PBDS Flashcards
CVA S/S
Difficulty walking Dizziness Loss of balance/coordination Numbness/paralysis Difficulty speaking Blurred vision Sudden headache N/V/D
Renal Failure S/S
Anorexia Back pain Delirium Diarrhea Dyspnea Ecchymosis Proteinuria Hematouria Decreased creatinine clearance Decreased serum bicarb Increased serum mag Increased serum uric acid Hyperkalemia Could lead to metabolic acidosis
Increased ICP S/S
Restlessness Irritability Drowsiness Confusion Changes in LOC Posturing Cushing's Triad: increased BP, abnormal breathing, decreased HR Headache N/V Seizures
Chest Pain/MI S/S
Chest pain Pain radiating down arm Dyspnea Diaphoresis N/V Abnormal heart and lung sounds Increased troponin/creatinine, kinase, LDH (lactate), ESR (measure of inflammation) and leukocytes
PE S/S
Tachypnea SOB Tachycardia Diaphoresis Anxiety Chest pain Splitting/loud second heart sound Restlessness
Pneumothorax S/S
Sudden chest pain SOB Coughing Tachy Dyspnea Cyanosis Asymmetrical respirations Diminished breath sounds
Dig Toxicity S/S
ECG changes Blurred vision Halos Confusion Headache N/V/D
Ilieus S/S
Anorexia Malaise Tachycardia HTN Fever N/V Distended abdomen Constipation Bloating
Thrombocytopenia S/S
(Low platelet count) Ecchymosis Bleeding Petechiae Hematouria Fatigue Blood in stool Jaundice Enlarged spleen
Chest Pain/MI Interventions
MONA: Morphine, Oxygen, Nitroglycerin, Aspirin
Monitoring
Bed rest
Report: BP, respiratory status, HR, LOC, chest pain, heart/lung sounds
MEDS: aspirin, heparin, nitroglycerin, sedatives, morphine, stool softener, metroprolol, lidocaine
Orders: O2, ECG, chest x-ray, ABGs, cardiac monitor, serum troponin, CBC, electrolytes, coagulation study, cardiac enzymes, card cath, IV access, morphine, aspirin
Chest Pain/MI Interventions
MONA: Morphine, Oxygen, Nitroglycerin, Aspirin
Monitoring
Bed rest
Report: BP, respiratory status, HR, LOC, chest pain, heart/lung sounds
MEDS: aspirin, heparin, nitroglycerin, sedatives, morphine, stool softener, metroprolol, lidocaine
Orders: O2, ECG, chest x-ray, ABGs, cardiac monitor, serum troponin, CBC, electrolytes, coagulation study, cardiac enzymes, card cath, IV access, morphine, aspirin
Pneumothorax Interventions
O2
Monitor vitals
Bedrest
Report: vitals, tracheal deviation, chest mobility, cyanosis, dyspnea, hypotension
Pneumothorax Interventions
O2
Monitor vitals
Bedrest
Report: vitals, tracheal deviation, chest mobility, cyanosis, dyspnea, hypotension
Orders: O2, ECG, chest xray, ABGs, cardiac monitor, pain reliever, IV access
Treatment: needle or chest tube to reinflate lung, pain reliever
PE Interventions
Monitor vitals
O2
EKG
IV fluids
Bed rest, ambulate per orders
Report: history of DVTs, heart/lung sounds, temp, vitals, respiratory status
Orders: IV access, IV heparin, vasopressors if hypotensive, chest xray, VQ scan, thrombolytics, surgery
Increased ICP Interventions
O2 Raise head of the bed IV access Maintain airway Monitor for hyperventilation Seizure precautions Avoid coughing/BMs that may increase ICP Report: LOC, vitals, changes in behavior, seizure activity Orders: diuretics, corticosteroids, urinary cath, barbiturates, intraventricular catheter, epidural pressure recording device
