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Med Surg 2 > unit 2 > Flashcards

unit 2 Flashcards

1
Q

pulmonary embolism

A

collection of matter that enters venous circulation and lodges in the pulmonary vessel

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2
Q

large emboli obstruct pulmonary blood flow

A 
reduced gas exchange
reduced oxygenation
pulmonary tissue hypoxia
decreased perfusion 
potential death
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3
Q

cause of pulmonary embolism

A

inappropriate blood clotting forms a DVT in vein in legs or pelvis

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4
Q

risk factors for pulmonary embolism

A 
prolonged immobility 
central venous catheters 
surgery
obesity
advancing age
conditions that increase blood clotting
history of thromboembolism
pregnancy
estrogen therapy
cancer
trauma
smoking
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5
Q

Pulmonary embolism prevention

A 
passive and active ROM
turn cough and deep breath
Ted hose
prevent compression in popliteal space
avoid constricting clothing
asses appropriateness of anticoagulant therapy 
frequent physical assessment of circulation
patient and family teaching
encourage smoking cessation
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6
Q

manifestations of pulmonary embolism

A 
dyspnea
pleuritic chest pain on inspiration
crackles or clear
wheezes or rub
dry or productive cough; hemoptysis 
tachycardia
low grade fever
JVD
syncope
cyanotic 
diaphoresis 
hypotension
abnormal heart sounds
shock and death
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7
Q

psychosocial assessment for pulmonary embolism

A 
anxiety
restlessness
fear
"impending doom"
change LOC
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8
Q

lab assessment for pulmonary embolism

A 
respiratory alkalosis 
low PaCO2
followed by metabolic acidosis 
Low SaO2
Metabolic panel
troponin 
BNP
d-Dimer
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9
Q

Imagining assessment pulmonary assessment

A

pulmonary angiography
C1-PA
Chest x-ray

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10
Q

Nursing diagnosis related to pulmonary embolism

A

Hypoxemia r/t mismatch of lunch perfusion and alveolar gas exchange
Hypotension r/t inadequate circulation to left ventricle
Potential for inadequate clotting and bleeding r/t anticoagulants therapy
Anxiety r/t hypoxemia and life threatening life

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11
Q

interventions for pulmonary embolism

A 
elevate HOB
apply oxygen
call Rapid response 
reassurance
telemetry continuous pulse oximeter 
Maintain adequate venous access
assess respiratory and cardiac every 30  minutes
 Administer prescribed anticoagulants: heparin, lovenox, fibrinolytics, warfin, 
Revesing agents
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12
Q

aPTT, PTT

A

measure heparin therapy
common range: 20-30 seconds
therapeutic range: 1.5-2.5 times normal value

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13
Q

PT (prothrombin time)

A

measures effectiveness’s of Coumadin
NR: 11-12.5 seconds
TR: 1.5-2.0 times normal value

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14
Q

INR

A

CR: 0.8-11
TR for PE: 2.5-3.0
TR: for recurrent PE: 3.0-4.5

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15
Q

Managing hypotension

A

IV fluid therapy ( crystalloid solution)
ECG and hemodynamic monitor
Monitor effectiveness of IF therapy( I&O, skin turgor)
DRug therapy and vassopressors; dopamine; levophed; dobutamine; nitroprusside
VS

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16
Q

Minimize bleeding

A 
assess for evidence of bleeding every 2 hours
check emesis, stool, urine for blood
asses IV every 4 hours
Avoid IM injections 
apply ice to sites of trauma 
use electrical razors 
use soft bristled toothbrush
avoid nose blowing
supportive shoes
hold pressure on IV site for 10 minutes after removing 
monitor labs
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17
Q

Home management of pulmonary embolism

A 
self-assessment of respiratory status
self-assessment of cardiac
assessment of lower extremities
bleeding precautions
change in LOC
assess family to assume care
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18
Q

thoracic trauma

A

first emergency approach to all chest injuries in BAC (breathing, airway, circulation)
rapid assessment and treatment of life threatening conditions

