Final Flashcards
Nursing Process:
A-assess- gather info about the pts condition
4Ps- pain, personal needs, position, possessions
D- diagnose (analyze)- identify pts problems, causes, symptoms
P-plan- set goals of care and desires outcomes and identify appropriate nursing actions
ABCs, safety, maslow
I- implement- perform the nursing actions identified in planning
bases on clinical judgment and knowledge
types of interventions: nurse initiated, HCP initiated, collaborative
E- evaluate- determine if goals and expected outcomes are achieved
Exogenous
Outside the body
Ex: C-Diff, UTI
Endogenous
Overgrowth of Flora
Ex) Candida (yeast), Thrush
Iatrogenic
HAI from health care staff
Procedures, breaking sterile field, poor hand hygiene
Hypertonic
-Get rid of excess volume,
Before fluids given S/S: Hyponatremia
Fluids given: 3% NS, D10 w/ NS,
After fluids given Monitor: Pulmonary Edema, elevated BP, lungs sounds (crackles), hypernatremia,
Isotonic
Replacement
Dehydration, Nausea, Vomiting
Fluids given: 0.9% NS, Lactaded ringers (ER and OR)
Hypotonic
Before fluids: Hypernatremia
Fluids given: D5 in water, 0.45% NS
Hypovolemia
Na+ and H20 loss
Causes: fever, low fluid intake, burns (intravascular to interstitial), hemorrhage
Assess: thirst, cold and clammy, decrease skin turgor, cap refill >3 sec, concentrated urine, decrease urine output, weight loss, elevated Hr & RR, elevated BUN, decreased GFR, increase sodium, weak pulse.
Hypervolemia
Na+ and H20 Gain
Causes: excess fluid intake, abnormal fluid retention (HF & Kidney disease), excess sodium, interstitial to intravascular.
Assess: Edema peripheral & pulmonary, JVD, crackles, high BP, bounding pulse, weight gain, decreased BUN, elevated BNP, excess urination, clear urine, daily weight, I/O,
Hyponatremia
<135
Assess: Neuro- headache, confusion, irritability, seizures, nausea, vomiting, weakness, abdominal cramps (Hyperactive bowls), cold and clammy, hypotension.
Implementation: 3% NS, D10 w/ NS, 0.9% NS, monitor sodium, strict I/O
Causes: Burns, Diuretics, N/V/D, low sodium intake
Hypernatremia
> 145
Assess: altered mental status, Neuro -twitching, confusion, seizures, thirst, fatigue, tired, restlessness, coma.
Implementation: 0.45% NS, D5 in H20, Monitor sodium
Causes: Hypertonic fluids, dehydration, heat stroke, burns, osmotic diuretic, fever.
Hypokalemia
<3.5
Assess: changes in cardiac (PVC), brady, irregular HR, weakness, fatigue.
Implementation: Foods high in potassium, K+ IV infusion, EKG, Vitals, urine output.
Causes: Diuretics, low K+ intake, insulin, N/V/D
Hyperkalemia
> 5.0
Assess: Cardiac arrhythmias, peaked T-waves, cardiac arrest.
Implementation: Insulin w/ D50, EKG, >7.0 start dialysis, diuretics, kayexalate- K+ exits in stool need good GI.
Causes: Renal failure, high K+ intake, Ace inhibitors -pril
Prerenal
Above Kidneys- Heart/Circulation
Causes:
- decreased cardiac output
- Severe dehydration
- HF
- deceases renovascular blood flow
- emboli, thrombosis (blood clot)
- Hemmhorage
- Hypovolemia
Intrarenal
Direct kidney injury
Causes:
- NSAIDs
- Ace Inhibitors
- acute tubular necrosis (tissue in kidney dying)
- antibiotics (aminoglycosides)
- acute pylelonephritis (bacterial)
- Epstein-Barr (viral)
- Candidiasis (fungal)
- chemical exposure
- Kidney Injury (crush injury)
- hemolytic transfusion reactions
Postrenal
-Bladder/obstruction
Causes:
- BPH
- Caliculi formation (kidney stones)
- back/pelvis trauma
- prostate cancer
Cranial Nerves
PERRLA
Swallow
PERRLA: 3, 4, 6/ III, IV, VI
Swallow: 9 &10/ IX, X
Oliguric
Assess: decreased urine output, fluid overload, JVD, crackles, high BP, bounding pulse, edema, <400mL/day, last 1-7 after injury.
