FINAL EXAM Flashcards
Nursing assessment and possible complications post-op pacemaker placement
● Risks post op: ○ Infection ○ Bleeding/hematoma ○ Dislocated lead ○ Cardiac tamponade ● Will see spikes on the ECG ○ Spikes before the P wave are normal
Understand percutaneous transluminal coronary angioplasty (PTCA) procedure and why it is used.
● minimally invasive procedure that opens blocked coronary arteries to improve blood flow to the heart muscle
Stable vs Unstable angina – assessment and nursing interventions
● Chest pain, indigestion, choking sensation
○ Impending doom
● Can radiate to arms and jaw
○ Stable will go away with rest and Nitro
○ Unstable will most likely need stent (PCI or CABG)
STEMI vs Non-STEMI – assessment and nursing interventions
● STEMI: elevated ST wave
○ Needs to be seen on 2 consecutive leads
○ NEED PCI
● MONA: morphine, oxygen, nitroglycerin, and aspirin
V-Tach and Asystole – what do these rhythms look like and what is the priority nursing action
● unresponsive/no pulse
○ Check patient, call code, begin compressions
● Call a rapid response if they still have a pulse
○ Vtach shock
Mechanical vs Non-mechanical valve replacement – Patient education
● Mechanical: will need anticoagulants for life
● Antibiotics before dental procedures
● Let them know you have an implant- especially for an MRI
○ Immunosuppressants
Clinical manifestations of cardiogenic shock and hypovolemic shock
● Cardiogenic: ○ Hypotension and tachycardia ■ JVD ○ Adventitious lung sounds ■ Need to be in the ICU ○ Vasopressors ● Hypovolemic: ○ Hypotension and tachycardia ■ No fever ○ Pale, cold, weak pulses, no urine output ■ Replace blood and fluid
Cardiomyopathy and heart failure discharge teaching
● Improve CO and peripheral blood flow.
Rest during symptomatic episodes, daily weight, decrease sodium, fluid restriction, alternate rest and activity, avoid strenuous activity, increase activity
. Decrease anxiety and powerlessness.
Sit up with legs down alternate rest and activity
○ Heart healthy diet, med education anticipatory grieving
CABG – priority assessment post op
● Pain management, o2, morphine, bedrest, elevate hob, increase tidal volume, fluid volume status, adequate tissue perfusion, anxiety, monitor for complication, are they confused, look for retroperitoneal bleed, assess insertion site, look for hematoma
CAD risk factors and lipid lab levels (lipid panel) normal vs abnormal
● Total cholesterol <200
ldl bad cholesterol <100
hdl good cholesterol > 40 male >75 female
triglycerides <150
when these labs are high it increases risk for CAD
Blood Transfusion: What are nursing implications for the administration of all blood components, including administration, and complications.
● 1. Verify Dr Order, 2. Obtain consent, 3. Assess IV site and patency, 4. Obtain blood from blood bank, 5 check accuracy of blood label and patient ID, 6. Baseline vs & assessment, 7. Start infusion, 8. 15 minute vs assessment 9. Monitor transfusion reaction
○ Listen to heart and lung for fluid overload: temp goes down w/ blood admin
● Blood administration: only w/ NS, never meds or other fluid thru blood tubing w/ appropriate filter tubing, change tubing after 2 unit
○ Admin w/ in 3 ½ hours, normal rate 100-150 ml/hr, 300 ml infused over 3 hours, amount of blood divided by 3, healthy patient can have 150 ml in 2 hour, special consideration for CHF and kidney no faster than 125 ml/hr
● Transfusion reactions occurs w/in 10-15 mins on 1st 50 cc of blood
○ w/ all reactions stop blood maintain line w/ ns
Plan of care for the patient with Myeloma and Leukemia (including leukemia in general and complication of chemotherapy)
● Multiple Myeloma: Pain management is priority, nsaids and possible opioids, monitor renal function w/ nsaids, educate of activity restrictions, do not fall, watch for hypercalcemia, hydration, infection prevention, wear mask hand hygiene
