Random Flashcards
Atrial Natriuretic Peptide (ANP)
opposite of aldosterone - so causes the excretion of sodium and water
Is released as the heart is stretched to fix FVE
Antidiuretic hormone
causes you to retain WATER WATER WATER
With urine specific gravity, sodium, and HCT concentrated makes the #s go
up
With urine specific gravity, sodium, and HCT dilute makes the #s go
down
Not enough antidiuretic hormone
Diuresis Water Fluid Volume Deficit Diabetes Insipidus - nothing to do with blood sugar Blood Concentrated (so increased #s) Urine Dilute (so decreased #s) Increased urine output
When not enough antidiuretic hormone number one thing to worry about is?
shock
What are some potential causes of antidiuretic hormone problems
(anything that upsets pitutary gland)
craniotomy, head injury, sinus surgery, transphenoidal hypophysectomy
Any condition that can lead to and increase in ICP can lead to *
an antidiuretic hormone problem
Pt had transphenoidal hypophysectomy and voided 1300 ml worry about
pt getting diabetes incipidus and developing shock
If going into FVE where will you hear “wet” sounds first?
posteriorly in the bases of the lungs
If in FVE what happens to pulse
increases and will be full and bounding
the heart is now pumping harder to keep fluid moving forwards and not backwards (if goes backwards will lead to HF and pulmonary edema)
any acute weight gain is
water not fat
MORE VOLUME…. MORE
PRESSURE
If fluid retention then think what first? *
heart problem
Bed rest and diuresis
Bed rest induces diuresis by release of ANP (opposite of aldactone) and decreases production of ADH
Bed rest can increase risk for
DVT, dehydration, kidney stones, pneumonia, and constipation (all because bed rest causes diuresis and can go into FVD)
If pt on bed rest what is very important to do?
push fluids because bed rest induces diuresis
anytime you see an assessment or evaluation you should be looking for the presence or absence of
PERTINENT signs and symptoms
Give IV fluids slowly to
elderly, very young, and hx of kidney disease
can put in FVE very fast
If pt loosing fluid worry about
shock
Pts with ascites important problems
breathing problems (fluid pushing on diaphragm) and hypotension (fluid in wrong spot)
PID (particle induced diuresis) with diabetes
sugar particles have to come out in volume and is why the diabetic pt gets diuresis
When pt goes from polyuria to oliguria to anuria worry about
renal failure
with polyuria think what first?*
shock
FVD pts at risk for
orthostatic hypotension because there is less volume and less pressure
in FVD respirations are
increased because body thinks hypoxic so increases rate to fix hypoxia
Isotonic solutions
Normal Saline (0.9%), Lacted Ringers, D5W, D51/4NS
Uses for isotonic solutions:
N/V, burns, sweating, trauma
solutions with blood
NS
Best solution for shock
LR because has electrolytes
Do not use isotonic solutions with
HTN, cardiac disease, or renal disease
solutions can cause FVE, HTN, or Hypernatremia
Only solution that can cause hypernatremia
isotonic
Hypotonic solutions definition:
go into vascular space then shift out into the cells to replace cellular fluid
they rehydrate but do not cause hypertension (won’t increase bp because don’t stay in vascular space)
Hypotonic solutions:
D2.5W, 1/2 NS, 0.33% NS
Uses of hypotonic solutions
HTN, renal disease, cardiac disease, N/V, burns, hemorrhage, used for dilution with hypernatremia and for cellular rehydration
With hypotonic solutions watch for
cellular edema because this fluid is moving out into cells which could lead to FVD and decreased bp
hypertonic =
colloid
isotonic =
cyrstaloid
hypertonic solutions definition:
volume expanders that will draw fluid into the vascular space from the cell
hypertonic think!
