Exam #2 Cardiac Flashcards
The client diagnosed with DVT suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced? A. MI B. PNA C. PE D. Pneumothorax
Pulmonary Embolism
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication? A. PTT is 38 B. INR is 5 C. PT is 22 D. ESR is 10
The client’s INR is 5.
The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis? A. D-dimer B. ABG C. CXR D. MRI
D-DIMER
Which nursing intervention should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply.
A. Keep protamine sulfate readily available
B. Avoid applying pressure to the venipuncture site
C. Assess for overt and covert signs of bleeding
D. Avoid invasive procedures and injections
E. Administer stool softeners
A. Keep protamine readily available
C. Assess for overt and covert signs of bleeding
D. Avoid invasive procedures and injections
E. Administer stool softeners.
The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering? A. Coumadin, when INR is 1.9 B. Regular insulin, when BG is 218 C. Heparin, when PT/PTT is 12.9/98 D. CCB, when BP is 112/82
C. Heparin with a PT/PTT is 12.9/98
The client is admitted to the surgery department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax?
A. Bronchovesicular lung sounds and bradypnea
B. Unequal lung expansion and disypnea
C. Frothy, bloody sputum and consolidation
D. Barrel chest and polycythemia
B. Unequal lung expansion and disypnea
Which intervention should the nurse implement for a male client who has a left-sided chest tube for six hours and refuses to take deep breaths because of the pain?
A. Medicate the client and have the client take deep breathes
B. Encourage the client to take shallow breathes to help with the pain
C. Explain deep breathes do not have to be taken at this time
D. Tell the client if he doesn’t take deep breathes he could die
A. Medicate the client and have the client take deep breathes
The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax?
A. A tension pneumothorax develops when an air-filled blew on the surface of the lung ruptures
B. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere
C. The injury allows air into the pleural space but prevents it from escaping from the pleural space
D. A tension pneumothorax results from a puncture of the pleura during a central line placement
C. The injury allows air into the pleural space but prevents it from escaping from the pleural space
The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the HCP is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first?
A. Gather the needed supplies for the procedure
B. Obtain a signed informed consent form
C. Assist the client into a side-lying position
D. Discuss the procedure with the client
A. Gather the needed supplies for the procedure
The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which intervention should the nurse implement when caring for this client? select all that apply.
A. Place the client in the low fowler’s position
B. Assess chest tube drainage tubing frequently
C. maintain strict bedrest for the client
D. Secure a loop of drainage tubing to the sheet
E. Observe the site for subcutaneous emphysema.
B. Asses chest tube drainage frequently
D. Secure a loop of drainage tubing to the sheet (avoid dependent loops that impede drainage or pressure)
E. Observe the site for subcutaneous emphysema.
Which assessment data indicate to the nurse the chest tube inserted 3 days ago, have been effective in treating the client with a hemothorax?
A. Gentle bubbling in the suction compartment
B. No fluctuation (tidaling) in the water-seal compartment
C. The drainage compartment has 250mL of blood
D. The client is able to deep breathe without pain.
B. No fluctuation (tidaling) in water-seal compartment
Pulmonary Embolism (PE):
Is a clot
If DVT/VTE breaks free and travels to pulmonary artery, which triggers VASOCONSTRICTION, and leads to pulmonary HTN
Results in: impaired gas exchange and tissue perfusion, hypoxia, potential death
Pulmonary Embolism (PE): Risk factors:
Immobility, surgery, trauma, CVC (PICC), Hx of thromboembolism, age, smoker, obesity, pregnancy, estrogen therapy
PE evidence based practice and QSEN:
PROM/AROM TCDB and A TED hose and SCDs Avoid constrictive clothes Anticoagulants (heparin and lovenox) Patient and family teaching Smoking cessation Frequent access circulation and perfusion
PE assessment:
Sharp, stabling chest pain on inspiration Anxious, IMPENDING DOOM Altered LOC Tachycardia Diaphoresis- cool, clammy, sweaty Dry, productive cough Low-grade fever JVD Syncope, hypotension
PE labs to assess:
Metabolic panel Troponin BNP D-Dimer Clot studies (INR)
PE imaging to assess:
PULMONARY ANGIOGRAPHY- test of choice- assess kidney function, allergies, use of metformin before contrast
CT-PA
CXR
PE interventions:
Elevate HOB, apply oxygen Activate RRT Reassurance Telemetry and continuous pulse ox IV access Assess cardiac and resp q30 mins Anticoagulants and bleed precaution- heparin and lovenox ANTIDOTE for heparin- protamine sulfate
Heparin: lab test: PTT
Normal range: 20-30 seconds
Therapeutic range: 1.5-2.5 times normal value
Coumadin: lab test: PT/INR
PT: normal value 11-12.5, therapeutic value 1.5-2.0 time the normal value
INR: normal value 0.8-1.1, therapeutic value 2.5-3.0, if recurrent PE 3.5-4.0
PE hypotension drug therapy: Vassopressors:
Nitroprusside
Dopamine
Levophed
Dobutamine (kidney friendly)
Give NS or LR
PE Minimize bleeding
Assess bleeding q2hr
Antidote
Soft bristle toothbrush, electric razor, soft diet, caution with transfers, no injections or rectal medications.
