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
Renal Failure Interventions
O2
Discontinue any meds affecting kidneys
Aseptic technique
Cardiac monitoring
Report: vitals, any change in condition, urine output, edema, ecchymosis
Orders: O2, cardiac monitoring, urinalysis, urine electrolyte/osmolarity, creatinine, mag, angiogram, renal scan, bleeding time, BUN, daily weights, IV fluids, kidney ultrasound
MEDS: insulin/glucose or kayexelate for hyperkalemia, IV fluids
Dig Toxicity Interventions
Discontinue Dig
Maintain airway
O2
Cardiac monitoring
Frequent apical pulse
Report: ECG changes, visual disturbances, LOC, headache, GI upset
Orders: O2, cardiac monitoring, discontinue dig, ECG, serum electrolytes, dig level, IV fluids, bed rest, cardiac enzymes, cardiac diet, electrolyte therapy
Meds: digibind, Procainamide, lidocaine, mag, potassium
Ilieus Interventions
Pain medications
Assess for trauma
Report: pain quality, changes in BM, vitals, signs of trauma, last menstrual period
Orders: NPO, pain meds, IV fluids, antiemetic, surgical consultation, guaiac, abdominal CT, CBC, electrolytes
CVA Interventions
Determine ischemic vs hemorrhagic Angiogram Head CT Ischemic: thrombolytic, heparin, aspirin Hemorrhagic: lower BP, surgery
Elevate head of bed Monitor vitals Monitor ICP Maintain airway Neurologic assessment frequently
Thrombocytopenia Interventions
Minimize falls, bleeding risks, injury risks Monitor platelet count, PT, PTT Avoid injections Platelet infusion Administer blood as ordered
CHF S/S
Fluid in lungs DOE Fluid retention Edema Bloating Appetite loss/nausea Fatigue Weakness
CHF Interventions
Monitor vitals Assess heart/lung sounds Assess LOC O2 ABGs Lasix IOs Daily weights Frequent periods of rest High fowler's Low sodium/fluid restricted diet
