Med Surg 3 Final Exam Flashcards
patho behind shock
cells lack blood suppply and are deprived of oxgyen and nutrients
not just circulation blood volume
Tx for Tachycardia
beta blockers, antipyretics, analgesics, fluid (dehydrated),
Each square in EKG represents how many seconds
0.04 seconds
Defribrillation procedure similarities to Cardioversion
- placement over right sternal border and over apex of the heart–CLEAR perimeter
- require conductive materials to the chest
- operator applies 20-25 lbs pressure
Diet for SLE
limit sodium and protein intake (should be well balanced)
What test is used to determinue poluria is diabetes insipidus
Water Deprivation Test
What diet needs to be reducied in encephalopathy
protein.
AKI intervention during acute diuretic phase
- you do not need to monitor glucose
- monitor blood pressure
- draw blood to check for hypokalemia
- you do not need to place pt on fluid restrictive diet.
What is a priority assessment question for pt with end stage alcoholic cirrhosis
when did you have your last alcoholic drink
because could be at risk for tremors or withdrawal
Ventricular Fibrillation
what is always the priority in burn patients
hypoxia–then hyperkalemia
Full Thickness Burn
grafting may be required
S/Sx of Hyperglycemia
- polyphagia
- polydipsia
- polyuria
- fatigue
- dry mouth
- pruiritus
- headache
- nausea/vomiting
- blurred vision
Vitals signs for Cardiogenic shock
- Increased central venous pressure
- decreased cardiac output
- increase HR, decreased BP
- decreased temperature
Creatnine
0.6 - 1.3 mg/dL
vasogenic shock think
afterload due to artery, need vasoconstrictors
What can PVC’s lead to?
angina, heart fiailure
Assess response to the dysrthmia , hemodynamic status to determine if drug therapy is needed
Normal Albumin levels
3.5 - 5.5 g/dL
What does acute pyelonephritis look like
fever, chills, flank pain, dysuria
Rehabilitation for spinal cord injury, medical nursing implementation
DVT risk, physical immobility, SQ anticoagulants (Lovenox)
What lab value shows signs of increased fluid shifts
increased hematocrit, dute to hemoconcentration
each normal beat is followed by an abnormal one
Bigeminy/ Premature Ventricular Complex
what is a complication of calcitonin nasal spray
nosebleeds, report to HCP
Diagnostic test for SLE
CBC and antinuclear antibody tests
anemia, leukopeia, thrombocytopenia
normal LDH levels
100-200 units
Neomycin
kills ALL bacteria in the gut good/bad for encephalopathy
In Cirrhosis where does blood get backed into?
Intestines, Spleen, Esophageal tract (swelling)
a complication of stress reaction to burn injury
curling ulcer, happens to those suffering from traumatic injury
superficial partial thickness burn
injury deeper in the dermis, blood supply is reduced
heals 10-21 days, with no scarring
What is Supraventricular Tachycardia
- coduction signal loops and reenters atrium
- HR > 140 bpm
- Tx: Adenosine IV push
- Narrow QRS
- Atrial Tachycardia
Diet for burn injury patietn
protein for catabolism and vitamin c promotes wound healing
Endocrine disorders go unrecognized in older adults because
symptoms are attributed to aging
Deep partial thickness burn?
stage 2, still pink
What does Albumin do?
transports drugs, binds w/ calcium, attracts water into vascular space.
Why is cirrhosis pt increased risk of bleeding?
formation of coagulation factors, GI bleed Epistaxis common
What should you observe after concusiion
changes in level of consciousness, difficulty awakening, lethargy, dizziness, confusion, irritability
physical assessment of pt with MS
- blurred vision
- tremor, urinary
- hesitancy
- difficulty swallowing
- fatigue (not the same as lethargy)
- dymetria (under/overestimating range of movement
- muscle flaccidity
fatigue and lethargy are not the same!
Electrolytes in repolarization
potassium goes up, sodium goes down
Risk with aspirin
otoxicity, tinnusitis
first action when caring for pt with electrical burn
turn off the electrical current.
what drug do you give for curling ulcer
PPIs, Cimetidine
When CKD patient is receiving peritoneal dialysis, what would you expect intake output to be
output should be more
If client has end stage liver failure, what could be a risk for developing hepatic encephalopathy
GI bleed
blood in the intestinal tract digests as protein, increasea ammonial levels.
