Final Exam Flashcards
PACU/Recovery Room purpose
ongoing evaluation and stabilization of patients
anticipate, prevent and manage complications after surgery
hand off report
two way verbal interaction
report between two health care professionals is required to communicate the patient’s condition and needs
Assessments in PACU
history
initial assessment- LOC and awareness, Respiratory assessment, temp, pulse, resp, BP, O2 sat, examine surgical site for bleeding and drainage
discharge from PACU
determined by health care team
criteria for discharge: stable VS, normal temp, no overt bleeding, return of swallow and gag reflux, ability to take liquids, adequate UO
places people can be discharged to
hospital unit- ICU, telemetry, med surg
home
respiratory complications of surgery
atelectasis
pneumonia
PE
laryngeal edema
ventilator dependence
pulmonary edema
cardiovascular complications of surgery
HTN
hypotension
hypovolemic shock
dysrhythmias
VTE (venous thromboembolism)
DVT
heart failure
General complications of surgery
sepsis
anemia
anaphylaxis
pressure ulcer
wound infection
wound dehiscence
wound evisceration
skin rashes or contact allergies
gastrointestional complications of surgery
paralytic ileus
gastrointestinal ulcers and bleeding
neuromuscular complications of surgery
hypothermia
hyperthermia
nerve damage/paralysis
joint contractures
kidney/urinary complications from surgery
UTI
acute urinary retention
electrolyte imbalance
AKI
stone formation
common reactions after surgery
postoperative n/v
decreased or no peristalsis for up to 24 hours
paralytic ileus
constipation
Labs for after surgery
electrolytes
CBC
ABGs
Urinanalysis
Creatinine
Priority patient problems after surgery
potential for hypoxemia
potential for wound infection and delayed healing
acute pain
interventions to prevent hypoxemia
airway maintenance
monitor O2 sat/pulse ox
positioning
oxygen therapy
breathing exercises
movement/mobility
preventions for wound infection and delayed healing
dressing changes
asses wound for infection
assess drains
drug therapy
wound complications
dehiscence- partial or complete separation
evisceration- total separation of all wound layers and protrusion of internal organs
managing pain
drug therapy
relaxation
distraction
massage
positioning
patient teachings on discharge
prevention of infection
care and assessment of surgical wound
management of drains and catheters
nutrition therapy
pain management
drug therapy
pre-operative
begins when the patient is scheduled for surgery and ends at the time of transfer to the surgical site
post-operative
starts with completion of surgery and transfer of the patient to a specialized area of monitoring such as the PACU and may continue after discharge from the hospital until all activity restrictions have been lifted
preoperative assessments
complete set of VS
focus on problem areas identified in patients history
s/s of infection
increased PT and INR
abnormal electrolytes
HCG test
psychosocial exam
lab test: UA, CBC, H/H, Clotting study, electrolyte, BUN, creatinine, ABGs
Imaging
ECG
informed consent
implies that the patient has sufficient information to understand:
nature and reason for surgery
who will be preforming surgery and other ppl present
all available options and risks
risk associated with procedure and potential outcomes
nurse’s responsibility in informed consent
that the consent form is signed, and you serve as a witness to the signature, not to the fact that patient is informed
preoperative chart review
ensure all documentation, preoperative procedures, order are complete
check consent forms
preoperative patient preparation
Hospital gown
Antiembolism stockings or pneumatic compression devices, if ordered
Give valuables to a family member or lock them in a safe place
ID band in place, bracelet indicating allergies, bracelet indicating type and screen was completed
Remove dentures (some facilities allow them in the OR)
Remove all prosthetic devices, hairpins, and clips
Remove hearing aids (some facilities allow them in the OR)
Per hospital policy, remove nail polish, artificial nails
Have the patient empty their bladder
After drug administration that can affect cognition or judgment, raise siderails, ensure call system is within easy reach of the patient, and the bed is in low position
Answer questions and offer reassurance as needed
preoperative drugs
Sedatives
Hypnotics
Anxiolytics
Opioid analgesics
Anticholinergic agents
Antibiotics
Specific – purpose drug
May be given “on call” or after the patient is
transferred to the preoperative area
Because of an unexpected emergency case, a patient
scheduled for colon surgery at 8 AM has been rescheduled
for 11 AM. What is the nurse’s best action related to
preoperative prophylactic antibiotic administration according
to the Surgical Care Improvement Project (SCIP)
guidelines?
1. Administer the preoperative antibiotic at 7 AM as originally
prescribed
2. Administer the antibiotic at the same time as the other
prescribed preoperative drugs
3. Adjust the antibiotic administration time to be within 1 hour
before the surgical incision
4. Hold the preoperative antibiotic until the patient is actually in
the operating room and has been anesthetized
3
A 75-year old patient is having an exploratory
laparotomy tomorrow. The wife tells the nurse that at
night the patient gets up and walks around his room.
What priority action does the nurse take after hearing
this information?
1. Notifies the provider
2. Develops a plan to keep the patient safe
3. Obtains an order for sleep medication
4. Tells the patient not to get out of bed at night
2
The nurse is preparing the patient for surgery. Which
common laboratory tests does the nurse anticipate to be
ordered? (Select all that apply)
1. Total cholesterol
2. Urinalysis
3. Electrolyte levels
4. Uric acid
5. Clotting studies
6. Serum creatinine
2,3,5,6
The nurse has given the ordered preoperative
medications to the patient. What actions must the
nurse take after administering these drugs?
(Select all that apply)
1. Raise the side rails
2. Place the call light within the patient’s reach
3. Ask the patient to sign the consent form
4. Instruct the patient not to get out of bed
5. Place the bed in its lowest position
1,2,4,5
The nurse is assessing a postoperative patient’s
gastrointestinal system. What is the best indicator
that peristaltic activity has resumed?
1. Presence of bowel sounds
2. Patient states he is hungry
3. Passing of flatus or stool
4. Presence of abdominal cramping
3
What is the priority nursing assessment when a
patient is admitted to the PACU?
1. Level of consciousness
2. Airway and gas exchange
3. Dressing and incision status
4. Vital signs and body temperature
2
A patient who is 2 days postoperative for abdominal
surgery states, “I coughed and heard something pop.”
The nurse’s immediate assessment reveals an opened
incision with a portion of large intestine protruding.
Which statements apply to this clinical situation?
(Select all that apply)
1. Dehiscence has occurred
2. This is an emergency situation
3. The wound must be kept moist with normal saline-
soaked sterile dressings
4. This is an urgent situation
5. Evisceration has occurred
2,3,5
Which are interventions for the medical-surgical nurse
to use in preventing hypoxemia for the postoperative
patient? (Select all that apply)
1. Monitor the patient’s oxygen saturation
2. Position the patient supine
3. Encourage the patient to cough and breathe
deeply
4. Get the patient up ambulating as soon as possible
5. Instruct the patient to rest as much as possible
1,3,4
- You know that nursing care in PACU is
multifaceted and involves: (select all that apply)
A. Monitoring the patient’s physiological status
B. Intervening to ensure uneventful recovery from
anesthesia and surgery
C. Providing a safe environment for the patient
experiencing limitations in physical, mental, and
emotional function
D. Preventing or promptly treating complications in
the immediate post-anesthesia period
E. Upholding the patient’s rights to dignity, privacy,
and confidentiality
F. Utilizing high tech equipment so health care
costs will be justified
ABCDE
The nurse anesthetist gives you Mr. Potter’s
record, and prepares to give you a verbal report.
You know that her verbal report should include:
(Select all that apply)
A. Mr. Potter’s height and weight
B. The name of the surgical procedure Mr. Potter
had
C. Mr. Potter’s relevant health history
D. Anesthetic agents and other drugs that were
administered to Mr. Potter
E. Mr. Potter’s estimated blood loss during surgery
F. Mr. Potter’s religious preference
G.Mr. Potter’s fluid status and IV therapy
ABCDEG
In providing care for Mr. Potter, your first
step is to:
A. Assess your patient
B. Analyze patient data
C. Plan care
D. Intervene
E. Evaluate care
A
In PACU, many assessments and
interventions are done simultaneously.
However, the most critical, high-priority
assessment to be done with Mr. Potter is his:
A. Operative site
B. Skin integrity
C. Pulse
D. Airway
E. Blood Pressure
D
Which TWO assessments are your next
priorities?
A. Operative site
B. Skin color
C. Skin integrity
D. Pulse
E. Blood pressure
F. Orientation
DE
Since Mr. Potter is a smoker, he has
increased risk associated with surgery and
anesthesia. You are aware that smoking can
be responsible for which of the following in
the immediate postoperative period? (Select
all that apply)
A. Dehydration
B. Difficulty in clearing secretions
C. Cardiac dysrhythmias
D. Increased drowsiness
BC
Why is it important to measure arterial
oxygen saturation (SpO2) levels in
PACU?
A. Levels indicate how much oxygen is
available for use by tissues
B. Levels reflect the effectiveness of
intraoperative sedation
C. Levels reflect the ability to absorb
medications from the bloodstream
D. Levels reflect how much oxygen has
been used by tissues
A
Given Mr. Potter’s SpO2 of 97%, what
intervention is indicated?
A. Continue to monitor SpO2
B. Increase oxygen to 100%
C. Increase liter flow to 15 liters per minute
D. Remove Mr. Potter from the ventilator
A
You recognize that a number of conditions
may be responsible for Mr. Potter’s low body
temperature. These include which of the
following? (Select all that apply)
A. Surgical wound infection
B. The anesthetics Mr. Potter received
C. The environmental temperature in the OR
D. Mr. Potter’s preoperative skin prep
E. The common use of cooled irrigation
solutions during surgery
BCD
The opiate antagonist ____________
should be readily available in PACU should
reversal of respiratory depression be
necessary.
A. atropine sulfate
B. naloxone hydrochloride
C. protamine sulfate
D. aminophylline
B
You assist Mr. Potter to a sitting position
on the side of the PACU bed and allows
him to dangle his feet for ten minutes. This
will help prevent _____________ when Mr.
Potter stands.
A. Orthostatic hypotension
B. Orthostatic hypertension
C. Orthostatic paresis
D. Orthostatic paralysis
A
Before discharge, Mr. Potter is given
instructions regarding the need to: (Select
all that apply)
A. Report an elevated temperature
B. Monitor and protect his operative site
C. Avoid strenuous activity
D. Have a glass of wine at bedtime
E. Continue deep breathing exercises
F. Let someone else drive him home
G. Continue ice packs at home
ABCEFG
The nurse anesthetist reports that your patient is Mr. Potter, a 69-year-old man, who had a right inguinal hernia repair under general anesthesia. Mr. Potter smokes 1 1/2 packs of cigarettes per day and has a history of chronic bronchitis. He received no preoperative medication. During surgery, Mr. Potter received 900 mL of Lactated Ringer’s intravenously. Estimated blood loss was 20 mL. A variety of general anesthetics were administered. Mr. Potter remains intubated with a 7.5 oral endotracheal (ET) tube because he is not fully awake. Continued intubation in PACU will allow for maintenance of a patent airway until Mr. Potter is in a more alert state and can breathe and expectorate secretions on his own.