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19
Q

pulmonary contusion

A 
car crashes
life threatening
respiratory occur
hemorrhage and edema in alveoli 
hypoxia and dyspnea
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20
Q

Notes to take on pulmonary contusion

A 
bruising over chest
cough
tachycardia
tachypnea
decreased breath sounds
wheezes or crackles
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21
Q

Pulmonary contusion x-ray

A

may be normal at first then develop over several days

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22
Q

Rib fractures

A

blunt force

pain on movement and splints the affected side

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23
Q

1st and 2nd ribs flail chest

A

poor prognosis

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24
Q

Focus of treatment with rib fractures

A

analgesics to reduce pain so they can deep breath

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25
Q

flail chest

A

blunt chest trauma
high speed car crashes
CPR

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26
Q

Flail chest

A

fractures of at least 2 neighboring ribs in 2 or more places
causes paradoxical chest wall movement

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27
Q

Asses for paradoxical chest movement

A 
dyspnea
cyanotic 
tachycardia
increased work of breathing
hypotension
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28
Q

flail chest interventions

A 
humidified oxygen
pain management 
deep breathing with positioning 
deep breathing and coughing
tracheal suctioning
Mechanical ventilation 
ABG's
Monitor VS, fluid and electrolyte balances SaO2
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29
Q

pneumothorax

A 
any injury that allows air to enter the pleural space 
increases chest pressure
reduces vital capacity 
blunt chest trauma or medical procedure
can be opened or closed
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30
Q

pneumothorax assessment findings

A 
reduced breath sounds
hyperresonance on percussion
lack of chest wall movement 
deviation of trachea away from side of injury 
pleuritic pain 
tachypnea 
subcutaneous emphysema
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31
Q

pneumothorax interventions

A 
chest x-ray 
chest tube
pain control
pulmonary hygiene 
continuous assessment for impending respiratory failure
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32
Q

tension pneumothorax

A

air leak in the lung or chest wall
causes collapse of affected lung
air entering pleural cavity on inspiration
air does not leave on expiration
air under pressure collapses blood vessels and decreases blood return

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33
Q

causes of tension pneumothorax

A

blunt chest trauma
mechanical ventilation
chest tubes
insertion of central venous access devices

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34
Q

assessment findings of tension pneumothorax

A 
asymmetry of thorax 
tracheal movement from midline toward the unaffected side
extreme respiratory distress
absence of breath sounds
distended neck veins
cyanosis 
hyper tympanic sound on percussion 
hemodynamic instability 
ABG's reveal hypoxia and respiratory alkalosis  
chest x-ray
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35
Q

tension pneumothorax emergency management

A 
needle thoracotomy with large bore needle inserted in 2nd intercostal space midclavicular 
chest tube in fourth intercostal space 
pain control
pulmonary hygiene
psychosocial interventions
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36
Q

hemothorax

A

penetrating injuries
bleeding from injury to lung tissue or fractured ribs or sternum
bleeding from trauma to heart, great vessels, or intercostal arteries

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37
Q

assessment findings of hemothorax

A

decreased breath sounds
percussion on affected side is dull
chest x-ray

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38
Q

hemothorax interventions

A 
remove blood 
chest tubes
serial chest x-rays
aggressive pain management 
frequent VS 
accurate I&O
fluid replacement
surgical management 
open thoracotomy 
mechanical ventilation
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39
Q

chest tubes

A

drain air, blood or fluid from pleural space
placed in pleural space to allow re expansion and prevents air and fluid from re-entering
has water seal compartment to ensure that air does not enter the patient

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40
Q

Chest tubes are used for

A

after thoracic surgery
pneumothorax
hemothorax
palliative treatment of lung cancer or HF

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41
Q

chest tubes placement and care

A

tip of tube placed near front lung apex
tip of tube is placed on side near base of lung
insertion sites are protected with airtight dressing
approx. 6 feet into patients chest