Why does a Chronic Kidney Failure patient have metabolic acidosis
kidney cannot excrete increased levels of acid b/c they cannot excete ammonia or reabsorb sodium bicarb
Immediate tx for graves disease
propanolol, thionamide, glucocorticoids
Prevention Tx with RA
exercise, increase muscle strenth, improves joint stability, preserve joint motion/flexibility, boosting aerobic condition.
Causes for Ventricular Tachycardia
drugs, electroylte, hypotension, ischemia
what is an example of a secondary intervention for osteoporosis
bone density evaluation test
think screening.
If a client comes in from nursing home with catheter, what is you first intervention
change the catheter, can’t determine when the catheter was inserted otherwise
AST normal levels
10 - 40 U/L
post op surgery, what should be reported to HCP immediately
rigid abdomen- perforation??
3rd Degree Block
Atropine is for bradycardia, how are you supposed to administer it
rapidly boluse ever 3-5 minutes. Max total dose of 3 mg.
What nursing intervention should you do if patient has pain in right shoulder after laparscopic cholecystectomy
apply a heating pad to the abdomen for 15-20 minutes migrates CO2.
Early Signs of ICP
pupils fixed, Inc BP, Ataxia (can’t move), Uneven gate, 8 GCS, Rapid/deep breathing
All cells in the body have intracellular receptors for
thyroid hormone
HIV diet
high calorie, high protein, low residue
Premature Ventricular Complex
Wide QRS/bizarre
No P wave
Epidural Hematoma Nursing Interventions
- HOB no more than 30 degrees
- sedative for agitation
- NO narcotics
- Stool softeners
Assessment findings of pancreatitis?
High RR, SOB, Increase HR, Pain, Abdominal distention, absent bowel sounds.
If pt has gunshot wound to abdomen and acute renal failure what is the first intervention
administer normal saline. risk for shock.
hypovolemic shock kicks on ADH, how do you know this is happening with your patient
increased thirst
Priority Nursing Actions for Autonomic Dysreflexia
- raise hob
- loosen tight clothing
- check bladder distention or noxious stimulus
- administer antihypertensive medication
- Sinus Bradycardia
- Regular Rate
- HR 50
Name some hypertonic solution
- 10% dextrose + Water
- 5% dextrose + 0.9% saline
- 5% destrose + 0.45% saline
What does stress, illness and infection do to insulin needs
increases it
Other than bilirubin, what does the bile bus transport?
cholesterol, recycles waste in the body. LDLs go up, HDL decrease.
If you are a first responder for a head injury, what would you implement first
stabilize client’s cervical spine. Always assume head injury has a spinal injury
what is the most reliable and non invasive assessment to measure cardiac output and tissue perfusion
urinary output
Normal cardiac output
4-8 L/minute
AST
entire body sooo broad (Hear & Liver Cells)
Manifestations of neurogenic shock
bradycardia, hypotension
findings w/ fluid volume deficit
low plasma osmolality, low hematocrit (diluted), low specific gravity, low BUN, low sodium
ALT
Liver Specific
Post op laparoscopic cholecystectomy nutrition
may experience discomfort with high fat meals
What does the liver Produce?
Albumin, Bile Bus, Coagulation Factors
AV Node Rate
40-60 BPM
Post op care burn ,( after echarotomy, fasciotomy
CTMS, control bleeding, topical antimicrobial agents
What do the enzymes in the pancreas do?
explode things into the duodenum
What is temporary tx for portal hypertension
TIPS
Best way for burn patient to recieve medication
Intravenously
S/Sx of fat embolism
originates in bone marrow after fracture. Tachycardia, hypotension, confusion, pale
vtach
how is HIV tested
- blood test with ELISA
- if positive another ELISA
- then Western Blot
The patient has hypokalemia, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm; the P wave is 0.06 seconds (sec) and normal shape; the PR interval is 0.24 sec; the QRS is 0.09 sec. How should the nurse document this rhythm?
