ATI MEDSURG FINAL EXAM REVISION STUDY GUIDE 2020(DOWNLOAD FOR GRADE A)

ATI MEDSURG FINAL EXAM REVISION STUDY GUIDE 2020(DOWNLOAD FOR GRADE A) 2. RESPIRATORY: procedure- thoracentesis, lung biopsy; complications and interventions a. Thoracentesis: aspiration of fluid and air from the pleural space to decrease pressure on lung tissue i. Complications: pneumothorax, bleeding ii. Interventions: see below b. Lung biopsy: to obtain tissue for examination when other diagnostic testing indicates potential interstitial lung disease i. Complications: pneumothorax, pulmonary hemorrhage, empyema ii. Interventions: 1. monitor for complications such as SOB (change in lung sounds, change in chest rise, shifted trachea) bleeding, or infection 2. instruct pt to report any pain, SOB, visible bleeding, redness of site, or purulent drainage to provider 3. pt’s are anxious- provide biopsy care and pt education 3. RESPIRATORY: suctioning- proper technique; complications and intervention a. Suctioning: performed to keep airway clear and promote gas exchange when adventitious breath sounds are detected, pt unable to cough, pt sounds wet and secretions are present b. Proper technique: i. check pulse ox, HYPEROXYGENATE pt before suctioning ii. suction pulling out, NOT going in iii. rotate catheter during removal iv. suction for no more than 10 seconds at a time v. must be sterile to prevent sepsis c. complications: i. HYPOXIA ii. dysrhythmias (lack of oxygen makes heart work harder) iii. unnecessary bronchospasm can cause mechanical trauma to tracheal mucosa d. Interventions i. Keep pulse ox on pt during suctioning and if O2 drops below 90%, STOP suctioning and oxygenate (can continue when O2 comes back up) 4. RESPIRATORY: trauma- facial trauma; nursing assessment, complications, and interventions a. Nursing assessment i. Look for deviated septum ii. Make sure there’s no C-spine problem- CT of head 1. Clear CSF-look for halos in nasal drainage, test glucose 2. Frequent swallowing signifies posterior nose bleed 3. Assess neuro with halos iii. Look in mouth to see if you see anything iv. Notice if they’re swallowing v. Look for battle sign 1. If you see this, it can indicate basilar skull fractures and you need to do a focused neuro assessment b. Complications i. Hemorrhage from the nose ii. Septum deviation iii. CSF leak c. Interventions i. Airway, breathing, circulation 1. Watch for respiratory distress 2. Keep head elevated 3. ice ii. Monitor vital signs- cardiac monitoring and pulse ox iii. provide tissues and emesis basin to allow expectorate of blood iv. nasal packing 1. check pt every hour v. calm pt bc anxious vi. pt teaching: 1. avoid nasal trauma, nose picking, forceful blowing, spicy foods, tobacco, exercise 2. adequate humidification to prevent dryness 3. pinch nose to stop bleeding; if bleeding does not stop in 15 minutes, seek medical attention 5. RESPIRATORY: medications- common medications for COPD, pneumonia, TB; action and side effects a. COPD i. Common medications: 1. Bronchodilators a. relive bronchospasm by improving expiratory flow through widening of the airways and promoting lung emptying with each breath i. Beta-agonists (albuterol) SABA 1. Side effects: TACHYCARDIA, muscle tremor, hypokalemia, increased lactic acid, headache, hyperglycemia ii. Beta-agonist LABA- severent/ salmeterol iii. Anticholinergics (Atrovent) iv. Combination agents b. Side effects: makes your heart race 2. Corticosteroids (budesonide, fluticasone) a. Improve symptoms of COPD b. Side effects: Hyperglycemia 3. antibiotics 4. mucolytics 5. antitussives 6. anxiolytics b. Pneumonia i. Common medications: 1. Antibiotics for BACTERIAL infection (PNC, amoxicillin, ceftriaxone) 2. Fluids for replacement 3. Oxygen for hypoxia 4. Antipyretics for fever 5. antitussives for cough 6. Decongestants for congestion 7. antihistamines ii. side effects: no side effects discussed c. TB (below is what she starred in class) i. Common medications: therapy 6-12 months with 4 or more meds: INH, rifampin, pyrazinamide, ethambutol (all are antibiotics for TB) 1. Isoniazid (INH): a. prophylaxis med b. avoid foods containing tyramine and histamine (tuna, cheese, red wine, soy sauce, yeast extracts)-can result in: headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis 2. Rifampin: a. changes color of body secretions b. can make oral contraceptives less effective- use second form! 3. INH: increased phenytoin levels 4. Ethambutol: a. can cause neuritis- take with vit b6 (pyridoxine) for prophylaxis b. get vision checked ii. Liver and kidneys impacted from these meds- monitor liver enzymes, BUN and creatinine (avoid alcohol) 6. RESPIRATORY: COPD- clinical manifestations, nursing assessment, complications, nursing interventions including pt education a. Clinical manifestations: i. Sputum and chronic cough (chronic bronchitis) ii. Wheezing, weight loss, barrel chest (emphysema) iii. Dyspnea b. Nursing assessment i. Health history ii. Pulmonary function test iii. spirometry to determine airflow obstruction iv. ABGs to obtain and assess baseline oxygenation and gas exchange v. Chest xray c. physical assessment i. Pt position: are they leaning forward? ii. Increased work of breathing and retraction of respiratory muscles iii. Low paO2 and high pCO2 iv. Cyanotic and edema in chronic bronchitis (blue bloater) v. Thin appearance and pursed lip breathing in emphysema (pink puffer) vi. Hard for them to eat or talk because too out of breath d. Complications i. Hypoxemia ii. Respiratory insufficiency and failure iii. Acidosis (from hypercapnia) iv. Respiratory infections v. Pneumothorax (coughing too hard) vi. Cardiac failure, especially core pulmonale vii. Cardiac dysrhythmias (from hypoxemia, acidosis, potassium) e. Nursing interventions including pt education i. Assessing pt and obtaining hx ii. Review of dx tests iii. Achieving airway clearance iv. Improving breathing patterns v. Improving activity tolerance vi. MDI pt education 1. Remove cap and hold inhaler upright 2. Shake the inhaler 3. Sit upright or stand upright. Breathe out slowly and all the way 4. Use open mouth technique or closed-mouth technique a. Open-mouth i. Place pMDI 2 finger widths away from lips ii. With mouth open and tongue flat, tilt outlet of the pMDI so that it is pointed toward the upper back of the mouth iii. Actuate the pMDI and begin to breathe in slowly. Breath slowly and deeply through mouth and try to hold breath for 10 seconds b. Closed-mouth i. Place pMDI between the teeth and make sure the tongue is flat under the mouth-piece and does not block the pMDI ii. Seal lips around mouth-piece and actuate the pMDI. Breath in slowly through the mouth and try to hold breath for 10 seconds 5. Repeat puffs as directed, allowing 1 minute between puffs: no need to wait for other meds 6. Apply cap for storage 7. After inhalation, rinse mouth with water when using corticosteroid-containing PMDI vii. Pt education 1. Promote smoking cessation and educate importance 2. Promote pt to get pneumococcal and influenza vaccine 3. Educate early s/sx of infection and other complications 4. Make sure they are familiar with meds and side effects a. Bronchodilators make your heart race b. Corticosteroids cause hyperglycemia- let pt know you’ll be doing accuchecks 7. RESPIRATORY: TB- nursing assessment, treatment, pt education a. Nursing assessment i. Health history and physical ii. Tb skin test: Mantoux- has to be red and elevated iii. Ask if they have had BCG vaccine- can cause a positive TB test iv. Chest x-ray if there’s any question about it v. Need sputum culture for definitive dx b. Physical assessment i. Low grade fever ii. Cough; nonproductive or mucropurulent; hemoptysis iii. Night sweats, fatigue, weight loss c. Treatment i. First line medications for 6-12 months with 4 or more meds. Resistance develops more slowly if several anti TB drugs given instead of just one 1. Isoniazid, rifampin, pyrazinamide, ethambutol 2. Take once daily 3. People are considered noninfectious