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Foundations of Nursing > Week 7 Circulation and Perfusion > Flashcards

Week 7 Circulation and Perfusion Flashcards

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1
Q

Explain the cardiac cycle and what would occur if each of the nodes failed

A
  1. sinoatrial node acts as the pacemaker of the heart because it initiates an impulse that triggers each heartbeat; rate will be 60 to 100 beats/min, depending on the body’s oxygen needs
    - damage to the SA node interferes with the electrical activity of the heart but does not direct affect the pumping action of the heart
    - if the SA node fails, the AV node can take over as the pacemaker, but it generally triggers a slower heart rate. Cardiac output will decrease as a result of the decrease in heart rate
    - AV node: electrical activity passes through the AV node into the left and right bundles of HIS and into Purkinje fibers to the ventricles; if the SA node fails, the AV node can take over as the pacemaker, but it generally triggers a slower heart rate (40-60)
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2
Q

The vessels of the vascular system include what?

Why are they lined with a smooth endothelial layer?

A
  • arteries, veins, capillaries
  • lined with smooth endothelial layer that promotes nonturbulent blood flow and prevent platelets from sticking to the sides of the walls and beginning clot formation which can cause an obstruction
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3
Q

Explain the characteristics of the coronary arteries

A
  • the heart has its own blood supply via the coronary arteries
  • the coronary arteries are the only arteries in the body that fill during diastole (normally a resting phase)
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4
Q

What system regulates cardiovascular function and how does it do that?

A
  • the autonomic nervous system regulates CV function through its influence on the
    1. heart: cardiac heart rate and cardiac muscle contractility
  1. vascular system: maintains vascular tone
    - sympathetic control maintains the blood vessels in a constant baseline state of partial contraction (tone)
    - vascular tone maintains blood pressure and blood flow even when a person is resting or asleep
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5
Q

Explain baroreceptors

A
  • located in the walls of heart and blood vessels
  • sensitive to pressure changes
  • when baroreceptors sense even a small drop in pressure, they send messages to the brainstem centers to stimulate the sympathetic nervous system to increase heart rate and induce vasoconstriction
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6
Q

Explain the vascular system

A
  • chemoreceptors located in the aortic arch and the carotid arteries are sensitive to changes in blood pH, oxygen levels, and CO2
  • their main function is to regulate ventilation, but they also send information to the vasomotor center in response to a lack of oxygen
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7
Q

Define mean arterial pressure

A
  1. MAP is a calculation that checks whether there’s enough blood flow, resistance, and pressure to supply blood to the major/vital organs (heart, brain, and kidneys)
    - think of MAP as the average pressure in the arteries throughout one cardiac cycle, which includes the series of events that happen every time the heart beats
    - (IN RED) most people need a MAP of at least 60 mmHg or greater to ensure enough blood flow to vital organs
    - a high MAP is anything over 100 mmHg, which indicates that there’s a lot of pressure in the arteries
    - anything under 60 mmHg indicates that the blood may not be reaching vital organs; without blood and nutrients, the tissue of these organs begins to die, leading to permanent organ damage
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8
Q

What are the components of cardiac output

What is normal CO?

What would occur with decreased CO

A

heart rate and stroke volume

Normal: 4-7 L/min

Decreased CO is the appropriate diagnosis when the heart is unable to pump adequate amounts of blood to meet the metabolic demands of the body

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9
Q

What are the components of stroke volume

A
  • contractility (think force)
  • preload (think volume)
  • afterload (think resistance)
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10
Q

Explain ejection fraction. What is normal? How does heart failure with reduced EF happen?

A
  • the EF measures how much blood inside the ventricle is pumped out with each contraction
  • the left ventricle squeezes and pumps some (but not all) of the blood in the ventricle out of the body
  • a normal EF is more than 55%. This means that 55% of the total blood in the left ventricle is pumped out with each heartbeat
  • the types of heart failure are based on a measurement called the ejection fraction. Heart failure with reduces EF happens when the muscle of the left ventricle is not pumping as well as normal; the EF will be 40 or less
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11
Q

What are the factors that influence cardiac function?