● Leukemia: Infection prevention, assess for bleeding, prevent bleeding, watch for bleed/infection, address risk for rejected stem cells
Arterial Blood Gas Interpretation
Respiratory
Opposite
Metabolic
Equal
● Respiratory Acidosis: caused by hypoventilation Carbonic acid excess, Retention of CO2 by the lungs
Causes:
· Airway Obstruction
· COPD
· Chest Trauma
· Neuromuscular Disease
· Pulmonary Edema
· Drug Overdose
· Hypoventilation
Respiratory Depression: Anesthesia, increased ICP
● Respiratory Alkalosis: dka, shock, sepsis, diarrhea, salicylate od Carbonic acid deficit, Increased loss of CO2 from the lungs
Causes:
· Anxiety
· High altitudes
· Pregnancy
· Fever
· Hypoxia
· Initial stages of pulmonary emboli
-Hyperventilation
● Metabolic Acidosis: Base bicarbonate deficit, decreased ability of the kidneys to excrete acid or conserve base
Causes:
· Shock
· Sepsis
· Severe Diarrhea
· Renal Failure
· Salicylate OD
-Diabetic Ketoacidosis
● Metabolic Alkalosis: loss of gastric juices Base bicarbonate excess, Decrease or increase in base
Causes:
· Loss of Gastric Juices
· Potassium Wasting Diuretics (Increased loss of H+)
-Overuse of antacids
Airway Management: Identify the nursing care of a patient with an endotracheal tube and a patient with a tracheostomy. Trach care, Suction, Provide ostomy care and/or education (e.g., tracheal, enteral)
● Endotracheal Tube: Passage of an endotracheal tube through the nose or mouth into the trachea.
○ Intubation: Putting the tube in
■ Auscultate for breath sounds bilaterally and observe for symmetric chest movement.
● Get chest x-ray to ensure the tube is in the correct position
■ Administer O2, Secure the tube to the patients face
● Use sterile technique to suction- this is not on schedule it is as needed
■ Reposition Q2H, Provide oral hygiene, Have resuscitation equipment at the bedside.
○ Extubation: Removal of a tube
■ Give heated humidity and oxygen while maintaining patient sitting or in high-fowler’s position
● Monitor respiratory rate, Monitor patient sp02 using a pulse ox
■ Keep patient NPO for a few hours, Provide mouth care
● Educate on cough and deep breathing exercises
● Tracheostomy: Surgical procedure in which an opening is made in the trachea (permanent or temporarily)
■ Administer adequate warmed humidity
■ Maintain cuff pressure at appropriate level
● Suction as needed- keep opening patent, Maintain skin integrity
■ Auscultate lung sounds, Monitor s/s of infection: Temp and WBC count
● Administer O2 and monitor O2 sats
■ Use sterile technique for suction and trach care
● After vitals are stable, place patient in semi-Fowler’s to facilitate ventilation, promote drainage, minimize edema, and prevent strain on suture lines
■ Give analgesia and sedative agents with caution because of the risk of suppressing the cough reflex.
● Use paper and pencil and call light within reach to ensure communication
■ Ensure a patent airway, monitor respiratory status, monitor for complications, alleviate the patient’s apprehension, improve effective communication (White board, call light in pt’s reach)
Mechanical Ventilator: Use the nursing process as a framework for care of patients who are mechanically ventilated assessment.
● Nursing Management:
○ Frequent, comprehensive assessment
■ Respiratory status: breath sounds, respiratory effort, VS, hypoxia (skin color).
■ Skin breakdown
■ Pt elevated 30 degrees or higher
■ Assessment of the ventilator equipment: When an alarm sounds something is wrong.
■ Promoting effective airway clearance: Suction as needed, frequent position changes, increased mobility, CPT
■ Promote mobility
■ Promote coping: Encourage family and patient to share their emotions about the given situation
■ Promote communication: White board, paper pencil, use pictures, body language, call light.
■ Prevent complications: Pneumonia, infection.
