Module 1 Flashcards
What does SIRS stand for?
systemic inflammatory response syndrome
What are the stages of sepsis?
SIRS, sepsis, late sepsis, warm shock, cold shock, MODS
Is SIRS only triggered by an infection?
NO; can also be triggered by inflammation
How many of the criteria must be met before SIRS can be confirmed?
2/4
What criteria are monitored with SIRS
body temp, heart rate, respiratory rate, leukocyte count
What must the body temp be to meet SIRS criteria?
> 100.5 or <96.8
What must the heart rate be to meet SIRS criteria?
> 90bpm
What must the leukocyte count be to meet SIRS criteria?
> 12,000 or <4,000 (or > 10% immature bands)
What must the respiratory rate be to meet SIRS criteria?
> 20 breaths/ min (or PaCO2 <32 mmHg)
what does PaCO2 measure?
partial pressure of carbon dioxide in the blood
Will older adults always meet SIRS criteria?
NO
What may be the first signs of SIRS/sepsis in the older adult?
AMS, confusion, agitation, irritability, incontinence
what are band cells?
young, immature white blood cells
What can band cells indicate?
mature WBC are becoming unavailable to fight off infection
What is classified as sepsis?
SIRS + a confirmed infection
In early sepsis, symptoms of our patient may include?
mild hypotension, low urine output, increased respiratory rate
mild hypotension, low urine output, and increased respiratory rate result in (hyper/hypodynamic state)? Will our cardiac output be decreased or increased?
hypodynamic states; decreased cardiac output
What are compensatory responses to impaired gas exchange and perfusion
reduced urine output and increased respiratory rate
Body temperature varies depending on the duration of sepsis meaning we can have
low, high, and normal temperatures
When sepsis first begins, our WBC will most likely be?
elevated
When white blood cells enter the bloodstream, they release cytokines that?
dilate blood vessels and damage blood vessels
When blood vessels dilate, we have decreased
systemic vascular resistance = decreased blood pressure
When the blood vessels become damaged by cytokines, their permeability increases or decreases
increases
When the blood vessels leak into the tissues, what can happen to perfusion and oxygenation?
Fluid buildup = decreased perfusion= decreased oxygenation
What is disseminated intravascular coagulation?
when micro-thrombi form to combat capillary leak and we have systemic clotting. When clotting factors and fibrinogen are used up, it leads to hemorrhage of the blood vessels.
What is the outcome of DIC?
decreased cardiac output, blood pressure, and pulse pressure, decreased platelet count
Micro- thrombi clotting will increase or decrease oxygen to the cells?
decrease –> extra fluid that has leaked + hyper clotting reduces perfusion and gas exchange. can lead to systemic hypoxia which drops O2SAT
When our cells are starved for oxygen, we begin what type of metabolism?
anaerobic
Anaerobic metabolism will cause an increase of this lab value
lactic acid
How does sepsis raise the blood glucose?
raised cortisol levels from stress will stimulate release of glucose from the liver
How will adrenal function be altered during sepsis?
stress of sepsis caused adrenal insufficiency. We have alterations in cortisol metabolism and tissue resistance to glucocorticoids
During the late stages of sepsis and into septic shock, is cardiac function hypo or hyperdynamic?
hyperdynamic
Why does the heart become hyper dynamic in late sepsis/early shock
capillary leaks stimulate the heart into increasing cardiac output
What symptoms can occur during the hyperdynamic state in late sepsis/ early shock?
rapid heart rate, elevated systolic BP, warm extremities, pink skin and MM (no cyanosis)
During late sepsis/ early shock, what may happen to the WBC count?
no longer be elevated/ getting low (bone marrow can no longer keep up)
What are other late signs of sepsis that need to be addressed?
low O2SAT, decreased or absent urine output, change in cognition
What is required for patients to be in septic shock
vasopressor to maintain a map of 65 mm Hg and have a serum lactate level greater than 2mmol/L despite IV fluids (low blood pressure)
what is the early stage of septic shock
warm shock (compensated stage)
What symptoms are seen in warm shock?
low systemic vascular resistance, normal / increased cardiac output, warm extremities, flash capillary refill
During warm shock, is the heart in a hypo or hyper dynamic state
hyper dynamic
In cold shock (decompensated stage) why does peripheral vascular resistance increase
to shunt blood away from nonvital to vital organs (when vascular resistance is higher, it requires less cardiac output which also decreases work on the dysfunctioning heart)
What symptoms are seen during cold shock
cool clammy skin, PVR trying to raise, decreased cardiac output, delayed capillary refill, organ dysfunction, poor clotting
During cold shock, is the heart in a hypo or hyperdnyamic state
hypodynamic
what is MODS
multi-organ dysfunction syndrome (last stage of sepsis)
What stage of shock includes MODS
cold shock
During MODS, we can see skin discoloration known as
cyanosis
What stage of sepsis has the highest death rate?