Monitor labs
PE; decrease anxiety:
Oxygen and drug therapy (anti-anxiety agents)
Educate pt and family on self-assessment, monitor lower extremities, bleeding precautions, altered LOC
Thoracic trauma
BACs- breathing, airway, circulation
From car accident, hitting the steering wheel is most common
Pulmonary Contusions
1st see: increased HR, OBS for 24hrs
Caused by rapid deceleration car crash
Is hemorrhage and edema in or between the avioli causing decreased lung movement and impaired gas exchange
Pulmonary contusions: signs and symptoms
Bruising over chest, cough, tachycardia, tachypnea, decreased breath sounds- wheezes and crackles.
Rib fractures
Increased risk for pulmonary contusions, pneumothorax, hemothorax, atelectasis, PNA
S/Sx: pain with movement, splinting on affected side
Fracture of rib 1 and 2, flail chest, or multiple fractures have:
poor prognosis
Decrease pain with analgesics and promote normal ventilation (TCDB)
Flail chest
Fracture of 2 neighboring ribs in 2 or more places
Signs and symptoms: paradoxical chest wall movement, dyspnea, cyanosis, tachycardia, increased work to breath, hypotension
Flail chest: interventions:
Provide oxygen and ventilation as needed (PEEP)- leaves air in lungs to keep from collapsing (counter pressure) ABGs VS and pulse ox Labs Psychosocial support
Pneumothorax
Air enters the pleural space between the parietal and visceral spaces- causes increased chest pressure and lung collapse
Open- outside air, external source
Closed- inside chest, internal source
Pneumothorax: signs and symptoms
Decreased oxygen, decrease breathe sounds on affect side Hyper resonance with percussion Lack of chest wall movement Pleuritic pain Tachypnea Subcutaneous emphysema
Pneumothorax: interventions:
CXR
Chest tube
Pain control pulmonary hygiene
Tension pneumothorax:
Rapid development resulting in air leak or complete collapse of lung caused by blunt force trauma, mechanical ventilation with PEEP, chest tubes, CVC devices
Air enters but doesn’t exist on expiration
Tension Pneumothorax: signs and symptoms
Tracheal deviation, asymmetry of chest, respiratory depression
Absent breath sounds on affected side, JVD, cyanosis
Hypertympanic sounds, hemodynamic instability
Collapsed lung, shift of internal organs away from affected side
Emergency management of tension pneumothorax:
Needle thoracostomy with large bore needle at the 2nd intercostal space, midcavicular on affected side
Chest tube at the 4th intercostal space with water seal drain system
Pain control, pulmonary hygiene, psychosocial
Hemothorax
Bleeding injury to the lung tissue or fractured rib/sternum
Caused by trauma or the heart, great vessels, or intercostal arteries, blunt force trauma or penetrating injury
Hemothorax: signs and symptoms
Decreased breath sounds on affected side
Percussion dull on the affected side
CXR- blood in the pleural space
Focus on removing blood and prevent infection, chest tube, CXR, transfusions and fluid replacement, surgery (thoracotomy), mechanical ventilation
Chest tubes
Drain air, blood, fluids from the pleural space or thoracic cavity- use water seal drainage
Chest tube placement and care:
Place tip of tube in front apex of lung for air
Place tip of tube on side near base of lung for blood/fluids
Air tight dressing
6ft of tubing to allow movement
Water seal drainage system
Water seal drainage system: Pleura-Vac: 3 parts:
Chamber 1: collection chamber- collects draining fluids, assess q 24 hours
Chamber 2: water seal- prevents air from re-entering, keep 2cm water in chamber
Chamber 3: suction regulator- controls suctioning
No bubbling- air is removed or kinked
excessive bubbling- air leak
Flutter valve:
Aka hemilich valve- used for palliative care
Lead placement for cardiac monitor or 5 lead EKG:
White over green
Black over red
Brown in the middle
green is grass is ground!
Lead 2- white is negative and red is positive
Automaticity
Electrical action- ability of the heart cells to fire spontaneously and repetitively
Excitability
Electrical action- cells response to electrical charge
controlled by electrolytes
Conductivity
Electrical action- sends a charge from cell to cell
Contractility
Mechanical action- ability of the heart to contract
P wave-
Depolarization of the atrium (electrical impulse)
PR interval-
Atrial kick (mechanical action)
QRS segment-
Depolarization of the ventricles (electrical impulse)
ST segment-
Contraction of the ventricles (mechanical action)
T wave-
Repolarization
