Midterm Flashcards
Describe the pathophysiology of a deep vein thrombosis (DVT)
triad - stasis of blood; vessel wall injury; increased blood coagulability
past DVT biggest risk for future DVT after surgery: increased in the presence of impaired cardiac function (acute MI/CHF)
venous stasis, hyperreactivity of blood coagulation and vascular trauma are all risk factors of DVT
immobility of an extremity or the entire body causes decreased blood flow, venous pooling in the lower extremities and increased risk of DVT
A piece of a clot becomes dislodged and travels to the lung - can cause pulmonary infarction
What are the signs and symptoms of a DVT?
many are asymptomatic; vein not totally occluded or collateral circulation,
pain, swelling, deep muscle tenderness (redness or warmth of leg, pain or cramp in calf, swellling of leg, areas feel hard to touch)
fever, general malaise (chills, diaphoresis)
elevated WBC and sedimentation rate
any client complaining of tachypnea, dyspnea, tachycardia, especially when already receiving O2 therapy
chest pain, hypotension, hemoptysis, dysrhythmias or HF.
fainting, orthostatic hypotension,
How can you prevent DVT’s in post operative clients?
Pharmacological
anticoagulation drugs - heparin
Non-pharmacological
leg exercises q1-2 hrs, flex and extend all joints
apply TEDS or AES - thrombo embolic deterrent or antiembolic stockings
early ambulation
avoid positioning that disrupts blood flow to extremities
adequate fluid intake
regular CV assessment - BP, HR, perfusion (pulses), hemorrhage, CSM
How do we treat a DVT?
goal is to prevent further thromi, prevent extension and embolization of existing thrombi and minimize venous valve damage
anticoagulation therapy to treat and prevent
15-20 degree elevation of legs to prevent stasis
footboard enables person to perform leg exercises, ankle flexion and extension while in bed
surgical removal under selected circumstances when at risk for experiencing pulmonary emboli
What risk does a DVT pose?
postphlebitic syndrome - damage to vessel
Blood clot in the kidney, called renal vein thrombosis.
Blood clot in the heart, leading to heart attack.
Blood clot in the brain, leading to stroke.
blood clot in the lung, leading to pulmonary embolism
Describe the rationale for deep breathing and coughing in the post operative patient
helps to clear the anesthesia from system
prevents atelectasis and pneumonia
How do you assess perfusion distal to a surgical site or area of injury?
Peripheral perfusion assessment consisted of capillary refill time (CRT), peripheral perfusion index (PPI) and forearm-to-fingertip skin temperature gradient to measure the strength of the pulse as the assessment area
collect Perfusion prior to surgery, immediately following and d1,2 & 3.
What findings indicate normal perfusion? What findings indicate abnormal perfusion
cap refill time - 3 is delayed)
bilateral pulse rates - normal between 60-100, gradient scale 0-4 - 0 = absent to 4= bounding, non-bilarterally equal
forearm-to fingertip skin temperature gradient - warm, (cold and hot are abnormal)
colour - wnr (cynotic, pale, red, flush)
What is your priority intervention if you notice your patient’s distal extremities to be pale and cold with decreased cap refill?
place O2 on the client at .5L via NC
What is a paralytic ileus? How is it treated? How do you assess for it?
defined as cessation of peristalsis - complaints of abdominal pain, distension, nausea, vomiting and poor appetite
monitor for distension, auscultate all four quadrants to determine presence, frequency and characteristics of bowel sounds
absent or diminished and abdomen sounds tympanic to percussion
normal bowel movements are accompanied by flatus
Review total parenteral nutrition (TPN). What is it and how is it administered?