A
  • developmental stage
  • environment
  • lifestyle
  • substance abuse
  • medications
  • pathophysiological conditions
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12
Q

How does each developmental stage influence cardiac function

A
  1. Infants: transition to life outside the uterus, may be born with a congenital heart defect
  2. preschool/school age: have body systems mature enough to adapt to moderate stress and change, including the heart and circulatory systems
    - however, children as young as school age sometimes begin habits that can have long term adverse effects on the CV system (a diet high in fats and sugars contributes to hyperlipidemia and the beginning of plaque lining the walls of blood vessels and processed foods contain a great deal of salt and fat, which can contribute to high BP and high cholesterol
  3. adolescents: developmentally at little risk for heart or circulatory disorders, although some athletes can be at risk for collapse and sudden cardiac dysrhythmia that is familial/hereditary
    - some adolescents adopt behaviors and habits that can create risk throughout life
    - 87% of the adults who use tobacco were regular smokers by their 18th birthdays
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13
Q

What factors influence cardiac function with young and middle adults

A
  • sedentary lifestyle, lack of aerobic exercise, and tobacco use also contribute to CV disorders in this group
  • crack cocaine and methamphetamine abuse can lead to sudden cardiac failure
  • family history of CV disease is yet another risk factor for this age group
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14
Q

What factors influence cardiac function for older adults

A
  • thicker and more rigid valves
  • decreased myocardial strength
  • cardiac efficiency gradually decline
  • lower exercise tolerance, need more rest after exercise
  • are more prone to orthostatic/postural hypotension (IN RED)
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15
Q

How long should you wait before taking a blood pressure after each change of position for orthostatic BPs

A

1 - 3 minutes after

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16
Q

What are the environmental factors that influence cardiac function

A
  1. stress:
    - stress response stimulates release of catecholamines from the SNS
    - this results in increased heart rate and contractility, vasoconstriction, and increased tendency of blood to clot
    - in other words, when the body is under stress, it releases a chemical that increases the heart rate and the tendency of the blood to clot
  2. allergic reactions and air quality:
    - inflammatory substances released during an allergic response (histamine, protease) can cause CV events
  3. altitude: oxygen pressure falls proportionally with increased altitude; hence, people who live at high altitudes undergo physiological changes that facilitate oxygenation
  4. heat and cold: heat generally causes vasodilation, which increases cardiac output and oxygenation
    - heat also increases metabolism
    - cold causes vasoconstriction and slows the heart rate, prolonged exposure to cold causes frostbite, loss of hypothalamic temperature regulation, and death
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17
Q

What are the nonmodifiable risk factors for cardiovascular function

A
  • age
  • gender (women are more likely than men to experience some other symptoms, particularly shortness of breath, nausea/vomiting, and back of jaw pain
  • family history
  • ethnic background
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18
Q

What are the modifiable risk factors of cardiovascular disease

A
  • elevated serum cholesterol
  • tobacco/nicotine use (afterload)
  • hypertension (afterload)
  • impaired glucose tolerance/DM
  • obesity
  • excessive alcohol
  • limited physical activity
  • stress
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19
Q

What are the lifestyle factors that influence cardiac function and why

A
  1. pregnancy: oxygen demand increases dramatically, to compensate, the mother’s blood volume increases by 30%, the woman requires additional iron to produce this blood as well to meet fetal requirements, failure to meet these iron demands can result in maternal anemia
  2. nutrition
  3. obesity: BMI above 30
    - increases risk of developing atherosclerosis and hypertension
    - excess fat stores in and around the heart reduce the pumping action of the heart
  4. exercise
  5. tobacco use
  6. substance abuse
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20
Q