Mr. potter report… useful for practice questions
PaO2 range
80-100 mmHg
pH range
7.35-7.45
PaCO2 range
35-45 mmHg
HCO3 range
22-26 mEq/L
transtracheal oxygen
oxygen delivered through a small flexible catheter that is places in the trachea through a small incision
used for patients with long term O2 needs
avoids irritation that nasal prongs cause
typically require less O2 when delivered in this method
tracheotomy
surgical incision into trachea for purpose of establishing an airway
tracheostomy
stoma that results from tracheotomy
may be temporary or permanent
indications for a tracheostomy
stenosis of airway
obstruction of airway
laryngeal or neck trauma
neck cancer
extended need for mechanical ventilation
complications of tracheostomy
dislodgment
obstruction (mucus plugging)
SQ emphysema
skin breakdown (moisture and pressure)
infection (lung infection)
bleeding (from mucosal irritation)
features of tracheostomy tubes
single lumen and dual lumen
cuffed and un-cuffed
reusable and disposable
fenestrated and un-fenestrated
nursing care with trachs
stoma care
humification of airway
suctioning
ensure placement and patency
monitor cuff pressures
maintain extra trach and obturator at bedside
frequent oral care
aspiration precaution
complications of trach suctioning
hypoxia
tissue trauma
infection
vagal stimulation and bronchospasm
cardiac dysrhythmias
nutritional concerns with trachs
aspiration- inflated cuff can interfere with passage of food through the esophagus and weakened muscles
elevate HOB 30 min after eating
may need enteral feeding tube
weaning from trach tubes
trials of cuff deflation
gradual decrease in size of trach tube
may change from cuffed to un-cuffed
may change to fenestrated tube
cap trach with speaking valve or trach button
psychosocial considerations with trachs
communication
support for patients and families
become involved in self care activities
ABG
most accurate, invasive, obtained by arterial blood draw
A patient is receiving preoperative
teaching for a partial laryngectomy and
will have a tracheostomy. How does the
nurse define a tracheostomy to the
patient?
– A. Opening in the trachea that enables
breathing
– B. Temporary procedure that will be
reversed later
– C. Technique using positive pressure to
improve gas exchange
– D. Procedure that holds the airway open
A
A patient returns from the operating
room after a tracheostomy placement.
While assessing the patient which
observations by the nurse warrant
immediate notification to the provider?
– A. Patient is alert but unable to speak
– B. Small amount of bleeding present at
incision
– C. Skin is puffy at the neck area with a
crackling sensation
– D. Respirations are audible and noisy with
increased respiratory rate
C
To prevent accidental decannulation
of a tracheostomy tube, what does
the nurse do?
– A. Obtain an order for continuous upper
extremity restraints
– B. Secure the tube in place using ties or
fabric fasteners
– C. Allow some flexibility in motion of the
tube while coughing
– D. Instruct the patient to hold the tube
with a tissue while coughing
B
A patient has a recent tracheostomy.
What necessary equipment does the
nurse ensure is kept at the bedside?
(select all that apply)
– A. Ambu bag
– B. Pair of wire cutters
– C. Oxygen tubing
– D. Suction equipment
– E. Tracheostomy tube with obturator
ACDE
A nurse is educating a client who will be going home with a tracheostomy. When discussing suctioning frequency, what should be included in the education?
– A. The tracheostomy should be suctioned every 4 hours
– B. The tracheostomy should be suctioned when secretions can not be cleared and physical symptoms are present
– C. The tracheostomy should only be suctioned in an emergency
– D. The tracheostomy should only be suctioned at times when the home health nurse is available.
B
A patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach to the situation?
– A. Rely on the family to interpret for the patient
– B. Ask questions that can be answered with a yes or no
– C. Obtain an immediate speech consult
– D. Encourage the patient to rest rather than struggle with communication
B
steps for trach suction
- Assess the need for suctioning (routine unnecessary suctioning causes mucosal damage, bleeding, and bronchospasm).
- Wash hands. Don protective eyewear. Maintain Standard Precautions.
- Explain to the patient that sensations such as shortness of breath and coughing are to be expected but that any discomfort will be very brief.
- Check the suction source.
- Set up a sterile field.
- Preoxygenate (hyperventilate) the patient with 100% oxygen for 3 ventilations prior to suction.
- Quickly insert the suction catheter until resistance is met. Do not apply suction during insertion.
- Withdraw the catheter 1 to 2 m, and begin to apply suction. Apply suction and use a twirling motion of the catheter during withdrawal. Never suction longer than 10 to 15 seconds.
- Hyperoxygenate for 1 to 5 minutes or until the patient’s baseline heart rate and oxygen saturation are within normal limits.
Chronic airflow limitations (CAL)
asthma and COPD (chronic bronchitis and emphysema)
Causes of Asthma
inflammation and hyper responsiveness of airways to common stimuli
inflammation in the mucous membranes and hyper responsiveness constricts the bronchial smooth muscle
intermittent if well controlled
triggers of asthma
allergens
cold air/poor air quality
exercise
respiratory illness/ URI
general irritants
microorganisms
GERD
diagnostics on asthma
ABG (hypoxemia or acidosis)
PFTs
treatment and nursing care for asthma
goal: control and prevent episodes, improve airflow, relieve symptoms
medications: inhaled or systemic; preventative and rescue; bronchodilators and anti-inflammatory agents
avoidance of triggers, inhalers and nebulizers, oxygen therapy if extreme
status asthmaticus
severe and life threatening
treatment: oxygen, IV fluids, potent systemic bronchodilation, IV steroids, epinephrine
emergency intubation
can develop pneumothorax and cardiac respiratory arrest
absence of wheezing can indicate complete airway obstructions
COPD causes
chronic exposure to irritants, commonly smoking.
causes inflammation, congestion, mucosal edema and bronchospasm.
only effects airways, not alveoli
production of large amounts of thick mucus
EMPHYSEMA
Symptoms of COPD
dyspnea
orthopnea
cough with sputum production
use of accessory muscles
hypoxemia
chronic acidosis
weight loss
fatigue
barrel chest
cyanosis
clubbing of fingers
anxiety
diagnostics for COPD
ABG
sputum sample
CBC
chest xray
chest CT
PFTs
nursing care for COPD
attain or maintain gas exchange within the patient’s baseline and control symptoms
O2 therapy: O2 sat between 88-90
Hypoxic vasoconstriction with emphysema (blood shunting from unhealthy part of lung to healthy part… artificial O2 will mess up this process)
Positioning; elevate the HOB, tripoding
Cessation of smoking
energy conservation
breathing exercise
nutritional counseling
medications (bronchodilators, anti-inflammatories, mucolytic agents)
COPD complications
hypoxemia
acidosis
respiratory infection
cardiac failure
cardiac dysrhythmias
purpose of lung cancer chest tubes
collects air, fluid, or blood from the pleural space
allows the lung to re-expand
prevents air from re-entering the pleural space
wet drainage system
nursing care for lung cancer chest tubes
ensure dressing is tight and intact around tubing
assess SOB and breath sounds
check alignment of trachea
Palpate for puffiness or crackling
observe for signs of infection
check to see if tube ‘eyelets’ (holes indicating dislodgment) are visible
Keep drainage system lower than the level of the patient’s chest
asses for tidaling
watch for tension pneumothorax and SQ emphysema
lung cancer chest tube emergencies
tracheal deviation
sudden onset or increased intensity of dyspnea
O2 sat less than 90
Drainage greater than 70mL/hr
eyelets on the chest tube
chest tube falls out of patient’s chest
What are some most common types of
pneumonia? (Select all that apply)
A. community acquired
B. hospital acquired
C. ventilator associated
D. healthcare associated
E. dormant pneumonia
ABCD
Which clinical manifestations would the
nurse most likely see in a client
diagnosed with pneumonia? (Select all
that apply)
A. Chest discomfort
B. Dyspnea
C. Fever
D. Cough
E. Myalgia
F. Increased respiratory rate
ABCDEF
Which diagnostic tests does the nurse
initially expect to be ordered for the client
with pneumonia? (Select all that apply)
A. Pulse oximetry
B. Arterial blood gases
C. Chest X-ray
D. Chest CT
E. Sputum culture
F. Complete Blood Count (CBC)
G. Complete Metabolic Panel (CMP)
H. Coagulation panel
I. Pulmonary function test
ABCEF
When caring for a client with
pneumonia, which nursing
intervention is the highest
priority?
A. Increase fluid intake
B. Encourage deep breathing exercises
and controlled coughing
C. Ambulate as much as possible
E. Maintain a nothing-by-mouth (NPO)
B
What should the nurse include in
discharge teaching for a client to
prevent further pneumonia? (Select all
that apply)
A. Continue IV antibiotics
B. Continue breathing exercises
C. Healthy balanced diet
D. Decrease fluid intake
E. Avoid crowded public areas
F. Annual flu vaccine
G. Pneumococcal vaccine
BCEFG
pneumonia
excess fluid in the lungs resulting from an inflammatory process
inflammation triggered by many infectious organisms and inhalation of irritating agents
develops when the immune system cannot overcome the invading organisms
pneumonia types
community acquired CAP
hospital acquired HAP
health care associated HCAP
ventilator associated VAP
community acquired pneumonia CAP
acquired in community
hospital acquired pneumonia HAP
diagnosis less than 48 hours after admission to hospital
health care associated pneumonia HCAP
diagnosis greater than 48 hours after admission to a hospital and has had recent treatment at a health care facility (inpatient or outpatient)
ventilator associated pneumonia VAP
diagnosis within 48-72 hours of intubation
pneumonia risk factors
older adult
not vaccinated for flu or pneumococcal
Chronic health problems
limited mobility
uses tobacco or alcohol
altered LOC
aspiration
poor nutritional status
immunocompromised status
mechanical ventilation
pneumonia prevention
avoid risk factors
annual influenza vaccine
pneumococcal vaccine
avoid crowded areas during flu season
hand washing
cough, turn, and move if you have impaired mobility
Clean respiratory equipment
avoid indoor pollutants
stop smoking
drink 3L of fluid each day as recommended with diet
CM of pneumonia
increased RR or dyspnea
hypoxemia
cough
purulent, blood tinged, or rust colored sputum
fever with or without chills
pleuritic chest discomfort
acute confusion from hypoxia
pneumonia lab results
sputum by gram stain, culture, and sensitivity testing
CBC to assess elevated WBC
blood culture
ABGs
serum lactate level
procalcitonin
BUN and electrolytes
pneumonia imaging assessment
chest x ray
pulse ox
invasive tests: transtracheal aspiration, bronchoscopy, direct needle aspiration of the lung
Priority nursing diagnosis for pneumonia
impaired gas exchange related to decrease diffusion at the alveolar- capillary membrane
pneumonia nursing interventions
O2 therapy
monitor pulse ox
cough and deep breath every 2 hours
incentive spirometry
adequate hydration
assess fluid status
drug therapy
diabetes definition
chronic metabolic disease resulting from either a deficiency in insulin secretion, resistance of insulin action at the cellular level or both
resulting in hyperglycemia and inability to regulate blood glucose.
what happens in the absence of insulin?
body breaks down other sources for energy (fats and proteins)
counter-regulatory hormone levels are increased (glucagon, epinephrine, GH, and cortisol)
why is insulin important?
key that moves glucose into cells
a decrease can cause hyperglycemia
the cells don’t get the glucose they need
symptoms of DM
polyuria, polydipsia, polyphagia, metabolic acidosis, Kussmaul respirations, dehydration and electrolyte imbalance
polyuria
frequent and excessive urination
caused by osmotic diuresis secondary to excess glucose
polydipsia
excessive thirst
caused by dehydration
polyphagia
excessive eating
cause by cell starvation
types of diabetes
type 1, type 2, gestational
type 1 diabetes
no insulin is produces
autoimmune disorder
beta cells of the pancreas are destroyed by antibodies
onset usually occurs less than 30 yo
abrupt onset
weight loss
requires insulin
could be viral in etiology
Type 2 diabetes
reduction of the cells to respond to insulin and decreased secretion of insulin from beta cells
onset usually occurs greater than 50 yo
could have no symptoms or polydipsia, fatigue, blurred vision, vascular and neural comlications
gestational diabetes
glucose intolerance during pregnancy
Acute complications of DM
Diabetic Ketoacidosis
Hyperglycemic- Hyperosmolar state
Hypoglycemia
all considered medical emergencies
DKA
insulin deficiency and acidosis
HHS
insulin deficiency and severe dehydration
hypoglycemia
too much insulin or too little glucose
What are chronic complications of DM caused by
changes in blood vessels in tissue and organs (poor tissue perfusion, cell damage and death)
vascular changes result from:
hyperglycemia thickening basement membranes and causing organ damage.