First Degree Av Block
Precautions for levothyroixine therapy
- angina, or dysrhythmia (increase oxygen demand)
- prevent of med interactions, reduce dosase
- increase BS, DM
- initially starts w/ 50 mcg, may be increased to 75-125mcg/day gradually)
Burn Shock MGMT
- 2-4 mL LR/kg in first 24 hours
- One half of that in first 8 hours
- one half in next 8 hours.
burn patient how to receive feedings
jejunal feedings
What does adenosine do?
slows conduction time through the AV node. coronary artery vasodilation
AV Block Type 1
What does People Drink So Much Refer to with the Liver?
- Produce
- Detox
- Store
- Metabolize
Physical Assessment for Esophageal Varices
BP low, HR high, RBCs low because you are bleeding.
superficial thickness burn
afterload think
size of vessels (not volume)
How can pt relieve itching if in a cast?
ice pack to the area
Vital signs for vasogenic shock
- decreased central venou pressure (preload)
- increased output (early
- Increased HR (early)
- decreased BP
- decreased SVR
- Increased temperature
supraventricular tachycardia
Nursing interventions autonomic dysreflexia
elevate HOB, 45 degrees, notify physician, determine cause
Why does a client have to stay on bed rest if they have Acute Renal Failure
reduces the metabolic rate
Tx for Brady Cardia
Pacemaker, oxygen, epinephrine (don’t give fluids) atropine
Interventions for open fracture
ice pack for 10 minutes, remove for 20 minutes. Administer tetanus toxoid IM.
Afib, No Pwave, & Irregular
300-650 bpm
Nursing care for pancreatitis client
keep stomach empty and dry, NPO and NGT suction, BED REST
Assessment fo Glascow coma scale
- eye opeing
- verbal response
- motor response
- NOT–pupillary changes or gag reflex
What does Hypo ADH look like
- DI, hypopopituitary
- Hypokalemia, hypotension, thirsy
- tx: Vasopressin
what is a by product of RBC destruction
bilirubin
why do we measure lactic acid in septic shock?
reflects perfusion and amount of oxygen. Lactic acid build up because of anaerobic metabolism
what could pain uppon dorsiflexion of the ankle indicate?
deep vein thrombosis
deep full thickness burn
in the subcutaneous. Red and white, edema.
Preicteric phase of hepatitis presents like
flu like symptoms
rest is important
What else does the thyroid gland secrete, what does it do>
- Calcitonin-
- response to high ca+
- more calcium in blood, lower blood calcium levels
If glycogen is a wall of bricks, what are the individual bricks
glucose
What does glucagon in the pancreas do?
breaks down glycogen (brick wall, stored treaure)
autonomic dsyreflexia intervention
straight cath every 4-8 hours
Nursing Dx for Spinal Cord Injury
- Ineffective breathing pattern r/t respiratory muscle fatique
- Impaired skin integrity r/t immobility
- impair urinary elimination
- constipation r/t neurogenic bowel
- risk for autonomic dyreflexia
Nursing Dx for Head Injury
- Risk for ineffective cerebral tissue perfusion r/t interrupted CBF (hematoma)
- Hyperthermia r/t metbaolism, infection hypothalamic injury
Late signs of ICP
fixed dilated pupils, decreased HR, Widening Pulse Pressure, Decerebrate, Decorticate, Less than 8 GCS, slow breathing
What is the most common condition that predisposes a client to prerenal failure
hypotension
What is important characteristic to know about TBI
it is a process not an event. Risk for urinary retention or constipation.
What do the kidneys produce?
RBCs, erythropoetin (hormone)
Sign of anaphylactic shock
shortness of breath, notice when delivering penicillin iv fluid. STOP THE INFUSION.
S/Sx of IICP
decrease motor function, decrease LOC, headache, vomiting
Parkinson’s disease and diet
may cause dysphagia and constipation
soft, frequent meals
calculate burn to chest abdomen right arm and right leg
- chest= 18
- abdomen = 9
- right arm= 9
- right leg = 9
- total= 45%
- Atrial Flutter
- Regular Rate
- QRS 0.06
Nursing Care for esophageal varices
restrains, b/c LOCs. Skin Integrity, bleeding risk. Pruiritis
ST depresseion indicates
Myocardial ischemia
chemotherapy toxicity first affects
GI, cause for nausea and vomiting
give med 1 hour before treatment
What does cirrhosis do to Kupffer Cells
kills them off, left with scar tissue
When is hormone replacement therapy contraindicated
vascular thrombosis
Who is the protein wrapper?