packed particles
hypertonic solutions
D10W (sugar), 3% NS, 5% NS (salt), D5LR, D51/2 NS, TPN, Albumin
Uses of hypertonic solutions
hyponatremia, pt who has shifted large amounts of vascular volume to 3rd space, severe edema, burns, or ascites
a hypertonic solution will
return the fluid volume to the vascular space
with hypertonic solutions watch for
fluid volume excess
monitor bp, pulse, and CVP
especially with 3% NS or 5%NS
Insulin carries what into cell
glucose and potassium
so anytime give IV insulin worry about hypoglycemia and hypokalemia
hyperventilation and CO2
eliminate CO2
hypoventilation and CO2
retain CO2
causes of respiratory acidosis
(retaining CO2 and HYPOventilation)
mild abdominal incision (can’t take in deep breaths), narcotics and sleeping pills ( repress breathing), pneumothorax, collapsed lung, pneumonia (sticky secretions)
respiratory acidosis s/s
h/a, confused, sleepy
can go into coma
hypoxic (early s/s restless and tachycardia)
If restless pt think what 1st
hypoxia
to treat respiratory acidosis you
need to fix the breathing problem
so elevate bed, deep breathing, suctioning, voldyne
respiratory acidosis hypo/hyperventilating
hypo - retaining CO2 that’s an acid
respiratory alkalosis hypo/hyperventilating
hyper - losing CO2 (acid) and why alkalotic
respiratory alkalosis causes
hyperventilation
hysterical
acute aspirin overdose (stimulates respiratory center in the brain)
-pt breathing too fast and removing CO2
respiratory alkalosis s/s
lightheaded
faint
perioral numbness
numbness and tingling in fingers and toes
respiratory alkalosis treatment
breathing into paper bag to force back CO2
may sedate pt to decrease respiratory rate
metabolic acidosis causes
(too much hydrogen (acid) and too little bicarb (base)
DKA - body doesn’t have insulin to bring glucose into cells so breaks down body fats for energry leads to ketones (acids)
Starvation - starving for glucose so break down protein and produce ketones (acids)
Renal Failure - no longer can filter out acids or retain bases
Severe diarrhea - lower GI has lots of bases but when diarrhea loses bases
metabolic acidosis s/s
hyperkalemia - muscle twitching/weakness/flaccid, arrhythmias
increased respiratory rate - trying to blow off the acid
increased serum potassium level
see what kind of respirations with DKA
kausmals because the body has too much acid (resulting from ketones) and body tries to blow off CO2 to become less acidic
diarrhea what type of acid/base imbalance
metabolic acidosis
comes out of your acidosis
drug to help metabolic acidosis
IV push sodium bicarb - will not fix but buy time to figure out cause
will get pH back in normal range then figure out cause
metabolic alkalosis causes
loss of upper GI contents (acid in stomach)
too many antacids (so too much bases)
too much IV bicarb
metabolic alkalosis s/s
LOC alterations
serum K levels will go down
respirations will decrease to try to hold onto CO2
metabolic alkalosis treat with
potassium to replace lost
metabolic acidosis = (K)
hyperkalemia
metabolic alkalosis = (K)
hypokalemia
After a burn why does plasma seep out into the tissue?
increased capillary permeability (leaking) - the vessels are damaged from heat so thats why they leak
vascular volume is decreased so at risk for shock
occurs 1st 24 hours after burn
After a burn what happens to pulse and cardiac output
pulse increases (because in FVD) cardiac output decreases - because less volume
After a burn what happens to urine output
decreased because either kidneys trying to hold onto fluid or they aren’t being perfused (only takes 20 mins of poor kidney perfusion to have kidney necrosis)
After a burn why is epinephrine excreted
makes you vasoconstrict to shunt blood to vital organs and help to increase bp
After a burn why are ADH and aldosterone secreted?
aldosterone - retain Na and water
ADH - retain water
therefore blood volume will go up
problem with carbon monoxide
normally oxygen binds with hemoglobin but carbon monoxide travels much faster than oxygen therefore gets to hemoglobin faster and now oxygen can’t bind now pt is hypoxic
color of carbon monoxide pt
cherry red not blue
treatment for carbon monoxide poisoning
100% O2 - trying to increase the chances of O2 to bind with hemoglobin instead of carbon monoxide
What would MD do if pt has burns to chest/neck/face?
intabate! - do this before trach because less invasive
airway will swell then will have to trach so intabate before have to trach
Rule of Nines
Head and neck 9% Front of trunk 18% Back of trunk 18% Arms (each) 9% Genitals 1% Legs (each) 18%
Parkland formula
(4ml of LR) x (weight in kg) x (% of TBSA burned) = total fluid requirement for the 1st 24 hours after burn
1st 8 hours
Fluid therapy for burns depends on what
the time the injury occurred not when the treatment was started
restless burn pt means
inadequate fluid replacement, pain, or hypoxia
hypoxia is the priority, pain never killed anyone
in burn pts how would you tell if fluid volume is adequate -
urine output
not weight because burn pts getting fluids fast and causes an increase in weight gain which makes urine output a better indicator
Emergency burn management
put cool water! (not ice water - ice causes vasoconstriction)
remove jewelry to prevent swelling
place blanket to hold in body heat and keep out germs
remove non-adherent clothing and cover burn with a clean dry cloth
Shallow respirations means?
pt retaining CO2 and in respiratory acidosis
Test to take hourly to know if over doing fluid
CVP - right atrial pressure
will increase and the right atrium fills with fluid
Give what type of pain meds to burn pt
IV narcotics over IM
- act faster
- won’t have adequate perfusion to muscles
If a pt has a circumferential burn on their arm what should you be checking?
circulation!
Circulatory check:
- pulse
- skin color
- skin temp
- cap refill
escharotomy -
relieves the pressure and restores the circulation, cutes through the eschar
fasciotomy -
relieves the pressure and restores the circulation, but cut is much deeper into tissue than escharotomy, cut goes through the eschar
why when insert foley cath no urine returns?
kidneys are attempting to retain fluid or they aren’t being perfused adequately
If you see brown or red urine in burn pt what would you do?
call the MD
this happens because will have muscle and tissue destruction then myoglobin is released in urine, then worry about renal failure
want to increase fluids to flush out kidneys
mannitol used to flush out kidneys - exception to the no diuretics to burn pts
If no urine output or less than 30 ml/hour what would you worry about?
kidney failure
Why burn pt NPO and have an NG tube hooked to suction?
because they can develop a paralytic illeus - which could cause gastric secretions to build up in stomach and potential to aspirate
Why burn pts can get a paralytic illeus?