hyperglycemia affects cell integrity
What are the two types of chronic complications in DM
macro vascular
microvascular
Macrovascular examples
cardiovascular disease- MI
cerebral vascular disease- stroke
peripheral vascular disease- PAD/PVD
pulmonary embolism- PE
risk factors for macrovascular diseases
HTN
obesity
dyslipidemia
sedentary lifestyle
nursing implication for DM
decreasing modifiable risk factors
microvascular examples
retinopathy
neuropathy
nephropathy
retinopathy
caused by damage to the retinal vessels causing leaking and retinal hypoxia
neuropathy
progressive deterioration of nerves
loss in sensation or muscle weakness
blood vessel changes that lead to nerve hypoxia
can affect multiple body systems (extremities, GI, cardiac, urinary)
nephropathy
change in kidney that decreases function and causes kidney failure
chronic high blood glucose: causes leaking and hypoxia of nephrotic vessels
increase in filtration of large particles, damaging kidneys further
Fasting blood glucose range
70-100
above 126 on at least 2 occasions is diagnostic for DM
Glucose tolerance test
less than 140
Hemoglobin A1C
4-6%
levels greater than 6.5% are diagnostic for DM
Planning and Priorities for DM
injury related to hyperglycemia
impaired wound healing
injury related to diabetic neuropathy
acute and chronic pain related to diabetic neuropathy
injury related to retinopathy (reduced vision)
potential for kidney disease
potential l hypoglycemia
potential DKA
potential HHS
expected outcome for DM
maintaining blood glucose in expected range and preventing acute and chronic complications of DM are the primary outcomes
interventions for DM
proper nutrition- decrease alcohol, carb counting, watch saturated fats and cholesterol
exercise- watch for injury
blood glucose monitoring- accurate samples, clean technique, adequate supplies
medications- DM T1 will require insulin, DM T2 may require medication
ways to reduce risk for peripheral neuropathy by proper footcare
cleanse and inspect feet daily
wear properly fitting shoes
avoid walking with bare feet
wear clean, dry socks daily
trim toenails properly
report non healing breaks in the skin of the feet
s/s of neuropathy
tingling/numbness
burning
muscle cramps
piercing or stabbing pain
metatarsalgia (walking on marbles)
allodynia (pain from normal non-painful stimuli)
hyperalgesia (exaggerated pain response)
reducing injury from impaired vision
regular eye exams
appropriate eyewear
reading aids
adaptive devices for insulin administration/ BG monitoring
reducing injury for diabetic nephropathy
control HTN
control hyperlipidemia
assess kidney function annually
smoking cessation
hypoglycemia features
skin is cool and clammy
absent dehydration
no change in respirations
anxious, nervous, irritable mental status
seizure and coma
weakness, double vision, blurred vision, hunger tachycardia, palpitations
glucose is less than 70
negative ketones
hyperglycemia features
Skin is warm and moist
Dehydration is present
Kussmaul respirations- fruit odor
Mental status varies
No specific symptoms- acidosis and dehydration
Glucose greater than 250
Positive ketones
Laboratory findings for DKA
glucose greater than 300
variable osmolarity
positive serum ketones
pH less than 7.35
HCO3 less than 15
variable serum Na
BUN greater than 30
Creatinine greater than 1.5
positive urine ketones
Laboratory findings for HHS
glucose greater than 600
osmolarity greater than 320
negative serum ketones
pH greater than 7.4
HCO3 greater than 20
normal or low serum Na
elevated BUN and creatinine
negative urine ketones
60 yo woman is one day post op from a knee replacement; she is a type 2 diabetic on a new insulin regimen; the nurse gave took her BG and gave her short acting insulin knowing she ordered her lunch; one hour later she is pale, confused, and clammy; her lunch tray is on her table and appears totally untouched. Is her condition consistent with hyperglycemia or hypoglycemia? Explain why…
Hypoglycemia especially because she received her insulin about an hour ago and has not replenished her glucose supply.
60 yo woman is one day post op from a knee replacement; she is a type 2 diabetic on a new insulin regimen; the nurse gave took her BG and gave her short acting insulin knowing she ordered her lunch; one hour later she is pale, confused, and clammy; her lunch tray is on her table and appears totally untouched. What is your first action? Explain why…
Check her blood glucose level immediately because the methods to increase her blood glucose level are dependent on how the current level is.
60 yo woman is one day post op from a knee replacement; she is a type 2 diabetic on a new insulin regimen; the nurse gave took her BG and gave her short acting insulin knowing she ordered her lunch; one hour later she is pale, confused, and clammy; her lunch tray is on her table and appears totally untouched. What is the most likely cause leading to this problem?
Clearly, there was a delay in eating after receiving the insulin. Moreover, it is possible because of her recent change to insulin, she was not aware of the necessity of eating soon after receiving insulin.
60 yo woman is one day post op from a knee replacement; she is a type 2 diabetic on a new insulin regimen; the nurse gave took her BG and gave her short acting insulin knowing she ordered her lunch; one hour later she is pale, confused, and clammy; her lunch tray is on her table and appears totally untouched. What should happen to prevent this from happening again in the future?
More education to the patient about the relationship between insulin and eating. The nurse should also evaluate the patient 20 min after administering short acting insulin.
21 yo college student brought to the ED by his roommate. ABD pain, polyuria for the last 2 days, vomiting and extreme thirst. He is flushed, lips and mucus membranes are dry and cracked, skin turgor is poor. Rapid respirations, fruity odor, and may have skipped a few doses of insulin. He is alert but struggling to answer questions. O2 sat is 99, BP 110/60, pulse is 110/min, Resp. are 32/min, glucose 485 mg/dL . Should you apply oxygen at this time? Why or why not?
No. Applying oxygen would serve no useful purpose. His respiratory symptoms are a result of compensation for the metabolic acidosis.
21 yo college student brought to the ED by his roommate. ABD pain, polyuria for the last 2 days, vomiting and extreme thirst. He is flushed, lips and mucus membranes are dry and cracked, skin turgor is poor. Rapid respirations, fruity odor, and may have skipped a few doses of insulin. He is alert but struggling to answer questions. What is going on with this patient?
DKA
21 yo college student brought to the ED by his roommate. ABD pain, polyuria for the last 2 days, vomiting and extreme thirst. He is flushed, lips and mucus membranes are dry and cracked, skin turgor is poor. Rapid respirations, fruity odor, and may have skipped a few doses of insulin. He is alert but struggling to answer questions. What is the immediate intervention the Dr. would prescribe?
IV drip because SQ wont absorb fast enough and is inappropriate for emergency situations.
patient could also get IV fluids to correct fluid deficit.
21 yo college student brought to the ED by his roommate. ABD pain, polyuria for the last 2 days, vomiting and extreme thirst. He is flushed, lips and mucus membranes are dry and cracked, skin turgor is poor. Rapid respirations, fruity odor, and may have skipped a few doses of insulin. He is alert but struggling to answer questions. What is another acute complication of DM resulting from elevated glucose?
HHS
how long is each segment of a monitor strip
6 second strip
P wave
represents atrial depolarization (atrial contraction)
present, consistent, configuration, one P wave before each QRS complex
PR interval
represents the time required for atrial depolarization as well as impulse travel through the conduction system
QRS complex
is measured from the beginning of the Q (or R) wave to the end if of the S wave (ventricular contraction)
ST segment
represents early ventricular repolarization- ventricular returning to resting state. indication of MI
QT interval
total time required for ventricular depolarization and repolarization
Steps to ECG Rhythm Analysis
determine HR, Heart rhythm, analyze P waves, measure PR interval, QRS duration, examine the ST segment.
normal PR interval duration
0.12- 0.20 and constant
normal QRS duration
0.06-0.12 and constant
Elevations in ST segment
may indicate myocardial infarction, pericarditis, hyperkalemia
depression in ST segment
is associated with hypokalemia, myocardial infarction, ventricular hypertrophy.
normal sinus rhythm
rate 60-100 bpm
rhythm: atrial and ventricular rhythms are regular
sinus arrhythmia (SA)
variant of normal sinus rhythm, results from changes in intrathoracic pressure during breathing, has all the characteristics if normal sinus rhythm except for its irregularity. The PP and RR intervals vary, with the difference between the shortest and the longest intervals being greater than 0.12 second
Dysrhythmias
Any disorder of the heartbeat
Tachydysrhythmias
Heart rate greater than 100 beats per minute
Bradydysrhythmias
Heart rate less than 60 bpm
Premature complexes
Early rhythm complexes; if they become more frequent, especially those that are ventricular, the patient may experience symptoms of decreased cardiac output.
Repetitive rhythm complexes
Bigeminy, trigeminy, quadrigeminy
Etiology for dsyrhythmias
May occur for many reasons. Can be classified by their site of origins in the heart (sinus, atrial, ventricular). Managed with antidysrhythmic drug therapy.
Care of patients with dysrhythmias
Asses VS every 4 hours
Monitor for cardiac dysrhythmias
Evaluate and document patients response
Encourage patient to notify nurse if chest pain occurs
Asses for chest pain and respiratory difficulty
Asses peripheral circulation
Administer medication and monitor response
Monitor lab values
Monitor activity tolerance and schedule exercise/rest periods, avoid fatigue
Promote stress reduction
Offer spiritual support
Atrial Dysrhythmia-Supra-ventricular Tachycardia
Rapid stimulation of atrial tissue occurs at rate of 100-280 bpm in adults. P waves may not be visible, because they are embedded in the preceding T wave.
Atrial Fibrillation
Most common dysrhythmia. Associated with atrial fibrosis and loss of muscle mass. Common in heart disease such as HTN, heart failure, CAD. Many other risk factors. Cardiac output can decrease by as much as 20-30%
Assessment for A Fib
Assess for fatigue, weakness, SOB, dizziness, anxiety, syncope, palpitations, chest discomfort or pain, hypotension. High risk for PE, VTE, stroke
Drug Therapy for A fib
Calcium channel blocker, aminodarone, beta blockers, digoxin, anticoagulants, antiplatelet
Other treatments for A fib
Cardio version, per cutaneous radio frequency catheter ablation, bi-ventricular pacing, surgical maze procedure
Ventricular dysrhythmias
More life threatening than atrial dysrhythmias. Left ventricle pumps oxygenated blood throughout the body to perfume vital organs and other tissues. Most common or life threatening: PVC, VT, VF, VA
Ventricular dysrhythmia- ventricular tachycardia
Also called v tach- repetitive firing of an irritable ventricular ectopic focus, usually 140-180 bpm or more.
Stable VT
Treatment: oxygen amiodarone, lidocaine, or magnesium sulfate, elective cardio version radio frequency catheter ablation, implantable cardioverter debrillation.
Oral antidysrhythmic agent: mexiletine or sotalol
To prevent further occurrences.
Unstable VT
Can cause cardiac arrest, unstable VT without a pulse is treated the same way as v fib. Assess patient’s airway, breathing, circulation, LOC, and oxygenation level
Treatment for V Fib
Life threatening… no cardiac output or pulse, blood is no longer being pumped out of the heart and brain not receiving blood. May be the first manifestation of CAD. First priority: patient immediately. Continue high quality CPR, provide airway management, follow ACLS protocol.
Ventricular dysrhythmia- ventricular fibrillation
Called v fib. Result of electrical chaos in ventricles
Ventricular dysrhythmia-ventricular asystole
Called ventricular standstill- complete absence of any ventricular rhythm.