Explain how medications can influence cardiac function

A
  1. various types of medication are used to improve cardiac output and tissue oxygenation, they act to:
    - slow the heart rate or reduce the force of myocardial contraction
    - ease the workload of the heart
    - dilate blood vessels and reduce blood pressure in the pulmonary circulation and systemically
    - rid the body of excess fluid accumulation
    - block abnormal heart rhythms
  2. CV depressants:
    - used therapeutically to slow the heart rate or reduce the force of myocardial contraction; this may reduce cardiac output and impair tissue oxygenation
  • beta adrenergic blocking agents: are used therapeutically to reduce the workload of the heart to control abnormal heart rhythms and to control hypertension; drugs that block beta 1 receptors slow the heart rate and decrease the strength of myocardial contraction
  • Calcium channel blocking agents: block the flow of calcium into cells of the heart and blood vessels; they decrease blood pressure and the strength of myocardial contraction, slow the heart rate and dilate the arteries and arterioles
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21
Q

Explain how heart failure can influence cardiac function

A
  • heart becomes an inefficient pump and is unable to meet the body’s demands
  • blood is oxygenated when it passes through the lungs, but it is not well circulated to the organs and tissues
  • impaired circulation leads to systemic and pulmonary edema, which further impairs gas exchange
  • left sided heart failure occurs when the left ventricle does not pump sufficient amounts of blood to body organs and tissues; fluid may back up in the lungs, causing shortness of breath, tachypnea and or rales
  • right sided heart failure occurs when the right ventricle does not pump sufficient amount of blood to the lungs for oxygenation, and blood back up into the peripheral veins; when the right side loses pumping power, blood backs up in the body’s veins; this usually causes (IN RED) swelling or congestion in the legs, ankles, and swelling within the abdomen such as the GI tract and live (causing ascites); jugular vein distention can occur, and clients will also have left sided heart failure symptoms
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22
Q

______ causes blood to back up into the lungs and can result in ______; therefore clear _____ with no _______ would be an effective outcome

A
  • heart failure
  • pulmonary edema
  • clear breath sounds
  • shortness of breath
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23
Q

A client is diagnosed with left sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply

a. peripheral edema
b. crackles in both lungs
c. breathlessness
d. ascites
e. tachypnea

A

b. crackles in both lungs
c. breathlessness
e. tachypnea

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24
Q

A client has been admitted to the cardiac unit with a diagnosis of right ventricular failure. which of the following assessment findings would the healthcare provider expect to observe?

a. fatigue and hemoptysis
b. bradycardia and hypoxia
c. peripheral edema and jugular vein distention
d. dyspnea and pulmonary crackles

A

c. peripheral edema and jugular vein distention

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25
Q

Explain cardiomyopathy and cardiac ischemia

A

Cardiomyopathy: heart muscle disorder that results in heart enlargement and impaired cardiac contractility

Cardiac ischemia: oxygen requirements of the heart are unmet; prolonged ischemia leads to myocardial infarction as parts of the heart necrose( (die) from inadequate oxygen

26
Q

Explain why hypertension is a factor that influences cardiac function. What are the risk factors? Why is it considered a silent disease? How many readings do you need to confirm a new diagnosis? List the clinical manifestations

A
  • HTN is a major risk factor for atherosclerosis cardiovascular disease, heart failure, stroke and kidney failure and is a common and manageable chronic condition
  • Risk factors: age, gender, race, and socioeconomic status
  • considered a silent disease because it rarely produces symptoms until it’s extreme

Clinical manifestation:

  • evident only after long-term increased BP has results in target organ damage
  • symptoms of chronic uncontrolled HTN are headaches , chest pain, vision changes, shortness of breath, renal dysfunction, dizziness, fatigue, or nosebleeds
  • never diagnose based on one BP measurement, look at a series/trends
  • 75% are using antihypertensive medications
27
Q

What are the managements for hypertension. what are the complications?