after 2-3 weeks of continuous therapy ii. Patient education 1. Promote adherence to tx regimen a. People don’t want to take because it makes them feel crummy and they can’t drink alcohol b. Home direct observation if not compliant 2. Energy conservation a. They may get tired, tell them to take frequent breaks and give them time to do things 3. Encourage small frequent meals a. This helps with dyspnea 4. Let them know they are not contagious after 2-3 weeks of therapy 8. RESPIRATORY: assessment- priority findings and appropriate interventions a. Indicators or respiratory inadequacy i. Acute: 1. Respirations rapid and shallow 2. Respirations noisy a. Crackles: when we hear fluid b. Wheezes: narrowing, constriction, inflammation c. Friction rub: secondary to inflammation d. Ronchi: indicative of heavier secretions 3. Cannot speak more than 4 or 5 words without pausing for breath 4. Change in cognition, acute confusion 5. Decrease oxygen saturation by pulse ox 6. Skin cyanosis or pallor 7. Cyanosis or pallor of lips and mucous membranes 8. Tachycardia 9. Pt appears to strain to catch a breath- anxious 10. Fatigue ii. Chronic 1. Clubbing of fingers 2. Weight loss 3. Unevenly developed muscles 4. Activity tolerance b. Interventions i. First thing to do is SIT THM UP (don’t do if they have a low BP) ii. Ask them to stop talking and focus on their breathing iii. Get pt comfortable before continuing iv. Be very calm with them if they’re anxious v. Take vitals vi. Auscultate all lung fields vii. Monitor oxygen saturation by pulse ox viii. CHECK H&H, HGB, ABGS ix. Assess cognition x. ASSESS FOR USE OF ACCESSORY MUSCLES xi. Assess for presence of thick or excessive secretions 1. Have suction ready and hydrate pt xii. ASSESS THE PT’S ABILITY TO COUGH AND CLEAR THE AIRWAY xiii. Apply oxygen if needed 9. RESPIRATORY: cancer- surgical interventions, nursing assessment, equipment, interventions LARYNGECTOMY: Partial: one set -airway remains intact, pt expected to have no difficulty swallowing. Voice quality may change Total laryngectomy: all structures are removed, won’t be able to talk, have established communication method BEFORE surgery- ASK THEM HOW THEY WANT TO COMMUNICATE PRE-OP NEED SUCTION IN THE ROOM permanent loss of voice and a change in airway requiring permanent tracheostomy. Normal swallowing In post-op phase, still managing stoma: bc the larynx that provides the protective sphincter is no longer present still at risk for aspiration suction secretions When they’re past that phase, they may swallow and have a sensation they will choke, but they won’t because there's nothing there Tell pt: they’re going to have a tube, then it’s going to feel different for them to swallow, but they don’t need to worry, they won’t aspirate Sometimes with surgical procedures they have it with neck dissection, and now they’re going to have a shoulder drop and need therapy EQUIPMENT for respiratory surgery: chest tubes know what indicates normal functioning: -Water seal system-in water seal chamber intermittent bubbling/fluctuation expected. Continuous bubbling can indicate an air leak -Water seal-dry suction-if there is bubbling in the water seal chamber it can indicate an air leak -Dry seal dry suction has an air leak indicator CHET TUBE BELOW THE PT Positioning is usually toward the chest tube side or operative side, then to semi upright • When there is a water seal: – When the wall vacuum is turned off, the drainage system must be open to atmosphere so that the intrapleural air can escape from the system. This is done by detaching the tubing from the suction port to provide a vent – If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent a pneumothorax, a temporary water seal can be established by immersing the chest tube's open end in a bottle of sterile water • If the CT becomes dislodged from patient, the nurse should cover the site with sterile dressing vaseline or sterile dry gauze dressing taped on 3 sides. If an air leak is noted, taping the dressing on 3 sides only allows air to escape and prevents the formation of a tension pneumothorax. Call provider! 