Treatment for ventricular asystole
Full cardiac arrest- no cardiac output or perfusion to the rest of the body. Prognosis is poor. Manage airway. Administer CPR- compressions, airway, breathing. DO NOT DEFIBRILLATE… no electrical activity to shock. Follow ACLS protocols
Patient teachings with dysrhythmias
Prevention, early, recognition, and management. Lifestyle, modifications, (avoid caffeinated beverages, stop, drinking, drink, alcohol in moderation, follow prescribe diet). Drug therapy instructions. Teach the patient and family how to take pulse and or blood pressure and report any changes. Keep follow up appointments. Provide oral and written instruction for pacemaker, ICDS, cardiac exercise programs, support groups as applicable.
A client who had open abdominal surgery 4
hours ago reports feeling weak and dizzy.
The client’s current blood pressure has
decreased to 98/50, and pulse rate is 120.
What is the nurse’s best action at this time?
–A. Document the vital signs, and continue to
monitor the client.
–B. Remind the client to stay in bed if feeling
weak and dizzy.
–C. Call the health care provider immediately.
–D. Increase the client’s IV rate to restore fluid
volume.
C
A client in the telemetry unit is on a
cardiac monitor. The monitor technician
notices there are no ECG complexes and
the alarm sounds. What is the first action
by the nurse?
–A. Begin CPR immediately.
–B. Call the emergency response team.
–C. Press the record button to get an ECG
strip.
–D. Assess the client and check lead
placement
D
Hypertension
most common health problem seen in primary settings. AHA 2017 guidelines above 130/80
desired BP in 60 yo and older
below 150/90
desired BP in younger than 60 yo
below 140/90
desired BP in patients with DM and heart disease
below 130/90
BP elevations…
results in damage to organs, causes thickening of the arterioles, as the blood vessels thicken, perfusion decreases and body organs are damaged
HTN is a major risk for…
stroke, myocardial infarction, kidney failure, death
Classifications of HTN
primary and secondary
primary classification of HTN
most common type, not caused by an existing health problem: can develop when a patient has any one or more of the risk factors: family history, African American ethnicity, hyperlipidemia, smoking, older than 60 or postmenopausal, excessive sodium and caffeine intake, overweight/obesity, physical inactivity, excessive alcohol intake, low potassium, calcium or magnesium intake, excessive and continuous stress.
secondary classification of HTN
results from specific diseases and some drugs. kidney disease is one of the most common causes of secondary HTN
physical assessment/clinical manifestations of HTN
most people have no symptoms, some patients experience headaches, facial flushing (redness), dizziness, fainting, blood pressure screenings (take in both arms, two or more readings at a visit, use appropriate size cuff)
orthostatic hypotension
decrease in BP with changes in position, 20 mmHg for systolic and or 10 mmHg for diastolic
psychosocial considerations for HTN
assess for stressors that can worsen HTN
Diagnostic assessment for HTN
no specific lab or x-rays are diagnostic of primary hypertension. secondary hypertension can be screened with labs specific to the underlying disease
ex: kidney disease
interventions for HTN
lifestyle changes, complementary and alternative therapies, drug therapy, avoid OTC medications (NSAIDS, decongestants)
lifestyle changes for HTN
dietary sodium restriction to less than 2g per day, reduce weight, use alcohol sparingly, exercise 3-4 times a week for 40 min, use relaxation techniques to decrease stress, avoid tobacco and caffeine
complementary and alternative therapies for HTN
biofeedback and meditation
Drug therapies for HTN
diuretics, calcium channel blocker, angiotensin converting enzyme (ACE) inhibitor, angiotensin II recpetor blockers (ARBs), Aldosterone receptors antagonists, beta adrenergic blockers,
Venous Thromboembolism VTE
includes deep vein thrombosis DVT and pulmonary embolism PE
Risk factors for VTE
stasis of blood, vessel wall injury, altered blood coagulation
VIRCHOW’S TRIAD
VTE prevention
prevention is key to address this challenge in health care: patient education, leg exercises, early ambulation, adequate hydration, graduated compression stockings, intermittent pneumatic compression, such as SCDs, venous plexus foot pump, avoid oral contraceptive, anticoagulant therapy
Unfractionated Heparin Therapy (UFH)
Baseline PT, aPTT, INR, CBC with platelet count
antidote: protamine sulfate
heparin-induced thrombocytopenia (HIT)- life threatening complication
Low Molecular Weight Heparin (LMWH)
Preferred for prevention and treatment of VTE
antidote: protamine sulfate
May see an overlap of enoxaparin and warfarin given for treatment of DVT or PE
Warfarin
given PO
monitor PT and INR
Assess for bleeding
antidote: vitamin K
teach patients to avoid foods with high concentrations of vitamin K
It is shift change. The oncoming nurse
enters the room and notices observable
hematuria in Mrs. Adam’s urinary
catheter.
- What action should the nurse initiate
first?
–1. Obtain a stat aPTT
–2. Stop the heparin infusion
–3. Assess vital signs
–4. Observe the surgical site for bleeding
2
After consulting with the HCP, the
nurse is to administer a heparin
antagonist.
*
* Which medication will be
administered?
–1. Vitamin K
–2. Protamine Sulfate
–3. Enoxaparin (Lovenox)
–4. Ticlopidine (Ticlid)
2
To which nursing diagnosis should
the nurse give the highest priority
when planning care for Mrs. Adams?
– 1. Pain related to decreased venous flow
– 2. Risk for injury (bleeding) related to
anticoagulant therapy
– 3. Impaired physical mobility related to
prescribed bedrest
– 4. Knowledge deficit related to lack of
discharge teaching
2
Mrs. Adams is transitioned to warfarin
by mouth. Mrs. Adams should receive
additional teaching about foods
- Which food should the nurse instruct
Mrs. Adams to avoid?
–1. Apple products
–2. Red meats
–3. Green leafy vegetables
–4. Nuts
3
heart failure statistics
leading cause of hospital admission for patients over 65. major cause of disability and death. Readmission an important quality measure in acute care. CMS core measure.
heart failure
chronic inability of heart to work effectively as a pump. Heart not able to maintain adequate cardiac output to meet the metabolic needs of the body.
types of heart failure
left sided
right sided
high output failure
most heart failure of the left ventricle and progresses to failure of both ventricles.
right sided heart failure
right ventricle can not empty effectively.
causes of right sided heart failure
left ventricular failure
right ventricular MI
pulmonary HTN
chronic ling disease
symptoms of right sided heart failure
systemic congestion
- JVD
- enlarged liver and spleen
- anorexia and nausea
- dependent edema
- distended abdomen
- swollen hands and fingers
- polyuria at night
- weight gain
- increased blood pressure from excess volume
- decrease blood pressure from failure
left sided heart failure
decreased tissue perfusion form poor cardiac output and pulmonary congestion.
systolic heart failure
heart can not contract forcefully enough to eject adequate blood
diastolic heart failure
ventricle can not relax adequately during diastole preventing adequate filling of blood
causes of left sided heart failure
HTN
CAD
valvular disease
symptoms of left sided heart failure
pulmonary congestion
- hacking cough, worse at night
- dyspnea
- crackles/wheezes in lungs
- pink, frothy sputum
- tachypnea
- S3/S4 gallop
Decreased cardiac output
- fatigue and weakness
- oliguria during day/nocturia at night
- angina
- confusion and restlessness
- dizziness
- pallor and cool extremities
- weak peripheral pulses
- tachycardia
high output heart failure
occurs when cardiac output remains normal or above normal but there are increased metabolic needs to hyperkinetic conditions
causes of high output heart failure
septicemia
high fever
anemia
hyperthyroidism
**not as common as the other two types
Cardiac compensatory mechanisms
when cardiac output is insufficient to meet the demands of the body, compensatory mechanisms work to improve cardiac output. eventually the heart can not keep up with the demands, then CM of HF occur.
compensatory mechanism: sympathetic nervous system stimulation
increase HR and blood pressure
compensatory mechanism: RAAS
causes vasoconstriction and retention of Na and water
compensatory mechanism: other chemical responses
immune responses causes ventricular remodeling. endothelium causes vasoconstriction. vasopressin causes vasoconstriction
compensatory mechanism: myocardial hypertrophy
thicken of heart walls to increase muscle mass lead to more forceful contractions
electrolytes related to cardiac
abnormalities from complications of HF or side effects of drug therapy
BUN and creatinine
inadequate perfusion of kidneys can result in impairment and elevated levels
hemoglobin and hematocrit
could be low secondary to demodilution
urinalysis
possible proteinuria and high specific gravity
microalbuminuria
early indicator of decreased compliance of heart and occurs before the BNP rises
ABGs
evaluates hypoxemia
decrease in gas exchange secondary to fluid filled alveoli
BNP
will be elevated and used for diagnosing HF
BNP is produced and released by the ventricles when the patient is fluid overload
natiuretic peptides are neurohormones that promote vasodilation and diuresis through sodium loss in the renal tubules
patients with renal disease may also have elevated levels
Cardiac imaging
chest xray
echocardiography
chest xray
cardiomegaly may be present
echocardiography
best tool in diagnosing HF
measures chamber size, EF and flow
Cardiac priority problems
impaired gas exchange related to ventilation/perfusion imbalance. decreased cardiac output related to altered contractility, preload, and after load. fatigue related hypoxemia. potential for pulmonary edema.
HF nursing interventions
oxygen (90% or greater)
monitor respirations and lung sounds
if dyspnea present, high fowlers position
reposition, cough, deep breath every 2 hours
drug therapy
nutrition therapy
fluid restriction
weight daily
monitor and record I&O
provide periods of uninterrupted rest
asses the patient’s response to increased activity
Cardiac drug therapy effect
to improve stroke volume- reduced after load, preload, but improve cardiac muscle contractility
if dyspnea present, high fowlers position because…
maximize chest expansion and improve oxygenation
reposition, cough, deep breath every 2 hours because…
improve oxygenation and prevent atelectasis
nutrition therapy because…
goal to reduce sodium and water retention
reduce sodium intake 2g/day
fluid restriction limit…
range from 2 liters to 3 liters per day
weigh daily because
most reliable indicator of fluid gain or loss. 1 kg of weight gin or loss equals 1 liter of retained or lost fluid
Cardiac nonsurgical options
CPAP- improves sleep apnea and supports cardiac output and ejection fraction
cardiac resynchronization therapy- uses a permanent pacemaker alone or in combination with implantable cardioverter-defibrillator
gene therapy
Cardiac surgical options
heart transplant
ventricular assistive devices (VAD)- mechanical pump is implanted to work with patient’s heart to improve function
patient teaching for heart failure
diet: sodium restriction and fluid restriction
activity schedule
drug therapy
discharge instructions
resources and equipment needs
decreases readmissions!!!
HF symptoms to report to HCP
rapid weight gain (3 lb/week or 1-2 lb/night)
decrease in exercise tolerance lasting 2-3 days
cold symptoms lasting more than 3-5 days
excessive awakening at night to urinate
development of dyspnea or angina at rest or worsening angina
increased swelling in feet, ankles or hands
Bert is concerned and he is not sure
what caused this problem? What
prior medical history puts Bert at risk
for heart failure(Select all that
apply)?
– 1. Hypertension
– 2. Hypothyroidism
– 3. GERD
– 4. Aortic valve stenosis
1,4
Which question will provide the
nurse the best data about any
additional risk factors for heart
failure? (Select all that apply)
1. “Do you have any chronic lung disorders?”
2. “Have you ever had a heart attack?”
3. “Do you have varicose veins?”
4. “Have you ever had low blood pressure?”
1, 2
When planning care for Bert the
nurse anticipates what diagnostic
procedure?
– 1. Cardiac catheterization
– 2. Echocardiogram
– 3. Angiography
– 4. Exercise electrocardiograpy
2
Which assessment finding would
indicate to the nurse that Bert is
experiencing right-sided heart
failure?
1. Dyspnea
2. Tachycardia
3. Edema
4. Fatigue
3
The nurse prepares a dose of Digoxin
(Lanoxin) 0.125 mg IV push. The drug
is supplied 0.25 mg in 2 mL.