A
  • diagnosis, treatment, and medications
  • lifestyle such as weight, diet, alcohol, exercise

Complications:

  • stroke, aneurysm, and hypertensive crisis
  • the client with HTN who is not taking medications as prescribed can risk damage to the tiny arterioles in the kidneys, resulting in poor renal tissue perfusion
28
Q

Explain coronary artery disease and how it influences cardiac function

A
  • condition in which plaque builds up inside the coronary arteries
  • plaque narrows the arteries, reducing blood flow to the heart muscle and making it more likely that clots will form and block the arteries
29
Q

Explain dysrhythmias

A
  • alterations in heart rate and rhythm

- can lower cardiac output, decrease tissue oxygenation, and increase the risk of stroke

30
Q

explain how heart valve abnormalities influence cardiac function

A
  • they create turbulent flow, leading to a decrease in cardiac output and compromised tissue oxygenation
  • often there is an audible murmur
  • valves most commonly affected are the mitral and aortic valves
31
Q

Explain how peripheral vascular abnormalities influence cardiac function

A
  • impair blood flow to and from organs and tissues
  • arterial abnormalities disrupt flow of oxygenated blood to tissues
  • signs include pallor, pain, weak or absent pulses, poor capillary refill, cool skin, and tissue dysfunction
  • venous abnormalities disrupt blood return to the heart
  • signs include edema, brown skin discoloration, and tissue dysfunction (stasis ulcers)
32
Q

Explain how oxygen transport abnormalities influence cardiac function. Explain anemia and carbon monoxide poisoning

A
  • even if the heart is functioning well and arterial blood flow is intact, tissues can become hypoxic if the blood is unable to carry adequate amounts of oxygen
  • anemia is an abnormally low level or red blood cells, hemoglobin, or both
  • carbon monoxide poisoning: colorless, odorless gas produced by the combustion of flammable materials and fuels. when inhaled, carbon monoxide binds tightly to hemoglobin at the oxygen receptor sites, making it impossible for hemoglobin to carry oxygen
33
Q

What are the pain assessments you will do for a cardiovascular assessment

A
  • if a client has chest pain, evaluate immediately because chest pain is the most common heart attack symptom
  • ask the client to rate the pain on a scale of 0-10, with 0 meaning no pain and 10 meaning worse possible pain
  • ask the client to describe the pain
  • you can differentiate cardiac pain because it is usually in the center or on the left side of the chest and radiates to the left arm, in men
  • some women have milder chest pain, sometimes non at all, they are thought to be more likely than men are to experience other symptoms such as jaw or back pain, nausea, fatigue, and shortness of breath
  • the pain typically lasts several minutes; may be intermittent
  • chest pain may also be caused by MSK or respiratory conditions, for ex. a fractured rib or pleuritis
34
Q

What should you keep in mind when assessing fatigue for a cardiovascular assessment

A
  • subjective experience
  • client feels tired and lacks endurance
  • fatigue is a common symptom of various oxygenation problems, including anemia and HF
  • ask client to rate fatigue on 0-10 scale as you would pain
35
Q

What do you keep in mind when assessing dyspnea for a cardiovascular assessment

A
  • any signs of hypoxia this can be associated with CV disease and anemia as well with respiratory problems
  • as with pain, dyspnea provokes anxiety
36
Q

How would you assess peripheral circulation for the cardiovascular assessment

A
  • palpate the peripheral pulses, assess skin color and temperature, and note the distribution of hair on the extremities
  • weak pulses, cool feet, lack of hair, and shiny skin on lower legs and feet usually accompany peripheral vascular disease
  • look for skin ulcers (which differ from pressure ulcers) that often accompany sever venous or arterial disease
  • check for edema of the feet and ankles; this is a sx of HF
37
Q

Explain DVT and how to assess for it

A
  • assess for a clot in the veins, deep under the muscle of the leg
  • serious condition because blood clots can loosen and lodge in the lungs
  • signs of DVT may be leg pain, warmth, redness, and swelling of the leg, but there may be no symptoms (unilateral)
  • Homan’s sign (pulling toes forward) and Pratt’s sign (squeezing calf to trigger pain) are not reliable in diagnosing DVT, however, these signs may help confirm DVT when also considering the clinical signs of DVT
38
Q