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42
Q

3 parts of the drainage system on chest tubes

A

water seal chamber
collection chamber
suction regulator

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43
Q

chest tube chamber #1

A

collects fluid draining from patient and is checked hourly x24 hours

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44
Q

chest tube chamber #2

A

water seal that prevents air from reentering the patients pleural space
causes gently bubbling
keep filled with 2 cm of water
bubbling will stop once chest tube removed
blocked or kinked can cause bubbling to stop
excessive bubbling means an air leak

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45
Q

Chest tube chamber #3

A

suction control

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46
Q

Management of chest tubes drainage system

A 
maintain patency 
sterility of drainage system
keep manipulation of tubing
frequent respiratory assessment
pain management
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47
Q

Acute Coronary Syndrome

A 
Unstable angina
Last longer than 15 minutes 
May not be relieved by rest of NTG
ST elevation but not troponin or CK-MB changes 
Untreated may lead to MI
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48
Q

Unstable angina

A

Chest pain
Discomfort that occurs at rest or with exception
Causes severe activity limitation

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49
Q

Acute myocardial infarction

A

Ischemia lead to injury and necrosis of myocardial tissue

80-90% occluded

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50
Q

Myocardial infarction

A

Myocardial tissue abruptly

Severely deprived of oxygen

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51
Q

NSTEMI (Non ST Elevation)

A

ST segment and T wave changes on 12 lead indicating myocardial ischemia
Enzyme elevate over 3-12 hours

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52
Q

STEMI (ST elevation MI)

A

ST elevation in 2 contiguous leads on 12 lead ECG
Cause by plaque rupture
Complete occlusion of coronary artery

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53
Q

Acute MI

A

Evolves over several hours
Hypoxemia from ischemia
Increased oxygen demand may cause life-threatening ventricular dysrhythmias

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54
Q

Acute MI Extent of infarction depends on

A

Collateral circulation
Metabolism
Workload demands

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55
Q

Acute MI timeframe

A

At 6 hours tissue blue and swollen
48 hours infarction area gray and yellow striped
8-10 days granulation tissue develops
3 months thin, firm scar formation causes ventricular remodeling

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56
Q

LAD. Acute MI

A

Left. Anterior or septal MI
Highest mortality rate
Ventricular dysrhymaias

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57
Q

Circumflex Acute MI

A

Left lateral ventricle
Possible posterior wall
SA node and AV node
Sinus dysrhythmias

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58
Q

RCA Acute MI

A

SA and AV nodes
Right ventricle and inferior portion of LV
Right sided MI

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59
Q

Atherosclerosis nonmodification risk factors

A

Age
Gender
Family history
Ethnic background

60
Q

Atherosclerosis modifiable risk factors

A 
Elevated serum lipid levels 
Smoking/tobacco use
Limited physical activity 
Hypertension
Diabetes mellitus 
Obesity
Excessive alcohol 
Excessive stress/ poor coping skills
61
Q

Hypoxemia from ischemia

A

Acidosis and electrolyte imbalances

62
Q

Metabolic Syndrome (Syndrome X) Indicators of Risk Factors

A

Additional risk factor for CVD
Hypertension: either BP of 130/85 or higher or taking HTN meds
Decreased HDL; high LDL: either HDL,45 (men) or than 160 (men) or 135 (women) or taking antichlosterol meds
Elevated FBS: either 100 or higher or taking anti diabetic drugs
Large waist size: 40 inches or greater (men) or 35 inches for women; excessive abdominal fat causing central obesity

63
Q

Patient Centered Collaborative Care

A

History: presenting symptoms
Physical assessment: assessment, VS, pain, symptoms
Psychosocial: denial, fear, anxiety, anger, depression,
Laboratory: troponins, CK-MB, chemistries
Radiology: chest X-Ray
12 lead ECG within 10 minutes

64
Q

Immediate assessment

A

Labs
ECG
Patients wait before presenting so loss of 4-6 hours window
“Time is tissue”

