Signature Assignment PREP Flashcards
PNA clinical diagnosis
-S/S on assessment: wheezing, productive cough (bacterial- purulent), Scant cough (viral) fever, dyspnea, chills, malaise, confusion in elderly.
-Diagnostic Tests: CXR (infiltrates), WBC w/diff (leukocytosis, shift to the left)
-(+) sputum for C&S
-usually follows some other respiratory infection/flu.
Nursing management: PNA
-VS/pulse ox regularly and trend
-lung auscultation
-supplemental O2 ordered (>95%)
-pulm toilet/IS
-Increase fluid intake (IVF or PO)
-Ambulation
-Energy conservation
-DRUG therapy (analgesics for pleuritic pain, ABX for bacterial, antipyretics for fever).
Teaching: PNA vaccine/FLU vaccine, stay healthy.
-strict adherence to hygiene.
-pneumococcal vaccine.
Emphysema
Alveolar damage- alveoli are over-inflated/stretched out –> impaired gas exchange.
Chronic bronchitis
excessive secretion production.
COPD characteristic features
Increased AP diameter (1:1) due to hyperinflation
Breath sounds decreased, wheezing, rales, rhonchi
Prolonged expiration (having to push it out).
Adv disease: PLB’ing, neck vein distention, peripheral edema (pulm HTN), cachexia (malnourished).
COPD nursing related problems
activity intolerance, SOB, ineffective breathing pattern (too fast, too slow, shallow, deep), ineffective airway clearance (congestion and can’t expectorate), impaired gas exchange, anxiety, poor nutritional status.
-Target O2 88-92%
-Tripod positioning
-huff cough technique
-energy conservation.
**O2 should never be withheld…
COPD nursing implications
-Smoking cessation
-teach flu/PNA vaccine
-Teach early detection of respiratory infections
-Inhaler therapy
Medications for Bacterial PNA:
-Macrolides: azithromycin & erythromycin
-Penicillin: Amoxicillin
-cephalosporin: Cefepime
-IVF to thin secretions
-Tylenol for antipyretic needs.
-neb treatment
-
Medications for emphysema:
-Bronchodilators- Salmeterol, albuterol for rescue only.
-Corticosteroids: Budesonide (inhaled)
-ABX (if you have bacterial inf or acute bronchitis)
-smoking cessation therapies
-Selective PD4 inhibitor: Roflumilast (anti-inflammatory to prevent exacerbations)
Diagnostic testing/Labs for emphysema
-Lung function tests, CXR, CT scan, spirometry
Treatment for Pleural Effusion:
-Thoracentesis-needle into the pleural space to remove pleural fluid. Before: RN gets signed consent, upright on elbows over bedside table to open intercostal spaces. Instruct pt not to talk. After: CXR, assess for hypoxia/pneumothorax
-Chest tube
Central Venous Catheter
(advantages)
TPN
Chemotherapy
Long -term antibiotic use
loss of peripheral access
Nursing implications for Anemia:
-monitor labs (CBC, serum iron, serum transferrin/serum ferritin)
-Monitor signs of hypoxia (decreased O2 in blood).
-Monitor VS & O2 (may administer O2)
-Assess neuro status (B12)
-provide rest periods.
-Keep warm
-Blood transfusion (PRBC) if severe.
Central Venous Catheters (CVC)
Types
Non-tunneled
Tunneled
Implanted Ports
Peripherally-inserted
central catheter
NON-TUNNELED CVC
“deep lines”
Subclavian (SC)
Internal Jugular (IJ)
Tunneled CVC
Hickman
Groshong
Broviac
“Hungry Groundhogs Burrow”
What does an acute asthma attack patient look like?
-Severe wheezing, SOB, coughing that wont stop, chest tightening, pale/sweaty face, tachypnea (30RR), use of accessory muscles & tachycardia (HR 120)
Medication for Acute Asthma Attack
Bronchodilator: Albuterol (short-acting B2)
Non-tunneled CVC
FACTS
inserted by HCP pr specially trained RN
1-5 ports; 710 in long
Tip located in superior vena cava
CXR post -procedure
used for short term - emergency, trauma, critical care, surgery
Non- tunneled CVC
Complications
bleeding
air embolus
pneumothorax
CLABSI
Signs of FVE
HF/Renal patient
- Increased BP
- Bounding pulse
- Increased central venous pressure
- dyspnea-crackles, SOB (pulm edema)
- S3 heart sound
- jugular vein distention
- water weight gain
- pitting edema
- hyponatremia
- Hyponatermia- think change in mental status
Non- tunneled CVC
RN care
Removed by RN
-check INR if on anticoag
- gather supplies (sterile suture removal kit, sterile & clean gloves, occlusive dressing, measure tape)
- Explain procedure (supine or trendelenburg, Valsalva maneuver
- apply pressure x 3-5 minutes
- apply occlusive dressing
- measure length of catheter (may culture tip)
Tunneled CVC
FACTS
placed in OR
used when infusion therapy is frequent and prolonged (even years)
Adv- stability and does not require needle sticks
Disadv- Prolonged break in skin integrity
Removed by HCP
Signs of FVD
Dehydrated
- Tachycardia, but weak/thready pulse
- postural hypotension (BP initially shoots up, then drops)
- restless, drowsy, confused
- dry mucous membranes
- cold, clammy skin
- decreased urine output
- increased RR
- weight loss
- Dry skin
- Hypernatremia-think change in mental status.
