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Nursing 163 Exam 1 > Unit 1.3 > Flashcards

Unit 1.3 Flashcards

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1
Q

Types of Emboli that may cause pulmonary embolism

A
  • Air Emboli
  • Thrombus: DVT
  • Fat Emboli: from long bone or Hip Fx
  • Tumor: cells enter blood stream
  • Foreign body: IV catheter
  • Vegetations: growth on valves that break loose
  • Amniotic Fluid emboli; risk @ delivery
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2
Q

Main PE manifestations

A
  • dyspnea (SOB)
  • angina (chest pain)
  • anxiety, sense of impending doom
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3
Q

Other PE manifestations

A
  • increased respiratory rate (tachypnea)
  • increased heart rate (tachycardia)
  • crackles present in lungs
  • low grade fever
  • change in LOC
  • Hypoxia (less O2 in blood)
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4
Q

What is happening in lungs with PE

A
  • vasoconstriction

- brochoconstriction

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5
Q

Stereotypical DVT risk factors (the model)

A

Female 40 year old smoker on oral contraceptive or estrogen therapy.

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6
Q

Dx Tests for PE

A
  • plasma D-dimer (blood test)
  • ABG’s (show hypoxemia & respiratory alkolosis)
  • Coagulation studies (PTT, INR, platelet)
  • Chest CT with contrast
  • Lung scans
  • Pulmonary angiography (if less invasive doesn’t work)
  • Chest Xray
  • Electrocardiography (rule our MI)
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7
Q

Prevention is key to preventing PE. What measures will the nurse use:

A
  • hydration
  • prevent stasis of blood (early ambulation)
  • assess for complications that may cause emboli
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8
Q

If a nurse finds a client with possible PE what actions would they take?

A
  • Give O2 to raise sats
  • Position into high fowlers
  • place lower extremities in dependent position
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9
Q

Placing LE in dependent position achieves what?

A
  • decreased venous return to heart

- decreased load on right side of heart.

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10
Q

Pulmonary embolism can cause heart failure on which side?

A

Right sided heart failure

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11
Q

Special Fat emboli symptom

A

petechiae on chest & arms

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12
Q

Gold standard Dx test for PE

A

Pulmonary angiography, accurate.

-dangerous and rarely ordered

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13
Q

When not to use Chest CT for Dx

A

when client has elevated creatinine.

-iodine is contrast media and kidneys must excrete.

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14
Q

Best pharmacologic therapy for PE

A

Anticoagulant therapy (blood thinners)

  • Heparin
  • Warfarin
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15
Q

What to know about Heparin

A
  • IV or IM
  • monitor PTT range (60-90)
  • therapeutic range is established after 2 consecutive normal range results are received. test must be run at least 6 hours apart
  • Anti-dote = protamine
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16
Q

What to know about Warfarin

A
  • oral anticoagulant
  • monitor INR (2-3)
  • anti-dote = vitamin K
  • teach client to eat consistent leafy greens.
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17
Q

Nurse teaching for anticoagulants

A
  • educate about eating greens
  • inform doctors & dentists about use
  • safety conscious lifestyle choices
  • Electric razors
  • What to look for in stool for GI bleed.
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18
Q

Other treatment for PE

A

Bed rest. decreases demand for O2.

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19
Q

Possible Emergency Nursing Dx for PE

A

-Impaired gas exchange

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20
Q

Other Nursing Dx for PE

A
  • Ineffective protection
  • Decreased cardiac output
  • Impaired gas exchange
  • Anxiety
  • Activity Intolerance
21
Q

Thromboemboli

A

created by blood clot

22
Q

Embolus

A

debris blocking blood vessel

23
Q

CVA

A

Cerebrovascular accident

OR brain attack

24
Q

Types of CVA

A

Ischemic Stroke

Hemorrhagic Stroke

25
Q

3 types of Ischemic Stroke

A

TIA
Thrombotic
Embolic

26
Q

TIA

A
  • transient ischemic attack
  • narrowing of veins/arteries
  • Low O2
  • temporary
  • Mini-stroke
  • May precede a stroke
27
Q

Thrombotic Stroke

A
  • Large cerebral vessel occlusion - by thrombus
  • often in bifurcating arteries w/ narrowed lumen
  • older clients when resting
28
Q

Embolic Stroke

A
  • blood clot or debris lodges in cerebral blood vessels
  • area past clot become ischemic
  • younger clients, awake & active
  • possibly a thrombus created in Left chamber of heart
29
Q

FAST

A
  • face
  • arms
  • speech
  • time to call 911
30
Q

Hemorrhagic Stroke

A
  • intracranial hemorrhage
  • blood vessel ruptures
  • HTN most common risk
  • Occurs suddenly during activity
  • most often fatal
31
Q

Symptoms of Hemorrhagic stroke

A
  • hemiplegia
  • loss of consciousness
  • vomit
  • headache
  • seizures
32
Q

Common symptoms of stroke

A
  • Weakness of extremities
  • Sudden severe headache
  • speech difficulties
  • loss of coordination
  • facial droop
33
Q

Risk factors for stroke

A
  • HTN
  • diabetes
  • sleep apnea
  • smoking
  • cholesterol levels
  • drug use
34
Q

Dx Tests

A

1 - CT Scan

  • Stroke Scale
  • MRI
  • neurologic exam
35
Q

Pharmacologic prevention

A

-antiplatelet agents: aspirin, plavix, etc

36
Q

Pharmacologic for acute stroke

A
  • Anticoagulants (not for hemorrhagic)
  • Fibrinolytic (clot buster) drugs: 3 hour window
  • Antithrombotic drugs: inhibit platelet phase of clot form.
37
Q

If a CVA happens on the right side of brain, which side of body is affected

A

Left

38
Q

Hemianopia

A

loss of half of visual field

39
Q

Agnosia

A

inability to recognize one or more subjects that were previously familiar

40
Q

Apraxia

A

inability to carry out some motor pattern

41
Q

Neglect syndrome

A

person cannot integrate & use perceptions from affected side of body.

42
Q

Aphasia

A

inability to use or understand language

43
Q

Hemiplegia

A

paralysis of left OR right half of body

44
Q

Hemiparesis

A

weakness of left OR right half of body

45
Q

Flaccidity

A

abscence of muscle tone

46
Q

spasticity

A

increased muscle tone, but with a degree of weakness

47
Q

Possible Nursing Dx for Stroke patients

A
  • Ineffective tissue perfusion
  • Impaired physical mobility
  • Self-care deficit
  • Impaired verbal communication
  • Impaired swallowing
  • Impaired urinary elimination
48
Q

What physical assessments would a nurse perform on someone suspected of a stroke?

A
  • PMSC (pulses, motor, sensation, circulation)
  • LOC
  • speech
  • neuro (cranial nerves)
49
Q

What is stenosis?

A

narrowing.

Nursing 163 Exam 1 (4 decks)

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