IV administration for the delivery of 100% of a patient’s calculated nutritional requirements (carbs, fat, protein, vitamins, minerals and often fluid)
Review post operative care of patients following gastrointestinal surgery – Initial admission to the acute care floor and ongoing management.
usually NPO therefore NG tube - care for tube -
• proper placement through nose to stomach (measure from the nare to the top of ear to base of xiphoid)
• intermittent suctioning
• irrigate to avoid occlusion - flush with 30mL of water to ensure that no residual food will occlude the tube
• measure/record drainage
• monitor and record losses
medicate for nausea
Assess bowel sounds Q4 for paralytic ileus
inspect for distension (tympanic/dull)
monitor constipation
What is the normal range for glucose?
non-diabetic is random 4.4-6.6 and fasting 4.0-6.0
how you would interpret abnormal high BG
abnormal highs means hyperglycemia diabetes mellitus acute stress respone cushing's syndrome pheochromocytoma chronic renal failure glucagonoma acute pancreatitis diuretic therapy corticosteroid therapy acromegaly
how you would interpret abnormal lows BG
insolinoma - no reflex feedback loop present to “turn off” production
hypothyroidism - thyroid hormones effect glucose metabolism
addison’s disease - cortisol affects glucose metabolism - diminished levels effect glucose to fall
extensive liver disease
insulin overdose
starvation
What is a hemoglobin A1C and why is it measured?
used to monitor diabetes treatment. accurate long-term index of the average BG levels
Which test would you wish to have done on a patient on the medical floor who complains that they feel shaky and fatigued
test random BG
Which test would you wish to have done on a patient on the medical floor who has significant weight loss and being checked to see if the patient has developed diabetes
hemoglobin A1C, fasting BG, urine glucose level
Which test would you wish to have done on an outpatient who reports that they have had fairly normal blood sugar levels since their last visit 2 months ago
• Hemoglobin A1C
What labs measure kidney function and explain why
Blood Urea Nitrogen (BUN) - normal 3.6-7.1 mmol/L
measures the amount of nitrogen in blood that comes from the waste product urea - rises when the kidneys cannot remove urea from the blood
• used to evaluate and diagnose kidney function and acute or chronic kidney failure
• heart failure, dehydration or a diet high in protein can elevate BUN
Creatinine (Cr) - normal males (53-106) female (44-97)
is a breakdown product of creatine, used in muscle contraction
removed entirely by kidneys. increased levels means kidney function is abnormal
good indicator of glomerular filtration and chronic renal damage
What labs measure liver function and why?
ALT - normal -4-36 u/L
found predominantely in the liver - more specific test
for detecting hepatocellular disease
AST - normal 0-35u/L
AST found in the liver, heart, muscle, brain and
kidney tissue - damage to any can raise levels
GGT - 8-38 u/L
sensitive indicator of hepatobiliary disease and chronic alcohol abuse
Albumin - 3.5-5g/dL
main protein in blood that is made by the liver.
purpose is to maintain colloidal osmotic pressure and transport drugs, hormones and enzymes.
in disease the liver looses its ability to synthesize albumin and so albumin decreases while dehydration can increase albumin levels
bilirubin - 0.3-1.0 mg/dl
produced from b/d of RBC hemoglobin
liver clears bilirubin from the body so elevated levels can indicate a disorder or blockage of the bile ducts
Electrolytes Labs
Potassium Sodium Chloride Calcium Magnesium
Liver Labs
ALT/AST
GGT/Albumin
Bilirubin
Renal Labs
BUN
Creatinine
Diabetic Labs
A1C
BG - fasting/random
Cardiac Labs
Troponins
CK
CK-MB
Cholesterol Labs
cholesterol
triglycerides
LDL
HDL
Discuss Anemia
refers to a deficiency of either erythrocytes or hemoglobin - low RBC count contributes to anemia
3 types
- hypovolemic anemia - caused by blood loss
- inadequate/abnormal erythrocyte production = iron deficiency, pernicious, folic acid deficiency, sickle cell anemas
- hemolytic anemia - destruction of normally formed RBC
discuss INR and what abnormal value means
International Normalized Ratio - prothrombin time > 20sec for individuals not taking anticoagulants and >3.6 for those on anticoagulants - used to evaluate the adequacy of the extrinsic system and common pathway in the clotting mechanism ^ levels - liver disease - hereditary factor deficiency - vit K deficiency - bile duct obstruction - coumarin ingestion - disseminated intravascular coagulation - massive blood transfusion -salicylate intoxication
WBC count
normal range 5-10x 109/L
- used as an indicator of infection inflammation, tissue necrosis or leukemic neoplasia
decreased - bone marrow failure, dietary deficiencies or autoimmune diseases
Red blood Cell Count
normal findings RBC x 1012/L
adult/older adult - male - 4.7-6.1 female - 4.2-5.4
closely related to hemoglobin and hematocrit levels - reps different ways of evaluating the number of RBCs in peripheral blood.