Tunneled CVC
complications
catheter damage
occlusion
thrombosis
sepsis
Tunneled CVC
RN care
irrigation protocol varies - may or may not require heparin (know agency policy )
Site care- per agency policy
Implanted Ports
FACTS
-for patients who require IV therapy >a year
-considered “semi-permanent”
-Placed in the OR - catheter attached to a port which is placed in SQ tissue pocket on chest wall
-Closed incision post- procedural
-Uses Huber needle for punctures
-Removed by HCP
GLU
Normal: 70-100
Increase: DM, stress, steroid use, IVF w/dextrose, diet, chronic renal failure, infection.
Decrease: NPO, insulin overdose.
How many punctures can an Implanted port receive?
Chest port = 2000 punctures
Upper arm port= 750 punctures
Implanted Ports
Complications
catheter occlusion
Implanted Ports
RN care
site care - none when not accessed
Change Huber needle weekly
Clean/dress -per hospital protocol
PICC line
FACTS
placed at bedside by certified RN, HCP, radiologist
Duration 3-12 months
placed at antecubital fossa; basilic or cephalic vein
Tip is placed in the superior vena cava or right atrium
PICC line
Complications
lower complication rate than CVC
-less microorganisms on arm
-less insertion complications
Phlebitis
Catheter occlusion
PICC line
RN care
NO BP’s or blood draws
site care- per agency protocol (includes swabbing all capps with alcohol , dressing changed- day after, than every other wednesday- UK)
Removed by RN - sit/ lay down - hold arm below heart, bear down while withdrawaling - withdrawl slowly and relax catheter after each inch- DO NOT pull catheter if vein spasms
measure length of catheter
BUN
Normal: 10-20
Increase: Renal/kidney disease, dehydration (false high), CHF, MI, increase protein intake/tube feeding. IF BUN is high and Cr is not, check H&H for possible GI bleed (blood is rich in protein).
Decrease: Overhydration (false), liver failure, malnutrition.
Cr
Normal: 0.5-1.2
Increase: RENAL FAILURE- most reliable indicator of kidney disease.
Decrease: somone who does not have much muscle to break down (malnourishment, muscle atrophy, debilitation).
K+
Normal: 3.5-5.0
Increase: Renal failure/kidney disease (K+ is not getting excreted by kidneys), increased intake, dehydration.
Decrease: Decreased intake, diuretics, vomit/diarrhea, increase urine output, burns, insulin.
Think CARDIAC DYSRHYTHMIAS
Na
Normal: 135-145
Increase: Increased intake, dehydration, hypertonic tube feeds w/o free water, DM, insensible loss: sweat, increased RR.
Decrease: Decreased intake, FVE/3rd spacing, diuretics, V/D, renal insufficiency, HF, AKI, cirrhosis
Ca
Normal: 9.0-10.5
Increase: Hyperparathyroidism, increased intake, malignancy (paraneal plastic disorder), Vit D supplement.
Decrease: Renal failure–>renal osteodystrophy, parathyroid def/removed, increased phos, VitD def, malnutrition, muliple blood transfusions.
H&H
RBC
Hgb: men 14-18; women 12-16
HCT: men 42-52% women 37-47%
Increase: polycythemia vera, dehydration, COPD
Decreased: hemorrhage, chemo, renal disease, dietary insufficiency.
Platelets
Increased: polycythemia vera, RA, iron deficiency, infection, malignancy.
Decreased: hemorrhage, chemo, infection.
PT/INR
Increased: liver disease, warfarin use.
PTT
Anti Xa
Increased: clotting deficiency, cirrhosis, Heparin use.
Treatment for high K+
hyperkalemia
- Stop intake
- loop/HCTZ diuretics
- dialysis (really high)
- temporary fixes: IV insulin/dextrose, polystyrene sulfonate, if acidic–>sodium bicarb
Monitor EKG
Treatment for decreased K+
Hypokalemia
- Increase med intake (oral or IV)
- Increase PO intake: apricot, orange, prune, dried fruit, peanut butter, beans, broc, potato, chocolate. yogurt, bran, nuts, avacado.
- IV KCL–> never IV PUSH!!!!!!!! always dilute.
- hypokalemia precipitates digitoxicity (digoxin).
Treatment for Increased Na
Hypernatremia
- Dilute the Na with fluids (hypotonic) SLOWLY
- Remove/decrease Na from diet
- Monitor serum sodium/osmolality
Treatment for decreased Na
Hyponatremia
- If mild, restrict fluids & loop diuretics
- Acute (Na around 120): small amounts of Hypertonic IVF (NS 3%) slowly over 24-48 hours (cerebral edema)
- Seizure precautions as needed/safe environement.
Nursing implications for CKD:
- Excess fluid volume: r/t kidneys inability to excrete fluid.
-Monitor for FVE, weigh daily, fluid restrictions. - Malnourishment: pt does not feel like eating & is in a hyper metabolic state.
-Monitor for N/V, weight trends, serum protein levels, H&H and offer desirable foods. - Risk for injury: r/t alteration in bone structure Irenal osterodystrophy)
-Monitor electrolyte levels, administer prescribed supplements- calcium, Vit D - Address grieving: involve family and offer community resources.
- Risk for infection: suppressed immune system.
-limit visitors, monitor for s/s of infection, aseptic tech for for line mgmt. - Activity intolerance: need rest time.
- can admin erythropoietin monitor H&H.
Drugs not to give to CKD patients secondary to nephrotoxicity:
NSAIDS
aminogycocydes: Gentamycin