Decreased vascular volume - blood shunted to vital organs and gut not perfused
Decreased GI motility - normal stress response
Hyperkalemia - symptom of muscle weakness - intestines are smooth muscle
if pt doesn’t have bowel sounds, what will happen to the abdominal girth?
increases
Diet for burn pts
high protein and vitamin C*, need maximum nutrition - they are in a hypermetabolic states
NG tube removed when
hear bowl sounds
when start GI what should you measure to ensure the supplement is moving through GI tract
gastric residuals
Order to hold feeding if >50 - means parstolic activity is very slow so hold feeding and put residual back in to prevent fluid/electrolyte imbalances
lab work to ensure proper nutrition and a positive nitrogen balance?
prealbumin, total protein, or albumin
prealbumin - most sensitive indicator of overall nutritional status
what to do if burns on neck?
hyperextend the neck, head is back
no pillows, promotes chin-to-chest
what is eschar
necrotic dead tissue
has to be removed - new tissue can not regenerate if not removed
also, bacteria can grow in bacteria
If see skin graft hanging by sutures then
immediately put on sterile dressings and call MD
what to put on a donor site of skin graft
transparent dressing until bleeding stops, then can be left open to air
what to do first with a chemical burn
begin flushing for 15-20 mins
if eye burn then
take out contacts
flush immediately
1st thing to do with electrical burns
put on continuous heart monitor for 24 hours - at risk for ventricular fibrillation
with electrical burns how does kidney damage occur
the build up of myoglobin and hemoglobin
complications of electrical burns
kidney damage, cataracts, gait problems, and any NEUROlogical deficit
Monthly self breath exam after the age
over 20
7-12 days after period
Yearly clinical breast exam for women
> 40 years old
needed every 3 years for 20-39
Mammogram yearly at 40 (with 2 views of each breast)
What not to do before pap smear
douching or sex
Before mammogram instruct pt to not
have on lotion, powder or deodorant
When to have colonoscopy
at 50 then every 10 years after that
digit exam for men
yearly and yearly prostate specific antigen for me after age 50
testicular tumors grown between
15-36
Warning signs for cancer (CAUTION)
Change in bowel/bladder habits A sore that does not heal Unusual bleeding/discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in wart or mole Nagging cough or hoarseness
internal radiation
(brachytherapy) radioactive source is inside the pt and radiation is being emitted so hazard to others
Unseal - pt and body fluids emit radiation (hypothyriodism)
Sealed or solid - pt emits radiation body fluids don’t
When radiation implants pt should
rotate nursing assignments rotated daily so nurse not continuously exposed
nurse should only care for 1 pt with radiation implants
How to help prevent dislodgment of internal radiation implant
keep pt on bed rest
decrease fiber in the diet - will distend bowl and push out implant
prevent bladder distention - will put foley in
What do you do if the implant becomes dislodged and you can see it?
1st put on gloves
pick it up with forceps or tongs
place it in a lead lined container
leave it in room and call radiation to come and pick it up
external radation
(teletherapy, beam radiation)
s/e usually limited to exposed tissue
do not wash or put anything on markings unless MD ordered
protect site for 1 year after completion of therapy
when handling chemo nurses
need to be careful because chemo drugs can be absorbed through the skin and mucous membranes
vesicant
type of chemo that if extravasation (infiltrates) will cause tissue necrosis
have to stay with pt the whole time
extravasation
vesicant infiltration
s/s: pain, swelling, and no blood return
need to prevent
if extravasation occurs what do you do?
Stop the infusion, put ice packs on the promote vasoconstriction, and call MD
what to do when IV infiltrates
apply warm moist heat
water for pts that are immunospressed
do not leave sitting for longer than 15 mins
conization
when remove part of the cervix for pts with cervical cancer
this is for someone who wants to preserve part of their fertility but depends on stage of cancer
endometrial cancer -
uterine cancer
Major s/s for uterine cancer
post menopausal bleeding (50% chance)
teach pts if ever have bleeding after menopause to tell MD
total abdominal hysterectomy means
uterus and cervix only!!!
bilateral oophorectomy
ovaries removed
bilateral salpingectomy
tubes are removed
radical hysterectomy
may remove all of the pelvic organs
major complication with abdominal hysterectomy?
hemorrhage
major complication with vaginal hysterectomy?
infection
why avoid high fowlers with hysterectomy
because it makes blood pool to the pelvis
One thing for pt after surgery to prevent risk of pneumonia, thrombophlebitis, and constipation
early ambulation
pts with surgery for best cancer important to
elevate arm on affected side and they need to be taught to protect this arm - no bp, watch, or purse on arm, no IVs
know with surgery after breast cancer might have had to
removed lymph nodes and now swell (lymphedema) and lymph nodes purpose is to fight infection and promote drainage
where most breast tumors occur
tail of spence located in upper outer quadrant
hemoptysis and dyspnea are s/s of lung cancer but can be confused with
TB but TB has night sweats
after bronchoscopy could have
SQ emphysema - air under the tissues
feels like rice cripys sounds
EMERGENCY!