MODS
During MODS, what other symptoms will we see?
evident organ failure, poor clotting, uncontrollable bleeding, severe hypovolemic shock
Who is at risk for sepsis
immunocompromised (HIV, AIDS, Chemo, transplant, cancer), invasive procedures, malnutrition, diabetes, older adults, open wounds, central lines
Which screening is used in a non-ICU setting
qSOFA
What does qSOFA stand for?
quick sequential organ failure assessment
What does the qSOFA assessment evaluate
hypotension (systolic <100), AMS, tachypnea > 22 breaths/min
A qSOFA score of ____ suggests a greater risk of poor outcomes
2
What assessment tool is used in ICU settings
SOFA
A high SOFA score indicates
greater risk of organ failure, poor outcomes, and death
What is an ideal SOFA score
1 or less
During sepsis, platelets and clotting factors will first be _______. Eventually, they begin to ______.
increased ; decrease
What is procalcitonin, a lab commonly looked at in septic patients
biomarker released in response to bacterial infections
Hemoglobin and hematocrit are labs monitored during sepsis; however,
they typically do not change until late sepsis
Blood cultures need to be taken before
administration of antibiotics
Arterial blood gases can be drawn to help determine
how much oxygen remains in the blood
what is the 1 hr bundle for management of sepsis
steps that must be completed within 1 hour of recognizing sepsis may be present
What is contained in the 1 Hour Bundle?
- measure lactate level
- obtain blood cultures before
- administering broad spectrum antibiotics
- begin rapid administration of 30mL/kg of crystalloid for hypotension or lactate 4mmol/L
- apply vasopressors if hypotensive during or after fluid resuscitation to maintain a MAP of 65mmHg
What two labs track inflammation
CRP and ESR
What does a vasopressor do?
decrease dilation of blood vessel in order to raise systemic vascular resistance
The nurse is caring for a client with septic shock. Which assessment data alerts the nurse to severe tissue hypoxia?
PaCO2: 58 mm Hg
Lactate: 81 mg/dL (9.0 mmol/L)
Partial thromboplastin time: 64 seconds
Potassium: 2.8 mEq/L (2.8 mmol/L
Lactate
The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action will the nurse take first?
Administer the antibiotic.
Ensure that blood cultures were drawn
Insert an intravenous line.
Take the client’s vital sign
ensure that blood cultures were drawn
Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated
Localized erythema and edema
Low-grade fever and mild hypotension
Low oxygen saturation rate and decreased cognition
Reduced urinary output and increased respiratory rate
low - grade fever and mild hypotension
If we have a client that weighs 50kg, how much fluid would they require
1500 mL
If our blood pressure does not raise after administering fluids, this is classified as
shock
The nurse is caring for a client with suspected sepsis. The nurse knows that the following may indicate sepsis:
a. HR less than 80 BPM
b. Elevated lactic acid levels
c. increased capillary refill
d. hypoglycemia
elevated lactic acid levels
which assessment findings would alert the nurse of possible sepsis?
a. increased HR, increased RR, decreased BP
b. decreased HR, increased RR, decreased BP
c. increased HR, increased RR, hypertensive crisis
d. Increased HR, increased RR, increased BP
A
A nurse educating clients on sepsis prevention includes teaching that the risk of sepsis is increased with?
a. adequate nutriiton
b. undergoing surgery
c. being 25 years old
d. having a history of headaches
B
The nurse is caring fora client with sepsis. The nurse should question orders for?
a. lactate levels
b. administration of vasodilator
c. Central venous pressure monitoring
d. blood cultures
B
when caring for a client with sepsis, the nurse knows that the following should be performed first?
a. give a broad spectrum antibiotic
b. obtain blood cultures
c. give narrow spectrum antibiotic
d. obtain blood type
b
At what stage of the sepsis spectrum may a client look better?
a. septic shock
b. organ failure
c. severe sepsis
d. sepsis
C (heart is in hyper dynamic state)
When caring for a client with sepsis, the nurse knows that the pathophysiology of sepsis includes?
a. decrease in pro-inflammatory cytokines
b. decreased utilization of clotting factors
c. hypoxia
d. vasoconstriction
c
the nurse is caring for a client with sepsis knows that elevated lactic acid levels indicate?
a. decreased kidney funciton
b. increased bleeding risk
c. infection
d. cellular hypoxia
d
the nurse caring for a client with sepsis knows that gram - bacteria is the most likely cause. Gram - bacteria does not include?
a. E-coli
b. pseudomonas aeruginosa
c. klebseilla
d. staphylococcus
d
The nurse caring fora client who has sepsis is hypotensive. The nurse should give the following amount of fluids intravenously?
a. 40mL/kg
b. 45 ml/kg
c. 30 ML/kg
d. 35 mL/kg
c
what is not apart of the sepsis 1-hour bundle?
a. lactate levels
b. obtain blood culture
c. administer antibiotics
d. medicate for pain
d
What lab is indicative of sepsis?
a. decreased lactate
b. positive wound cultures
c. increased lactate
d. decreased potassium
c
What caused procalcitonin levels to be high during sepsis?
responding to inflammatory cytokines
What assessment finding requires the nurse to notify the provider?
a. redness around surgical incision
b. serous drainage from a surgical incision
c. pain at a surgical incision
d. mild edema ata surgical site
a
What is a priority action when administering antibiotics in a patient with sepsis?
a. administer ABX within 2 hours
b. obtain Vs
c. ensure blood culture was drawn
d. obtain informed consent
c
Which of the following indicates organ dysfunction?
a. temp 97.5
b. o2 95
c. capillary refill less than 3 seconds
d. urinary output 15mL/h
d
During sepsis, procalcitonin levels will?
rise
During sepsis, lactic acid levels will?
rise
During sepsis, the white blood cell count will?
be elevated –> become normal or low
During sepsis, platelets and fibrinogens levels will?
be elevated –> become low from DIC
CRP and ESR, used to track inflammation, will be?
very elevated in the beginning
Indicators for improved tissue perfusion?