erythrocytosis
Congenital Heart disease
sever chronic obstructive pulmonary disease
polycythemia vera
severe dehydration
decreased anemia hemoglobinopathy cirrhosis hemolytic anemia hemorrhage dietary deficiency bone marrow failure prosthetic valves renal disease normal pregnancy rheumatoid/collagen-vascular diseases lymphoma multiple myeloma leukemia hodgkins disease
Platelet count
adult - adult/older adult 150,000 /mm3 to 400,000/mm3
malignant disorders
polycythemia versa
postplenectomy syndrome
rheumatoid arthritis
iron-deficiency anemia or following hemorrhagic anemia
decreased levels (thrombocytopenia) hypersplenism hemorrhage immune thrombocytopenia leukemia thrombotic thrombocytopenia graves disease inherited disorders dic systemic lupus erythematosus pernicious anemia hemolytic anemia cancer chemotherapy infection
Potassium
adult/older adult - 3.5-5 mmol/L ^ excessive dietary intake excessive iv intake acute/chronic renal failure addison's disease hypoaldosteronism aldosterone-inhibiting diuretics crush injury hemolysis transfusion of hemolyzed blood infection acidosis dehydration
decreased deficient dietary or iv burns GI disorders diuretics hyperaldosteronism cushing's syndrome renal tubular aidosis licorice ingestion alkalosis insulin administration glucose administration ascites renal artery stenosis cystic fibrosis trauma/surgery/burns
Sodium
normal adult - 136-145 mmol/L
hypernatremia
increased sodium intake
- excessive in dietary/IV
decreased sodium loss
- cushing’s syndrome
- hyperaldosteronism
excessive free body water loss
- GI loss
- excess sweating
- extensive thermal burns
- diabetes insipidus
- osmotic diuresis
hyponatremia
decreased sodium intake
-iv/dietary
increased sodium loss
- addison’s dissease
- diarrhea, vomiting, nasogastric aspiration
- intraluminal bowel loss (ileus, obstruction)
- diuretic admin
- chronic renal insufficiency
- large volume aspiration of pleural or peritoneal fluids
increased free body water
- excessive oral water intake - oral/iv
- hyperglycemia
- CHF
- peripheral edema
- pleural effusion
- intraluminal bowel loss
- syndrome of inappropriate or ectopic secretion of ADH
troponin & creatine kinase
- measures the levels of proteins called troponin T and troponin I in the blood which are released specifically in cardiac muscle injury
- creatine raises when skeletal, neurological or heart muscle are injured
cholesterol/triglycerides
two forms of lipid or fats
cholesterol - normal <200 mg/dL
-is associated with arteriosclerosis vascular disease - necessary for building and maintaining cells and making essential hormones
triglycerides - male 40-160 mg/dL ; female 35-135 mg/dL
- associated with risk of CHD in patients w/ fat metabolism disorders
LDL/HDL Labs
75% of blood cholesterol bound to LDL and 25% to HDL
LDL - normal 40 mg/dL - removes excess cholesterol
when there are too many LDL - too much cholesterol is delivered for HDL to remove. therefore buildup of fat in arteries and veins - narrowing
Isotonic Solutions
o.9% NaCL (NS)
Ringer’s Lactated
used to expand vascular volume
watch for signs of bounding pulse and SO
D5W - 5% dextrose in water - dextrose is rapidly metabolized providing only free water to expand extra in intracellular spaces
Hypotonic Solutions
o.45% NaCl - (1/2 NS)
0.33% NaCl - (1/3 NS)
used to provide free water and treat cellular dehydration - promote waste elimination by the kidneys