respiratory depression
depressed
sputum specimen
should take 1st in the morning
should be sterile - don’t want mouth touching cup
first the pt should rinse mouth out with water - to decrease the bacteria in the mouth
Lobectomy
part of the lung is removed
surgical side up
will have chest tubes
Pneumonectomy
entire lung is removed
position on affected side (surgical side down, good lung up) - so lung can expand and not get pneumonia
No chest tubes - because there’s no lung
Avoid lateral positioning (don’t turn all the way on their side) - can lead to mediastinal shift!!
total laryngectomy
removal of vocal cords, epiglottis, thyroid cartilage
because epiglottis is removed at risk for aspiration
pt will have a permanent trachostomy and breath out of stoma the rest of their life
post opp position after total laryngectomy
mid folwers
if emergency and have the options call MD or check VS
CALL MD
because this only gives you one option
side effect emergency of a total laryngectomy
rupture of innominate artery!
begins with bleeding massively from trach
with a total laryngectomy ALL breathing is
done through the stoma
If trach comes out
if can’t get new sterile trach then run and insert dirty trach
better to be alive with infection then dead infection free
Bloom Singer device
connection is made between the trachea and esophagus
pt can insert soft plastic device and move air from lungs to trachea and then over to esophagus and out of mouth
tongue and lips can form words with the rush of air
nothing can be pulled from esophagus into lungs - so don’t have to worry about aspiration
Can pt with total laryngectomy: whistle? use straw? smoke? swim?
whistle? no
use straw? no
smoke? not recommended, but could
swim? no
suctioning with total laryngectomy
sterile technique
hyperoxygenate before and after
stop advancing catheter when you MEET RESISTANCE* or pt coughs
apply suction on the way out
do intermittent suction no longer than 10 seconds
watch for arrhythmias
If suctioning and heart rate drops
vagus nerve was stimulate, pt is not hypoxic
stop suctioning and hyperoxygenate
Colorectal cancer most frequent site of metastasis
liver
so take bleeding precautions
colectomy
part of the colon removed
may not need colostomy, depends on how much is removed
abdominoperineal resection
removal of the colon anus, rectum
cannot take rectal temp *
Can’t take rectal temp with which pts
abdominoperineal resection, thrombocytopenic, or immunosuppressed
major symptom of bladder cancer
painless intermittent gross/microscopic hematuria
illeal conduit
piece of the ileum is turned into a bladder
ureters are placed in one end is brought to the abdominal surface as a stoma
so urostomy!
need to flush out so drink lots of fluid (2,000-3,000)
now normal to have mucus - because bladder made from part of intestine
change appliance in morning (because output will be its lowest
Also, its ok to place a little piece of 4x4 inside the stoma during skin care to absorb urine just don’t forget to remove it
after any urinary surgery with males chance of
impotent
most common sign of prostate cancer
painless hematuria
(others: hesitancy, frequency, frequent infections - because can’t empty bladder completely, nocturia, urgency, dribbling)
radical prostatectomy
biopsy must be done prior to surgery for confirmation of prostate cancer
take out the prostate and if pt is cancer free then no metastasis
may have erectile dysfunction due to pudendal nerve damage
may have incotinence
pt is sterile
prostatectomy TURP
transurethral resection of the prostate
used to help urine flow NOT a cure for prostate
no incision
excessive bleeding complication - worried about clogging up kidneys so use continuous bladder irrigation to maintain patency and flush out clots
Can you manually irrigate a catheter with a fresh surgery pt?
NEVER without MD order
When walk into room assess tubing for kinks or bladder distention on pt 1st
bladder distention
always assess pt first
and always assess before implement
bilateral orchiectomy
decreases testosterone
most common s/s of stomach cancer
heart burn and abdominal discomfort
gastrectomy
take out stomach but leave some if can
fowlers position
will have NG tube - do not reposition
complications of gastrectomy
dumping syndrome
vitamin B12 deficient anemia
no stomach r/t vitamin B12
no stomach then no instrinic factor then can’t absorb PO B12 can’t make good RBC so pt is anemic
will get B12 shots every week for a month then monthly after that
Schilling’s Test*
measures the urinary excretion of vitamin B12 for diagnosis of PERNICOUS ANEMIA not iron deficiency
You need what to produce hormones?
Dietary iodine (different than drug)
Thyroid hormones give us
energy!
