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Adult Health 3 > Final Exam > Flashcards

Final Exam Flashcards

1
Q

How should all hemodynamic measurements be taken?

A

At phlebostatic axis with the HOB 45 degrees

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2
Q

PVR (Pulmonary Vascular Resistance): Value

A

37 - 250 dynes

Right Afterload

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3
Q

SVR (Systemic Vascular Resistance): Value

A

800 - 1,400 dynes

Left Afterload

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4
Q

Cardiac Output (CO)

A

4 - 8 L/min

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5
Q

Stroke Volume (SV)

A

50 - 100 ml/beat

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6
Q

RA/CVP

A

2 - 6 mmHg

Right Preload

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7
Q

Wedge Pressure

A

8 - 12 mmHg

Left Preload

*If unavailable, check PA diastolic

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8
Q

Ejection Fraction

A

60 - 70%

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9
Q

Monro-Kellie Hypothesis

A

3 components in the skull: CSF, brain, blood

Increases in any one, increases ICP

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10
Q

ICP: Normal Value

A

5 - 15

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11
Q

Intracranial HTN: Value

A

> 20

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12
Q

High ICP: S/S

A
  • LOC change**
  • Pupillary changes
  • Papilledema
  • Motor changes (decorticate, decerebrate, flaccid)
  • Headache
  • Projectile Vomiting
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13
Q

High ICP: Treatment

A

-Hypertonic Saline (3% NaCl)*
-Osmitrol (Mannitol)*
Use a filter d/t crystallization possibility
Bolus is best method
-Dexamethasone, Solumedrol (steroids)

No hypotonic fluids (D5W or 1/2 NS) -> causes swelling

HOB >30 degrees

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14
Q

Spinal Shock: Definition

A

Temporary loss of all motor and sensory function BELOW LOI - immediately after injury

Gradual return of function: 4-6 weeks

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15
Q

Spinal Shock: S/S

A
  • Complete loss of motor reflexes
  • Flaccid paralysis
  • Loss of Bowel and Bladder control (retention)

Assess for (+) anal wink at onset = incomplete injury (good sign)

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16
Q

Neurogenic Shock: Definition

A

Temporary loss of SNS innervation (often SCI above T6) - immediately after injury

Without SNS, PNS takes over (vagal nerve)

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17
Q

Neurogenic Shock: S/S

A
  • Vasodilation
  • Hypotension (treat with vasopressors and volume)
  • Bradycardia (treat with Atropine if bpm 40s-50s)
  • Skin, warm and dry
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18
Q

Neurogenic Shock: Care

A
  • Ace wraps, compression boots (to circulate perfusion centrally)
  • Vasopressors and volume
  • Atropine
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19
Q

Autonomic Dysreflexia: Definition

A

Overstimulation of SNS below LOI - a few weeks after the injury

Common cause: Bowel and Bladder

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20
Q

Autonomic Dysreflexia: S/S

A
  • HA
  • Facial flushing and warmth
  • Nasal congestion
  • # 1 HTN
  • Bradycardia
  • Anxiety/impending doom

Below Injury: cold skin with goosebumps

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21
Q

Autonomic Dysreflexia: Interventions

A
  • Sit patient up, elevate HOB to lower BP
  • Identify and remove stimulus
  • Treat BP if remaining high
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22
Q

Stroke: Presentation

A

GFAST

Gaze
Facial Droop
Arm Weakness
Speech Difficulty
Time of Onset
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23
Q

Basilar Artery Syndrome: S/S

A

Basilar Artery supplies 95% of blood to brain stem

  • Dizziness
  • Ataxia (loss of body control)
  • Tinnitus
  • N/V
  • One sided weakness
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24
Q

Right MCA Stroke: S/S

A

Most common

  • Left weakness
  • Head/eyes turn to stroke side (right)
  • “Let side neglect”
  • Disoriented
  • Impulsive
  • Poor judgement
  • Lack of proprioception
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25
Q

