytic)
what is normal MCV?
80-95
3 different types of anemia r/t decreased RBC production
- normocytic
- microcytic
- macrocytic
macrocytic anemia is an issue with what?
DNA synthesis (B12 or folic acid deficiency anemia)
microcyctic anemia is an issue with what?
hemoglobin issue (iron deficiency anemia)
risk factors for anemia
- blood loss
- malabsorption
- GI bleed
- age
- immune issue (SCD)
- bone marrow suppression
s+s of anemia
- pallor
- jaundice (RBCs breaking down - only with hemolytic)
- fatigue
- dysrhythmias
- dizziness
- angina
what is the most common anemia?
iron deficiency
what is normal reticulocyte?
0.5-2%
mouth fissures are associated with which type of anemia?
iron deficiency anemia
interventions (3) for iron deficiency anemia
- diet changes
- supplements
- IV iron infusion
what are the macrocytic anemias?
B12 + folic acid deficiency anemias
common cause of folic acid deficiency
ETOH use
common cause of B12 deficiency anemia
pernicious anemia: lacking intrinsic factor to absorb B12
name the unique symptom of macrocytic anemias
name unique symptom of specifically B12 deficiency anemia
macrocytic: glossitis
B12 deficiency: paresthesia
what happens with the hemoglobin in Sickle Cell Disease?
the normal HgbA undergoes a mutation on one beta chain –> HgbS
this mutated Hgb is sensitive to low O2 environments + loses its structure
with SCD, what happens to the mutated Hgb in low O2 environments?
loses its structure –> sickles –> clumps together –> creates occlusion in vascular system –> exacerbates low O2 environment –> more RBCs sickle
vicious cycle
describe what As and ss mean with SCD inheritence
As = carrier w/mild symptoms
ss = have disease
conditions that can cause sickling
- low O2 environments
- high altitudes
- stress
- extreme temperatures
- exercise
- pregnancy
- dehydration
- infection
assessment of pt with SCD
think of what’s happening in the body - tissues not being perfused + there’s an occlusion
- PAIN
- pallor
- fatigue
- LE ulcers
- joint pain
- diminished pulses
- tachycardia
major complication of SCD + what can it lead to?
Sickle cell CRISIS –> multisystem organ failure
tissue death r/t chronic hypoxia
what is most common cause of death with SCD patients?
acute chest syndrome
re: SCD, what is their “new normal” for hematocrit levels?
* KNOW THIS*
20-30%
what values for bilirubin, reticulocytes + WBCs would you expect to see with SCD?
bilirubin: high (RBCs breaking down)
reticulocytes: high (destruction of RBCs)
WBCs: high (inflammatory response)
primary interventions (3) with SCD
- O2 if hypoxic
- pain management
- hydration - to “washout” occlusion (ex: D5 1/2 NS)
not in order… don’t stress, friends
most commonly given blood product? and at what Hgb value should we give this?
PRBCs
Hgb <7
what blood product would we expect to give to patient with previous reaction to blood products or allergy history?
washed PRBCs
what blood product would we give for active bleed and <50,000 platelet count or only <20,000 platelet count?
platelets ◡̈
hi you!
you’re doing such a good job ◡̈
hello future nurse
keep it up! ◡̈
what blood type is the universal donor?
universal recipient?
donor: O-
recipient: AB+
what is your role as a nurse for blood product administration?
- verify order
- verify consent
- recent type + cross
- appropriate IV access (18-20g)
- get blood + start within 15 minutes
- identify pt + compare with blood product
- verify w/2nd nurse or barcode system
- administer all within 4 hours
- stay with patient at bedside for 1st 15 minutes
- frequent VS checks + monitoring
re: blood transfusions, what adjustments do we need to make between an 18 gauge needle vs a 20 gauge needle?
run slower with 20g b/c of hemolysis risk
what is most common transfusion rxn?
acute non-hemolytic febrile
if you suspect an infusion reaction, what are your steps as a nurse? (8)
KNOW THIS
- STOP transfusion!
- remove tubing
- notify charge + activate rapid response
- flush IV unless only access
- O2 therapy
- benadryl + tylenol
- assess pt
- notify provider
peripheral arterial disease is often r/t what?
atherosclerosis
assessment findings of PAD
- pain
- diminished pulses
- pallor
- cool extremities
- hair loss
- thickened toenails
- ulcers
- dependent rubor
describe what ulcers would look like with PAD
round, distinct edges
usually on foot or toes
describe what dependent rubor is and what type of PVD you’d find this in
Peripheral Arterial Disease
pallor when legs are elevated + turn red when feet are danging
how can we diagnose PAD?
ankle-brachial index: BP of both, should be 1:1 ratio (any less than that = PAD)
interventions for PAD
- exercise
- legs in dependent position /\
- heat to open things up ( only warm socks!! )
- fluids
- NOT HEATING PADS OR HOT WATER OR COLD**
a patient has undergone a surgical vein bypass as an intervention for peripheral arterial disease. in the post op area, patient complains of throbbing pain in affected extremity. what should you do?
reassure patient this is a normal sign after vein bypass for PAD. this pain is reperfusion pain and it will improve.
your patient is in the postoperative area following a vein bypass for peripheral arterial disease. what complaint by your patient should you recognize as a medical emergency?