arterial blood gases within normal range (pH, Pao2, PaCo2), maintenance of urine out 0.5ml/kg/hr, maintenance of MAP >65, absence of MODS, extremities warm
Treatment of sepsis after the 1 hr bundle
- drug therapy 2. source control 3. temperature 4. address adrenal insufficiency 5. blood glucose 6. bicarbonate therapy 7. clotting 8. blood replacement 9. oxygen therapy
What does source control mean when related to sepsis?
finding the route of the source ; ex: abscess drainage, removal of infected device (such as Foley catheter), and debridement of infected tissue
What medications are given for adrenal insufficiency
corticosteroids such as IV hydrocortisone and oral fludrocortisone
How do we manage hyperglycemia and sepsis
insulin therapy , should maintain between 140-180 (remember that if blood glucose is less than 110 it can increase mortality)
What do we administer to help combat metabolic acidosis?
bicarbonate therapy
What are expected outcomes of sepsis treatment?
maintain normal aerobic metabolism and increased blood pressure
Discharge teaching for a patient at risk for sepsis?
importance of vaccines, wound care, self care strategies, how to obtain temperature, notify provider if signs of infection appear, importance of taking antibiotic as prescribed
What are examples of self-care strategies should we include in our discharge teaching?
good hygiene, handwashing, balanced diet, rest, exercise, skin care, mouth care
The nurse is caring for a client with sepsis. Which client assessment date would reflect an early sign of progression to shock?
heart rate 118beats/min
cool, mottled extremities
MAP changes from 62 to 80
dilated pupils
heart rate 118 bpm (client is progressing to warm shock and the high heart rate is compensating)
the nurse is teaching a client’s family about septic shock. Which of the following teachings will the nurse include. Select all that apply
a. the blood cultures will tell us for sure if your loved one has septic shock
b. the clients change in behavior and lethargy may be associated with septic shock
c.antibiotics will be started within the hour to treat the sepsis
d.an insulin drip has been started to keep the clients glucose as low as possible
e.septic shock is easily treated with multiple antibiotics
b. the clients behavior
c.antibiotics started within an hour
rationale:
a: blood cultures are not always definitive or bacteria may not be present
b. late sepsis (which progresses into shock) can show AMS
c. abx are included in the 1 hour bundle
d. we want the clients glucose between 140-180
e. shock is not easily treated when it is this late
The nurse is caring for a client with septic shock. Which assessment findings indicate improvement in organ perfusion?
a. MAP change from 85 to 60 mmhm
b. change in heart rate from 98 to 76 bpm
c. urine output remains 15 ml
d. capillary refill changed from >3 s to 2 s
d
What are non-modifiable risk factors for CVD?
age, sex, ethnic origin, family history of CVD
do males or females have a higher risk of CVD
males
Our clients with coronary artery disease and valvular disease have an increased or decreased risk of heart disease
increased
Clients with diabetes have an increased or decreased risk of heart disease
increased
What are modifiable risk factors our patients at risk of CVD can change?
lifestyle habits such as smoking, physical inactivity, obesity, psychological variables
Cigarettes increase or decrease risk of CVD
increase ; specifically CAD and PVD
What are pack years?
number of packs per day multiplied by years patient has smoked
Sedentary lifestyles will increase or decrease risk of CVD
increase
What are the exercise recommendations for adults in the US to not have a sedentary lifestyle. Doing these can decrease risk of CVD
150 minutes moderate exercise, 70 minutes vigorous exercise ; 2 weight lifting days/week
Does obesity increase or decrease risk of CVD
increase
What does a BMI of 25-30 or greater indicate ?
25-30overweight ; 31 or greater is obesity
A BMI of greater than 30 is associated with?
HTN, hyperlipidemia, diabetes –> increaseed risk for CVD
What psychological factors can increase chances of CVD?
high stress, depression, frequent hostility/angriness
What past medical history should the nurse recognize as risks for CVD
DM, renal disease, high BP, heart disease, pulmonary diseases, anemia, bleeding disorders, thrombophlebitis
A normal sinus rhythm will have a heart rate between
60-100
Sinus bradycardia will show a heart rate less than?
60
Sinus tachycardia will show a heart rate greater than
100
the nurse is conducting an admission assessment on a female client. which o the following assessment data would the nurse identify s a risk factor for cardiovascular disease
a. vmi of 28
b. bp of 120/68 mm HG
c. triglycerides 128
d. exposure to second hand smoke
e. moderate exercise for 20-30 min weekly
a, d, e
the nurse is caring for a client with hypovolemia, which assessment data would the nurse anticipate?
a hyperkinetic pulse
b. auscultation of a bruit
c.orthostatic hypotension
d. increased pulse pressure
c
The nurse is caring for a client scheduled for a cardiac catheterization, which statement made by the client on the way to the procedure would require immediate action by the nurse
a. I don’t know what Ill do if they find a blockage in my heat
b. my allergies are bothering me, so I took some Benadryl last night
c. I was nervous last night but I still remembered to take my warfarin
d. I am hungry
c
the nurse is teaching course on blood pressure management. which of the following statements would the nurse include?
a. blood pressure is a measure of the force that exits against the vessel walls
b. cardiac output has little effect on overall blood pressure
c. the kidneys have a role in the regulation of blood pressure in the body
d. If the peripheral vascular resistance increases, blood pressure decreases
e. respiratory rate is most affected by increased blood pressure
a, c
the nurse is caring for an older adult client who reports dizziness upon standing. How should the nurse explain this to the client
a. activity intolerance is normal as you age
b. this may be associated with age related EKG changes
c. when you move too quickly your aging heart cannot keep up
d. baroreceptor function that helps regulate BP can decline with a ge
d
The client with HF has reported a 7.6 lb weight gain over the past week. the nurse suspects the primary HCP to do this intervention?