Diagnosing graves disease
(Hyperthyroidism)
draw serum T4 levels -increased
thyroid scan - enlarged thyroid
what must pts do prior to thyroid scan?
pts must discontinue any iodine containing medication 1 week prior
eu =
normal so euthyroid (normal thyroid)
tyroidectomy pt care
Teach how to support neck because incision on front of neck and don’t want tension on suture lines
elevate HOB
check for bleeding behind the neck (pooling)
will need more calories
assess for recurrent laryngeal nerve damage by listening for hoarsness
thyroidectomy can lead to what
vocal cord paralysis, if both then possibly airway obstruction will occur then require immediate trach
When would you trach at bedside of thyroidectomy
swelling
recurrent laryngeal nerve damage (vocal cord paralysis)
hypocalcemia
- assess for parathyroid hormone by the s/s of hypocalcemia (not sedated, rigid and tight muscles) - could possibly have seizure
People with hypothyroidism tend to have underlying
CAD
so monitor for chest pain and rhythm changes when giving meds that increase HR and BP
the parathyroid secretes
parathormone which makes you pull calcium from the bones and place it in the blood
if too much parathormone then serum Ca will
be high
if too little parathormone then serum Ca will be
low
partial parathyroidectomy
when take out 2 of your parathyroids to decrease PTH secretion
done when pt hyperparathyroid/hypercalcium/hypophastemia
monitor hypocalcium post opp (non sedated, rigid tight muscles)
vanillylmandelic acid test
24 hours urine specimen is done to see if pt has pheocromocytoma (adrenal medulla problem)
looking for increased levels of epi and norepi
can’t have anything with vanilla in it for a wk prior
throw away first void and keep the last for 24 hours
have to remain calm for those 24 hours so that epi and norepi don’t increase
even though the body secretes steroids normally the adverse effects are going to be more pronounced when the
pt is receiving PO or IV steriods
too much aldosterone =
too much Na and Water
so FVE
decrease serum potassium
not enough aldosterone =
decrease Na and water
so FVD
increase serum potassium
hyperkalemia s/s
begins with muscle twitching, then weakness then flaccid paralysis
Tx of Addison’s disease
Increase sodium in diet (processed fruit juice)
I&Os (this is a fluid problem)
Addisonian Crisis =
severe hypotension and vascular collapse
can occur when stop taking steroids abruptly
have to taper steroids because body not making on steriods
What happens with blood sugar with addison’s disease?
Will go do
normally steroids increase bs but now don’t have steroids
If see fluid retention think what first?
heart problem and worry about pulmonary edema
too many glucocorticoids s/s
cushing’s
growth arrest thin extremities/skin (lipolysis) increased risk of infection hyperglycemia psychosis to depression moon faced (fat redistribution or fluid retention) truncal obesity (fat redistribution; lipogenesis) buffalo hump (fat redistribution)
too many sex hormone s/s
cushing’s
oily skin/acne
women with male traits
poor sex drive (libido)
libido
poor sex drive
too many mineralocorticoids s/s
cushing’s
(too much aldosterone) high bp CHF weight gain Fluid volume excess*
if the pt has too much mineralocorticoid (aldosterone) the serum K level would be
low
adrenalectomy
removal of adrenal glands
if both are removed will need lifetime replacement of steroids
what type of environment for cushings pts
quiet because when steroids are messed up can’t handle stress
diet for cushings pre-treatment
increase K decrease NA increase Protein increase CA
steroids can cause what to develop
osteoporosis
because steroids decrease serum calcium by excreting it through the GI tract and then pull Ca out of the bones and make them brittle
What could appear in cushings pt urine
glucose and ketones
NOT protein
if their is protein in urine then
holes in glomerulus
why diabetes polyuria
because too many sugar particles so PID (particle induced diuresis) kidneys try to excrete sugar and has to come out in volume so could lead to shocke
why diabetes polydipsia
losing volume so now thirsty
why diabetes polyphagia
cells are starving so they start breaking down protein and fat for energy and than leads to ketones
Acid base balance for diabetes
Type I metabolic acidosis
Type II not acidosis - because not breaking down fats
Pts with type II diabetes should be evaluated for
Metabolic syndrome (syndrome x) - know to teach how to decrease risk factor by lifestyle changes
screen pregnant women for gestational diabetes at
24-28 weeks gestations
if mom has risk factors screen at first visit
complications to baby of gestational diabetes
increased birth weight and hypoglycemia
(while baby in mom the baby’s pancreas is producing excess insulin because of increased blood sugar in mom, once born, baby still over producing insulin)
protein diet for diabetes
limit protein to 10-20%
increase protein = increased workload on kidneys - diabetics tend to have renal disease
why are diabetics prone to CAD?