Albumin
Corticosteroid therapy teaching
- Assess for cataracts
- avoid infected persons
- exercise
- protein, calcium potassium diet
- low fat and simple carbohyrdates
Name some isotonic solutions
- Lactated Ringers
- 0.9% NS
- 5% dextrose in 0.225% saline
Cardiogenic shock means…
broken heart pump, contractility
Only treatment to asystole
epinephrine and atropine (no response to defribrillation)
Intra AKI
holy crap fire is inside. HYperkalemia,
Burns of the extremities porduce
compartment syndrome lead to vascular compromise
What does a PSA test indicate?
urinary retention, BPH, prostate cancer, prostate infarct.
2 major modifieable risk factors for CAD
Diabetes Mellitus, hypertension
Lactulose does what
poops out ammonia
intervention for BPH and urinary retention
insert catheter
What organ is the washing machine of the body?
Kidneys
Causes for Sinus dysrthmias
digoxin/morphine, autonomic dysfunction, diabetic neuropathy, slower HRs
What would level of pressure would be considered portal hypertension
greater than 10mmHg
Hypothyroidism and mental status
memory loss/confusion. Keep personal belongings in the same place.
compartment syndrome tx
fasciotomy.
what is a major problem for closed fracture wounds
neurovascular status
Post op TURP what is a sign of catheter blockage
urine leakage around 3 way catheter at the meatus.
Electrolytes in Depolarization
Sodium goes up, potassium goes down (exits intracellular)
the Kidneys filter HUC, what does that mean?
- Hydrogen Ions (very acidic by product
- Urea (BUN, high dehydrated “Burned Buns”
- Creatnine, by product of muscle/protein breakdown
Priority Action for Burn Injury
- assess airway patency
- administer oxygen
- vitals
- IV line and begin fluid replacement
- Elevate extremities if no factures
- keep client warm and place the client NPO
primary goal maintain airway
- Normal Sinus Rhythm
- Regular Rate
- Heart Rate 70
Teaching for an MRI
lie still, loud noise
patietn with BPH and is weak what does he need
help if he needs to void.
Occiptal Lobe
visual area
Myxedema occurs..
low thyroid production, abrupt stop in medication, hypothermia, hypotension, hypoglycemia, bradycardia
What are the 5 steps for reading and ekg
- Are there any P waves?
- Are there any QRS?
- Measure PR Interval
- Rate
- Rhythmn
PR Interval should be no greater than
0.20 seconds
what is happening with each different type of shock
a different type of O2 delivery system is effected
SA Node rate
60-100 BPM = Pacemaker
Hypercortex
- Cushing’s Disease
- moonface, buffalo hump
- Hyperglycemia, hypernatremia, hairy face
- tx: Potassium low surgar, exercise. Insulin NO, b/c dec potassium
How does the Liver Detox
- Kupffer Cells- trash man, breaks down bacteria
- First Pass= liver is the border patrol
When does Atrial flutter most often occur
- COPD, CAD, Atrial Septal Defects
- Tx: Same as Afib
what does TNM stand for
Tumor Node Metasis
Burns of the face are associated with
corneal abrasion
what is the most important nursing management in burn patients
fluid replacement
How does a pacemaker work
provides electrical stimuli to the heart muscle, stimulated to contract. If heart rate drops too low
pacemaker spike before CRS comples
Where do PVC’s orginiate
focus in the ventricles
Neurogenic shock treatment
dopamine, vasopressing, epinephrine, atropine
Why should an aids patient have good nutrition, exercise and stress redction
improve immune function (not strenght/self care)
What happens to renal tubules when ADH is released
reabsorb water, causes urine to be more concentrated
What organ specificallly is concerning for SLE
kidney, proteinuria
What causes the release of ADH
increase in serum sodium because that it when you are dehydrated
What is the word association with ureters, urine etc
UREA
What are the 3 most common complications in pts with neuro disorders?