a. dietary consult
b. sodium restriction
c. daily weight monitoring
d. restricted activity
c
the nurse is conducting a health history on a client experiencing dyspnea on exertion and heart failure (HF). which assessment data will the nurse anticipate
a. fatigue
b. swelling of one leg
c. slow heart rate
d. brown discoloration of lower extremities
a
Which client has the highest risk for cardiovascular disease?
a. man who smokes and whose father died at 49 to MI
b. woman with abdominal obesity who exercises three times per week
c. woman with diabetes who HDL is 75 mg/dL
d. man who is sedentary and reports four episodes of strep throat
a
Which nursing assessment statement reflects appropriate cardiac physical assessment technique?
a. I wil auscultate the aortic valve in the second intercostal space at the right sternal border
b. I will assess for orthostatic hypotension by moving the client from a standing to reclining positin
c. I will palpate the apical pulse over the 3rd intercostal space MCL
a
A client has been admitted to the ER with chest pain radiating down the left arm. which elevated lab value is most indicative of MI?
a. c reactive protein
b. homocysteine level
c. creatinine kinase
d. troponin
d
the nurse is teaching a class on risk factors for cardiovascular disease. which risk factors will the nurse include? select all that apply
a. fiber rich diet
b. elevated c - reactive protein levels
c. low blood pressure
d. elevated HDL
e. smoking history
b , e
(c- reactive protein is suggestive of inflammation, which is a risk factor for atherosclerosis and cardiac disease)
the client asks about MODIFIABLE risk factors for heart disease. Which nursing response is appropriate?
a. cigarette smoking is one of the most significant modifiable risk factors
b. your personal health over the past 10 years is a modifiable risk
c. diabetes is a modifiable risk factor
d. overall mass index is non modifiable
e. increasing exercise is a method to modify your risk
a ,e
What type of rhythm is this?
normal sinus
What type of rhythm is this?
sinus bradycardia
What type of rhythm is this?
sinus tachycardia
How to determine heart rate on a rhythm strip?
- determine we have three tick-marks at the top (or 30 large boxes)
- count how many QRS complexes in 6 seconds and multiple by 10
30 large boxes, or 3 tick marks is equivalent to how many seconds
6
How many seconds is one small box
.04
How many seconds is one large box
.20 s
What does the P wave represent ?
atrial depolarizatioin
What does the QRS interval represent
ventricular depolarizaton
What does the T wave represent
ventricular repolarizaitoin
what does the QT interval represent
time it takes for ventricular depolarization and depolarization
Normal values for the P-wave are
0.12 s
Normal values for the PR interval are
0.12-0.2 seconds
Normal values for the PR segment include
0.05 - 0.12 sec
Normal values for QRS interval
< 0.11 sec
Normal values for the ST segment
0.08 - 0.1
Normal values for the T wave
0.16
Normal values for the ST interval
0.32 sec
Normal values for the QT interval
<0.44 sec
What portion is this on the EKG
P wave
What portion is this on the EKG
PR interval
What portion is this on the EKF
PR segment
What portion is this on the EKG
QRS complex
What portion is this on the EKG
ST segment
What portion is this on the EKG
T wave
what portion is this on the EKG
QT Interval
What portion is this on the EKG
QT interval
What causes sinus bradycardia
vagal nerve stimulation , increased parasympathetic stimuli, disease of the nodes, ICP, ischemia, athlete (normal)
Examples of vagal nerve stimulation
valsalva maneuvers , carotid sinus massage, vomiting , suctioning
what are valsalva maneuvers
bearing down
Examples of increased parasympathetic stimuli
hypoxemia, inferior wall MI, administration of beta blockers, CCBs, digoxin
What should we assess for when our client is in sinus bradycardia
hemodynamic compromise, SOB, syncope, chest pain, dizziness, weakness, confusion, hypotension, diaphoresis
What can we administer if our client is in sinus bradycardia?
atropine to increase heart rate, IV fluids to increase BP, apply oxygen (if lower than 94). If bradycardia was caused by medication, dose may need to be DCT or lowered
What is transcutaneous pacing?
used temporarily to fix bradycardia. uses timed electrical impulse to help conduction
What is a transvenous system?
used for bradycardia. can be inserted in an emergency as a bridge until a permanent pacemaker can be inserted
What can cause sinus tachycardia?
sympathetic nervous system stimulation or vagal nerve inhibition
what are examples of sympathetic nervous system stimulation
anxiety, stress, pain, fever, anemia, hypoxemia, hyperthyroidism, epinephrine, atropine, caffeine, nicotine, thyroid medications
Tachycardia can be used a compensatory mechanism for?
increase BP and cardiac output
what should we assess for our clients in tachycardia?
symptoms of low cardiac output –> increased pulse rate, weak pulse, decreased urinary output , decreased blood pressure, SOB, AMS
Why should we assess for symptoms of low cardiac output if our client is in tachycardia?