10. RESPIRATORY: pneumonia- clinical manifestations, nursing assessment, interventions, prevention a. Clinical manifestations i. PINK FROTHY RUST COLORED SPUTUM ii. Orthostatic due to dehydration and vasodilation iii. Tachycardia iv. Tachypnea, orthopnea v. Crackles vi. Pleural pain 1. Report this so we can rule out cardiac vii. Chills and fever viii. Change in mental status, especially older adults (new onset could signal infection) b. Nursing assessment i. Vitals: pulse ox, respirations ii. Secretions: amount, odor, color 1. rust colored iii. Cough: frequency and severity iv. SOB v. Inspect and auscultate chest 1. Will likely have fluid and will hear crackles vi. changes in mental status, fatigue, edema, dehydration, HF c. Interventions i. Oxygen with humidification to loosen secretions 1. Face mask or nasal cannula ii. Suctioning iii. Coughing techniques and deep breathing exercises 1. Splinting if they’re in pain iv. Chest physiotherapy v. Position changes vi. Incentive spirometry 1. 10X per hour while awake vii. Daily weight viii. Nutrition 1. Dietary consult ix. Hydration x. Rest xi. Activity as tolerated xii. Patient teaching xiii. Self-care d. Prevention i. Pneumococcal vaccine 1. Recommended for adults 65+ and 19+ with weakened immune system, smokers, asthma ii. Promote coughing, breathing exercises iii. Precautions against infections iv. Encourage smoking cessation v. Reposition frequently vi. Suction and prevent risk of aspiration vii. Promote frequent oral hygiene viii. Elevate HOB at least 30 ix. Monitor pt’s receiving antibiotic’s x. Reduce alcohol intake xi. Observe respiratory rate and depth when recovering of anesthesia and before giving meds xii. Promote frequent turning, early ambulation, and mobilization xiii. Clean respiratory equipment xiv. Strict hand hygiene and gloves xv. VAP bundle (KNOW ITS USED FOR PNEUMONIA) 1. Elevate HOB (30-45) 2. Daily sedation vacations and assessment of readiness to extubate 3. PUD prophylaxis 4. DVT prophylaxis 5. Daily oral care with CHG 10. cardiac: ECG know components: P wave- atrial depolarization; can be positive negative or biphasic (refers to its shape); electrical impulse generated from SA node the P waves will have a consistent shape; PR segment- from end of P wave to beginning of QRS complex; when electrical impulse is traveling to the AV node; PR interval- measurement from the beginning of the P wave to end of PR segment; time for atrial depolarization as well as impulse delay in the AV node and travel time to purkinje fibers; normally will measure 0.12-0.20 second. Which is the equivalent of 5 small blocks. QRS complex- ventricular depolarization; shape of it depends on what lead you are in; QRS duration- time required for depolarization of both ventricles; the normal measurement is 0.04-0.12 seconds. Which is up to 3 small boxes. ST segment-Normally an isoelectric line and represents early ventricular repolarization; T wave- ventricular repolarization; normally rounded slightly asymmettric positive line; electrical imbalances could invert it; QT interval- total time required for ventricular depolarization and repolarization; measured at beginning of q wave to end of t wave; certain meds or electrical disturbances may alter what it appears like; how to identify abnormal findings: follow these steps in order: Rhythm Regular Rate Normal (60-100 bpm) P Wave Normal (positive & precedes each QRS) PR Interval Normal (0.12-0.20 sec) QRS Normal (0.06-0.10 sec) how to identify artifact: fuzzy line; not very clear; can be caused from leads not being on correctly, pt shivering, pt in physical therapy who’s moving around, or if there’s other electrical impulses near them. First thing you are going to do is check their equipment. 