What are the measurements to prevent DVT

A
  • avoid sitting still
  • leg exercises
  • early ambulation
  • adequate nutrition
  • graduated compression stockings (these apply pressure near the ankle and then apply gradually less and less as they move up the leg
  • intermittent pneumatic compression - sequential compression devices
  • medications (blood thinners)
  • no smoking / nicotine
  • exercising
  • manage weight
39
Q

What are the tests for blood oxygenation and what they mean

A
  • results from these tests are pertinent to cardiac conditions because the heart and lungs work together to provide oxygenation, a problem in one creates a problem in the other
  1. pulse oximetry: noninvasive and painless test that measures oxygen sat level
  2. capnography: non invasive and provides breath to breath ventilation data
  3. arterial blood gas: invasive, they measure the acidity and the levels of oxygen and carbon dioxide in the blood from an artery
40
Q

What are the labs you would draw for a cardiovascular assessment

A
  • cholesterol
  • lipid panel
  • c reactive protein
  • glucose testing
  • an elevated CRP level indicates the presence of inflammation in the body, this may, but does not necessarily, include arterial inflammation or a myocardial infarction
41
Q

What is cardiac monitoring for a cardiovascular assessment

A
  1. the purposes of cardiac monitoring are to:
    - identify the client’s baseline rhythm and rate
    - recognize significant changes in the baseline rhythm and rate
    - recognize lethal dysrhythmias that require immediate intervention
  2. electrocardiogram: rendering of the electrical activity of the heart, electrodes placed on the skin of the chest display a waveform on a monitor screen or printout
42
Q

How can you manage anxiety related to cardiovascular interventions

A
  • anxiety activates the SNS and triggers the stress response
  • hormone changes occur, including the release of aldosterone, which promotes fluid retention and increases blood pressure
  • the heart rate and contraction force increase, peripheral and visceral vessels constrict, and the blood clots more readily
  • all of these make a cardiac or vascular condition more serious
  • provide clear factual information and keep the client and family informed about treatments being given
  • many clients are reassured by the presence of a family member
43
Q

What are some of the ways to promote venous return

A
  • elevate the client’s legs above the level of the heart, gravity promotes venous return from the feet and legs
  • have the client sit in a recliner that elevates the legs rather than sitting upright in a chair with legs elevated on a stool; flexion of the hips, legs, and knees constricts the veins and slows venous blood flow
  • teach clients not to sit with the legs crossed, doing so interferes with blood flow
  • encourage and support early and frequent ambulation (after surgery); contraction of the muscle in the legs moves blood upward against gravity
  • encourage or provide range of motion exercises, which increase venous blood flow through rhythmic massaging of the veins by the active muscles
  • place antiembolism stockings; these are elastic stockings that compress superficial leg veins and promote venous return
  • place sequential compression devices, also called pneumatic compression devices, these are cuffs that surround the legs and alternately inflate and deflate to promote venous return to the heart
  • antiembolism stockings and SCDs are frequently used in perioperative clients to promote venous return and prevent clot formation
44
Q

What does PAD mean and what are the symptoms of peripheral arterial disease

A
  • peripheral artery disease, usually found in the legs and feet, occurs when tissues do not receive enough blood flow to keep up with the demand for oxygen; it is caused by the buildup of fatty deposits and plaque within the arteries (atherosclerosis)
  1. Symptoms include:
    - pain with exercise: when arteries that supply blood to the legs are narrowed, leg pain occurs, especially with walking; this is called intermittent claudication
    - pain at rest: as the blood flow becomes more restricted, pain occurs at rest, as well as numbness or a cold feeling to the leg or foot, especially on one side; other symptoms are weak pulse, change in color, hair loss or shiny skin on the legs, sores that won’t heal, and erectile dysfunction in men
45
Q