Hypertonic solutions
5% dextrose in NS (d5NS) 5% dextrose in o.45% NaCl (d5 1/2 NS) 5% dextrose in Lactated Ringers used to draw fluid out of intracellular and intrastitial compartements into vascular - expand vascular volume - do not use iwth kidney/hd patients - watch for signs of hypervolemia
respiration
process by which bodies cells are supplied o2 and co2 is eliminated
external respiration - movement of gases across alveolar-capillary membrane
internal respiration - movement of gasses across systemic capillary membranes - cell membranes
ventilation
mechanical movement of airflow to and from the atmosphere and the alveoli - actual work of breathing and requires adequate functioning of the lungs and airways, thorax, ventilatroy muscles and nervous system control.
inspiration
air moves because intrathoracic pressure changes. contraction of diaphragm increases chest dimensions
expiration
passive - elastic recoil of chest wall and lungs
Compliance
measure of elasticity of lungs and thorax
when decreased, lungs are more difficult to inflate
can be altered due to any condition that affects lung tissues - emphysema, pulmonary fibrosis, pulmonary edema, pleural effusion
Diffusion
O2 & CO2 move across the alveolar capillary membrane by diffusion; area of high to low pressure
ability of lungs to axygenate arterial blood adequately determined by looking at PaO2 and SaO2
O2-Hemaglobin Curve
Oxygen transport - O2 carried in blood in 2 ways - bound to hemoglobin or dissolved in plasma
PaO2 - arterial blood o2 tension - represents the amount of O2 dissolved in the plasma - expressed in mmHg
SaO2 - arterial blood oxygen satruation - measue of te % of Hgb in arterial blood sample that is occupied by O2 molecules- expressed as a percentage
if Sa)2 is 0% than 90% of the hemoglobin attachments have oxygen bound to them
Affinity of hemoglobin for O2
Large changes in PaO2 result in small changes in SaO2
as hemoglobin becomes desatruarted, SaO2 levels will fall rapidly
80-100 PaO2 mmHg means….
> 95% SaO2 (normal)
60 PaO2 mmHg means….
90% SaO2 adequate
55 PaO2 mmHg means….
88% SaO2 problematic - may need continuours O2 therapy
<40 PaO2 mmHg means….
<75% SaO2 - tissue hypoxia, cardiac arrhythmia - when you get to this point your patient will die.
Arterial Blood Gases
- measured to determine oxygenation status and acid-base balance
measures PaO2, PaCO2, PpH, bicarbonate (HCO3) in arterial blood
CO2 is very acidic if retained in the blood.
Spirometry Studies - Pulse Oximetry SpO2
probe on finger, toe, ear to measure light waves - oxygenated blood absorbes light differently
tissue in the tissues have only 60 receoptros so if probe is below 95% then critical issues as only about 40 receptors have O2
s/s Pneumonia
inspection
- tachypnea - use of accessory muscles, cyanosis
palpation
- unequal movement with lobar in involvement; fremitus over infected area
percussion
- dull over affected areas
auscultation
- early bronchial sounds
- later - crackles; wheezes
s/s & possible complications bronchitis
viral
persistant cough following an acute upper airway infection - rhinitis, phayngitis
cough accompanied by production of clear, mucoid sputum, sometimes purulent
fever, headace, malaise, sob on exertion
elevated pulse, RR, either normal breath sounds or expiratory weezing. no radiographic evidence of congestion.