How many mL should the nurse
prepare to administer?
1 mL
Prior to administration what assessment finding would prevent
the nurse from administering lanoxin?
1. BP 99/68
2. Apical pulse 48
3. Respiratory rate 28
4. SpO2 89%
2
Which assessment is most important
for the nurse to perform prior to the
administration of captopril(Capoten)?
1. Apical pulse
2. Blood pressure
3. Respiratory rate
4. Intake and output
2
Which complaint by Bert would be of
highest concern after adminstration
of captopril?
1. Diarrhea
2. Itching in throat
3. Constant dry cough
4. Dizziness when standing
2
When planning care for Bert what
should be the priority nursing
diagnosis?
1. Fluid volume deficit
2. Ineffective airway clearance
3. Altered nutrition, greater than
needs
4. Impaired gas exchange
4
Which intervention should be
implemented based on the diagnosis
of activity intolerance?
1. Provide 3 large meals daily
2. Provide all activities of daily living
(ADLs) for the patient
3. Encourage frequent rest periods
4. Encourage regular aerobic exercise
3
The nurse enters Bert’s room and finds
him lying in bed in a supine position. His
respiratory rate is 32 per minute and he
states that his back hurts. Which action
should the nurse implement first?
1. Notify the respiratory therapist
2. Assist Bert to turn on his side
3. Elevate the head of Bert’s bed
4. Offer Bert a back massage
3
The nurse assesses that Bert is becoming
increasingly confused and restless, and that he
has developed a frothy, productive cough. His
vital signs are temperature 98, P 148, R 36, BP
110/64. Which intervention should the nurse
implement first?
1. Obtain an oxygen saturation level via pulse
oximeter
2. Call the lab to obtain a stat serum potassium
level
3. Collect a sputum specimen for culture and
sensitivity
4. Initiate suctioning to remove lung secretions
1
Bert’s condition worsens and he is
transferred to ICU. What are the
priorities of care at this time (Select all
that apply)
1. Rapid acting diuretics
2. Nitroglycerin
3. Aggressive pulmonary therapy
4. Aggressive IVF replacement
5. Beta blockers
1,2,3
Bert is now recovered and on a medical
surgical unit preparing for discharge. What
statement by Bert indicates to the nurse
that further teaching is required?
1. “I must weigh myself once a month and
watch for fluid retention”
2. “If my heart feels like it is racing I should
call the doctor”
3. “I’ll need to consider my activities for the
day and rest as needed”
4. “I’ll need periods of rest and should avoid
activity after a meal”
1
Six months later Bert is back on your
unit recovering from an AVR (aortic
valve replacement) with an artificial
valve. What should be including in his
discharge teaching (Select all that
apply)?
– 1. Weigh yourself daily
– 2. Use electric razors for shaving
– 3. Pre-medicate with antibiotics prior to
invasive procedures
– 4. Avoid heavy lifting for 3-6 months
2,3,4
angina pectoris
chest pain caused by temporary imbalance between the coronary arteries’ ability to supply oxygen and the cardiac muscle’s demand for oxygen. ischemia that occurs is limited in duration and does not cause permanent damage.
Two types: chronic stable angina and unstable angina
chronic stable angina
chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient. Frequency, duration, and intensity of symptoms remain the same over several months. Results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque. Usually relieved by nitroglycerin or rest; managed with drug therapy.
acute coronary syndrome
term used to describe patients who have either unstable angina or acute myocardial infarction. Atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation (clumping), thrombus (clot) formation and vasoconstriction. ACS classified into one of three categories according to the presence or absence of ST- segment elevation on the ECG and positive serum troponin markers:
- STEMI: ST elevated MI (traditional manifestation)
- NSTEMI: Non ST elevated MI (common in women)
- unstable angina pectoris
unstable angina pectoris
chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation. Pressure may last longer than 15 min. Poorly relieved by rest or nitroglycerin. May present with ST changes but do not have changes in troponin or creatine kinase levels.
New onset angina
variant Prinzmetal’s angina
Pre-infarction angina
new onset angina
describes the patient who has his or her first angina symptoms, usually after exertion or other increased demands on the heart.
variant Prinzmetal’s angina
chest pain or discomfort resulting form coronary artery spasm and typically occurs after rest.
pre-infarction angina
refers to chest pain that occurs in the days or weeks before an MI
Myocardial Infarction (MI or AMI)
occurs when myocardial tissue is abruptly and severely deprived of oxygen. When blood flow is quickly reduced by 80% to 90%, ischemia develops. Ischemia can lead to injury and necrosis of myocardial tissue if blood flow is not restored. Evolves over a period of several hours. Extent of infarction depends on collateral circulation, anaerobic metabolism and workload demands. Physical changes do not occur in the heart until 6 hours after the infarction. Once infarction occurs, scare tissue permanently changes the size and shape of the entire left ventricle, called ventricular remodeling.
NSTEMI
Non ST segment elevation myocardial infarction. ST and T-wave changes on ECG. Indicates myocardial ischemia. Cardiac enzymes may be initially normal but elevate over the next 3-12 hours.
causes of a NSTEMI
coronary vasospasm, spontaneous dissection, sluggish blood flow due to narrowing of the coronary artery.
STEMI
ST elevated myocardial infarction. ST elevation in two leads on a ECG. Indicates myocardial infarction/necrosis. Attributable to rupture of the fibrous atherosclerotic plaque leading to platelet aggregation and thrombus formation at the site of rupture. Thrombus causes an abrupt 100% occlusion to the coronary artery.
CAD/ ACS Etiology
atherosclerosis is the primary factor in the development of CAD; non-modifiable and modifiable risk factors contribute to atherosclerosis
CAD/ACS incidence
average age for first MI, 65.1 years in men, 72 for women, postmenopausal women have lower incidence than men, postmenopausal women in their 70s or older have an equal chance.
CAD/ACS health promotion
control or alter modifiable risk factors for CAD
Physical assessment of ACS
may complain of pain or pressure, assess according to onset, location, radiation, intensity, duration, precipitating factors, relieving factors.
assess for associated symptoms such as NV, diaphoresis, dizziness, weakness, palpitations, SOB
assess BP, HR, Cardiac rhythm, dysrhythmias; sinus tach with PVC frequently occur in the first few hours after an MI
assess distal peripheral pulses and skin temp; poor cardiac output can be manifested by cool, diaphoretic skin and diminished or absent pulses.
auscultate for S3 gallop which often indicates HF (complication of MI)
assess resp rate and breath sounds, crackles and wheezes may indicate LSHF
assess for presence of JVD and peripheral edema.
Assess for fever, patient with MI may experience temperature elevation for several days, in response to myocardial necrosis, indicating the inflammatory response.
key features of angina
substernal chest discomfort: radiating to the left arm, precipitated by exertion or stress (or rest in variant angina) relieved by nitroglycerin or rest, lasting less than 15 min.
key features of MI
pain or discomfort: substernal chest pain/pressure radiating to the left arm, pain discomfort in jaw, back, shoulder, or abdomen, occurring without cause usually in the morning, relieved by opioids, lasting 30 min or more.
frequent associated symptoms of MI
N/V, diaphoresis, dyspnea, feelings of fear and anxiety, dysrhythmias, fatigue, palpitations, epigastric distress, anxiety dizziness, disorientation/ acute confusion, feeling SOB
ACS psychosocial assessment
denial is common
ACS lab assessment
Troponin’s- T&I criterion stnadard use today; can be elevated within 3-4 hours and may remain elevated for 10-14 days.
CK-MB (creatine kinase MB)
ACS imaging assessment
thallium scans, contrast enhanced cardiovascular magnetic resonance, echocardiogram, computed tomography coronary angiography
Other tests performed for ACS
12 lead ECG, stress test, cardiac catheterization
Interventions for ACS to manage acute pain
supplemental oxygen, drug therapy, semi fowler position, quiet, calm environment
Interventions for ACS to improve cardiopulmonary tissue perfusion
restoration of perfusion to injured area limits amount od extension, improves left ventricular function. complete, sustained reperfusion of coronary arteries after an ACS has decreased mortality rates.
Interventions for ACS to increase activity intolerance
phase 1: patients progress at their own rate to increase levels of activity
phase 2: cardiac rehab (all patients with MI should be referred)
Interventions for ACS to promote effective coping
denial, anger, depression
other examples of intervention for ACS
identify and manage dysrhythmias
monitor for and manage HF
monitor for and manage recurrent symptoms and extension of injury
Invasive corrections to resolve angina or prevent MI
percutaneous coronary intervention (PCI)
coronary artery bypass graft (CABG)
The patient states that the chest discomfort occurs
with moderate to prolonged exertion. He describes
the pain as being “about the same over the past
several months and going away with nitroglycerin
or rest.” Based on the patient’s description of
symptoms, what does the nurse suspect in this
patient?
A. Chronic stable angina (CSA)
B. Unstable angina
C. Acute ST elevated MI
D. Acute Non ST elevated MI
A
A 71-year-old female presents to the ED
via EMS with pain in her upper back and
shoulders that started 2 hours ago. She
has been experiencing nausea,
dizziness, shortness of breath, and
diaphoresis. She reports that she has
had more frequent indigestion over the
past week and has been unusually
fatigued
Which of the following is the most likely
diagnosis at this time?
a. Acute Myocardial Infarction
b. Chronic Stable Angina
c. Congestive Heart Failure
d. Deep Vein Thrombosis
A
Which early reaction is most common in
patients with the chest discomfort associated
with unstable angina or MI?
A. Depression
B. Anger
C. Fear
D. Denial
D
The patient is admitted for acute MI, but the nurse notes that the traditional manifestation of ST elevation myocardial infarction (STEMI) is not occurring. What other evidence for acute MI does the nurse expect to find in this patient? (Select all that apply)
A. Positive troponin markers
B. Chronic stable angina
C. Non-ST elevation MI (non-STEMI) on ECG
D. Cardiac dysrhythmia
E. Pulmonary embolus
F. Jugular vein distension (JVD)
AC
A thallium scan is scheduled for a client who had a
myocardial infarction (MI). What should the nurse
explain to the client regarding the reason the scan
has been prescribed?
A. That it will monitor the mitral and aortic valves
B. That it establishes the viability of myocardial
muscle
C. That it can visualize the ventricular systole
and diastole
D. That it will determine the adequacy of
electrical conductivity
B
The patient is traveling to the hospital via EMS to
be admitted with AMI. He begins c/o extreme
fatigue, chest pain, and shortness of breath. BP
84/59, HR 94, RR 28 and shallow, pulse
thready, skin pale and diaphoretic. These
symptoms are associated with:
A. Decreased lung capacity
B. Increased cardiac muscle tone
C. Decreased cardiac output
D. Increased cardiac output
C
The patient arrives to the hospital. Which of the following are appropriate interventions for managing an Acute Coronary Syndrome? (Select all that apply)
A. Supplemental oxygen
B. Nitroglycerin SL
C. Morphine IV
D. Aspirin PO
E. Propranolol PO
F. Nifedipine PO
ABCDE
Which of the following is considered a
treatment for acute myocardial infarction?