Left MCA Stroke: S/S

A
  • Right sided weakness
  • Altered intellectual ability
  • Slow
  • Cautious
  • Anxious
  • Depressed
  • Dyslexia
  • Aphasia
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26
Q

Expressive Aphasia

A

Affects Broca’s Area (frontal lobe)

Understand language, but can’t communicate/talk/write
Use a picture board

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27
Q

Receptive Aphasia

A

Affects Wernicke’s Area (temporal lobe)

Unable to understand language
Make up new words

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28
Q

Ischemic Stroke: Meds

A

Fibrinolytic/Thrombolytic Therapy

TPA (must meet criteria)

  • No acute hemorrhage
  • Tx sooner than 4.5 hours after onset
  • BP <185/110 (use Labetalol and Nicardipine)
  • Neuro assessment after admin

NO TPA IF RECENT BLEED OR RISK FOR BLEEDS

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29
Q

Stroke: Nursing Care

A

-Determine time of onset
-Urgent non-contrast CT (determines stroke type)
-Prioritize ABC
-Impaired swallowing
-Impaired communication
-Clothe weak side first
-If Blind on one side:
Rotate Tray
Neglect Syndrome (use mirror for self care)

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30
Q

Meningitis: Definition

A

Infection of the meninges surrounding the brain and spinal cord

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31
Q

Meningitis (Bacterial): Presentation

A

MOST LETHAL

  • Brain damage
  • Hearing loss
  • Epilepsy
  • Death
  • Meningococcal may cause death in 24 hr
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32
Q

Meningitis (Viral): Presentation

A

Self-limiting

Sometimes herpes can cause rapid brain tissue necrosis

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33
Q

Meningitis: General S/S

A
  • Photophobia
  • Nuchal Rigidity
  • Brudzinski’s Sign & Kernig’s Sign
  • HA
  • Weakened immune system
  • N/V, fever, chills, generalized muscle aches and pain
  • Red macular skin rash (meningococcal)
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34
Q

Meningitis: Diagnosis

A

Lumbar puncture and analyze CSF
Cloudy, low glucose: Bacterial
Clear, normal glucose: Viral

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35
Q

Meningitis: Nursing Care

A

-Droplet and Standard Precautions (until abx 24-48 hr)
Regular room
Don’t have to close door
Surgical mask within 3 ft.
Mask on patient when out of room
-Abx, anti-seizure, analgesic, anti-pyretic, corticosteroids

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36
Q

Pulmonary Embolism

A

Obstruction of pulmonary artery (most commonly a clot)

Large emboli can impair circulation and gas exchange

PE common in hospitalization (can cause death with 1 hr)

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37
Q

Pulmonary Embolism: Risk Factors

A
  • Prolonged immobility (venous stasis)
  • CVC
  • Surgery (vessel damage and clot formation)
  • Obesity
  • Advancing age
  • Conditions that increase clotting (pregnancy, sickle cell, estrogen tx)
  • History of thromboembolism
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38
Q

Pulmonary Embolism: Classic S/S

A
  • Sudden dyspnea
  • Pleuritic chest pain
  • Tachypnea
  • Anxiety
  • Cough
  • Hemoptysis
  • Feeling of impending doom/anxiety
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39
Q

Massive Pulmonary Embolism: S/S

A
  • Tachycardia
  • JVD
  • Hypotension
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40
Q

Pulmonary Embolism: Prevention

A
  • DVT prophylaxis
  • Passive and Active ROM
  • SCDs. TEDs
  • Anticoagulants/Antiplatelets
  • Avoid smoking
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41
Q

Pulmonary Embolism: Diagnosis

A
  • CT scan (check kidney function: BUN/Cr, UOP)
  • Multidetector or CT angiography
  • D Dimer assay
  • Ventilation perfusion scan (VQ scan)
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42
Q

Pulmonary Embolism: Drug Therapy

A

-Draw coagulation studies first**
-Anticoagulants
Heparin (PTT: 40-90)
Warfarin/Coumadin (INR: 2-3)
Lovenox (Enoxaparin)
Xarelto (Rivaroxaban)
-Thrombolytic if ordered (“-ase”