11. cardiac: Heart rhythms review ECG packet: look at packet identify those rhythms with appropriate nursing actions: look at packet 12. cardiac: medications –know common meds for these and focus on action and side effects sinus bradycardia: Atropine Action- antiarrhythmic; increase HR Side effects- drowsiness, blurred vision, tachycardia, palpitations, dry mouth, constipation, urinary retention, flushed skin. SVT: Adenosine (also important to note a period of asystole is an expected finding after giving this drug bc you are resetting the heart*) Action- antiarrhythmic; restores normal sinus rhythm. Side effects- dizziness, lightheadedness, headache, SOB, blurred vision, hyperventilation, facial flushing, CP, palpitations, metallic taste, nausea, numbness tingling. Atrial fibrillation: Cardizem Action- systemic vasodilation resulting in decreased BP. Coronary vasodilation resulting in decreased frequency of and severity of attacks of angina. Reduction of ventricular rate in atrial fibrillation. Side effects- drowsiness, confusion, dizziness, blurred vision, epistaxis, cough, dyspnea, peripheral edema, CP, bradycardia, constipation, n/v, anemia. Weight gain, etc. (also may treat with heparin or Coumadin combined with VTE prophylaxes to prevent blood clots); if Cardizem does not work we cardiovert them. Can also see external pacing or maze procedure. Heart failure: (in general teach pts to avoid NSAIDs bc they cause sodium and fluid retention) Vasotec (Enalopril)- ace-inhibitor Actions- works to reduce afterload Side effects- dizziness, headache, drowsiness, dry mouth, coughing, anorexia, rash, itching, insomnia, etc. Lasix (furosemide)- diuretic (give slowly bc may cause rapid drop in BP*) Action- reduces preload; decreases BP Side effects- blurred vision, dizziness, headache, dry mouth, n/v, dehydration, hypokalemia/hyponatremia, hypovolemia, etc. Metoprolol- beta-blocker (increased heart rate is an expected finding*) Action- decrease BP and HR. Side effects- fatigue, weakness, dizziness, drowsiness, blurred vision, bradycardia, erectile dysfunction, etc. Digoxin –cardiac glycoside (no longer commonly used bc its absorbed erratically and has small therapeutic range: 0.8-2ng/L and anything 4ng is considered toxic). Interferes with antacids. Action- increases contractility, reduces HR, slows conduction through AV node, and inhibits sympathetic activity. Side effects- if toxic levels reached- presents like GI bug with n/v, fatigue, anorexia, confusion. Also will see halo effect. antidote= Digifab. 13. cardiac: shockable rhythms ventricular tachycardia –pulseless only* call code blue, start cpr immediately, give epi and amiodarone. Ventricular fibrillation no measureable HR- complete chaos in heart and ventricles quivering. Hook up AED, begin cpr, give epi and defibrillate according to AED. 14. cardiac: HF manifestations of RHF: • Viscera and peripheral congestion • Jugular venous distention (JVD) • Dependent edema • Hepatomegaly • Ascites • Weight gain (the right ventricle cannot empty completely. This causes increased volume and pressure in the venous system resulting in peripheral edema. Weight gain is our best indicator of pt having RHF*)- i..e. rings or shoes feel tighter, socks leave indents in skin. manifestations of LHF: • Pulmonary congestion, crackles • S3 or “ventricular gallop” • Dyspnea on exertion (DOE) • Low O2 sat • Dry, nonproductive cough initially • Oliguria Nursing interventions and safety: Important to balance rest and activity. Plan periods of rest bw activity. Relieve fluid overload sx, decrease anxiety and help them manage it, educate the pt and families about management and their therapeutic regimen. Low ox- give them oxygen. Dyspnea- we can raise the HOB to high Fowlers. Important to have continuous pulse ox, listen to lung sounds, get daily weights/I and Os, and position pt to facilitate breathing and rest and support extremities to help relieve edema. Diet- low sodium and fluid restriction (no more than 2L/day). Stress management. Prevention of infection. For LHF- important to watch for s/sx of flash pulmonary edema: restlessness, anxiety, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood tinged), decreased level of consciousness 15. cardiac- meds, pt teaching, and precautions (#12 and #14 cover specifics): MAWDS-core measures on discharge when educating pts on HF. Medications- take as prescribed and do not run out of them. Know purpose and side effects of each one. (pts will be going home with lots of new meds). Avoid NSAIDS! (bc NSAIDs will cause sodium and fluid retention if taken on regular basis) Digoxin –cardiac glycoside (no longer commonly used bc its absorbed erratically and has small therapeutic range: 0.8-2ng/L and anything 2.4 ng is considered toxic). Interferes with antacids. Action- increases contractility, reduces HR, slows conduction through AV node, and inhibits sympathetic activity. Side effects- if toxic levels reached- presents like GI bug with n/v, fatigue, anorexia, confusion. Also will see halo effect. antidote= Digifab. Not commonly used today because of risks for toxicity dig is erratically absorbed in GI for some pt’s, it’s the only thing that works ***Therapeutic range is o.8-2 ng/ml8*** Anything over 2.4 is considered toxic If pt comes in and you see they’re on dig, automatically ask for serum testing to catch ahead of time Older adults, because GI tract is not functionally appropriately, they have high mortality rate, so more dangerous Interferes with a lot of other medication, OTC antacids mess with absorption of this drug a lot- INTERVEINE n/v, fatigue, anorexia- going to look like a GI bug will have visual changes with dig toxicity- halos Older adults will get confused If dig is at a life-threatening level-overdose-give antidote: DIGIFAB binds with dig in body and deactivates it If we give this med, think about what other meds we can give them so they stay save because they can go back into heart failure since we are reversing med-watch for fluid build up Activity- stay as active as possible but don’t overdue it. know your limitations. Be able to carry on a conversation when you exercise (this ensures that they arent overdoing it). Have exercise and activity program. Weight- teach them same scale, same time, same clothes. Tell them to monitor for fluid retention (if they g 16. cardiac- pericarditis clinical manifestations- Inflammation of the pericardium; ,may be asymptomatic; most characteristic symptom is substernal pericardial pain radiating to the left side of the shoulder, neck or back. This pain is aggravated by coughing, breathing, or swallowing and worsened by supine position and relieved by sitting up and leaning forward. The other common sx is pericardial friction rub. It sounds scratchy/creaky heard louder on exhalation. Watch for pericardial effusion- puts pts at risk for cardiac tamponade which can be medical emergency (s/sx of cardiac tamp- JVD, Paradoxical pulse, Decreased CO, Muffled heart sounds, Circulatory collapse). Pts may also have increased WBC count, elevated C-reactive protein, and a nonproductive cough. nursing interventions- get echo, CT, and MRI. NSAIDs, antibiotics, and if the inflammation is severe enough they may be put on corticosteroids. If they have a surgical procedure itd be a pericardial centesis or pericardialectomy –remove fluid and get it cultured. Our main intervention is to help with pain relief by repositioning pt in bed. Pain may be relieved having pt lean forward or sit up. Pt should restrict activity until pain subsides. pt education- educate on s/sx especially of cardiac tamponade. Teach them pain relief positions. o Prophylactic antibiotics before dental procedures 17. cardiac- Angina clinical manifestations of chronic stable- “Strangling of the chest”, temporary imbalance between coronary artery’s ability to supply oxygen and cardiac muscle’s demand for oxygen, ischemia limited in duration and does not cause permanent damage to myocardial tissue. Sx are provoked by physical exertion, stress, and emotional upset. The pain is a similar pattern of onset, duration, and intensity. Only lasts a few minutes (3-4min). Controlled