sugar destroys vessels just like fat
need to keep sugar normal to save vessels
fiber diet for diabetes
high fiber - slows down glucose absorption in the intestines, and eliminates the sharp rise/fall in blood sugar
ketones in urine
body breaking down fat
lead to metabolic acidosis
blood sugar and stress
increases so if not taken care of then DKA
ILLNESS=DKA
rotation of insulin sites
rotate within an area first
s/s of hypoglycemia
cold, clammy, confused, shaky, h/a, nervous, nauseated, increased pulse
if hypoglycemic then
eat or drink simple sugar
(4-6 oz of juice, coke, or milk
glucose absorption is delayed in foods with lots of
fat
after pt hypoglycemic and bs is up what should they do
eat a complex carb and protein to keep from bottoming out blood sugar
If totally unconscious pt then put what in mouth to increase bs
while pt on side in dependent position - honey, syrup, jelly, icing
kussmaul’s respirations
trying to blow off CO2 to compensate for metabolic acidosis
in DKA
DKA tx
hourly blood sugar and potassium levels IV insulin ECG Hourly outputs ABGs (will be in metabolic acidosis) IVFs - start with NS then switch to D5W when bs is 300 to prevent hypoglycemia
Type I diabetes = DKA so type II =
HHS or HHNK
diabetic foot care
cut toe nails straight, dry between toes, wear well fitting shoes, inspect feet daily, no chemicals on feet
Diabetics are at increased risk for
infection because full of sugar and bacteria love sugar
Weight _____ in mild depression
gain
Weight _____ in severe depression
loss
can people with depression make simple decisions?
no
As depression lifts what happens to suicide risk
it does up
now they have the energy to complete the task
do what to give depressed pts more time to process information
use silence!
depressed pts and sleep
have difficulty falling asleep, staying asleep, or have early morning awakening
depression + mania =
bipolar disorder
with manic pt and their beliefs
let them know you accept that they need the belief but you do not believe it!
manic pts are very
manipulative - it makes them feel powerful
with manic pts you must
set limits and the staff must be consistent
manic pts and staff
brief, frequent contact - too much intense conversation stimulates the pt
when manic pts eat
walk with them, they will eat better
what is important to do with schizophrenic pts
orient them frequently - pt may know person, place, and time, but still have delusions and hallucinations
when pt in restraints check on them
every 15 mins and remember hydration, nutrition, and elimination
if pt can’t contract for safety have to be one on one
make sure with paranoia pts you are
reliable!!
if you say you are going to do something then do it
always be honest!
anxiety increases performance at ________
decreases at _______
increases at mild levels
decreases at high levels
the pt who is anxious needs
step by step instructions - they can’t make simple decisions
do you let OCD pts time for rituals
yes but decrease each time
never take away ritual without replacing it with another coping mechanism
if can’t perform ritual increased anxiety
Stages of alcohol withdrawal
Stage I - Mild tremors, nervous, nausea
Stage II - increased tremors, hyperactive, nightmares, disorientation, hallucinations, increased pulse, increased bp
Stage III - MOST DANERGOUS, severe hallucinations, grand mal seizures
for bulimic pts when eating
sit with them while eating and 1 hour after
pts with panic disorder teach
that symptoms should peak within 10 mins
preload =
amount of blood in right side of heart and the muscle stretch
afterload =
resistance, pressure in the aorta and peripheral arteries that left vent has to pump against
bradycardia and CO
decrease
tachycardia and CO
decreases CO because don’t have time to fill up ventricles
CO head to toe assessment if decreased
decreased LOC (brain) chest pain (heart) short of breath and sound wet (lungs) cold and clammy (skin) UO decreases (kidneys) weak peripheral pulses
decreased perfusion why this happens
if see change in rhythm do what first before call MD?
assess cardiac output (head to toe assessment)
what relieves chronic stable angina
nitroglycerin and/or rest
(pain usually brought on by low O2 with exertion
before cardiac cath need to make sure to ask if
allergic to shellfish /iodine
can cause renal failure because you excrete the dye through the kidneys
post cardiac cath assess extremity distal to puncture site for
(5 Ps) pulslessness pallor pain parethesia paralysis (watch site for bleeding and hematoma formation) keep flat and straight for 4-6 hours
major complication from heart cath
bleeding!
unstable chronic angina =
impending MI
will rest or nitro relieve pain of MI/unstable angina
NO
1 sign of MI in elderly
SOB
ST elevation MI
pt having MI and goal to get them to the vath lab for PCI less than 90 mins*
CP-MB
increases with damage to cardiac cells
elevates 3-12 hours and peaks in 24 hours
which cardiac biomarker is the most sensitive indicator of MI
troponin and is good when pt delayed in seeking care
negative myoglobin
good! not MI
if pt in v fib then
defib! ASAP
do CPR inbetween
if first shock doesn’t work and pt is still in vfib then what vasopressor do we give
epinephrine
what antiarrythmic drugs commonly used to prevent second episode of v fib
amiodarone (cordarone) or lidocaine
Order of drugs given for chest pain in the ED
(oh a new method) Oxygen Aspirin (chewable) Nitro Morphine
what about ABGs in bleeding precautions
Do not draw, decrease the # of puncture sites - so draw blood when starting IV
PCI
percutaneous coronary intervertion stents and angioplasty major complication MI if any problems occur - go to surgery IF CHEST PAIN - CALL ASAP - pt reoccluding
s/s of HF
weight gain
ankle edema
shortness of breath
confusion
left main coronary artery occlusion think
sudden death or widow maker!