tachycardia could be a compensatory mechanism for a larger problems
Nursing interventions for tachycardia
treating underlying cause (bedrest for hypotension, avoiding caffeine, avoiding alcohol, stress management techniques, panic techniques) and medications
What medications are most used for treating tachycardia
beta-blockers
Impact of beta blocker on the heart
binds to beta receptor sites to lower the force of contraction, and decrease conduction velocity. Lowers force of contractions
the nurse is assessing the client’s cardiac rhythm and notes the following: HR 53 BPM, PR interval 0.20, QRS 0.08. How would you document this health record
a. sinus tachycardia
b. sinus bradycardia
c. normal sinus
d. sinus arrhythmia
b
the nurse is caring for a client with a regular heart rhythm, and a rate of 60 beats/min. a p-wave precedes each QRS complex, and the PR interval is 0.20 seconds. Additional VS: BP 118/68, RR 16 BPM, temp 98.8. What action will the nurse take
a. administer atropine
b. administer digoxin
c. administer clonidine
d. continue to monitor
d
The nurse is teaching a client about the risk of bradydysrhythmias. What teaching will the nurse include?
a. avoid potassium - containing foods
b. stop smoking and avoiding caffeine
c. take nitro for a slow heartbeat
d. use a stool softener
d (this will decrease the amount of valsalva maneuvers which will decrease heart rate)
The nurse is evaluating a client’s bedside telemetry monitor. Which assessment data indicates proper function of the SA node?
a. qrs complex is present
b. pr interval is 0.24 seconds
c. a p-wave precedes every qrs complex
d. st segment is elevated
c
A client’s rhythm strip shows ah heart rate of 116 bpm, one P wave occurring before each QRS complex, a PR interval measuring 0.16 seconds, and a QRS complex measuring 0.08 seconds. How does the nurse interpret this rhythm strip.
a. normal sinus
b. sinus Brady
c. sinus tachy
d. sinus rhythm with premature ventricular contractions
c
The nurse is caring for a client with heat rate of 143 beats/min. which assessment data will the nurse anticipate (SATA)
a. palpitations
b. increased energy
c. chest discomfort
d. flushing of the skin
e. hypotension
A , C , E
hypotension results from decreased time for ventricular filling, and reduced cardiac output is possible
Risk factors for DVT/PE
virchows triad : hypercoaguability, stasis of blood flow, endothelial injury
examples of hypercoaguability
malignancy, congenital coagulation defect, thrombophilia, pregnancy, oral contraceptives, inflammatory bowel disease
examples of stasis of blood flow
immobility, atrial fibrillation, venous insufficiency, venous obstruction, heart failure
Examples of endothelial injury
surgery(ex. prostate), trauma, atherosclerosis, smoker, catheterization
Symptoms of DVT and PE
DVT: unilateral acute pain, swelling, warmth, edema
PE: SOB, chest pain, acute confusion, crackles in lungs, diaphoresis, feelings of impending doom
What is a positive Homans sign? Is this a good indicator for DVT?
pain in the calf on dorsiflexion, NO!
What is the best diagnostic for DVT
venous duplex ultrasonography
What is a venous duplex ultrasonography?
noninvasive ultrasound that assesses flow of blood through the veins of the arms and legs
What is doppler flow study?
assesses the sounds of veins; thromboses veins produce little or no sounds ; useful in detecting proximal DVTs
When may an MRI be useful as a diagnostic for DVT
proximal deep veins, inferior vena cava/ pelvic veins
What is a D-dimer test?
global marker of coagulation and measures fibrin breakdown products produced from fibrinolysis
Nonsurgical interventions for DVT / PE
leg/calf exercises, early ambulation, adequate hydration, compression stockings, SCDs, anticoagulant therapy
oxygen therapy for PE
When elevating legs to prevent DVT, should we use a knee catch or pillow under the knees
NO
What are the different anticoagulant therapies utilized to prevent DVT?
unfractionated heparin, low molecular weight heparin, warfarin, novel oral anticoagulants
When is unfractionated heparin given?
given IV to prevent formation of other clots and to prevent enlargement of existing clot
when our client is on unfractionated heparin, what labs should we obtain and when?
PTT and aPTT baseline, and then at least daily. IF medication changes, we must draw labs 6 hours after change.
Therapeutic levels of aPTT
1.5-2.5 times normal levels
What is a major side effect of unfractionated heparin?
thrombocytopenia (platelets less than <150,000)
When on unfractionated heparin, we should have ______ readily available
protamine sulfate
How does low molecular weight heparin work?
inhibits thrombin formation
What is the LMWH given at home?
enoxaprin (given subcutaneous and based on client weight)
How does warfarin work?
inhibits synthesis of the four vitamin K dependent clotting factors
How long can therapeutic effects take to notice on warfarin
3-4 days
What labs do we monitor on warfarin
PT/ INR
What are the ranges for INR
1.5-2 times the baseline (if they have PE 3-4)
When on warfarin, we should ensure our client has ____ readily available
vitamin K
Why are novel oral anticoagulants (dabigatran, rivaroxaban, apixaban, edoxaban) useful?
allows for fixed dose without any lab monitoring.