Labs: hyponatremia (dilution) , high K+, elevated hydrogen, low bigarb, high Bun and Creat, low GFR.
Restrict fluids
Diuretic
Assess: Extreme urination, sudden increase in urination, true hyponatremia, and hypokalemia, dehydration, notify provider,
Recovery
Assess: GFR increases, BUN and CREAT decrease, major improvements in first few weeks, longer than 12 mos is considered early stages of chronic kidney failure
4 Reasons to start Dialysis
- BUN over 120
- K+ over 7
- cerebral changes due to hyponatremia
- severe metabolic acidosis
Pneumonia
Assess:
- cough, fever, chills
- fine or course crackles
- green/yellow/rust colored sputum
- pleuretic chest pain
- tachycardia
- SOB
- Dyspnea
- Tachypnea
- Altered mental status (eldery)
- elevated HR
Implementations
- incentive spirometry
- deep breathing
- early ambulation
- CXR
- Elevated WBC
- blood and sputum culture
- give lots a fluid to break up the sputum
- corticoid steroids
- bronchodilators
- Antibiotics (after sputum culture)
- Nasal canula 1-6
- Humidity >4
- Small frequent high protein meals
- antipyretics (tylenol)
COPD
-Air gets trapped in lungs, pursed lips to breath with air already in their lungs
Assess:
- Dyspnea
- SOB
- Chronic cough
- weight loss
- Finger clubbing
- trouble sleeping
- hx smoking
- barrel chest
- Wheezing
- NO fever/chills
- early dyspnea on exertion
- use of accessory muscles
- fatigue
Diagnostics:
- spirometry test
- fEV/FVC <70% (measure of forced volume lower the sicker)
- Chest X-Ray
- 6 min walk test
Causes of exacerbation:
- cold, flu
- pneumonia
Implementations:
- pursed lips and huff cough
- Smoking cessation
- bronchodilators
- 02 therapy
- corticosteroids
- antibiotics
- no cure for COPD just control of symptoms
- small frequent high calorie soft diet, rest 30 min before, give bronchodilator 1 hr before and after before meals
- start oxygen low and slowly titrate up
- Oxygen 88-90% (respiratory drive goes down and they become dependent)
Fine Crackles
Fluid overload Pneumonia Clear w/cough Incentive spirometer Left sided HF Pulmonary edema Hear at the end of inhalation Diuretics
Course Crackles
Excess fluid Pneumonia Do no clear w/ cough Sounds like bubbles popping Hear upon inspiration and expiration COPD Diuretics Long low pitched
Wheezes
COPD Pneumonia Asthma High fowler's Tripod High pitched and continuous
Left sided HF
Assess:
- crackles
- decreased
- dyspnea
- Increase in heart rate
- S3 S4
- Neuro: mental status, restlessness, confusion
- shallow respirations
- fast respiratory rate
- dry hacking cough
- frothy, pink tinged sputum
- nocturia (supine position when sleeping at night)
- orthopnea (difficulty breathing)
- HTN
- lower cardiac output
- how many pillows they use when sleeping at night (connor says 4 pillows)
Causes:
- HTN** (most common)
- CAD**
- MI
- PAD (pulmonary artery disease)
- DM
- tobacco use, older age
- higher incidence in males
Diagnostics
- Chest x-ray
- Echocardiogram
- EKG
- Exercise stress test
- heart catheterization
- 6 minute walk test
- BNP (brain natriuretic peptide) > 100
Interventions
- circulatory assist devices
- sodium restricted diet (< 1500 mg)
- semi-fowler’s
- beta blockers
- weight at same day/time/naked
- I&Os
- Digoxin
Right sided HF
Assess:
- JVD
- dependent edema
- weight gain
- abdominal distention
- increased heart rate, murmurs
- nausea, anorexia
- RUQ pain (liver pain)
- hepatomegaly (enlarged liver)
- fatigue
Causes:
- Left sided HF
- COPD
- pulmonary
- right ventricular MI
Diagnostics
- Chest x-ray
- Echocardiogram
- EKG
- Exercise stress test
- heart catheterization
- 6 minute walk test
- BNP (brain natriuretic peptide) > 100
Interventions
- circulatory assist devices