left sided HF
blood not moving forward so goes backwards into lungs pulmonary congestion dyspnea cough blood tinged frothy sputum restlessness tachycardia S3 orhtopnea noctural dyspnea
right sided HF
blood not moving forward into lungs so moves back into venous system distended neck veins edema enlarged organs weight gain ascites
systolic HF
heart can’t contract and eject
diastolic HF
ventricles can’t relax and fill
BNP
diagnosis HF - secreted in heart when ventricular volumes and pressure are increased stop nesiritide (Natrecor) 2 hours prior to drawing
rights sided HF usually caused by
a lung problem especially hypoxia
pulmonary emboli
pulmonary HTN
echocardiogram
looks at pumping action of heart
diet for HF
low Na
decreases preload
watch salt substitutes ( have lots of K)
HF pts should report weight gain of
2-3 lbs
always worry if pt has pacemaker and the *
HR drops below set rate
ok for rate to increase but never decrease
most common post opp pacemaker complication
displacement - wires pull out
need to immbolize the arm
ROM to prevent frozen shoulder
Don’t raise arm higher than shoulder
if pacemaker pt and needs to talk on cell phone
talk on right side if pacemaker on left side
pacemaker pts must avoid
MRIs
electromagnetic fields
will set off metal dector
teach how to check pulse everyday!
ICD
implantable cardiac device
may be used to pace heart or used to defib people in V fib!!
people at high risk for pulmonary edema
receiving IV fluids fast
young and old
hx of heart or kidney disease
pulmonary edema
fluid is back up into the lungs and heart unable to move volume forward breathless restless/anxious severe hypoxia productive cough (pink frothy sputum)
priority nursing action for pulmonary edema
admin high flow O2 and keep O2 sat above 90%
position for pulmonary edema pt
legs down upright position - improves CO and promotes pooling of blood in lower extremities
cardiac tamponade
blood, fluid, or exudates have leaked into the pericardial sac that compresses the heart decreased CO increased CVP decreased BP muffled heart sounds distended neck veins narrowed pulse pressure
hallmark signs for cardiac tamponade
increasing CVP (because increase pressure from fluid) decreasing BP
narrowed pulse pressure =
cardiac tamponade*
widened pulse pressure =
increased ICP *
tx for cardiac tomponade
pericardiocentesis to removed blood from around the heart
intermittent claudication hallmark sign for
arterial disorder - only with arterial problems not vein
arterial disorder
O2 not getting to tissues so
coldness, numbness, decreased peripheral pulses*, atrophy, bruit, skin/nail changes, and ulcerations
elevate veins or arteries?
veins!!
dangle veins or arteries?
arteries!!
If artery problem know that
certain part of body not getting O2
if descending lower back pain think
aorta blowing out
artery disorders vs. venous
artery = intermittent claudication pain, decreased or absent pulses, pale extremity when elevated and red when lowered, cool temp, thin skin, loss of hair, thick nails, ulceration on toes, possible gangrene
vein = edema, brown pigment around ankles, thick skin, scarring, ulceration on ankles, compression used
thoracentesis positioning if can’t sit up
good lung down HOB at 45
lay on unaffected side
What is the purpose of the CDU?
It is to restore the normal vacuum pressure in the pleural space. The CDU does this by removing all air and fluid in a closed one way system until the problem is corrected.
What is the purpose of the water seal?
This chamber contains 2 cm of water which acts as a one-way valve. In other words we are preventing backflow
so keeps fluid and air coming out and not going back into chest
bubbling normal in water seal chamber
yes when pt coughs, sneezes or exhales
tidaling
when see rise and fall of water in water seal as pt breaths
if stops then lung has re expanded
for CDU record drainage
every hour 1st 24 hrs then every 8 hours
pt with CDU notify MD if
drainage of 100 mL or greater in 1 hour and if there is a change in color
What if my CDU falls over and the water leaks out or shifts to the drainage compartment?
Do whatever you can to re-establish the water seal.
Set CDU upright, check all the chambers, and fill the water seal chamber to 2 cm of water.
Have the client deep breathe and cough in case any air went into the pleural space. - will shoot out of tubing
If there is not water in the water seal chamber then air can do what? Collapse the lung
if chest tubes accidentally pulled out
terile vaseline gauze taped down on 3 sides, otherwise every time they take a breath, they will pull air into the pleural space
Don’t pick air tight choice!!
if see continuous bubbling in WATER SEAL chamber then
then you have an air leak in the system.
get MD ORDER to clamp to figure out where
continuous bubbling in suction chamber is normal
hemothorax/peumothorax
blood or air accumulated in the pleural space and lung has collapsed
SOB
increased HR
Diminished breath sounds on affected side and less movement on that side
chest pain
cough
tension pneumothorax
pressure built up in chest/pleural space and has collapsed the lung then pressure pushes everything to the opposite side (mediastinal shift)
open pneumothorax
sucking chest wound
opening that allows air into pleural space
stabbing/shooting
take deep breath and hold or humm. - will increase the intra-thoracic pressure so no more air can get into body
then place petroleum guaze on 3 sides!