Patient education on preventing DVT/PE
- knee high or thigh high compression stockings
-early ambulation
-do not massage legs
-signs / symptoms of DVT and PE
Patient education for heparin
observe evidence of bleeding, electric toothbrush, use teach-back and return demonstration for LMWH at home
Patient education for warfarin
be aware of vitamin K food sources and avoid fluctuations in the amount. Observe for evidence of bleeding, take bleeding precautions, carry identification card, avoid NSAIDS
Patient education for DVT
-stop smoking
-avoid oral contraceptives
-teaching to avoid potentially traumatic situations
-tell dentists their history and if they are being treated currently
-avoid high fat and vitamin K rich foods
-drink adequate fluids
-avoid alcohol
-avoid sitting for long periods
A client who is receiving heparin therapy is started on warfarin. which nursing explanation is appropriate?
a. you will need both of these drugs long -term
b. warfarin is easier on your stomach
c. it takes several days for warfarin to work so both drugs are required for a few days
d. these drugs work the same, but one is taken by mouth , so it is easier to take at home
c
the nurse is assessing a client who is applying graduated compression stockings. Which of the following client actions would cause the nurse to intervene? SATA
a. placing the stocking over the toe and pulling from the top of the stocking toward the knee
b. applying lotion to the skin before the application of the stockings
c. applying the stockings before getting up in the morning, while seated in bed
d. placing the seam of the stocking on the inside towards the foot
e. gathering the stocking up around the toe and sliding the socking up like a sock
A (can cause stocking to tear or stretch) B (difficult to apply) D (seam of stocking should always be away from skin to avoid pressure injury) E (more difficult)
A client is receiving unfractionated heparin therapy. what laboratory data will the nurse report to the primary health care provider
a. PTT 60 seconds
b. Platelets 32,000
c. White blood cells 11,000
d. hemoglobin 12.2
b
Which client statement demonstrates that warfarin teaching has been effective?
a. I can use an electric razor or regular razor
b. eating foods like green beans won’t interfere with my warfarin therapy
c. If I notice I am bleeding a lot, I should stop taking my warfarin right away
d. when taking warfarin, I may notice some blood in my urine
b
What can cause metabolic acidosis?
DKA, renal and liver failure, HF
Symptoms of metabolic acidosis
increased RR depth (hyperventilation), decreased BP and CO, hyperkalemia
What causes respiratory acidosis
COPD, lung cancer, asthma, head injury with respiratory depression
Symptoms of respiratory acidosis
shallow and increased respirations, decreased bp, fullness in head/ ICP, hyperkalemia, dysrhythmias
What causes metabolic alkalosis
excessive vomiting, gastric suctioning, long term K wasting diuretics
Symptoms of metabolic alkalosis
weakness/lethargy/confusion, hypocalcemia, hypokalemia, respiratory depression
What is respiratory alkalosis caused by
increased respirations, anxiety, PE, fever, hypoxia, over ventilation with ventilator, salicylate toxicity
Symptoms of respiratory alkalosis
lightheadedness, hypocalcemia, hypokalemia, numbness, loss of consciousness
Patient prep for chest x-ray
remove metal and medication patches, rule out pregnancy
How often do we take x-rays with a chest tube
daily
Indications for chest x-ray
assess lung pathology (pneumonia, atelectasis, pneumothorax, tumor), asses tubes and lines
Patient prep for CT scan
provide information to the patient and determine if they have any allergy to the contrast material
Indications for CT scan
cross-sectional views of the entire chest (suspicious lesion or clot)
Intravenous contrast medium can be
nephrotoxic
How long must metformin be stopped before contrast medium can be administered
24 h
When can our patient restart metformin after CT with contrast
when normal kidney function is confirmed
what do our patients use while they cannot have metformin due to CT? What can we teach them?
subcutaneous insulin ; this does not mean your condition is getting worse
Nurse prep for pulmonary function test
no smoking 6-8 h before
no bronchodilator 4-6 h before
Nursing implications during pulmonary function test
document drugs given during testing
Indications for pulmonary function test
assess lung function and breathing problems
sometimes done before surgery to gage risk of pulmonary problems
Post - precedute care for pulmonary function test
assess for dyspnea or bronchospasm
Indications for bronchoscopy
tumors, biopsies, deep sputum, remove foreign bodies
Where are flexible bronchoscopies performed? what anesthesia do they require
beds ; moderate/conscious sedation
Where are rigid bronchoscopies performed? what type of anesthesia do they use
OR, general
Prep for bronchoscopy
NPO 4-8 hours, remove dentures, topical benzocaine
Severe adverse effect of benzocaine
methemoglobinemia
What happens during methemoglobinemia
conversion of hemoglobin ; it no longer has oxygen carrying capacity (causes hypoxia)
Symptoms of metheglobinemia
cyanosis even with O2 therapy, chocolate brown colored blood
Nursing action for confirmed metheglobinemia
call rapid response, administer IV methalene blue
Nursing implications during bronchoscopy procedure
monitor pulse, BP, RR, O2
Post-procedure care for bronchoscopy
monitor level of sedation, gag reflex, VS and breath sounds
How often do we monitor VS and breath sounds after bronchoscopy
q 15 min for first 2 hours
Potential complications of bronchoscopy
bleeding, infection, hypoxemia
Indications for a thoracentesis
removal of pleural fluid or air from the spaces
patient preparation for thoracentesis
tell patient they may feel sting and pressure. Stress the importance of staying completely still. Position them properly and ensure entire back is exposed with no hair.
Nursing implications during thoracentesis
monitor VS, respiratory status, s/s of pneumothorax. Assist in collecting specimens.