A. “The leg they did surgery on is throbbing!”
B. “I feel pretty nauseous right now.”
C. “Can I have a snack?”
D. “The pain in my leg is really aching and it’s not stopping!”
D - this could indicate a graft occlusion and is a medical emergency. pain turns to continuous severe aching. throbbing pain is normal and signals reperfusion of the extremity.
what are the 6 P’s of an acute arterial occlusion?
- poikilotherma
- pulselessness
- paresthesia
- paralysis
- pain
- pallor
SUDDEN ONSET
what is an acute arterial occlusion? and what is most common cause?
embolism traveling and lodging in artery
a fib most common cause
What are the 3 types of peripheral venous disease?
- venous insufficiency
- venous thromboembolism
- varicose veins
describe venous insufficiency
veins unable to get blood back to heart
–> pools in extremities
assessment findings of venous insufficiency
- skin discoloration (stasis dermatisis)
- ulcers
- edema
- thickened skin
interventions for venous insufficiency
- elevate legs \/ (20 mins 4-5x/day)
- compression devices
what is a venous thromboembolism?
blood clot in vein b/c of pooling of blood
where are venous thromboembolisms most likely to occur?
deep veins + lower extremities
a DVT is associated with a risk of what complication?
PE!!!
3 key* assessment findings of DVT
- unilateral redness
- swelling
- warmth
*pain is a MAYBE
interventions for DVT
(think risks + ABCs)
- assess respiratory status (monitoring for PE)
- anticoags
- elevate extremities
- ambulation
- compression socks
- DON’T MASSAGE*`
describe what varicose veins are
protruding veins that are dark + twisted
varicose veins are r/t what scenarios?
prolonged standing + heavy lifting
oh hi, it’s us
what is the normal Hgb range for male + female? (per Messer)
11-17
s+s of varicose veings
- feeling of fullness
- itching
- edema
what is parkinson’s?
progressive, neurodegenerative disorder of LOW DOPAMINE
what are the 4 cardinal s+s of parkinson’s
- tremors
- muscle rigidity
- bradykinesia/akinesia
- postural instability
what area of the brain is parkinson’s affecting?
substantia nigra –> decreased dopamine
parkinson’s also has an effect on what other area of the body causing irreversible damage?
ANS
(reduced sympathetic effect on heart + vessels because of decreased dopamine (SNS NT) and increase in acetylcholine (PsNS NT))
s+s of parkinson’s
- resting tremor
- handwriting changes
- slurred speech
- drooling
- freezing
- rigidity
- facial expression changes
- personality changes
- sleep disturbances
- parasympathetic symptoms
what is TOP PRIORITY for pt with parkinson’s (think ABC)
protect airway
aside from maintaining an airway, what’s the other priority for parkinson’s patients?
FALL RISK
how do we diagnose for parkinson’s?
rule out other causes; b/c no definitive test
main intervention goal for pt with parkinson’s
optimize independence
what is a seizure?
rapid, uncontrolled firing of neurons
epilepsy is defined as ……
> 2 seizures
epilepsy can be caused by what?
imbalance of NTs
+
abnormal neuron activity
what are the 3 types of seizures?
partial (focal) + generalized (both hemispheres) + unidentified
what are the 3 types of generalized seizures? describe them
- tonic-clonic
- myoclonic
- atonic
describe a tonic-clonic seizure
muscle rigidity then jerking
2-5 mins
loss of consciousness
describe a myoclonic seizure
jerking of extremities
no loss of consciousness
describe an atonic seizure
sudden loss of muscle tone; drops to ground
what is priority after an atonic seizure occurs?
assess patient for injuries (they’ve had a sudden loss of muscle tone and could have fallen/hit their head)
re: a complex partial seizure, how is LOC affected?
impaired consciousness
re: a simple partial seizure, how is LOC affected?
NO LOSS of consciousness
re: a complex partial seizure, what might you see with the patient?
- staring into space
- can’t follow commands
- automatism (lip smacking)
what classification of seizure is a pre seizure aura?
simple partial seizure
unilateral movement, weird feelings
if a patient is on seizure precautions, how should you have the room prepared/set up? (5)
- airway kit
- suction
- IV access
- O2
- bed lowered + locked
if a person starts having a seizure, what’s your role?
- turn on side
- protect their head
- remove harmful objects
- stay with them and record seizure activity
if a patient is having a seizure for > 5 minutes, what do you do?
meds + airway
status epilepticus is defined as what?
seizure >5 mins
what 2 complications are you worried about with status epilepticus?
hypoglycemia + hypoxia
what are your priority interventions with status epilepticus?