65
Q

Managing ACute pain

A

MONA
(morphine, oxygen, NTG, aspirin)
IV access X2

66
Q

Improving cardiopulmonary tissue perfusion

A

Adequate cardiac output
Normal sinus rhythm and VS within normal limits
90 minutes from door to intervention

67
Q

Monitoring for and Managing heart failure

A

Decreased CO due to ventricular dysfunction

Rupture of the intraventricular septum

68
Q

Killip Classification of heart failure

A

Class I: absent crackles and S3
ClassII: crackles in lower half of lung and possible S3
Class III: crackles more than halfway up the lung and frequent pulmonary edema
Class IV: cardio genie shock!!!!

69
Q

Drug therapy for ACS

A

ASpirin: recommended; chewing 4 baby aspirins; or chew 325 mg tab X1
Glycoproteins inhibitors: IV; decreased dosage with fibrolytics
Beta-adrenergic blocking agents: Metoprolol; decrease size of infarction;
ACEI’s and ARBS: given within 48 hours of ACS; prevent ventricular remodeling
CCB: promotes vasodilation and myocardial perfusion; NOT indicated after AMI; helps with angina
Thrombolytic therapy: dissolves thrombi in coronary arteries ; restore myocardial blood flow
Tissue plasminogen activator: IV (activase)
Reteplase: IV (retavase)
Tenecteplasae: IV push (TNK)

70
Q

Thrombolytics

A

Most effective within 6 hours of coronary event
Indicated for CP > 30 minutes duration unrelieved by NTG indications of STEMI by ECG
Start within 30 minutes of Ed admission

71
Q

Absolute contraindications to Thrombolytic therapy

A 
Prior intracranial hemorrhage 
Cerebral vascular lesion
Malignant intracranial neoplasm 
Ischemic stroke within last 3 months 
Suspected aortic dissection
Active bleeding
Significant CHT or facial trauma in last 3 months
72
Q

Relative contraindications to Thrombolytic therapy

A 
History of HTN 
History of ischemic stroke, dementia
Traumatic CPR or major surgery writhing last 3 weeks
No compressible vascular punctures 
Prior allergic reaction to strepto
Pregnancy
Active peptic ulcer
Current use of INR
73
Q

Percutaneous coronary intervention

A

Reopen clotted coronary artery

Restore perfusion writhin 2-3 hours of onset

74
Q

Indications that artery has re-perfused

A

Abrupt cessation of pain
Sudden onset of ventricular dysrhythmias
Resolution of ST segment depression/ elevation or T wave inversion
A peak at 12 hours of markers of MI damage

75
Q

Post thrombolytics

A

Heparin infusion for 3-5 days
APTT usually 1.5-2.5
Enoxaparin IV

76
Q

Coronary Artery Bypass Graft

A

Open heart surgical procedure

Replace occluded artery

77
Q

Arterectomy or stent placement

A

Angiography to remove plaque

Maintain potency of coronary artery

78
Q

Hemodynamic Monitoring

A

Swan Ganz catheters
CVP
PAWP
RAP

79
Q

Treatment of cardiogenic shock

A

Assessment
Fluids
Drug
Oxygen

80
Q

Troponin values

A
81
Q

CPK-MB values

A

3-5%

82
Q

Troponin values

A

Book

83
Q

CPK-MB values

A

Book

84
Q

Improving gas exchange

A 
Ventilation assistance
Monitor respiratory rate  q 1-4 hours
Auscultate breath sounds q 4-8 hours
Position in high fowlers
Maintain oxygen saturation of 90%
85
Q

Drugs to reduce afterload

A

ACE inhibitors
ARB
Human BNP

86
Q

Interventions that reduce preload

A

Diuretics

Venous vasodilators

87
Q

Drugs that enhance contractility

A

Digoxin

Beta blockers

88
Q

Managing pulmonary edema

A 
Early  signs: crackles, dyspnea at rest, disorietnation, confusion
High fowlers position
Oxygen therapy
Nitro
Rapid-acting diuretics
IV morphine sulfate
Continual assessment
89
Q