have sit up if possible to expand lungs
trauma pts stay flat unil evaulated for other injuries
fractured ribs/sterum acid base imbalance
respiratory acidosis
fail chest
multiple rib fractures
will see see saw chest thats opposite of normal breathing
stand at food of bed to see
PEEP
at end of respiration the vent exerts pressure down into the lungs to keep alveoli open
classic reason to use peep
ARDS
biPAP
exerts different levels of positive pressure along with O2
used for ARdS, COPD, HF, sleep apnea
CPAP
pressure is delivered continuously during spontaneous breathing for inspiration and expiration
obstructive sleep apnea
anytime see PEEP, CPAP, biPAP, then priority is to
assess bilateral lung sounds every 2 hours!!
if coding COPD then give
100% O2
need to check for PE in post opp pt D dimer or VQ scan
VQ scan
D dimer will always be increased in post opp pt
(post opp pt will be clotting to decrease bleeding so dimers increased
decrease risk of DVT
elevate extremities to increase venous blood return and decrease pooling
TED hose or SCD
warm moist heat to decrease inflammation
ambulation
hydration
worry about what with fractures
compartment syndrome
most important thing for ortho
neurvascular checkes: pulse, color, movement, sensation, cap refil, temp
fractures and fat emboli
long bones (femur), pelvic fractures, and crushing injuries
petechiae and rash over chest
conjunctival hemorrhages
snow storm on CXR
compartment syndrome
muscle becomes swollen and hard and the pt complains of severe pain that is not relieved by meds
compartment syndrome what to do with cast
loosen (bivalvement) cast
be careful with choosing remove
fasciotomy -
cut into tissue to relieve pressure and restore circulation
pt with cast complains of pain then
medicate, elevate extremity, and cold packs
if these do not work then think complication
what type of mattress for orthro pt
firm for support
hip replacement positioning
neutral rotation toes pointed to celling
limit flexion want extension of hip
abduction - legs apart to keep hips in socket
arthroplasty
total knee replacement
amputations post opp
keep truniquet at bedside
do not elevate on pillow elevate foot of bed
phantom pain
use diversional activity before give pills
walking with a walker
walk into walker
cruches and stairs
good leg up and down with bad
canes used on
strong side of body
left sided stroke, cane in left hand
fluid replacement for glomerulonephritis
24 hour fluid loss + 500 cc
diet need for glomerulonephritis
decreases protein decreased sodium increased carbs
limit protein with kidney problems except with
nephrotic syndrome**
nephrotic syndrome treatment
diuretics ace inhibitors to block aldosterone secretion prednisone to decrease inflammation - shrink hole so protein can't get out lipid lowering drugs decrease Na increase protein* anticoagulation therapy dialysis
renal failure s/s
increased creatinine and BUN fixed specific gravity anemia HTN and HF itching frost hyperkalemia metabolic acidosis hyperphosphemia so decreases calcium
two phases acute renal failure
oliguric - decrease UO (100-400), FVE, hyperkalemia (not voiding)
diuretic - sudden onset, increasing UO, FVD (shock), hypokalemia
for dialysis blood is removed through the
and return through the
removed from the arterial end and returned through the venous end
drainage from peritoneal dialysis should be
clear
cloudy=infection
CAPD vs CCPD
CAPD (continuous ambulatory peritoneal dialysis - done 4 times a day, 7 days a week
no arthritis pts or colostomy pts
CCPD (continuous cycle peritoneal dialysis) - done at night and exchanges while sleeping
CRRT
continuous renal replacement therapy
done in ICU
never more than 80 mL of blood comes out of body at one time so doesn’t stress cardiovascular system
dx for prancreatitis
increase serum lipase* and amylase
for the pancreas pt want to keep stomach
empty and dry **
pancreatitis pt tx
decrease gastric secretions pain meds steroids to decease inflammation anticholinergics to dry up insulin
if liver is sick #1 concern
bleeding*
if sick liver what to do with meds
decrease dosing (2x stronger now)
never give what med to liver pts
tylenol - will become toxic
give acetylycsteine instead
also avoid narcotics!!*
spleen enlargement means
the immune system is involved
liver biopsy
pt supine with right arm behind head
exhale and hold breath - to get diaphragm out of the way
after put on right side
worried about hemorrhage
liver diet
decreased protein*
hepatic coma
protein breaks down into ammonia (liver is supposed to convert to urea) when sick liver can’t convert and ammonia builds up in blood
acts like a sedative and decreases LOC
esophageal varices are only a problem when
they rupture
sengstaken-blakemore tube
used to hold pressure on bleeding varices
keep scissors at bed in case blocks airway
lay on what side to keep food in the stomach
left = leaves it right = releases it
watch for what after colonoscopy
perforation
pain and unusual discomfort
what side for enema and suppository
left side
side of pain for appendicitis
right lower quadrant (MucBurney’s point)
when on TPN check urine for what
glucose (increase bs) and ketones (body breaking down fats)
when central line place do not flush fluids until
placement is checked with CXR
if air gets into central line what side
left side trendelenburgg
