week 2 -- PE, chest trauma, valve diseases, & aneurysms Flashcards
common cause of a PE
DVT
ABG’s with a PE tell you
intubate or escalate O2
D-dimer
tells you how much fibrins were relaeased to take apart a clot
**higher # = more likely of a clot
**expected rage is less than 0.4 mcg/mL
if a patient w allergy to iodine/shellfish cannot do angiography to diagnose PE then they will do a
ventilation perfusion scan—– shows circulation of air and blood in the lungs
gold standard to diagnose PE
pulmonary angiography — allergy to shellfish & iodine
6 ways to diagnose a PE
- pulmonary angiography (gold standard)
- ABG
- Ventilation perfusion
- Ct Scan
- chest x-ray
- d- dimer
interventions for PE
- initiate o2 & high - fowlers (90 degrees)
- iv access
- vitals
INR range
describes blood clotting
0.8 to 1.1
goal of INR when on warfarin
2 to 3
normal pT time
11 to 12.5 seconds
normal ApTT time
30 to 40 seconds but 1.5 to 2.5x more w heparin
low molecular weight heparin
enoxaparin
anticoagulants are contraindicated in
peptic ulcer disease
uncontrolled HTN
stroke
trauma
thrombolytic agents are used for
bigger clots
ALTEPLASE
reteplase
tenecteplase
- -eplase
therapeutic procedures for a PE
embolectomy
vena cava filter
normal PaO2
80 to 100 mmhg
vitamin K foods on wafarin
do not increase or decrease
teaching to prevent DVT/PE
walk 5 min every hour
compression stockings
dorsi-plantar flexion
s/s of decreased cardiac output
hypotension
tachycardia
JVD
cyanosis
syncope
antidote for heparin
protamine sulphate
antidote for warfarin
vitamin K
a nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? sap
- bradypnea
- pleural friction rub
- hypertension
- petechiae
- tachycardia
- pleural friction rub
- petechiae
- tachycardia
** tachypnea
**hypotension
client has acute dyspnea & diaphoresis. client states “I am anxious & unable to get enough air”. vitals are HR 117/min, RR 38bpm , temp 101.2, and bp of 100/54. what is the nurses priority?
- notify the provider
- administer heparin via IV infusion
- administer oxygen therapy
- obtain a CT scan
- administer oxygen therapy
**ABC’s
BUN range
7 to 20
creatinine range
0.7 to 1.3
INR range when on warfarin
2 to 3
aPTT goal with heparin therapy
40 to 60 sec
PaO2 range
80 to 100 mmhg
flail chest is stabilized by
positive pressure ventilation
tension pneumothorax occurs when
air enters on INSPIRATION and cannot exit on expiration
lung sounds w a pneumothorax
hyper-reasonance
lungs sounds w a hemothorax
dull percussion
key sign of a flail chest
paradoxical chest movement
patient considerations for a thoracentesis
- sit on edge of bed leaned over side table
- no coughing, moving, or deep breathing
- will feel pressure but no pain
a nurse is assisting a provider to care for a client who has developed a spontaneous pneumothorax. which of the following actions should the nurse perform first?
- assess the client’s pain
- prepare a large bore IV needle for decompression
- administer lorazepam
- prepare for chest tube insertion
- prepare a large bore IV needle for decompression
nursing considerations for an angiography
**LYING FLAT
NPO for 8 hrs
*renal function
*iodine/shellfish allergy
*withhold metformin for 48hrs before & after
post op - pressure on site & lay flat
considerations for transesophageal echo
HOB @ 45 degrees
NPO 6hrs prior
IV access
Post op = GAG reflex
client education for angiography
report: chest pain, SOB, &changes of colors in extremities
leave dressing in place for 24 hrs
avoid heavy weight & bending at waist
withhold metformin 48 hrs before & after
cardiac tamponade nursing interventions
- notify provider
- admin IV fluid (combats hypotension)
- obtain CXR / echo
- prepare for a pericardiocentesis
structures on the left side of the heart
left atrium
mitral valve
left ventricle
aorta
structures on the right side of the heart
tricuspid valve
right atrium
right ventricle
pulmonic arteries
foods high in potassium and can be given w/
- thiazide & loop diuretics to prevent hypokalemia
spinach
bananas
potateos
nuts
dried & citrus fruit
considerations when taking digoxin
apical pulse greater than 60/min
same time every day
separate 2 hrs from antacids
digoxin toxicity manifestations
visual changes (green halos)
confusion
muscle weakness
fatigue
loss of appetite
mechanical valves require
life long anti-coagulant therapy
*prothrombin checked on a regular basis
*kids
tissue valves require
replacement every 7 to 10 years
older ppl
a nurse educator is reviewing expected findings who has right-sided valvular heart disease with a group of nurses. which of the following findings should the nurse include in the discussion? sap
- dyspnea
- client report of fatigue
- bradycardia
- pleural friction rub
- peripheral edema
- dyspnea
- client report of fatigue
- peripheral edema
expected outcome of a percutaneous balloon valvuloplasty. nurse response
this will assist with the ability to perform activities of daily living
a nurse is reviewing the health record of a client who is being evaluated for possible valvular disease. The nurse should recognize which of the following data as risk factors for this condition?
- surgical repair of an atrial septal defect at age 2
- hypertension for 5 years
- weight gain of 10 pounds in the last year
- diastolic murmur present
- surgical repair of an atrial septal defect at age 2
- hypertension for 5 years
- diastolic murmur present
a nurse is completing the admission physical assessment of a client who has mitral valve insufficiency. which of the following findings should the nurse expect?
- s4 heart sounds
- petechiae
- neck vein distention
- splenomegaly
- neck vein distention
*s3 heart sounds
*hepatomegaly
risk factors for valvular heart disease
HYPERTENSION
RHEUMATIC FEVER
marfan syndrome
ineffective endocarditis
s/s of MITRAL stenosis
**apical DIASTOLIC murmur
JVD
hepatomegaly
dry cough
pitting edema
afib
dyspnea / orthopnea
s/s of mitral insufficiency
**SYSTOLIC murmur @ apex
atypical chest pain
diminished lung sounds
hepatomegaly
JVD
dyspnea / orthopnea
s/s of aortic stenosis
SYSTOLIC MURMUR (A.S.S.)
NARROWED pulse pressure
syncope
angina
dyspnea / orthopnea
s/s of aortic insufficiency
DIASTOLIC murmur
WIDE pulse pressure
bounding pulse
NOCTURNAL angina w diaphoresis
tachycardia
palpitations
aneurysm & types
widening or ballooning of a blood vessel
*asymptomatic
1. saccular = one side
2. fusiform = both sides – complete circumference
risk factors for aneurysms
atherosclerosis
HTN
syphillis
hyperlipidemia
males
trauma
tobacco
s/s of aortic abdominal aneurysm
pulsating abdominal mass
bruit over area
low back pain
constant gnawing feeling in the abdomen
s/s of thoracic aortic aneurysm
SEVERE BACK PAIN
COUGH
sob
difficulty swallowing
decreased renal function
s/s of aortic disection
assoc. w marfan syndrome
tearing, ripping, stabbing
hypovolemic shock
priority intervention for aneurysms
to reduce systolic between 100 and 120
long term to maintain systolic between 130 to 140
nursing interventions for caring for aneurysms
hob below 45 degrees
warm environment
cough q 2 hrs w splint
Beck’s Triad
- hypotension
- JVD
- diminshed heart sounds