Describe the process of weaning the patient from mechanical ventilation. Prevent complication
● Monitor respiratory distress; RR, BP, HR goes up, O2 goes down. Patient removed from the ventilator, then the tube, and then the oxygen.
○ Have manual resuscitation bag at bedside and reintubation equipment
● Suction, deflate the cuff and remove during peak inspiration.
○ Encourage coughing, deep breathing, and IS use.
● Reposition patient to promote mobility of secretions
Thoracic Surgery: Examine the significance of preoperative nursing assessment and patient education for the patient who is going to have thoracic surgery. Potential for Complications from Surgical Procedures and Health Alterations
● Pre-op: Education
○ Expect vent and intubation, is will wake up and may have a chest tube
■ Inform them on (anesthesia and chest tubes), ventilator use, oxygen to promote ventilation, frequent turning, use of IS, diaphragmatic and pursed lip breathing, coughing routine, splint incision, will experience pain and can be given meds.
○ Improve airway clearance: airway cleared before surgery to prevent post op atelectasis.
○ Relieve Anxiety: Listen to the patient
● Post-op:
○ Check incision for drainage/bleeding
■ Pain MANAGEMENT IS PRIORITY
○ They will have a chest tube, monitor the drainage ( 350mL in 1 hour is too much)
■ Vitals, infection 3 days after sx
● Complications:
○ Respiratory distress
■ Dysrhythmias
○ Pneumothorax
■ Bronchopleural fistula
○ Hemorrhage and Shock
Chest Drainage System: Explain the principles of chest drainage and the nursing responsibilities related to the care of the patient with a chest drainage system. Pain, bubbling, purposes
● Indication: Fluid, blood, or air causing lung collapse
○ Air removed through upper tube
● Blood removed through lower tube
○ Connect to drainage collection devices with or without suction.
○ bubbling= air leak
Monitor Client:
Assess VS and Resp. status (lung sounds) q4 hr. and pain
· Palpate surrounding drsg for crepitus or SC-air
· Check and record drainage
· Encourage frequent cough and deep breathing
· Use IS
Monitor Drainage System:
· Secure to avoid dislodgement
· Never clamp or disconnect
· When full, do not empty. Connect a new system
· When transporting, keep drainage system below client’s chest and disconnect system from suction source
-Continuous bubbling; air leak
Thoracentesis: Educate clients about treatments and procedures. Monitor the client before and after a procedure/surgery
● Thoracentesis: Remove fluid from pleural space to obtain sample for analysis, restore lung to full volume, and relieve dyspnea
○ Limit amount removed to 1200-1500 mL to prevent CV collapse
■ 1 time thing chest tube is continuous
● Pre op:
■ Get consent signed first!!
○ Do assessment and provide education
■ Encourage patient to take cough suppressant before, don’t want them to cough or breath deeply to move during the test
○ Localized numbing, STAY STILL LEAN FORWARD no deep breathe or cough
● Post-op:
○ Assess patients breathing, send to lab
■ Look at insertion site to assess for bleeding or drainage
○ X-ray to make sure there is no complication: pneumothorax, lung collapse, pain, bleeding, bruising, infiltration, infection
○ Inform provider if they have trouble breathing, cough up blood, fever, chills, pain gets worse
■ Comp: pain, bleed, bruise, infection
● Nurses Role:
○ Prepare and position the patient for thoracentesis and offer support, position leaning forward on a surface, use a pillow for comfort, do not want them to move.
■ Record thoracentesis fluid amount and send for laboratory testing
○ If chest tube and water-seal systems are used, the nurse should monitor and record the amount of drainage at prescribed intervals
Acute Respiratory Failure: Describe the medical and nursing management of a patient with acute respiratory failure and hypoxia.
● ARF earliest sign is intercostal retractions, sudden life threatening deterioration of gas exchange, happens fast with no warning
○ Medical Management: Intubation
● Nursing Management:
○ Assist with intubation,
■ Hold patient still
■ HOB elevated 30 degrees to prevent aspiration which leads to pneumonia
■ Oral care: Q2-4H to prevent pneumonia best way
■ Suction PRN, do not suction on a schedule!!