43
Q

Acute Respiratory Distress Syndrome (ARDS): Criteria

A

-Onset <7 days
-Refractory hypoxemia (doesn’t respond to non-invasive O2 tx)
-Bilateral chest infiltrates (“white out” on X-Ray)
-No Left HF evidence
Normal Wedge: 8-12

44
Q

ARDS: Precipitating Factors

A
  • Shock
  • Trauma
  • Pancreatitis
  • Sepsis
  • Pulmonary Aspiration
  • Toxin Inhalation
  • Multiple Blood Transfusions
45
Q

ARDS: Manifestations

A
  • Rapid onset dyspnea**
  • Increased alveolar dead space**
  • Refractory hypoxemia (needs intubation)**
  • Abnormal lung sounds
  • Cyanosis
  • Intercostal/substernal retractions
  • Tachycardia
  • Hypotension
46
Q

ARDS: Nursing Implications

A

-Intubation and Mechanical Vent
-Corticosteroids (anti-inflammatory)
-Nutritional support
-Fluids per protocol
-Inhaled nitric oxide (vasodilator)
-Surfactant Replacement
-ECMO
Re-oxygenates blood
Allows lungs to rest and heal

47
Q

Laryngeal Trauma

A

Ensure patent airway

May have to prep for total laryngectomy (teach patient they won’t be able to speak after)

48
Q

Laryngeal Trauma: Presentation

A
  • Hoarse
  • Swelling
  • Dyspnea
  • Hemoptysis
  • Hematoma/Edema of neck
49
Q

Laryngeal Trauma: Interventions

A
  • Monitor Airway
  • Trach kit and emergency equipment at bedside
  • Provide humidified air
  • HOB >45 degrees
  • Aspiration precautions
  • Voice Rest
50
Q

Chest Trauma: Primary Survey

A

ABCDE

-Airway - C Spine (C4 and C5 innervate the diaphragm)
-Breathing - equality/quality of breath sounds
-Circulation - Pulse, HR, skin, BP, bleeding signs, IVF
-Disability - GCS or AVPU (alert, voice, pain, unresponsive)
-Expose (remove clothing for complete emergency assessment)
Cover with warm blanket

51
Q

Chest Trauma: Nursing Interventions (order)

A
  • Open airway under C-Spine precautions
  • Provide oxygen
  • Prepare for ETT
  • Establish IV access
  • Fluids as ordered (warmed)
  • Monitor temp
52
Q

Chest Trauma: Secondary Survey

A

AMPLE

Allergies
Medication use
Past medical hx
Last meal
Events leading to injury
53
Q

Assessment Findings for clues of injury

A

Pneumothorax - diminished breath sounds
Ruptured Diaphragm - Breath sounds in lower mid chest
Vascular Injury - bruit
Cardiac Tamponade or Pericardial Bleed - muffled heart sounds
Tension Pneumothorax or Cardiac Tamponade - Distended neck veins
Hypovolemia - flat jugulars
Tension Pneumothorax or Massive Hemothorax - tracheal shift

54
Q

Trauma Triad of Death

A

Coagulopathy
Hypothermia
Metabolic Acidosis

55
Q

Pneumothorax

A

Air in the pleural space

56
Q

Pneumothorax: Types

A

Closed - spontaneous after respiratory disorders (Thomas)

Open - wound opens pleural cavity to the outside

57
Q

Pneumothorax: S/S

A
  • Dyspnea
  • Tachycardia
  • Hyper resonance on affected side
  • Decreased breath sounds on affected side
  • Pleuritic chest pain
  • SubQ Emphysema/Crepitus
58
Q