What are the ways to promote arterial circulation

A
  • do not use tobacco: clients with poor peripheral circulation need to quit using tobacco because smoking restricts blood flow
  • foot care: when circulation is poor, healing is slower; it is especially important to take good care of feet and prevent injury to the feet; even dry, cracked skin can result in a sore and become infected; clients need to wear well fitting shoes with smooth, dry socks
  • regular exercise improves circulation and oxygen delivery to body tissue
  • proper positioning is important; remind clients that crossing their legs can interfere with blood flow; additionally DO NOT elevate feet above the heart level because is can slow circulation to the feet, leading to increased pain
  • medication might be needed to control blood pressure, control pain, lower cholesterol, prevent clots, and control blood sugar if the client has diabetes
  • warmth: promote vasodilation by preventing long periods of exposure to cold; keep the affected extremity warm by wearing socks or insulated shoes; however, never apply direct heat to the limb(heating pad, hot water bottle) because they increase the risk of burns
  • graft bypass surgery or angioplasty (last resort)
46
Q

Explain the components of extracellular compartments

A
  • interstitial fluid: lies in the spaces between the body cells; excess fluid within the interstitial space is called edema (40% of body weight)
  • intravascular fluid: plasma within the blood; its main function is to transport blood cells (20% of body weight)
  • transcellular fluid includes specialized fluids, such as cerebrospinal, pleural, peritoneal, and synovial fluid as well as digestive fluids
47
Q

Explain the movement of fluids and electrolytes

A
  1. osmosis: involves movement of water or other pure solute across a membrane from an area of a less concentrated solution to an area of more concentrated solution
  2. diffusion: passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration
  3. filtration: the movement of both water and smaller particles from an area of high pressure to one of low pressure
  4. active transport: occurs when molecules move across cell membranes from an area of low concentration to an are of high concentration; active transport requires energy versus passive transport
48
Q

When using hydration for the client at risk for thrombus formation, a urine output greater than _____ is ideal

A

1,500 mL/day (24 hours)

49
Q

What are the factors of hormone regulation

A
  • ADH
  • renin-angiotensin system
  • aldosterone
  • thyroid hormone
  • atrial natriuretic peptide, brain natriuretic peptide, and C type natriuretic peptide
50
Q

Name the major electrolytes and what each does

A
  1. sodium:
    - the major cation in extracellular fluid
    - regulates fluid volume
    - kidneys reabsorb
  2. potassium
    - the major cation in intracellular fluid
    - affects muscle contraction and cardiac conduction
    - kidneys eliminate
  3. calcium
    - affects bone health, neuromuscular function, and cardiac function
    - if dietary intake is not sufficient to replace it, bone loss occurs; prolonged deficiencies lead to osteoporosis
  4. phosphate:
    - bound with calcium in teeth and bones
    - has an inverse/reciprocal/opposite relationship with calcium
  5. magnesium:
    - affects the bone
    - has many cellular functions
    - although magnesium deficiency is rare, you may find low levels in individuals who have a high alcohol intake
  6. chloride
    - usually bound with other ions, especially sodium or potassium
  7. bicarbonate
    - acid base balance; produced by body to act as buffer
    - regulated by kidneys to maintain an acid base balance; when serum levels rise, the kidneys excrete excess bicarbonate; if serum levels are low, the kidneys conserve bicarb
51
Q

Explain deficit fluid volume. What are the causes

A
  • hypovolemia: occurs when there is a proportional loss of fluid and electrolytes from the ECF
  • dehydration: state of negative fluid balance in which there is a loss of water from the intracellular, extracellular, or intravascular spaces
  • weight loss of sudden 5% loss of body weight is considered clinically significant; when loss approaches 8%, fluid loss is severe; a sudden loss of 15% of body weight due to fluid loss is usually fatal

Causes:

  • insufficient fluid intake
  • excessive fluid loss (bleeding, vomiting, diarrhea)
  • fluid shifts (intravascular fluid may leak into body tissues, burns)
52
Q

Explain fluid volume excess

A
  • hypervolemia
  • involves excessive retention of sodium and water in the ECF
  • fluid volume excess can result from excessive salt intake, diseases affecting kidney or liver function, or poor pumping action of the heart
  • the retained sodium increases osmotic pressure in the ECF
  • this pressure pulls fluid from the cells into the ECF
53
Q