How much fluid is allowed to be pulled from a thoracentesis at once
1000 mL (rebound edema and tissue damage)
What is a ‘pig tail’
remains in pleural space to remove fluid periodically. Reduces amount of times patient has to be stuck from thoracentesis
Post procedure care for thoracentesis
chest x-ray to rule out pneumothorax and mediastinal shift, monitor vs and lung sounds, monitor dressing. turn, cough, and deep breathe
Complications of thoracentesis include
subcutaneous emphysema (crepitus), infection, tension pneumothorax
What is subcutaneous emphysema/ crepitus
presence of air in the tissue layer of the skin
What could subcutaneous emphysema indicate
persistent air leak caused by a puncture that tears the pleura
what is the difference between normal pneuomothorax and tension pneumothorax?
tension pneumothorax causes mediastinal shifts
Purpose of NPPV
use positive pressure to keep alveoli open and improve gas exchange without risk associated with intubation
How does CPAP work
uses one set pressure to keep alveoli open
Which patients would benefit from CPAP
sleep apnea, HF, respiratory failure, atelectasis, pulmonary edema, COPD
How does BiPAP work
a cycling machine delivers a set inspiratory positive airway pressure (ipap) and expiratory positive airway pressure (epap)
Who would benefit from BiPAP
COPD, some HF
If our patient is on NPPV and need to eat, we should get an order for
oxygen via nasal cannula
when should we not use NPPV
increased secretions, vomiting (aspiration risk)
What is PEEP
‘positive end expiratory pressure’
sends pressure into the patient during expiration to prevent alveoli from collapsing
What patients are PEEP devices used for
ventilated patients
NPPV can be used on patients with
sleep apnea, dyspnea, hypoxic, COPD, hypercapnia
Indications for chest tube insertion
pneumothorax, hemothorax, pleural effusion, penetrating chest trauma
Prep for chest tube insertion
idk
What do we monitor when our client has a chest tube
lung sounds, breathing effort, oxygen saturaton
How often do we monitor respiratory status when our client has a chest tube
q 4 h
Why should we monitor the insertion site of a chest tube
redness may indicate infection, we also do not want air getting in
Is chest tube insertion a sterile procedure?
yes
Pneumothorax chest tubes will be higher or lower in the chest
higher (2nd or 3rd intercostal space)
pleural effusion or hemothorax chest tubes will be higher or lower in the chest
lower
We should assess the skin around the chest tube for ?
crepitus (subcutaneous emphysema)
What is the collection chamber
fluid and blood is collected here
We should contact the provider if we have output of ____ mL in one hour from the chest tube
70
Drainage amounts can be marked directly on the front of the collection chamber? T/F
true
We mark the drainage amount in the chamber q h for?
24 h
If the fluid in the drainage system becomes too full, we can put our client at risk of
tension pneumothorax
What is the purpose of chamber two/water seal
prevent air from going back into the patient causing tension pneumothorax
The water seal chamber should always contain how much water
2 cm
We should only see bubbling in the water seal container during
expiration
If we see continuous bubbling in the water seal container, this can indicate
air leaks
How often should we check the water seal chamber to make sure it has the correct amount of water
at least once shift
What is tidaling?
when the patient breathes in and out, water in the water seal container moves with it
What can absence of tidaling indicate
obstruction in the tube or lung has fully re-expanded
The third chamber, suction, can be controlled by
water or a dial
How to control suctioning in a wet suction chamber
add water to the level prescribed
we should turn up wall suction until we see ____ in the suction chamber
bubbling
How often should we check sterility and patency of the drainage system
every hour
In case the chest tube gets pulled out, what supplies should we keep in the room
sterile gauze, hemostats (clamp), sterile water
When ambulating, we need to ensure we keep the chest tube container
upright and below the chest
When are the only times we can clamp a chest tube
- if it is being changed 2. if assessing for an air leak 3. if it becomes disconnected 4. removal
If our chest tube becomes disconnected from our patient, what should we do?
dip into two inches of sterile water to create a water seal (or clamp if absolutely necessary)
Clamping the chest tube for too long can cause
tension pneumothorax
Is dyspnea a subjective or objective finding
subjective
How to assess dyspnea in a patient
ask them “are you short of breath?”
What conditions can cause the trachea to move
tension pneumothorax, large pleural effusion
Unequal expansion of the chest, found during assessment, can indicate
air in the pleural cavity or trauma
During assessment, if we find crepitus (crackling sensation beneath fingertips what do we do?
document and report to provider
Crepitus (subcutaneous emphysema can indicate)
pneumothorax
During assessment, if we note decreased fremitus (vibrations from the chest wall), this can indicate
pleural space is filled with air or fluid (pneumothorax and pleural effusion/hemothorax)
During assessment, dullness/ flatness during percussion can indicate
pleural effusion/hemothorax
During assessment, hyperresonance can indicate
trapped air (such as in pneumothorax)
During auscultation, increased vocal resonance can indicate
pleural effusion/hemothorax
(because voice travels through liquid better than air, we will hear it more clearly through our stethoscope)
During auscultation, popping sounds can indicate this emergent condiiton
atelectasis
The nurse is caring for a client with a pleural effusion. What respiratory assessment data would the nurse anticipate
a. auscultation of a rough, grating sound with inspiration
b. squeaky continuous sound that can be heard without a stethoscope
c. lower- pitched rattle with auscultation in the large airway
d. palpable crepitus in the left lower lung field
a
A client receiving oxygen therapy via nasal cannula at 4L/min has dropped from 94 to 90%. What action will the nurse take
a. tighten the straps on the nasal cannula
b. assess the adequacy of humidification
c. increase the oxygen to 6L/min
d. check the tubing for kinks or obstructiosn
d
A client with COPD has all of the following ABGs from earlier today. Which change would alert the nurse to take immediate action?