- usually self-limiting
COPD patients may be prescribed antibiotics to deal wit bacterial infections that develop with broncitis
s/s & possible complications acute asthma attack
s/s - wheezing, breathlessness, sensation of chest tightness, coughing, combination of these
prolonged expiration - instead of 1:2 - 1:3, 1:4
wheezing, air trapping and hyperinflation due to mucous plugs
silent chest is an ominous sound
usually sit upright or bent forward, intercostal pulling,
pursed lips, anxiety/panic
moderate/severe - hypoxemia behaviour - increased pulse, bp and a drop in systolic pressure during inspiratory cycle of more than 10 mm Hg.
significantly increased resp rate >30bpm
difficult completing sentences
hyperresonence on purcussion
ss COPD
subjective:
anorexia, weight loss or gain, early satiety, difficulty eating
decreased level of activity and ability to perform ADLs or exercise
dyspnea, palpitations, recurrent cough, use of sitting-up position for sleeping, paroxysmal nocturnal dyspnea, ortopnea, swelling of feet
constipation, gas, bloating
headace, loss of memory, inability to concentrate
fatigue, insomnia, depression, anxiety , panic
Objective:
general -
weight weigh BMI
distress, increased work of breathing, use of compensatroy mechanisms for breating, anxiety, depression, restlessness
integumentary
cynosis, bronchitis, pallor or ruddy colour, poor skin turgor, thin skin, easy bruising, peripheral edema (cor pulmonale),
respiratory - rapid, shallow, accessory muscle use, inability to speak at al, prolonged expiratory phase, pursed-lip breating, wheezing, crackles, diminished breath sounds, decreased chest excursion and diaphramatic movements, hyper resonant or dull chest sounds on percussion
cardio - tachycardia, dysrythmias, jugular vein distension right-sided third heart sound (cor pulmonale), edema
GI - ascites, hepatomegaly (cor pulmonale)
MS - muscle atropy, increased anteroposterior diameter barrel-chest)
ss & possible complications atelectasis
collapsed airless alveoli - results from retained exudates and secretions - postoperative
deep breathing exercises prescribed
ss & possible complications emphysema
x
assessment and care associated with respiratory disorders - specifically asthma & COPD
x
understand bronchodilators, corticosteroids & differences
bronchodialators - cause the relaxation of the bronchial smoot muscle - rescue therapy
corticosteroids - anti-inflammatory medication to reduce bronchial hyper-responsiveness by blocking the late-phase reaction that inhibits migration of inflammatory cells - long-term therapy
peritonsillar abscess - risks
treat to airway patency - s/s hig fever, leukocytosis, chills
iv therapy of antibiotics
needle aspiration or incision and drainage of abscess
either an emergency tonsillectomy or scheduled once infection has subsided
sleep apnea
complete or partial upper airway obstruction during sleep
nursing considerations for tracheostomy
provide care - suction, clean around stoma, change ties, inner cannula cleaning
tidal volume, capacity and residual volume
volume of air inspired or expired during normal breathing (0.5L)
vital capacity - volume of air exhaled after maximal inspiration (3L)
residual capacity - volume of air left in eac lung after maximal exhalation - 1.2 L
IPPA review for a patient presenting with a respiratory complaint
I - inspect, P - palpate, P- percuss, A-auscultate
possible complications Pneumonia
complications -
pleurisy - inflammation of te pleura
pleural effusion - may require aspiration via thoracentesis
atelectsis - collapsed airless alveoli
delayed resolution - persistent infection
lung abscess - not common
empyema - accumulation of purulent exudate in pleural cavity
pericarditis - infection spreads to sac around heart
bacteremia -
meningitis - patient disoriented, confussed should have lumbar puncture
endocarditis - attacks the endocardium and/or valves of heart
possible complications COPD
cor pulmonale
emphysema