Pneumothorax: Implications

A
  • Prep for Chest Tube

- For open pneumo, non-porous dressing taped on 3 sides

59
Q

Tension Pneumothorax

A

Air enters on inspiration, can’t leave on expiration

Decreased CO

60
Q

Tension Pneumothorax: S/S

A
  • Increased HR
  • Severe respiratory distress
  • JVD
  • Angina
  • Tracheal shift
  • Cyanosis
61
Q

Tension Pneumothorax: Implications

A

Needle decompression
2nd intercostal at midclavicular

Prep for chest tube

62
Q

Hemothorax

A

Blood in the pleural space

63
Q

Hemothorax: S/S

A
  • Dyspnea, Tachycardia, chest pain, tracheal shift
  • Dullness on percussion of affected side

Hypovolemic Shock

  • Tachycardia
  • Hypotension
  • Tachypnea
  • Decreased LOC
  • Decreased UOP
  • Cold, clammy skin
64
Q

Hemothorax: Implications

A

-Chest tube
-Replace volume lost
-Open thoracotomy (if severe)
Immediate drainage of 20 mL/kg
Accumulation of >3mL/kg/hr

65
Q

ABGs

A

pH: 7.35 - 7.45
CO2: 35 - 45
HCO3: 22 - 26

66
Q

Chest Tube Placement

A

Pneumothorax: 2nd/3rd intercostal at midclavicular

Hemothorax: 4th-8th intercostal at midaxillary

67
Q

Ventilator: Monitor

A

For changes in:

  • VS
  • S/S of hypoxia or hypoxemia
  • Dysrhythmias
  • Aspiration
68
Q

Ventilator: Clinical Assessment

A

-Watch for chest rise
-Listen for breath sounds
-Check placement for gurgling in stomach (indicates esophagus instead of trachea)
Capnography can assess too
-Stabilize and mark tube at incisor or naris

69
Q

Proper CO2 Capnography: Value

A

35 - 45 mmHg

70
Q

Ventilator: Low Pressure Alarm

A
  • Leakage

- Patient stopped breathing if on CPAP or SIMV

71
Q

Ventilator: High Pressure Alarm

A
  • Blockage
  • Biting, coughing, mucus plug, kink, water collection

Suction to resolve

72
Q

Ventilator: Complications

A

-Hypotension (Increased intrathoracic pressure = decreased CO)
-Aspiration (epiglottis issues)
-Infection
-Ventilator Associated Pneumonia (VAP)
48+ after intubation
Prevent with daily “Chlorhexidine”
-Barotrauma (alveolar rupture)
Increased positive pressure
Overdistention of alveoli
Friable lung tissue

73
Q

ETT Patient Care

A

-HOB 30-45 degrees
-Monitor respiratory status
-Check ETT placement and vent settings
-Mouth care (“Chlorhexidine”)
Reduces VAP
-Monitor for S/S infection
VAP, aspiration pneumonia
-NPO, TPN/tube feeds
-Chemical sedation or restraints
-DVT prophylaxis
-Peptic ulcer prophylaxis

74
Q

Weaning Off a Ventilator: Criteria

A
  • Ability to breathe spontaneously
  • Ability to support adequate O2
  • Ability to maintain adequate hemodynamic stability
75
Q

Weaning Off a Ventilator: Nurse Responsibilities

A
  • DC Sedation
  • Assess for respiratory distress
  • Evaluate LOC
  • ABGs
76
Q

Tidal Volume: Value

A

500

77
Q

FiO2: Value

A

~30%

78
Q

SaO2: Value

A

> 90%

79
Q

PaO2: Value

A

80 - 100 mmHg (>60 mmHg if acute care)

80
Q

PEEP: Value

A

5 - 15 cmH2O

81
Q

PEEP: S/E

A
  • Additional thoracic pressure

- Risk for pneumo, barotrauma, and low CO

82
Q

5 P’s for Monitoring Distal to ABG site

A
  • Pain
  • Paresthesia
  • Pulse
  • Paralysis
  • Pallor
83
Q

GCS

A

15: normal
<8: need to be intubated
3: comatose

84
Q

What drugs slow healing?