Assessment for valvular heart disease

A 
Sudden illness
Ask about attacks of rheumatic fever, infective endocarditis, ask about possibility of IV drug abuse
Chest x-ray
ECG
Stress test
90
Q

Nonsurgical managment of valvular heart disease

A 
Rest
Drug therapy: 
Diuretics
Beta blockers
Dig
Oxygen
Nitrates
Vasodilators 
Anticoagulants
91
Q

Surgical management of valvular heart disease

A 
Reparative procedures
Balloon valvuloplasty
Open commissurotomy
Mitral valve annuloplasty
Replacement procedures
92
Q

Infective endocarditis risk factors

A

IV drug abusers
Valve replacement recipients
Systemic infections
Structural cardiac defects

93
Q

Manifestations of endocarditis

A 
Murmur
Heart failure 
Arterial embolization
Splenic infarction
Neurologic changes
Petechiae 
Splinter hemorrhages
94
Q

nonsurgical Management of endocarditis

A

Antimicrobials

Activites balanced with adequate rest

95
Q

Surgical management of endocarditis

A

Removal of infected valve
Repair or removal of congenital shunts
Repair of injured valves and chordae tendineae
Draining of abscesses in heart or elsewhere

96
Q

Assessment of pericarditis

A

Substernal precordial pain
Radiating to left side of neck, shoulder, or back
Grating, oppressive pain, aggravated by breathing, coughing, swallowing
Pain worsened by supine position
Relieved by sitting up and leaning forward
Pericardial friction rub

97
Q

Interventions for pericarditis

A

NSAIDs
Antibiotics for bacterial form
Pericardiectomy

98
Q

Pericardial effusion

A 
Puts patient at risk for cardiac tamponade 
Cardiac tamponade findings: 
JVD
Paradoxical pulse
Decreased CO
Muffled heart sounds
Circulatory collapse
99
Q

Rheumatic carditis

A

From upper respiratory tract infection with group A beta hemolytic streptococci
Inflammation in all layers of heart
Ashoff bodies

100
Q

Clinial manifestations of rheumatic carditis

A 
Tachycardia
Cardimegaly 
New or changed murmur
Pericardial friction rub
Precordial pain
Changed in ECG
Indications of heart failure
Existing streptococcal infeection
101
Q

Cardiomyopathy

A

Chronic disease of caridac muscle

102
Q

Cardiomyopathy nonsurgical management

A 
Diuretics
Vasodilation agents 
Cariac glycosides
Toxin exposure avoidance
Alcohol avoidance
103
Q

To decrease high potassium (hyperkalemia) do what

A

Insulin and dextrose

104
Q

Right MI do not give

A

A nitro drip

105
Q

Automaticity

A

Cardiac cells to generate an electrical impulse spontaneously and repetitively

106
Q

Excitability

A

Non-pacemaker cells to respond to an electrical impulse

Depolarize

107
Q

Conductivity

A

Ability to send an electrical stimulus from cell membrane to cell membrane

108
Q

Contractility

A

Atrial and ventricular muscle cells to shorten their fiber length
Mechanical

109
Q

SA node

A

Electrical impulses 60-100 bpm
Primary pacemaker
P wave on ECG

110
Q

(Atrioventricular) AV node

A

PR segment on ECG

Contraction known as atrial kick

111
Q

Bundle of His

A

Right and left bundle branch system

QRS on the ECG

112
Q

Purkinje cells

A

Responsible for rapid conduction of electrical impulses throughout ventricles
Leading to ventricular depolarization
Ventricular muscle contraction