- respiratory infection, UTI, infected pressure ulcers
Which enzyme in the pancrease breaks down carbohydrates
Amylase
deep partial thickness burn
can become full thickness if tissue damage increases with infection, hypoxia or ischemia
heals 3-6 weeks
Causes for Acute Renal Failure
Hypotension, Hypoperfusion (hypoxia), hypovolemia
What is glycogen storage for?
Think Carb loading before a big marathon. That is for you to use later.
which diagnostic test is most accurate for osteoporosis
dual energy xray asorptiometry (DEXA). Measures bone density.
Post Op Parathryoidectomy
hypocalcemia is life threatening risk, HOB elevated
Manifestations of spinal shock
flaccid paralysis, loss of reflex activity below the level of injury, bradycardia, hypotension, paralytic ileus
precautions for health care providers treating cancer patients
must wear PPE
Weight and 45% burn injury patient
loss of 10% of baseline is very concerning
What is hyper ADH
- SIADH
- Specific Gravity will be high
- Low Na+
- CNS disorder
- Tx: Lasix, fluid restriction, hypertonic solution
How does a paraplegia promote skin integrity
keep skin clean
AV Block 2nd Degree Type 1 is
- Progressive prolongation of PR until P wave fails to conuct
- No QRS follows a P wave
- Usually benign, seen with normal agins
Hypo thyroidism
- Myxedema (non-pitting), Hashimoto
- Cold, constipated, dry skin
- Tx: levothyroxine -take in the morning
Common characteristic of all hormones is…
influence cellular activity of target tissues
Halo Sign and Closed Head injury
CSF leakage. Monitor and inform the physician, not an emergency though.
7 warning signs of cancer
- change in bowel
- sore that does not heal
- unusual bleeding or discharge
- thickening or lump in brease or elsewhere
- indigestion or difficulty swallowing
- nagging cough
- persistnent hoarsness
When should pt take tums
30-60 minutes before a meal. Hydrochloric acid is needed for calcium absorption.
When assessing a patient with burn injury, what is MOST concerning sign
singed nasal hair, hoarseness, cough, drooling, difficulty swallowing, crowing, wheezing, stridor
preload think
blood volume. Central Venous pressure
First line of defense for increase ICP
Hyperventilation, because CO2 causes vasodilation which make it worse
Sinus Bradycardia treatment
requires atropine if symptomatic
Biggest problem with liver complications
Bleeding Risk
What is an important intervention with osteoarthritis
needs to move, pain will decrease with movement
Burns of the perineal area
prone to autocontamination by urine and feces
a patient with parkinson’s should have appointment scheduled late in the morning after a bath, why is that?
so they have time to complete ADL’s without pressure
A pt with RA has increased alterations in mobility. What should nurse do to keep pt safe
remove excess furniture, risk for falls.
wound care for deep partial thickness burn
gently clean away debris and dirt. Leave blister in tact do not apply sterile gauze
What does replacement of albumin cause?
high blood pressure, boudnign pulse, extra pressure on the heart, ICP, cerebral edema. Need to take with Diuretics.
First Degree AV Block
priority nursing diagnosis for pt with burn during acute phase
risk for infection
How does defribllation differ from cardioversion
the sitch on the defibrillator is differemt
an older woman has OP what intervention should be implemented to prevent secondary complication
provide nighttime lights to prevent falls!
when does a burn involve fluid resuscitation
if more than 10% of the body
Pancreatitis which electrolytes will be affected
low calcium, blood sugar
if pt with total hip replacemtn has popping sounds what does this mean?
dislocation, closed reduction, report to HCP. Groin pain in the affected leg.
Why would you need an NG tube for epidural hematoma
abdominal distention which could lead to IICP
Who is the recylcing company in the body?
the Liver
Risks with Premature Ventricular Contraction
may progress to Vetach and Vfib
Why does a cancer patient take many different drugs?
cancer cells resits chemotherapy drugs. Using different drugs, more cells are destroyed before resistance develops.