(Select all that apply)
A. Supplemental oxygen
B. Morphine IV
C. Aspirin PO
D. Tissue plasminogen activator IV
E. PCI (Percutaneous Coronary Intervention)
F. PTCA (Percutaneous transluminal coronary angioplasty)
G. CABG (Coronary Artery Bypass Graft)
DEFG
The patient received thrombolytic therapy for treatment of acute MI. What are post administration nursing responsibilities for this treatment? (Select all that apply)
A. Document the patient’s neurologic status
B. Observe all IV sites for bleeding and patency
C. Monitor white blood cell (WBC) count and differential
D. Monitor clotting studies
E. Monitor hemoglobin and hematocrit
F. Test stools, urine, and emesis for occult blood
G. Observe the sternal wound site
ABDEF
Which of the following is an appropriate recommendation for a patient being discharged from the hospital following an ACS episode? (Select all that apply)
A. You should utilize resources to help you quit smoking
B. You should consume no more than 2 g of sodium in 24 hours
C. You can return to your usual activities right away
D. You will be checking your labs regularly
E. You can stop your hypertension medication
F. You should find ways to manage your stress
ABDF
What are characteristics of chronic stable angina? (Select all that apply)
A. Pain is precipitated by exertion or stress
B. Pain occurs without cause, usually in the morning
C. Pain is relieved only by opioids
D. Pain is relieved by nitroglycerin and rest
E. Nausea, diaphoresis, feelings of fear, and dyspnea may occur
F. Pain lasts less than 15 minutes
ABDF
Within 4 to 6 hours after a client has a
myocardial infarction, the nurse expects which
blood level to increase?
A. Lactate dehydrogenase (LDH-1)
B. Creatine kinase-MB band (CK-MB)
C. Erythrocyte sedimentation rate (ESR)
D. Serum aspartate aminotransferase (AST)
B
A patient is admitted with AMI and c/o moderate
chest discomfort. The nurse asks about which
associated symptoms? (Select all that apply)
A. Nausea
B. Diarrhea
C. Diaphoresis
D. Dizziness
E. Joint pain
F. Shortness of breath
ACDF
Which of the following are appropriate
interventions for managing stable angina?
(Select all that apply)
A. Supplemental oxygen
B. Nitroglycerin SL
C. Morphine IV
D. Aspirin PO
E. Propranolol PO
F. Nifedipine PO
BDEF
A client is admitted to the hospital with the
diagnosis of myocardial infarction. The nurse
should monitor this client for which signs and
symptoms associated with heart failure?
(Select all that apply)
A. Weight loss
B. Unusual fatigue
C. Dependent edema
D. Nocturnal dyspnea
E. Increased urinary output
BCD
Four patients are admitted with an Acute MI.
Which one of them is least likely to be developing
a complication?
A. Pt c/o of increasing chest pain after
receiving Morphine IV
B. Pt with c/o increased need for urination
C. Pt with multiple multifocal PVCs on EKG
D. Pt with decreased level of consciousness
and thready pulse
B
Upper GI series (Barium Swallow)
X-ray from mouth to duodenojejunal junctions with use of barium
Small bowel follow through
Extension of the upper Gi x-ray with use of barium
Barium enema
x-ray of large intestine with use of barium
EGD- esophagogastroduodenoscopy
visual examination of the esophagus, stomach, duodenum with use of fiberoptic scope
EGD- esophagogastroduodenoscopy preparation
NPO for 6-8 hours and avoid anticoagulants, aspirin, NSADIS several days before the procedure.
EGD- esophagogastroduodenoscopy procedure
moderate sedation and lasts about 20-30 minutes
EGD- esophagogastroduodenoscopy post procedure
keep patient NPO until gag reflex returns, priority care includes preventing aspiration and assess for any bleeding or pain that could indicate perforation.
ERCP- endoscopic retrograde cholangiopancreatography
visual and radiographic exam of liver, gallbladder, bile ducts, and pancreas. uses radiopaque dye, used to diagnose obstruction as well as treat obstructions
ERCP- endoscopic retrograde cholangiopancreatography preparation
NPO for 6-8 hours and typically avoid anticoagulants as determined by provider
ERCP- endoscopic retrograde cholangiopancreatography procedure
moderate sedation and lasts 30 minutes to 2 hours
ERCP- endoscopic retrograde cholangiopancreatography post procedure
keep patient NPO until gaga reflex returns, priority care includes preventing aspiration and assess for any bleeding or pain that could indicate perforation. assess for gallbladder inflammation and pancreatitis, severe abd pain, n/v, fever and elevated lipase.
small bowel endoscopy- enteroscopy
provides a visual view of the small intestine. used to evaluate and locate source of GI bleeding
small bowel endoscopy- enteroscopy preparation
NPO except water for 8-10 hours then complete NPO for 2 hours before swallowing capsule
small bowel endoscopy- enteroscopy procedure
sensors are placed on abdomen and patient wears a data recorder. patient swallows the capsule endoscope and can resume normal activity. patient may eat 4 hours after swallowing the capsule. procedure lasts 8 hours.
small bowel endoscopy- enteroscopy post procedure
explain to the patient that the capsule endoscope is excreted naturally and will be seen in the stool.
colonoscopy
endoscopic exam of the entire large intestine- can be used to visually diagnose, biopsy, and treat. baseline test should be done at age 50 and every 10 years
colonoscopy preparation
clear liquids the day before, NPO 4-6 hours before, avoid aspirin, anticoagulants, and anti-platelet drugs several days before. adequate bowel cleansing is essential.
colonoscopy procedure
moderate sedation and procedure last 30-60 minutes
colonoscopy post procedure
observe for signs of perforation (severe pain) and hemorrhage, feelings of fullness and cramping are expected, fluids are permitted after the patient passes flatus to indicate that peristalsis has returned.
acute gastritis definition
inflammation of gastric mucosa or submucosa after exposure to local irritants or other causes. complete regeneration and healing occur within a few days. if the stomach muscle is not involved, complete recovery usually occurs with not residual gastric inflammation. if the stomach muscle is affected, hemorrhage could occur.
acute gastritis etiology
h. pylori and long term NSAID use (most common)
chronic gastritis definition
chronic inflammation of the mucosal lining of the stomach- thinning and atrophy, loss of intrinsic factor, vitamin b 12 and results in pernicious anemia. decrease in acid of the stomach- increase in gastric cancer risk
type a chronic gastritis
autoimmune
type b chronic gastritis
h pylori infection is the most common cause
atrophic chronic gastritis
caused by exposure to toxic substances in the workplace, h pylori infection, or autoimmune factors
gastritis prevention
eat a well balances diet, avoid drinking excessive amounts of alcohol, avoid taking large amounts of NSAIDs, aspirin, avoid coffee and caffeine, manage stress, stop smoking
acute gastritis CM
rapid onset of epigastric pain or discomfort**
n/v, hematemesis, gastric hemorrhage, dyspepsia, anorexia
chronic gastritis CM
vague report of epigastric pain that is relieved by food**
anorexia, n/v, intolerance of fatty and spicy foods, pernicious anemia
gastritis diagnostic test
biopsy via EGD is gold standard
acute gastritis interventions
treated symptomatically and supportively because healing process is spontaneous
chronic gastritis inteventions
varies with cause
h2 receptor antagonists
cimetidine/pepsid- decrease gastric acid secretions by blocking histamine receptors in parietal cells
mucosal barrier
sucralfate- binds with bile acids and pepsin to protect stomach mucosa, stimulates mucosal protection, may cause the stools to be discolored black
antacids
sodium bicarbonate- increases pH of gastric contents by deactivating pepsin
proton pump inhibitor
omeprazole- suppress gastric acid secretions
vitamin B 12
prevention or treatment of pernicious anemia
PUD- peptic ulcer disease definition
mucosal lesion of the stomach or duodenum- occurs when mucosal defenses become impaired and no longer protect the epithelium from the effects of the acid and pepsin
PUD- peptic ulcer disease types
gastric, duodenal, stress
PUD- peptic ulcer disease etiology
most gastric and duodenal ulcers are cause by H pylori infection or NSAIDs- harder to diagnose in older adults
PUD- peptic ulcer disease complications
hemorrhage, perforation, pyloric obstruction, intractable disease
PUD- peptic ulcer disease CM
dyspepsia (indigestion), epigastric tenderness, n/v
PUD- peptic ulcer disease diagnostic testing
EGD
PUD- peptic ulcer disease priority problems
acute or chronic pain and upper GI bleed
PUD- peptic ulcer disease interventions
diet- bland foods, avoid snacks, alcohol, tobaccos, caffeine
complimentary therapy: hypnosis, imagery, yoga, meditation
prostaglandins analogs
stimulates mucosal protection and decrease gastric acid secretions, help resist mucosal injury in patients taking NSAIDs and or high dose corticosteroids
PPI triple therapy
PPI and two antibiotics
PPI quadruple therapy
PPI, two antibiotics, bismuth (pepto-bismol)
small bowel obstruction CM
abdominal discomfort or pain, upper or epigastric abdominal distention, nausea and early, profuse vomiting, possible visible peristaltic waves in upper and middle abdomen, obstipation (no passage of stool), severe fluid and electrolyte imbalance
small bowel obstruction imaging
abdominal CT scan
small bowel obstruction interventions
NPO, nasogastric tube, Iv fluid replacement and maintenance, monitor pain and VS, exploratory laparotomy, assess for bowel sounds, flatus and stool indicating peristalsis returned.
osteoporosis definition
chronic metabolic disease in which bone loss causes decreased density and possible fracture- deceased bone mass
osteoporosis generalized types
primary:
postmenopausal women- decreased estrogen
men in their seventh or eight decade of life- decreasing levels of testosterone which builds bone
Secondary: results from other medical conditions
osteoporosis regional
occurs when a limb is immobilized related to a fracture, injury, or paralysis. immobility for longer than 8-12 weeks and result in this type of osteoporosis
osteoporosis risk factors
older age in both genders and all races, parent history of osteoporosis (especially mothers), low trauma fracture after 50, chronic low calcium and vitamin D intake, smoking, high alcohol intake, estrogen or androgen deficiency.
osteoporosis teaching prevention
build strong bones as a young person, decrease modifiable risk factors- sun exposure, include dietary calcium, limit carbonated beverages, exercise
osteoporosis physical assessment
kyphosis, “getting shorter”, pain and assess for fractures
osteoporosis imaging
DEXA scan- measures bone mineral density, best tool for definitive diagnosis
osteoporosis interventions
nutrition therapy- fruits and vegetables, low fat dairy and protein, increased fiber, moderation of alcohol and tobacco
exercise- walk 30 min 3-5 times a week
drug therapy- calcium/vitamin d, bisphosphonates, estrogen antagonists and agonists, calcitonin
71 year old Caucasian female has been
diagnosed with osteoporosis for 15 years.
* Both her mother and sister had osteoporosis
and her sister recently died after a hip fracture.
* She has been on calcium and vitamin D
supplements and risedronate (Actonel) on and
off for 12 years.
* According to her most recent DEXA scan (Dual
x-ray absorptometry) she continues to lose bone
density.
* Last year she sustained a fracture of her
humerus.
What risk factors does this patient
have for osteoporosis?
– Older age
– Maternal history of osteoporosis
– History of low trauma fracture after age
of 50
Other than fractures, what other signs
and symptoms might the nurse expect
when caring for this patient with osteoporosis?
Kyphosis
– Reports of “getting shorter”
– Pain
– Assess for fractures (pain, swelling,
misalignment)
What diagnostic test is used to diagnose
and monitor progression of
osteoporosis?
DEXA scan- measure bone density
Which statement by the patient
regarding lifestyle changes indicates a
need for further teaching?