113
Q

Depolarization

A

Negatively charged cells

And develop a positive charge

114
Q

P wave

A

Atrial depolarization

115
Q

PR segment

A

Impulse to travel through AV node

116
Q

Pr interval

A

Atrial depolarization

117
Q

QRS complex

A

Ventricular depolarization

118
Q

QRS duration

A

Depolarization of both ventricles

119
Q

ST segment

A

Ventricular repolarization

120
Q

T wave

A

Ventricular repolarization

121
Q

QT interval

A

Total time

122
Q

ECG rhythm analysis

A

Heart rate (slow, normal, fast)
Heart rhythm (regular, irregular)
Analyze P waves (present before each QRS)
Measure PR interval (0.12-0.20 Sec)
Measure QRS (after each P wave, less than or equal to 0.12 sec)
Q-T interval (less than or equal to 0.40 sec)
Interpret rhythm

123
Q

First degree atrioventricular block

A

All sinus impulses eventually reach ventricles

124
Q

Sinus bradycardia

A

HR less than 60 bpm

125
Q

Patient centered care for sinus bradycardia

A

Maintain perfusion and CO
Assess LOC and patient tolerance
Atropine
Pacemaker

126
Q

Atropine

A 
IV bolus 
Repeated every 3-5 minutes
Assess urinary retention
Dry mouth
Glaucoma
127
Q

Sinus tachycardia

A

HR greater than 100 bpm

SNS stimulation or PSN inhibition

128
Q

Patient collaborative care for sinus tachycardia

A 
Maintain perfusion and CO
Assess dehydration
Hypovolemia
Infection
HF
MI
Urinary output 
Assess emotional status , medications
129
Q

Supraventricular tachycardia

A

HR 100-280bpm
170 for adults
Terminated suddenly with or without intervention

130
Q

Interventions for supraventricular tachycardia

A

Vagal maneuvers: strain like having a BM
Carotid massage: only doctors can do those
Adenosine: push this medication fast alongwith flushing fast
If does not work can do two more times
Put arm over arm

131
Q

Atrial fibrillation

A 
Atrial fibrosis 
Loss of muscle mass
Cardiac decreases 20-30% 
350-450bpm 
No clear P waves
132
Q

Atrial fibrillation is common in

A

Hypertension
Heart failure
Coronary artery disease
COPD

133
Q

Atrial fibrillation patient centered care

A 
Risk for PE, VTE
Antidysrhythmic drugs 
Cardioversion
Percutaneous radiofrequency catheter ablation 
Biventricular pacing
Maze procedure 
All on anticoagulant
134
Q

Atrial flutter

A

220-350bpm
Saw tooth appearance
One-half of atrial beats are blocked at AV junction
Calcium channel blockers

135
Q

Cardioversion

A

Synchronized countershock

136
Q

Cardioversion used for

A

Emergencies for unstable patients
Ventricular
Supraventricular tachydysrhythmias
Stable tachydysrhythmias resistant to medical therapies

137
Q

Ventricular dysrhythmias

A

Life-threatening

Do not get oxygenated blood to vital organs

138
Q

Premature ventricular complexes

A

Early ventricular complexes followed by a pause

Unifocal or multifocal

139
Q

Common causes of premature ventricular complexes

A 
MI
Age
CHF
COPD
Anemia or hypoxia 
Stress
Caffeine
Nicotine
Infection
Hypokalemia
Hypomagnesium
140
Q

Ventricular tachycardia

A

Repetitive firing of irritable ventricular ectopic focus
140-180 bpm
May last longer than 15-30 seconds

141
Q

Causes of ventricular tachycardia

A 
Muscle ischemia 
MI
Valvular disease 
HF
Drug toxicity 
Hypomagnesium 
Hypokalemia
142
Q

Ventricular fibrillation

A

Electrical chaos in ventricles
Lethal dysrhythmias
Shock them
CPR

143
Q

Ventricular asystole

A

Complete absence of any ventricular rhythm
Dead
Not shockable
CPR

144
Q

CPR manegment

A

Maintain airway
Ventilate with mouth-to-mask device
Start chest compressions

145
Q

Defibrillation

A

Depolarizes critical mass of myocardium simultaneously

Stops and allows sinus node to regain control of heart

Med Surg 2 (5 decks)

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