A

Corticosteroids

85
Q

Acute Pancreatitis: Etiology

A

-ETOH
-Bile duct obstruction
-Other
Abd surgery
Trauma
Infection
Drug use
Idiopathic

86
Q

Acute Pancreatitis: S/S

A
  • LUQ severe pain**
  • N/V
  • Abd Distention
  • Jaundice
  • Low grade fever
  • Hypovolemic Shock: tachycardia and hypotension
  • Grey Turner’s Sign: flank
  • Cullen’s Sign: belly button
87
Q

Acute Pancreatitis: Complications

A

-Jaundice
-Hyperglycemia (can’t make insulin)
-Hypocalcemia (r/t fat/pancreatic necrosis)
Tetany and seizures
-Pulmonary (ARDS, atelectasis)
-Paralytic Ileus
-Hypovolemic shock d/t fluid shift and hemorrhage
-DIC
-Renal failure r/t hypovolemia

88
Q

Acute Pancreatitis: Diagnostic Tests

A 
WBC: >10,000
H&amp;H: <12; 36%
ALT: >20 = gallstones
Glucose: increased d/t insulin production stopped
E-lytes:
     Potassium (3.5 - 5.0)
     Calcium (8.5 - 10.5)
89
Q

Acute Pancreatitis: Interventions

A
  • PRIORITY: replace fluids**
  • ABC
  • Pain control (morphine, Dilaudid, Demerol)
  • Input and Output
  • Monitor labs
  • Nutrition
  • H2 blockers, PPI
90
Q

Gallstone Removal Procedure

A

ERCP

91
Q

Hep A: Transmission

A

Fecal –> Oral

92
Q

Hep A: Labs

A

IgM: current infection

IgG: immunity/recovery

93
Q

Hep A: Nursing Care

A

Post-Exposure:
Healthy- vaccine only
Unhealthy- vaccine + immunoglobulin

94
Q

Hep B: Transmission

A

Blood and Body Fluids

Mother -> child at birth

95
Q

Hep B: Labs

A

HBcAB/Core Antibody: exposure (presumptive infections)
HBsAG/Surface Antigen: currently infected
HBsAB: Immunity

96
Q

Hep B: Nursing Care

A

Most develop immunity after exposure
If becomes chronic (>6 mo) = liver cirrhosis and cancer risk

Post-Exposure: Vaccine + immunoglobulin

97
Q

Hep C: Transmission

A

Blood

Mainly IV drug abuse

98
Q

Hep C: Labs

A

HCV antibody: exposure/past infection

HCV RNA: current active infection

99
Q

Hep C: Nursing Care

A

Breastfeeding is ok if nipples not cracked/bleeding

No vaccine, but there is a cure

100
Q

Liver Cirrhosis: Types

A
  • Laennec’s: ETOH
  • Post Necrotic: r/t infection (MOST COMMON)***
  • Biliary Cirrhosis: biliary obstruction or destruction
  • Cardiac Cirrhosis: secondary to CHF
101
Q

Liver Cirrhosis: Presentation

A
  • Jaundice
  • Ascites
  • Edema
  • Vitamin Deficiency
  • Petechiae
  • Ecchymosis
102
Q

Liver Cirrhosis: Complications

A

-Portal hypotension
-Bleeding Esophageal varices
Rupture Causes: cough, strenuous exercise, trauma
-Coagulation defect
-Jaundice
-Ascites
-Gynecomastia

103
Q

Hepatic Encephalopathy: Precipitating Factors

A
  • Excessive protein intake
  • GI bleed*
  • Constipation
  • Drugs (opioids, sedatives, analgesics)
  • Infection
  • Hypokalemia
104
Q

Variceal Hemorrhage: Emergency Care

A
  • Maintain airway
  • Replace volume (not LR = increased ammonia = decreased LOC)
  • Prep for emergency endoscopy
  • Insert NGT
  • Reduce hepatic blood flow (vasopressin)
  • Watch for Projectile Vomiting

Adult Health 3 (12 decks)

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