– A. “I will get rid of my scatter rugs”
– B. “ I will cut back to 3 martinis a day”
– C. “I will increase my calcium and vitamin
D intake”
– D. “I am going to walk every day”
B
osteoarthritis definition
most common arthritis, major cause of disability among adults older than 60, also called degenerative joint disease, deterioration and loss cartilage in one or more joints
osteoarthritis causes
combination of factors; aging, genetics, obesity, joint injury, occupation. females more commonly
osteoarthritis physical assessment
unilateral, single joint, affects weight bearing joints, spines, and hands, non-systemic, pain and stiffness, Herbeden’s nodes.
osteoarthritis treatments
Tylenol, topical drug administration, NSAIDs, cortisone injections, muscle relaxants
rest, exercise, heat or cold applicants, weight control
surgery
Total Joint Arthroplasty complications
dislocation, infection, VTE, bleeding, hypotension, neuromuscular compromise, scar tissue formation
Total Joint Arthroplasty interventions
positioning, aseptic technique for wound care, monitor temp, use SCDs, teach leg exercises, encourage fluids, administer anticoagulant, do not massage legs, VS q4, check for 5 Ps, continuous passive motion machine
Which patients are at risk for
developing OA? (Select all that apply)
– A. Obese, older woman living alone
– B. Slender, non smoking middle aged
man
– C. Middle aged man with 25 years
working in construction
– D. Young woman with a family history of
cancer
– E. Middle aged adult with multiple knee
surgeries from high school soccer
ACE
Postoperative care of a total knee
replacement may include which of the
following? (Select all that apply)
– A. Hot compress to incisional area
– B. Continuous passive movement (CPM)
used immediately or several days post op
– C. Ice packs to incisional area
– D. Check CMS (circulation, movement,
sensation)
– E. Maintaining abduction
BCD
The nurse is preparing an educational
session for nursing students on the
orthopedic unit. Which three signs of
hip dislocation would be included?
(Select all that apply)
– A. Increased pain
– B. Hip flexing at 45 degrees
– C. Shortening of affected leg
– D. Leg rotation
– E. Skin breakdown near the incision
ACD
factors contributing to UTI
obstruction, stones, vesicoureteral reflux, DM, characteristics of urine, gender, age, sexual activity, recent use of antibiotics
minimizing catheter related infections
good hygiene, insert for appropriate use only, assess for daily need, use sterile technique when inserting, select a small sized catheter, keep tubing and collection bags lower than the bladder, perform daily catheter care.
UTI CM that may occur in the older adult
increasing mental confusion or frequent unexplained falls, sudden onset of incontinence or worsening incontinence, loss of appetite, nocturia, dysuria,
cystitis prevention
drink 2-3 L per day, get sleep and rest, stay away from spermicides, women should clean peri-area front to back, empty bladder before and after intercourse, do not delay urination, notify provider if s/s of UTI develop, nutritional supplements to reduce the risk of developing UTI
cystitis lab assessment
Urinalysis
cystitis diagnostic assessment
Pelvic US or CT, voiding cystiurethrography, cystoscopy
cystitis interventions
antiseptics, antibiotics, analgesics, antispasmodics, maintain adequate fluid intake, avoid fluids or food that will irritate bladder, comfort measures
urolithiasis definition
presence of stones in urinary tract
urolithiasis etiology
unknown, 90% have metabolic risk factors
urolithiasis risk factors
family history, over weight, diet, history of urinary tract infections
urolithiasis CM
severe pain, hematuria, n/v, pallor, diaphoresis, frequency, dysuria, flank pain, most intense pain when stone is moving, oliguria
urolithiasis diagnostic assessment
KUB, x-ray, CT, US
urolithiasis interventions
IV opioids, NSAIDs, spasmolytic drugs, tamsulosin to relax urethra, strain urine, antibiotics, assess for infection, monitor nutrition, high intake of fluids 3L, accurate I&Os, walk as often as possible, shock wave lithotripsy surgery.
solid cancer
develop from specific tissues
hematologic cancer
develop from blood cell forming tissues
untreated cancers can cause
reduced immunity and blood producing functions, altered Gi structure and function, motor and sensory deficits, reduced gas exchange
purpose of cancer management
prolong surivival time or improve quality of life
cancer therapy includes
surgery, radiation, chemo, hormonal therapy, photodynamic therapy, immunotherapy, molecular targeted therapy, gene therapy.
prophylactic surgery
removes at-risk tissue to prevent cancer development
diagnostic surgery
removal of all or part of a suspected lesion for examination and testing.
curative surgery
removes all cancer tissue
cancer surgery post op
same physical needs as other patients, emotional and spiritual support, expression of concerns, help patient accept changes in appearance and function, support group resources, PT/OT planning for discharge
purpose of radiation therapy
destroy cancer cells and have minimal damaging effects on the surrounding normal cells.
teletherapy
radiation delivered from a source outside the patient, delivered in small doses on a daily basis for a set time period, patient is not radioactive.
bracytherapy
radiation source is within the patient, sealed or unsealed, patient emits radiation for a period of time and is a potential hazard to others.
sealed brachytherapy
patient emits radiation when implant is in place
unsealed brachytherapy
patient body fluids are radioactive and must be handled according to guidelines.
radiation side effects
skin changes, hair loss, altered taste, fatigue, inflammation of tissue lead to tissue fibrosis and scarring
radiation therapy precautions
private room and bathroom, signage on doors, keep door closed, wear film badges, no pregnant nurses or nurse trying to conceive should care for this patient, no one under 16 should visit this patient, limit visitors, never touch radiation source with bare hands, keep dressings and linens in the patients rooms.
chemotherapy purpose
used to cure and increase survival time and acts by damaging DNA and interferes with cell division. used along with other therapies.
chemo administration
usually given every 3-4 weeks for a certain number of times. Typically given IV, monitor for extravasation, requires additional education and teachings to administer, wear PPE
chemo side effects
anemia, neutropenia, thrombocytopenia, n/v, mucositis, alopecia, skin changes, anxiety, sleep disturbance, altered bowel elimination, psychosocial issues.
anemia
decreased RBCs and hemoglobin
neutropenia
decreased WBCs leading to immunosuppression
thrombocytopenia
decreased number of platelets
chemo interventions- neutropenia
avoid infection since bone marrow function is suppressed, encourage patient. to report signs of infection , strict hand washing, aseptic technique, avoid crowds and sick people, monitor CBC, administer filgrastim as needed.
chemo interventions- anemia
monitor for symptoms of anemia, administer erythrocyte stimulating agents to improve, blood transfusion is common.
chemo interventions- thrombocytopenia
monitor for bleeding and bruising, transfusion of platelets, administer growth factor, prevent injury
chemo interventions- other
give antiemetics, frequent mouth assessment, soft bristle toothbrush, reassure that hair loss is temporary, give coping resources, avoid alcohol, drugs, and activities that increase head injury, avoid injury and protect feet, wear well fitting shoes, inspect feet daily, avoid rugs (Chemotherapy induced peripheral neuropathy)
anemia can result from
dietary problems, genetic disorders, bone marrow disease, excessive bleeding, GI bleed.
anemia key features
pallor, cool to touch, tachycardia, orthostatic hypotension, dyspnea on exertion, fatigue and somnolence
iron deficiency anemia- causes
blood loss, poor GI absorption of iron, poor iron intake
iron deficiency anemia- labs
hbg/hct and RBC decreased, ferritin decreased
iron deficiency anemia- CM
weakness and pallor, fatigue, reduced exercise tolerance, fissures at the corners of the mouth
iron deficiency anemia- interventions
increase oral intake of iron in food, oral iron supplements, give IV or IM iron for severe cases
vitamin B12 anemia- causes
vegan diets or lacking dairy, Gi disorders, pernicious anemia secondary to gastritis
vitamin B12 anemia- CM
pallor, jaundice, glossitis (beefy red tongue), fatigue, weight loss, paresthesias, poor balance
vitamin B12 anemia- interventions
increase intake of foods rich in vitamin B12, vitamin supplements if anemia is severe, for pernicious anemia- administer B12 injections weekly and then monthly for the rest of their lives
folic acid deficiency anemia- causes
poor nutrition, malabsorption, drugs- develops slowly
folic acid deficiency anemia- CM
similar to those of vitamin B 12 deficiency anemia- does not affect nerve function
folic acid deficiency anemia- treatment
diet rich in foods containing folic acid and vitamin b12, folic acid replacement
aplastic anemia- definition
deficiency of circulating RBCs because of failure of the bone marrow to produce these cells
pancytopenia (loss of all bone marrow parts)
aplastic anemia- causes
long term exposure to toxic agents, drugs, ionizing radiation, viral infection
aplastic anemia- treatment
assess for bone marrow failure, close monitoring of CBC, infection prevention, bleeding precaution, blood transfusion, immunosuppressive medications, splenectomy (could be destroying RBCs)
hemolytic anemia- definition
results from an autoimmune process that causes excessive destruction of RBCs
hemolytic anemia- causes
autoimmune, trauma, viral infection, exposure to chemical or drug
hemolytic anemia-interventions
immunosuppressive therapy, plasma exchanges, splenectomy,
Which statement about hematologic
changes associated with aging is true?
A. The older adult has increased blood
volume
B. The older adult has increased levels
of plasma proteins
C. Platelet counts decrease with age
D. Antibody levels and responses are
lower and slower in older adults
D
The patient reports a history of
splenectomy. Based on this
information, what is the nurse most
likely to assess for?
A. Signs of bleeding
B. Signs of infection
C. Digestive problems
D. Jaundice of the skin
B
An experienced nurse is supervising a
new graduate who is assessing a patient
with a suspected hematologic problem.
The experienced nurse would intervene if
the new nurse performed which action?
A. Auscultated the heart for abnormal
heart sounds or irregular rhythm
B. Palpated the abdomen to attempt to
locate an enlarged spleen
C. Assessed joints for swelling or pain
D. Assessed the skin for petechiae and
ecchymoses
B
Question
When assessing the patient with
darker skin for pallor and cyanosis,
which area would the nurse examine?
A. Chest and abdomen
B. General appearance of face
C. Fingertips and toes
D. Oral mucous membranes
D
Question
Which of the following interventions
should the nurse implement for
bleeding precautions? (SATA)
A. Assess skin and mucous membranes
B. Inspect stool and urine
C. Measure abdominal girth
D. Offer soft bristle tooth brush
E. Offer to shave patient with razor
F. Monitor lab values
ABCDF
Question
All of the following is true about bone
marrow aspiration, EXCEPT:
A. It is performed to evaluate patient’s
blood cells and hematologic status
B. It is performed in OR
C. Biopsy could be obtained
D. It could provide a differential
diagnosis
B
The nurse understands that anemia is a
reduction in the number of which of
the following? (Select all that apply)
A. WBCs
B. RBCs
C. Platelets
D. Hemoglobin
E. Hematocrit
F. Neutrophills
BDE
What is the most common
manifestation of anemia?
A. Fatigue
B. Long bone pain
C. Weight gain
D. Loss of appetite
E. Headache
A
What are integumentary
manifestations of anemia? (SATA)
A. Flashed cheeks
B. Cyanosis
C. Pallor
D. Cool skin
E. Intolerance of cold
F. Dry flaky skin
CDE
What are CV manifestations of
anemia? (SATA)
A. Tachycardia
B. Bradycardia
C. Hypertension
D. Orthostatic hypotension
E. Systemic edema
AD
What are respiratory manifestations of
anemia? (SATA)
A. Dyspnea on exertion
B. Orthopnea
C. Decreased SaO2
D. Nagging cough
E. Decreased breath sounds
F. Tachypnea
ACF
What are neurologic manifestations of
anemia? (SATA)
A. Neuropathy
B. Somnolence
C. Fatigue
D. Headache
E. Confusion
F. Delirium
BCDE
Question
The nurse is caring for four patients.
Which of these patients has the most
common risk factor for anemia?
A. Patient on vegan diet
B. Patient with history of exposure to
radiation
C. Patient with lower GI bleed
D. Patient with anorexia
C
Which of the following are risk factors
for pernicious anemia?
A. Infections and chemotherapy
B. Sickle cell disease
C. Gastric resection and small bowel
resection
D. Blood loss and poor iron absorption
C
Which of the following is treatment for
folic acid deficiency anemia? (SATA)
A. Blood products transfusion
B. Cyanocobalamin injections IM
C. Iron supplements IV
D. Epoetin alfa injections SQ
E. Folic acid tablets PO
F. Lentil, spinach and broccoli
G. Salmon, cantaloupe and eggs
EF
A deficiency in RBC, WBC and
platelets?