- AIRWAY
- lorazepam
- dilantin
what is alzheimer’s?
a progressive loss of brain function
+
impaired cognition
alzheimer’s is associated with a low level of what? + high level of what?
LOW acetyltransferase
high beta amyloid
definitive diagnosis for alzheimer’s
with autopsy ONLY
tau tangles + beta amyloid plaques
alzheimer’s disease begins with what ….
mild memory loss (losing keys, forgetting where you put something)
death with alzheimer’s disease is commonly related to what?
immobility (PNA)
what is agnosia? (r/t alzheimer’s)
can’t identify known objects + recall how to use them (ie: pencil)
what is vitally important when caring for alzheimer’s patients?
structure
consistency
removing environmental simulation (but keep overall stimulation balanced for them)
what is a TIA?
a brief interruption of blood flow to brain that causes neuro dysfunction
warning sign for CVA
symptoms with TIA usually resolve when?
30-60 mins; can last 24 hours
mnemonic to remember s+s of stroke
BEFAST
balance, eyes, face, arms, speech, TIME
what is aphasia?
problems with comprehension + saying the wrong words
what is dysarthria?
slurred speech
assessment tool for TIA to determine if patient should be admitted to hospital
ABCD
Age: >60
BP: >140/90
Clinical features: unilateral weakness = increased CVA risk
Duration of symptoms: longer = increased CVA risk
what is a CVA?
interruption in brain perfusion –> CELL DEATH
what are the main 2 types of CVAs?
ischemic (blockage) + hemorrhagic (bleed)
what are the 2 types of ischemic strokes?
thrombotic + embolic
which type of ischemic stroke can cause a hemorrhagic stroke? why?
embolic stroke - because usually these emboli travel to smaller vessels in brain and the pressure causes the vessel to burst –> bleed
what are the 2 types of hemorrhagic strokes?
intracerebral + subarachnoid
both are severe + sudden onset
which type of stroke is often r/t uncontrolled HTN?
intracerebral hemorrhagic
which type of stroke is associated with the common complaint: “WORST HEADACHE OF MY LIFE!!!”
subarachnoid hemorrhagic stroke
which type of hemorrhagic stroke is more common?
subarachnoid hemorrhagic stroke
what is agnosia?
can’t recognize well known object or use correctly (ie: pencil)
what is apraxia?
can’t perform previous learned skill (motor or speech)
re: CVAs, how are the stroke locations related to the manifestations?
effects are r/t location
s+s manifest on opposite side of body
(R sided CVA = L sided weakness)
R hemisphere stroke s+s
L sided hemiparesis/plegia
impaired proprioception
personality changes
impulsiveness / poor judgement
UNAWARE
L hemisphere stroke s+s
R sided hemiparesis/plegia
speech + language issues (agraphia + alexia)
can’t do math problems
impaired logic
cautious
depressed
this complication of CVA most commonly occurs within 72 hours of onset of CVA
increased ICP (secondary to edema)
what posturing would we see with increased ICP?
decorticate (arms to core)
decerebrate (arms by side)
what is early sign of increased ICP?
decreased LOC
what is late sign of increased ICP?
pupil constriction
re: complications of CVA, when would you likely see a seizure occur?
within 24 hrs (r/t ICP)
re: increased ICP + cushing’s triad, what are the hallmark signs?
HTN, widening pulse pressure, bradycardia
cerebral vasospams are most common with which type of stroke? and when is higher occurrence (time frame)?
subarachnoid hemorrhage
4-14 days
re: CVA complications, what is one you can think of r/t airway?
PNA (b/c of dysphagia, aspiration, immobility)
what is protocol for ASA + tPa use?
no ASA within 24 hours of tPa!!!!!!
what is most common risk factor for stroke?
HTN
for prevention of CVA, where would we like to keep patients with Diabetes at w/blood glucose?
100-180
which stroke center has more resources? (primary or secondary)
secondary
primary only has stroke team + IV thrombolytics
when caring for patient with change in neurological function, what should you aim to do?
RULE OUT OTHER CAUSES
blood glucose changes, hypoxia, UTI, delirium, etc
what is the NIHSS? what score determines a patient is NOT a candidate for tPa?
assessment tool to measure stroke-related neurological impairments
> 25 = not candidate for tPa
what is our 1st line diagnostic for CVA?
CT scan (determines ischemic vs hemorrhagic; negative hemorrhagic –> ischemic)
for which type of stroke should we use IV thrombolytics? what is our time frame for administration?
ISCHEMIC ONLY!!!!
within 4.5 hours of symptom onset
Who is ineligible for tPa therapy?
>80 yrs >25 on NIHSS score stroke involves 1/3 of brain hx of stroke AND diabetes (must have both) active bleeding
how should you dress a stroke survivor?
dress WEAK 1st
take off strong 1st
(to avoid damaging the affected extremity more through awkward movements)
what side of patient should you walk on with CVA survivor?
nurse walk on UNAFFECTED side
+ pt hold cane on on UNAFFECTED side