with meds on outpatient basis. i.e. beta blockers, calcium channel blockers, statin, etc. pts may be on sublingual nitroglycerin tablets at home. We teach these pts about relaxation techniques. Pain relieved by rest or nitroglycerin. Clinical manifestations of unstable- Pain is new onset. Occurs at rest. Has increased frequency and duration. Pain lasting over 10min. Any unstable angina has to be treated immediately bc its unpredictable and can cause other issues. Pain is not relieved by rest or nitroglycerin. Interventions- the pt experiencing angina is directed to stop all activities and sit or rest in bed in a semi-Fowler’s position to reduce oxygen requirements of the ischemic myocardium. The nurse assess the angina and asks questions to determine the type, then monitors vital signs and observes for signs of respiratory distress. 12 lead ECG usually obtained and assessed for ST-segment changes and T wave changes. Nitroglycerin is given sublingually and the pts response is assessed. If the chest pain is unchanged or lessened but still present, the nitro administration can be repeated up to three doses. Each time, BP, HR, and ST-segment are assessed. If pain is significant and continues after these interventions, the pt is further evaluated for acute MI. The nurse should use stress-reduction strategies such as guided imagry or music therapy to relieve anxiety. The nurse can also address the pt’s spiritual needs. Prevention of pain by planning activities and balancing them with rest periods. pt education- educate pt on sx of cardiac ischemia (sensations of indigestion or nausea, heaviness, weakness or numbness in upper extremities, dyspnea, or dizziness). Educate about self-care including how to prevent chest pain and the advancement of CAD. Pt should be instructed to call 911 if any pain is unrelieved after 15 minutes by rest or nitro. After education the pt should be able to: state impact of angina, changes in lifestyle including diet (low in saturated fat, high in fiber, and low in calories if indicated) and activity well balanced with rest periods to avoid producing angina attack, follow prescribed regimen and be able to state the name, dose, side effects, and schedule for all meds, know to carry nitro at all times and when and how to use it, avoid OTC meds that can increase HR like diet pills or decongestants, stop smoking, and achieve and monitor normal BP and blood glucose levels. 18. cardiac: MI clinical manifestations- STEMI- ST elevation MI. will have an occlusive thrombus. Emergency situation. They need to go to cath lab within 90 min of sx presenation. NSTEMI- non ST elevation MI. nonocclusive thrombus. Isnt urgent to go to cath lab but still need to go. Go bw 12-72hrs. s/sx of complete occlusive: pain (chest pain that may radiate to left jaw/shoulder), stimulation of SNS, n/v, fever. Appearance= gray/ashen and cool/clammy. risk factors- modifiable: elevated serum cholesterol, cigarette smoking/tobacco, hypertension, impaired glucose tolerance/DM, obesity, excessive alcohol, limited physical exercise, stress, and substance abuse. Nonmodifiable: age, gender (middle aged men are at higher risk), family hx (CAD or MI in first degree relative), and ethnic background (African Americans have greater onset and mortality rates). treatment- (focus on core measures) aspirin (325mg chewable daily after discharge) and thrombolytic agents if STEMI as “clot buster”. nitro/morphine sulfate IV to help with pain, semi-Fowler’s position; oxygen. Percutaneous coronary intervention if drug therapy alone doesn’t work. May give heparin or Clopidogrel before/after this procedure. Also can do intra-aortic balloon pump. 19. FLUID/ELECTROLYTE: dehydration- manifestations, interventions, medications, safety a. Dehydration: i. loss of water alone, with increased serum sodium levels b. Manifestations: FVD plus hypernatremia i. FVD 1. ORTHOSTATIC HYPOTENSION-low BP and increased HR 2. THIRSTY AND CONFUSED 3. RAPID, WEAK PULSE 4. Weight loss 5. Decreased