– A. Aplastic anemia
– B. Pancytopenia
– C. Neutropenia
– D. Thrombocytopenia
B
Question
* An unidentified male trauma client
requires an emergent transfusion.
What is the correct transfusion option
for packed RBC?
– A. Type AB-negative, uncrossmatched
blood
– B. Type AB-positive, uncrossmatched
blood
– C. Type O-negative, uncrossmatched blood
– D. Type O-positive, uncrossmatched blood
C
Question
* When preparing to administer RBCs,
the nurse notes that lactated Ringer
solution is hanging on the IV pole.
Which substance should be used to
flush the line before hanging the
blood?
– A. Lactated Ringer solution
– B. Normal saline
– C. Heparin by infusion pump
– D. Prophylactic antibiotics
B
A nurse is preparing to administer a
blood transfusion. What action is
most important?
– A. Correctly identifying client using two
identifiers
– B. Hanging blood product with lactated
Ringers
– C. Staying with the client for the entire
transfusion
– D. Keeping blood product refrigerated
A
When a client undergoing a blood
transfusion complains of flank pain
and a sense of doom, which adverse
reactions should be suspected?
– A. A hemolytic transfusion reaction
– B. Bacterial contamination of the blood
– C. An allergic transfusion reaction
– D. TACO
A
If a client develops a skin rash,
edema, and wheezing during a blood
transfusion, what should the nurse
do?
– A. Discard the blood bag and tubing.
– B. Decrease the rate of the transfusion.
– C. Stop the transfusion immediately.
– D. Reassess the client in 10 minutes.
C
Red Blood Cell/ Packed Red Blood Cells Transfusion
replace lost blood or anemia, ABO Rh factors, Infuse over 2-4 hours, use filtered pump tubing
Platelet transfusion
to treat thrombocytopenia or active bleeding, pooled from multiple donors so the blood type doesn’t matter, use specific tubing, infuse over 15-30 min
Plasma transfusion
to treat deficiency in plasma coagulation factors, must be ABO compatible, infuse over 15-30 min, use y set tubing.
Granulocyte (WBC) transfusion
used with sepsis or neutropenic infection, rare, more at risk for transfusion reactions (WBC surfaces have many antigens), usually requires closer monitoring, infuse over 1 hour
Pre Transfusion protocol
assess labs, verify order with another RN, ensure IV access, assess vitals, obtain blood product from blood bank and administer asap, safety check (ID, MRN, expiration, ABO, Rh) and inspect blood for discoloration, gas bubbles, cloudiness
During transfusion protocol
VS before starting. and 30 minutes after starting, use appropriate tubing, stay with patients for 30 min, assess for hyperkalemia.
Blood transfusion complications
febrile transfusion reaction, hemolytic transfusion reaction, allergic reaction, bacterial transfusion reaction, transfusion-associated circulatory overload, transfusion related graft v. host disease, acute pain transfusion reaction
febrile transfusion reaction
signs: fever, chills, tachycardia, hypotension and tachypnea
occurs when a patient has has multiple transfusions and develop WBC, antibiotics
prevention: give leukocyte reduced blood or single donor blood; use of WBC filters when administering blood products
hemolytic transfusion reaction
signs: chills, fever, apprehension, HA, chest pain, low back pain, tachycardia, tachypnea, hypotension, sense of impending doom
occurs when there is a blood type or Rh incompatibility- antigen antibody complexes form and destroy cells and cause inflammatory response
prevention: ensure that all blood products are typed and cross matched, adhere to all safety checks prior to administration
allergic reaction blood transfusion
signs: urticaria, itching, bronchospasm, anaphylaxis
usually seen in patients with other allergies- immediately or within 24 hours
prevention: give leukocyte reduced blood
bacterial transfusion reaction
signs: tachycardia, hypotension, fever, chills
caused by contaminated blood and onset is rapid.
transfusion associated circulatory overload (TACO)
hypertension, bounding pulses, JVD, dyspnea, restlessness and confusion
occurs when blood product is infused too quickly
prevention: infuse blood products slowly, diuretics, monitor I&O
transfusion related graft v. host disease
thrombocytopenia, anorexia, n&v, weight loss, infection
occurs in immunocompromised patient and occurs within 1-2 weeks
prevention: administered irradiated blood products that destroy t cells and cytokine
acute pain transfusion reaction
signs: severe chest pain, back pain, joint pain, hypertension, anxiety and redness of head and neck
rare and occurs during or immediately after transfusion
treatment: control symptoms
nursing interventions for blood transfusion complications
stop the infusion (don’t flush tubing and put anymore blood into the patient) take down all blood tubing and save with all labels, oxygen, diphenhydramine, iv fluids for shock, antibiotics, antipyretics for fever, meperidine for rigors
bone marrow
responsible for blood formation, first produces blood stem cells (stem cells can become whatever type of blood cell the body needs), also has a role in immune responses, located in flat bones and ends of long bones
plasma
extracellular fluid with plasma proteins- albumin, globulins, fibrinogen
RBCs
largest portion of blood, produce hemoglobin which carries oxygen and carbon dioxide, iron is important component of hemoglobin
WBCs
role in inflammation and infection protection
platelets
smallest blood cells, stick to injured vessel walls and aggregate to assist clotting, stored in spleen
spleen- accessory organ of blood formation
destroys old or imperfect RBCs, breaks down the hemoglobin, stores platelets, antibody production and filters antigens
liver- accessory organ of blood formation
produces prothrombin and other clotting factors, assists in the forming of vitamin K in the intestine, stores blood cells, stores iron in the form of ferritin
hematologic changes with aging
decreased blood volume, lower levels of plasma proteins, bone marrow produces less blood cells, hemoglobin levels i men and women fall after middle age, immune response changes (weaker, lower and slower, WBC count lower)
hematological assessment
patient history (age, gender, liver function, immunologic or hematologic disorders, drug use)
nutrition status
environmental exposure
family history and genetic risk (sickle cells or hemophilia)
current health problems (lymph node swelling, easy bruising or bleeding, common symptoms of hemo disease)
hematologic skin assessment
inspect skin and mucous membranes for pallor
nail beds for pallor and cyanosis
petechiae and ecchymoses
hematologic head and neck assessment
inspect and palpate all lymph node areas
hematologic respiratory assessment
assess respirations and dyspnea on exertion/rest
fatigue
orthopnea
hematologic cardiovascular assessment
assess pulses
BP
abnormal heart sounds
irregular rhythms
hematologic kidney and urinary assessment
assess urine for hematuria
hematologic musculoskeletal assessment
rib or sternal tenderness may occur with leukemia
assess range of joint motion
document pain and joint swelling
hematologic abdominal assessment
evaluate spleen
stool psecimen to check for occult blood testing
hematologic CNS assessment
neurologic checks and checks of cognitive function
RBC count
4.2-6.1
Hgb count
12-18 g/dL
Hct count
37%-52%
WBC count
5,000-10,000
platelet count
150,000-400,000
Prothrombin time
11-12.5 seconds
iron count
60-180 mcg/dL
ferritin count
10-300 ng/mL
total iron binding capacity
250-460 mg/dL
Bone marrow aspiration and biopsy
Evaluates hematologic status
Specifically for a possible problem in blood
cell production or maturation
Invasive procedure
Aspiration
– cells and fluids are suctioned from the
bone marrow
Biopsy
– solid tissue and cells are obtained by
coring out an area of bone marrow with a
large-bore needle
Informed consent needed
Bone marrow aspiration and biopsy preparation
Preparation:
– Provide information and emotional
support
– Explain the procedure
* Local anesthetic is used and may feel stinging
or burning sensation
* Mild tranquilizer or a rapid-acting sedative
could be used
* Expect a heavy sensation of pressure and
pushing while the needle is being inserted
– Positioning
* Usually use the iliac crest
* Patient should be placed in the prone or side-
lying position
Bone marrow aspiration and biopsy post operative procedure
Post procedure care:
– Hold pressure briefly to site
– Cover the site with a dressing after
bleeding is controlled
– Give mild analgesic for discomfort
– Apply ice bag to the needle site to limit
bruising
– Observe site every 2 hours for 24 hours for
signs of bleeding, bruising, and infection
– Advise the patient to avoid contact sports
or any activity that might result in trauma
to the site for 48 hours
What is cancer?
- Mutation of cells
– Rapid growth
– Can migrate or metastasize easily - Solid tumors or hematologic (blood)
- Classified by type of tissue originating
from or primary site - Cellular aspects of the cancer are also
important to consider - Staging done at diagnosis
– TNM system (tumor; node; metastasis)
division
uncontrolled cell division
growth
formation of a lump (tumor)
or large numbers of abnormal white
cells in the blood
mutation
changes to how the cell is
viewed by the immune system
spread
ability to move within the
body and survive in another part
cancer prevention
- Don’t smoke
- Avoid exposure to know carcinogens
– Ex. UV light, asbestos - Eat a healthy diet
– Fruits and vegetables, limit alcohol; low fat - Be physically active
- Vaccinate against or early detection of to
prevent cancer causing infections
– Ex. Hepatits B; Human Papilloma virus (HPV);
H.Pylori - Have the right genes
– Certain genes have been isolated
**Sometimes there is no predisposing factor
cancer surigcal treatment
Can be prophylactic, diagnostic, or
curative
* 30 % survival rate with surgery alone
* Post op care
– All traditional post op physical care
– Need to address emotional and
spiritual needs
cancer raditaion therpay
- Destroys cancer cells but will also affect
surrounding tissue - Typically given daily for a designated period of
time - Can be external (teletherapy) or implanted
(brachytherapy) - For external radiation patients will have
markings for course of therapy - Side effects:
– Fatigue
– Hair loss
– Skin changes - Skin care is very important
– Altered taste
– Inflammation and scarring of surrounding tissue
cancer chemotherapy
Cytotoxic agents
* Used to cure and/or increase survival
time
* Typically given IV but can also be PO
* Administration requires special
education
– **Infiltration of the medication can be a
serious complication (see next slide)
* Adhere to all “chemo precautions”
– Special handling of medications (IV or PO)
– Special handling of all bodily fluids
cancer chemotherapy AE
Side Effects caused by the damage of normal cells as
well cancer cells
– Anemia
– Neutropenia
– Thrombocytopenia
– Nausea and vomiting
– Mucositis
– Hair loss
– Skin changes
– Chemo induced peripheral neuropathy
– Altered bowel elimination
– Anxiety
– Sleep disturbances
– Changes in cognition
– Psychosocial concerns
AB+
Antigen: A and B
Antibody: None
Compatible RBCs: All ABO and Rh groups
Compatible Plasma: AB
AB-
Antigen: A and B
Antibody: None
Compatible RBCs: O-, AB-, A-, B-
Compatible Plasma: AB
B+
Antigen: B
Antibody: Anti A
Compatible RBCs: B+, B-, O+, O-
Compatible Plasma: B, AB
B-
Antigen: B
Antibody: Anti A
Compatible RBCs: B-, O-
Compatible Plasma: B, AB
A+
Antigen: A
Antibody: Anti B
Compatible RBCs: O-, A-, A+,O+
Compatible Plasma: A, AB
A-
Antigen: A
Antibody: Anti B
Compatible RBCs: O-, A-
Compatible Plasma: A, AB
O+
Antigen: NO A or B
Antibody: Anti A and B
Compatible RBCs: O-, O+
Compatible Plasma: O, A, B, AB
O-
Antigen: NO A or B
Antibody: Anti A and B
Compatible RBCs: O-, O+
Compatible Plasma: O, A, B, AB
15 gtts
1 mL
1 tsp
5 mL
1tbsp
15 mL
1 oz
30 mL
1 c
240 mL
1 pint
500 mL
1 quart
1000mL
1 kg
2.2 lbs
1 kg
1000 gm
1 gm
1000 mg
1mg
1000 mcg
1L
1000 mL
1 mL
1 cc