Explain signs of fluid overload

A
  • elevated blood pressure
  • neck veins may become distended
  • pale, cool skin
  • edema: excess ECF may accumulate in the tissues, especially in dependent areas; will see weight gain
  • in severe fluid overload, the client develops moist crackles in the lungs, dyspnea, and ascites
54
Q

What are the nursing interventions for fluid and electrolyte imbalances

A
  1. dietary teaching:
    - promote fluid and electrolyte balance, most people need to limit their sodium intake and increase their dietary potassium and calcium
    - instruct clients to read food labels, particularly when trying to limit sodium intake
  2. oral electrolyte supplements
    - many clients are unable to correct electrolyte disturbances with dietary changes alone
    - encourage clients to take potassium supplements with juice to mask the taste
    - caution clients that salt substitutes contain potassium; if the client has been advised to use salt substitutes, review the need for potassium supplements
  3. limiting or facilitating oral fluid intake
  4. parenteral replacement of fluids and or electrolytes:
    - whenever possible, clients should take fluids by mouth
    - when fluid loss is severe or the client cannot tolerate oral or tube feedings, fluid volume is replaced parenterally
    - IV therapy is the administration of fluids, electrolytes, meds, or nutrients by the venous route
55
Q

Explain isotonic, hypotonic and hypertonic solutions

A

Isotonic:

  • of the same osmolality as blood; thus, no osmosis will occur
  • remain inside the blood vessels
  • as a result, they are useful for clients with hypertension or hypovolemia

Hypotonic:

  • lower osmolality than blood
  • when hypotonic solution is infused, water moves by osmosis from the vascular system into the cells
  • these solutions pull body water from the intravascular compartment into the interstitial fluid compartment
  • used to correct cellular dehydration

Hypertonic:

  • when this solution is given to a client, water moves by osmosis from the cells into the ECF
  • these solutions pull fluids and electrolytes from the intracellular and interstitial compartments into the intravascular compartment
56
Q

What are the key thing to remember for replacement of blood and blood products

A
  • client must give consent for blood products
  • obtain vitals
  • ensure client has good IV access
  • to help prevent transfusion reactions, be extremely careful in identifying the client and the blood, start the transfusion slowly, remain with the client for the first 5 min of the transfusion, and assess again at 15 min
  • you must assess your client throughout the transfusion
  • monitor for transfusion reactions (allergic, bacterial, febrile, hemolytic, and circulatory overload)
  • STOP THE BLOOD TRANSFUSION
  • assess client and notify provider
57
Q

If the intake is less than output or if the output is MORE than the intake, think ________

If the intake is more than output or if the output is LESS than the intake, think that the patient may be ___________

A
  1. dehydration

2. retaining fluid and is in fluid overload

58
Q

What are the different ways to administer nitroglycerin

A
  1. transdermal:
    - a paste or ointment
    - patch - releases medication slowly into the system
  2. oral:
    - extended release tablets
    - buccal tables: holds tablet between the cheek and gum or underneath the upper lip
    - sublingual tablets; place under the client’s tongue and wait for it to dissolve
  3. sublingual/translingual spray spray that is administered under or on the tongue (used in emergencies)
  4. IV
59
Q

What is important to remember when administering nitroglycerin

A
  • do not get it on hands or any other part of body since it is absorbed transdermal; you would be dosing yourself with ntiro causing hypotension and a “nitro headache” that results when vessels in the brain dilate
  • it is dosed in INCHES (1 inch nitro BID q 8 hours)
  • the medication comes in a tube or a single use small packet and a pad of waxy paper about the size of a credit card
  • on one side, paper has a small ruler so you can see how many inches to dispense from the packet
  • you measure out the prescribed amount of ointment, place the paper on the patient with the ointment side down, write the date, time and your initials on the other side, then tape
60
Q

What are the common sites for nitro?

What does repeated exposure do to the body

A
  1. chest or deltoid
  2. repeated exposure to the medication decreases the body’s sensitivity to it, making it less effective; hence it will likely be ordered to be worn 12-14 hours per day, giving the patient a nitro holiday so that tolerance does not build up

Foundations of Nursing (12 decks)

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