skin turgor 6. Oliguria, concentrated urine 7. Cap refill prolonged 8. Low CVP 9. Flattened neck veins 10. Dizziness, weakness 11. Muscle cramps 12. Sunken eyes 13. Nausea 14. Increased temp 15. Cool, clammy, pale skin ii. Hypernatremia 1. THIRST 2. ELEVATED TEMP 3. n/v, diarrhea, cramping, anorexia 4. dry mouth, sticky mucous membranes 5. hallucinations, lethargy, irritability, seizures 6. hyperreflexia, twitching 7. increase pulse 8. pulmonary edema c. interventions i. FVD 1. I/O 2. Daily weight a. 1L of water= 1kg (2.2 Ibs) 3. Vitals signs- HR and BP 4. Skin and tongue turgor, mucosa 5. Urine output a. Want pt to have 30 ml output per hour 6. Mental status 7. Measures to minimize fluid loss a. Figure out cause and stop it, may need meds 8. Oral fluids a. Remind them to drink! Can be delegated 9. Parenteral fluids a. Be careful with HF and kidney failure 10. Oxygen on elderly; dehydration leads to poor perfusion- hypoxia and confusion ii. Hypernatremia 1. Gradual lowering of serum level with hypotonic IV solution a. Restore both sodium and fluid 2. Potassium and sodium labs 3. Assessment for abnormal loss of water and low water intake 4. Slowly increase water intake a. If you overload these pt’s with fluid, they can have seizures 5. Educate pt’s to read labels on what they should be eating 6. Monitor for CNS changes d. Meds: i. Parental fluids (hypotonic) ii. Diuretics iii. Antibiotics IV if fluid loss is related to bacterial problem iv. Tylenol for fever e. Safety i. Fall precautions ii. Seizure precautions 20. FLUID/ELECTRYOLTE: fluid overload- manifestations, interventions, medications, safety a. Manifestations i. BOUNDING PULSE ii. HYPERTENSION iii. WEIGHT GAIN iv. PITTING EDEMA v. CRACKLES IN LUNGS vi. PITTING EDEMA vii. Distended neck veins b. Interventions i. I/O ii. Daily weight 1. If they gain MORE THAN 3 POUNDS in one week, or 2 POUNDS in 24hr, call doc iii. Assess lungs sounds, edema, other sx iv. Monitor responses to meds 1. Monitor HR- if we give too many diuretics, can cause changes in ECG (potassium) a. Pt will be on heart monitor v. Sodium and potassium labs vi. Promote adherence to fluid restrictions- pt teaching vii. Low sodium diet viii. Encourage rest 1. Reposition frequently to prevent breakdown with extra fluids c. Meds: i. Diuretics ii. ACE inhibitors 1. Prevents kidneys from reabsorbing water and sodium for BP iii. Vaprisol 1. Improves urine output without losing too much sodium d. Safety: 21. FLUID/ELECTROLYTE: K+, Na+, Ca+- clinical manifestations, causes, interventions (look at electrolyte imbalances sheet on blackboard to put it more simpler) a. Sodium i. Hyponatremia 135 mEq/dL 1. Clinical manifestations: a. WEAKNESS, CONFUSION, SEIZURES i. Seizure and fall precautions ii. Neuromuscular and respiratory assessment 2. Causes: a. Loss of sodium i. Diuretics, GI fluid loss, renal dz, adrenal insufficiency b. Gain of water i. Excess D5w or hypotonic fluids/ tube feedings 1. (D5W isotonic, but when metabolized, solution becomes hypotonic & fluid shifts into cells) c. SIDADH d. Meds associated with water retention (oxytocin) e. Psychogenic polydipsia f. Hyperglycemia & HF cause loss of sodium 3. Interventions: a. Treat underlying condition b. Sodium replacement/ encourage dietary sodium i. Encourage salt intake; salt packets c. Water restriction i. Make sure they’re not drinking water from their sink d. Meds i. Vasopril e. Assessment: i. I/O, daily weight, lab values, CNS CHANGES ii. Neuromuscular & respiratory assessment if weakness is present f. Monitor fluid intake g. Effects of meds (diuretics, lithium) i. If IV is prescribed (only if not fluids restriction)- administer slowly ii. Hypernatremia 145 mEq/L 1. Clinical manifestations a. LETHARGY, SEIZURES i. Seizure precautions 2. causes ..............................................................................................................................................CONTINUED....................................DOWNLOAD FOR GRADE A........................