■ Turn Q2H
○ Maintain ventilator
■ Monitor LOC, ABGs, Pulse oximetry, VS
○ Implement turning, mouth care, skin care, ROM, dvt prophylaxis
■ Communication: Enable client to express concerns and needs
● Check neuro status 1x per shift to see if pt can be extubated
Acute Respiratory Distress Syndrome (ARDS): Identify, describe, and prioritize the components of the nursing process in caring for the patient with ARDS.
● Medical Management: ONLY TX W/ VENT AND INTUBATION, happens fast o2 therapy does not increase o2 sat
○ Intubation with positive end-expiratory pressure (PEEP)
■ Identify and treat underlying condition
○ Circulatory/fluid support: Treat hypovolemia, hypotension without causing further overload
■ Nutritional support (35-45 kcal/kd/day)
○ Pharmacologic treatments:
■ Inotropic, vasopressor agents
■ Neuromuscular blockers, sedatives
● Nursing Management: ARDS
○ Close, ICU monitoring:
■ VS, pulse ox, ABGs exchange
■ Tracheostomy, suctioning, bronchoscopy
■ Neuro: LOC, stop sedation 1x a day for mental status check
■ Oral care q4, monitor skin, eye care
● PRONE POSITION
○ Positioning: Oxygenation may improve in prone position (specialty beds), HOB elevated if not prone
○ Rest is essential (limit oxygenation consumption)
○ Maintain ventilator:
■ Peep: maintain gas exchange
● “fight” ventilator
○ Sedative: midazolam
○ NMBDs: pancuronium
■ Unable to breathe on own, move, appears unconscious
● Has sensations and is “awake” and able to hear
■ Ensure all alarms are on
○ Eye and oral care
■ VTE prophylaxis
○ Prevent foot drop, PUD, skin breakdown (assess lips, restraint sites, and back of neck)
Lung Cancer: Discuss the modes of therapy and related medical, surgical, chemotherapy, radiation therapy and nursing management of patients with lung cancer.
● Lung Surgery:
○ Pre-op:
■ History of smoking, cardiac and respiratory disorders, and other chronic disorders, poor prognosis tobacco is major cause
● Provide emotional, psychological support
■ Instruct about respiratory therapy, breathing exercises, coughing techniques
● Establish a way to communicate if endotracheal tube planned post-op
○ Post-op: SURGERY, CHEMO RADIATION IS TX, manage s.s and palliative care
○ Hemorrhage: Can happen right after surgery!
■ Assess drainage from chest tubes, look at tube for color of the drainage
■ Report excess bleeding >70 mL/hr
○ Respiratory Therapy:
■ Critical for recovery!
■ Cough/deep breathing/splinting
■ IS QH while awake
■ Monitor O2
■ Oxygen delivery/mechanical ventilation
○ Pain management
○ Activity Plan
● Chemotherapy:
○ Fresh flowers and fresh plants not in the room
■ Raw fish and meat try to limit, can bring bacteria and infection
○ Side Effects:
■ GI/mucous membranes
● Anorexia; loss of taste; aversion to food
● Erythema, painful ulcerations in GI tract
● N/V/D
■ Alopecia
■ Bone Marrow Suppression
● Neutropenia, anemia, thrombocytopenia
● Radiation:
○ Treatment of choice if surgery is not feasible due to tumor location or extension into surrounding tissue
○ Treatment goals:
■ Curative
■ Palliative- to shrink tumor to improve symptoms
■ Pre-surgical treatment to debulk tumor
● Nursing Interventions:
○ Manage symptoms: side effects of treatment, such as dyspnea, fatigue, N/V, and anorexia
■ Relieve breathing problem: Breathing pattern may be affected by tumor or by treatment of tumor
○ Reduce fatigue, Provide psychological support: Anticipatory grieving
■ Pain management
