NUR265 test 2 Notes/AdvMedSurge Test 2 (NUR265)

AdvMedSurge Test 2 Assess patients at risk for PE for the symptom cluster of distended neck veins, syncope, cyanosis, & hypotension. If this cluster is present, notify the Rapid Response Team. It is important to remember that many patients with PE do not have the ‘classic’ manifestations but instead have vague symptoms resembling the flu, such as N/V, & general malaise. Classic Symptoms Signs *dyspnea, sudden onset *tachypnea *sharp, stabbing chest pain *crackles *apprehension, restlessness *pleural friction rub *feeling of impending doom *tachycardia *cough *S3 or S4 heart sound *hemoptysis *diaphoresis *fever, low-grade *Petechiae over chest & axillae *decreased arterial oxygen saturation (SaO2) Even if ABG studies & pulse oximetry show hypoxemia, these results alone are not sufficient for the diagnosis of PE. A patient with a small embolus may not be hypoxemic, & PE is not the only cause hypoxemia. When a patient has a sudden onset of dyspnea & chest pain, immediately notify the Rapid Response Team. – Reassure the Pt, elevate HOB, prepare for oxygen therapy & blood gas analysis while continuing to monitor & assess for other changes. Anticoagulants are not used in active bleeding, stroke, & recent trauma. Heparin is usually used unless the PE is massive or occurs with hemodynamic instability. Fibrinolytic drug may then be used to break up existing clot. Be sure to review PTT before drug therapy starts, every 4hrs once started and daily thereafter. Range should be 1.5 – 2.5 times the control value. Heparin comes in a variety of concentrations. Ck prescribed dose carefully & ensure the correct concentration is being used to prevent overdosing or underdosing. Enoxaparin (Lovenox) can be given only subQ, NOT intravenously or intramuscularly. Heparin & fibrinolytics are high alert drugs. Keep antidotes to anticoagulant drugs & fibrinolytic drugs on the unit for PTs undergoing these therapies. The antidote for heparin is protamine sulfate; the antidote for warfarin is injectable phytonadione, vitK (aquaMEPHYTON, mehyton). Antidotes for fibrinolytic therapy include clotting factors, fresh frozen plasma, & aminocaproic acid (Amicar). The nursing priority in the prevention of ARDS is early recognition of patients at high risk for the syndrome. Abnormal lung sounds are not heard on auscultation because the edema occurs first in the interstitial spaces and not in the airways. The patient cannot talk when the endotracheal tube (ET) cuff is inflated. Basic life support measures, such as obtaining a patent airway and delivering 100% oxygen by a manual resuscitation bag with a facemask, are crucial to survival until help arrives. For the patient requiring emergency intubation and ventilation, bring the code (crash) cart, airway equipment box, and suction equipment (often already on the code cart) to the bedside. Maintain a patent airway throug