- sodium restricted diet (< 1500 mg)
- semi-fowler’s
- beta blockers
- weight at same day/time/naked
- I&Os
- Digoxin
- Diuretics
Acute Decompensated HF
Assess
- mild increased RR
- decrease in PaO2
- Decreased cardiac output
- manifest pulmonary edema (L and R combined)
- edema
- dyspnea
- JVD
- sudden onset of HF symptoms
- S3S4
- crackles and wheezes
- Elevated BP initially than decreased BP as worsens
Causes:
- Left-sided HF
- Uncontrolled HF
Interventions:
- Urinary output
- High-fowlers
- Positive pressure ventilation
- Oxygen therapy
- I/O
- Diuretics
- Vasodilators (HR up & BP down)
- Morphine (lower dose than what used for pain)
- Sodium restriction
EKG
PR: 0.12-0.20 sec
QRS: 0.06-0.11
QT: 0.36-0.44
P Wave: impulse across the atria
PR Interval: Beginning of P wave to beginning of QRS
QRS Complex: Impulse through bundle branches & into Purkinje fibers, ventricular depolarization
ST Segment: From end of QRS to beginning of T wave
T Wave: ventricular depolarization, rounded, larger than P wave
QR interval: Measures from beginning of QRS to end of the T wave.
7 steps to Rhythm Interpretation
- Identify P wave, QRS complex, & T wave.
- Is there a P for every QRS?
- Are all the complexes consistent? - Determine if rhythm is regular or irregular?
- What is the rate?
- 6 second method: count number of complexes and multiply by 10= HR in bpm
- Can be used for regular and irregular rhythms - Measure the PR interval.
- Normal PR 0.12-0.20 seconds (3-5 small boxes) - Measure the QRS complex.
- Normal QRS is less than 0.12 seconds (less than 3 small boxes) - Measure the QT interval
- Normal QT is 0.36 – 0.44 seconds - Name the rhythm.
- Where is the impulse generated? Sinus, Atrial, Junctional, Ventricular
- What is the rate? Normal, Brady-, Accelerated, Tachy-
- Are there any additional abnormal characteristics noted?
Hypertension
Hepatitis
Asess:
- fever
- vomiting
- clay colored stools
- jaundice
- dark colored urine
- pruritus
- spider angiomas
- fatigue
- anorexia
- malaise
- decreased sense of taste of smell
- hepatomegaly
- splenomegaly
- asterixis (loss of motor control)
- High bilirubin
- Low platelets
- Bleeding abnormalities
interventions:
- Hep C- antiviral pegases
- Avoid alcohol, acetaminophen (tylenol)
- rest
- High calorie, high crab, moderate protein and fat
- Vitamin supplements (E)
AST
5-40
ALT
7-56
Bilirubin
<1
Platelets
150,000-400,000
Pruritus (jaundice)
Interventions:
- Trim nails and scratch w/ knuckles
- antihistamines
- oatmeal bath
- lotion
- soft, old linens
- atarax (itching)
- control temp
- baking soda
Cirrhosis
Assess:
- jaundice
- edema
- ascites -causes SOB
- Fever
- portal hypertension
- cachexia
- petechiae
- ecchymoses
- spider angiomas
- Shallow, rapid respirations
Labs:
- ALT/AST elevated
- decreased albumin
- high bilirubin
- high ammonia
Interventions:
- albumin
- diuretics
- Diuretics (spiralactolone)
- nonselective beta blockers
- parasynthesis (ascites) -pee before, high fowler, girth, hypovolemia, electrolyte imbalances.
- Avoid alcohol and NSAIDS
- elevated ammonia - mental status change
- lactulose
- fluid restriction
- Liver biopsy
Nutrition:
- High carb
- high calorie
- moderate fat
- low protein if encephalopathy (high ammonia)
Airborne Precautions
Measles, tuberculosis, varicella- private room, negative airflow (6-12)- I wear N95, pt wears mask outside of room, full face if splashing or spraying possible
Mild Dementia
short term memory impairment (especially for new learning)
Moderate Dementia
lack of judgment and wandering, has more trouble organizing, planning, and following directions
Severe Dementia
unable to perform self-care activities