What is amiodarone
used to treat ventricular tachycardia or ventricular fibrillation
Hyper Thyroidism
- Graves, Thyroid Storm, Goiter
- BP increase, hyperactive bowel, weight loss, bulging eyes
- tx: Blockers, removal, propythioracil, radioiodine
what does chronic pyelonephritis look like
fatigue, headache, poluria, anorexia, weight loss
Av Block Type 2
what is an appropriate long term goal for someone with acute glomerulonephritis?
the client will maintain normal renal function. Otherwise can lead to end stage renal disease
post op position for pt with total hip replacemtn
high seated chair for flexion of less than 90 degrees
Hypovolemic shock mean..
low volume, pre load
body systems and chemo
infection control, increase workload of kidney,
Burns of the ear are associated with
auricular chronditis
What temporary tx for Ascites?
paracentesis, replace albumin
higher the percentage the worse. Fluid and electrolye shift. Oxygen non rebreather mask
In a spinal cord injury what causes headch and high blood pressure,
bladder distention
Manifestation of basilar skull fracture
- Battle’s sign (bruising mastoid)
- Bulging of tympanic membranes
- CSF
- tinnitus or hearing difficulty
- rhinorrhea
- facial paralysis
- deviation of gaze
- vertigo
What do you do for intra AKI
Bolus of fluids, Volume restriction (diuretics), dopamine to dilate and increase pressure)
what should be kept at the bedside for pt with amputation
tourniquet for bleeding internally or externally
Normal GFR
80-100. 65 is bare minimum
How can you tell if a patient post op needs pain managment
shallow respirations
radiation therapy risk factors & nursing care
- anemia, immunse system, ulcers, hair, gonads. Visitors only for 30 minutes (6ft perimeter)
- skin clean and dry
- can’t use topical over the counter unless prescribed
- nutrtional support
normal hemoglobin values
12-16
below 8 requires blood transfusion
Burns of the head and neck are associated with….
pulmonary complications
tx for Afib
Warfarin, Coumadin, Digoxin, Calcium Channel Blockers, Amiodarone
What should you think with an addiosnian crisis
severe hypotension and vascular collapse
S/Sx Of Hypoglycemia
- shakiness
- anxiety
- nervousness
- diaphoresis
- palpitations
- coldness
- hunger
- irritability
- headache
Signs and Symptoms of an old woman with pneumonia
confusion and lethargy
Hematoma treatment
think blood, bleeding edema, mannitol, respiratory acidosis or alkalosis.
Autonomic dysreflexia
diaphoresis, nasal congestion, throbbing headach, hyptertension, bradycardia
Where does the washing machine send dirty blood to?
ureters into the potty and not the body
2nd Degree Block Type II
- Normal EKG, sudden Drop in QRS
- Block in His thru Purkinje sys, ischemia
- Implantable pacemaker
After HCP inflates a triple lumen NG tube in client with esophageal bleeding, why does the nurse stay w/ client at all times
if it becomes dislodged it could occlude the airway
Teaching for Addison’s Disease
- Medic Alert Bracelet
- avoid strenuous exercise (stress)
- Call physician before dental procedures
- Call for weakness or fatigue
Trigeminy PVC.
PVC after 2 normal QRS
How do you know if client is in remobilization phase for burn injury
rochni in lungs, increased urinary output, jugular vein distention, decreased heamtocrit and BUN. Client beocomes hypervolemic
What is a priority problem for client diagnosed with RA?
Alteration in comfort due to chronic pain
Teaching for Pt with OA
wear white socks when walking and supportive shoes
BUN
8-25 mg/dL
What is the first intervention for ventricular tachycardia
assess the client’s apical pulse and BP
Atropine
SE- Myocardial Ischemia, antiarrythmic, increase HR
what is escharotomy
crust formation dead tissue
what is the first intervention of pt has a fractured injury
assess the nailbeds for cap refill time
s/sx of thyroid storm
fever, tachycardia, hypertensioin, tremors, agitation, vomiting, coma
What diagnostics can help determine if its pancreatitis or a liver issue
Xray, CT, ultrasound
What defines cardiogenic shock
anything less than 2L/minute
What does the liver store?
glycogen, iron, copper, fat soluble vitamins
What can trigger anginal pain
stress emotion provoking situation
What does the Thyroid do
- decrease Calcium, metabolism
- Increase protein and bone turnover
- Increase response to catecholamines
- Needed for fetal, infant growth
- chief complaint is difficulty swallowing
psychosocial issues associated with OA
depression and hopelessness.