a. ph from 7.21 to 7.20
b. HCO3 remains at 31
c. Paco2 from 45 to 68
d. Pao2 from 88 to 86
c
Are we allowed to strip tubing in a chest drain
no
The nurse is caring for a client with a closed chest tube drainage system. Upon assessment, the nurse notes tidalign in the water seal chamber
a. check all connections , anticipates a leak in the system
b. assess the tubing for a blockage, kinks, or possible clot
c. continue to monitor the client, document this as a normal assessment finding
d. clamp tubing at distal end , away from the patient
c
Most chest traumas can be treated with
basic resuscitation, intubation, chest tube placement
The first emergency approach t chest trauma is the
ABCDE trauma resuscitation approach
How does pulmonary contusion most often occur
rapid deceleration like a car crash
During a pulmonary contusion, hemorrhage and edema can occur between the
alveoli –> reducing available gas exchange
During pulmonary contusion, will respiratory failure occur immediately or will symptoms progress later
both (it depends)
Symptoms of pulmonary contusion
decreased breath sounds and crackles. bruising, dry cough, tachycardia, tachypnea, dullness to percussion, hemoptysis
Management of pulmonary contusion
oxygen, IV fluids, moderate-fowlers posiiton
During treatment for pulmonary contusion, if our client is side-lying, we should put
the good lung down
What vicious cycle can occur during pulmonary contusion
muscle effort increased –> uses more oxygen –> alveoli have reduced gas exchange –> increasingly becomes more hypoxemia –> more effort to increase oxygenation
What is flail chest
fractures of three or more adjacent ribs in two or more places
What sort of chest wall movement can occur during flail chest
paradoxical
What is paradoxical chest wall movement
chest moves in opposite direction during inspiration and expiration
What lung functions are altered during flail chest
gas exchange, coughing, clearance of secretions
Symptoms of flail chest
paradoxical chest movement, dyspnea, cyanosis, tachycardia, hypotension
Interventions for flail chest
humidified oxygen, pain management, deep breathing/coughing/ positioning ( deep breathing) , suctioning and coughing (secretion clearance), Iv fluids (hypotension)
For a client with flail chest, we should monitor these labs closely
ABGs and vital capacity
With severe hypoxemia and hypercarbia (hypercapnia) the patient with flail chest is typically
placed on mechanical ventilation
For a patient with flail chest, it is important to monitor
signs of hypovolemic shock (vitals signs, fluid and electrolyte imbalances)
What is a pneumothorax
air in the pleural space causing reduction in vital capacity, which can lead to lung collapse
What is a hemothorax
bleeding into the chest cavity
What is an open pneumothorax
caused by an open wound allowing air inside
What is a closed pneumothorax
spontaneous pneumothorax (usually from a present disease)
What is a tension pneumothorax
a medical emergency in which air enters the pleural space during inspiration and doesn’t leave on expiration
Why is tension pneumothorax a medical emergency
intense pressure in the lung causes collapse of the blood vessels limiting blood return. This leads to decrease filling of the heart and reduced cardiac output
With hemothorax and pleural effusion, percussion produces a
dull sound
With pneumothorax, percussion produces a
hyper resonance sound
Assessment findings for pneumothorax, hemothorax, and pleural effusion
chest pain, SOB, tachypnea, hypoxia, sensation of air hunger,tachycardia, use of accessory muscles
Pneumothorax, hemothorax, pleural effusion breath sounds will be
absent or reduced
With tension pneumothorax, what may happen to the trachea
MOVES AWAY FROM MIDLINE AND TOWARDS THE UNAFFECTED SIDE (MEDIASTINAL SHIFT)
sry I just yelled
Additional signs and symptoms for tension pneumothorax
extreme respiratory distress, cyanosis, distended neck veins, tachycardia, hypotension, respiratory failure
What diagnostics may be used to diagnose pneumo/hemothorax and pleural effusion
Xrays, CT scans, ultrasonography
For a stable patient with a small pneumothorax, treatment may be
unnecessary
For severe pneumothorax, tension pneumothorax, pleural effusion, and hemothorax, this therapy is essential
chest tube therapy
What is initial treatment for tension pneumothorax
using needle decompression to turn tension pneumothorax into normal pneumothorax
After needle decompression, how is tension pneumothorax treated
chest tube insertion
What are used to determine chest tube treatment effectiveness
serial chest x-rays
the nurse is caring for a client with multiple rib fractures. The client reports chest pain and shortness of breath. assessment reveals diminished breath sounds on the left side, HR 115 bpm, BP 85/50mmg, and O2 86% on room air.
which action is nursing priority
a. initiate oxygen therapy
b. notify respiratory therapist
c. alert rapid response team
d. apply noninvasive mechanical ventilation
C
- do not leave the client. call rapid response as client will probably need compressions. then administer oxygen
the nurse is caring for a client with PE who is receiving continuous heparin infusion. Which nursing intervention is a priority
a. assessing breath sounds
b. comparing pedal pulses bilaterally
c. monitoring platelet count daily
d. assessing gums daily
c
Which assessment finding on a client who is being mechanically ventilated indicates to the nurse a possible left sided tension pneumothorax?
a. sputum and wheezes
b. chest caves in on inspiraiton and puffs out on expiraiton
c.chest is asymmetrical and trachea deviates towards the right side
d. left lung field is dull to percussion
c
The nurse has just received report on a group of clients. Which client will be the nurse’s priority?
a. a 30 year old on CPAP and has intermittent wheezing
b. a 40 year old on oxygen face mask with respirations 24 b/min
c. a 50 year old who is being mechanically ventilated and has tracheal deviation
d. a 60 year old who was recently extubated and reports a sore throat
c