Post op, why is it important to Turn Cough Deep breath
risk for pneumonia
If the protein wrappers don’t come off, what can happen
wind up in the brain, cause encephalopathy. Affected by metabolism
early sign of shock
cooly clammy skin, blood is shunting to central organs
Vital Signs for increasing ICP
high temp, high bp, low pulse, low respirations
What is the priority for a patient with atrial flutter?
give supplemental oxygen 2-3 l/min
In a person with RA what do movable nodules in SQ tissue represent
rapidly progressive destruction of affected tissue
What is a sign client may have ulcer due to NSAIDS
vomiting blood, notify HCP
What provokes the pain in pancreatitis?
eating, enzymes are being activated in the pancreas rather than the duodenum
Looking at an EKG strip what would indicate to the nurse that the rhtymn is abnormal
2 P waves appear before each QRS complex
3rd Degree AV Block
- Irreversible damage to AV node following a MI
- P-P length does not equal R-R length
- Requires pacemaker
If a client is dizzy and lightheaded from dialysis what is your first intervention
trendelenburg position
deep full thickness burn. Down to bone and tendons
Lack of pain because nerve endings have been destroyed.
Healing takes months, grafts are required
What is a high priority post op for nurse to identify
paint control, alteration in comfort. Pain can be life threatening
What is a priority for DKA
fluid replacement
what is Mean arterial pressure
measures perfusion, should be > 60. Diastolic - 1/3 Pulse Pressure.
How does cardioversion work
synchronized with qrs, 50-200 joules, synch on
Patient prep for EKG
no smoking or caffeine 24 hours bnefore, must lie still
What labs would you find w. pancreatitis?
increased amylase, increased lipase, increase Blood Sugar
Where will pancreatitis pain be located?
LUQ
AV Block 1st Degree characteristics
- PR Inverval above 0.2 seconds (> 1 big square)
- Atropine for low heart rate
- Usually benign
- Delay in AV node
Normal ALT levels
5-35 units
The emergent phase of burn injury s/sx
decreased urinary output. Blood shunted away from kidneys.
F &Es for chemo
uric acid will be hi, potassium will be high, caclium will be low.
these will occur with tumor lysis syndrome (complication
A patient is recovering from DI if x4
- decreaseing urine outut
- increasing blood pressure
- increasing specific gravity
- decreasing serum sodium
What is a major characteristics of ventricular fibrillation
pulseless, initiate code
Cushings triad
systolic hypertension, widening pulse pressure, bradycardia, bounding pulse, irregular respirations)
Nursing Dx for ICP
- Ineffective Cerbral Tissue Perfusion
- Impaired Physical Mobility
Appropriate intervention for a pt with peripheral insufficiency
encourage moderate amount of exercise
Post Op TURP you see large clots, which intervention should you complete
Titrate NS irrigation to run faster to flush it out
This type of hematoma forms slowly and results from a venous bleed
subdural hematoma
Why does Cirrhosis cause portal hypertension
increased pressure because of scar tissue blood cannot get passed
how does amputee toughen their residual limb
push limb against harder sufrace to prep for prosthesis
Why is Cushings disease at risk for infection
- Decreased macrophage production
- antibodies decreased
Effects of corticosteroid therapy
- hypokalemia
- peptic ulcer
- hypocalcemia
- BP increase
- protein depletion
Rhthm strip reveals atrial rate 74 bpm, ventricular rate 62 bpm, and irregular P wave normal shape, PR interval lengthens progressively until P wave is not conducted. Priority Nursing Intervention?
- AV Block Type I
- Assess: Bradycardia, hypotension, Angina
- TX: atropine or temporary pacemaker
proper PPE for chemotherapy
face shield, gown and gloves
Multiple myeloma symptoms
CRAB
Calcium elevatued
Renal Failure
Anemia
Bone breakdown
What acid base imbalance occurs after vomiting
metabolic alkalosis, as a result of loss of hydrochloric acids
palliative care pain medications consist of
anti anxiety (benzos), albuterol, oxygen
