ATI MedSurg complete test

ATI MedSurg complete test hypokalemia ECG reading low potassium = Flat T waves hypercalcemia deep tendon reflexes too much calcium = Decreased deep tendon reflexes hyperkalemia too much potassium = tall peaked T waves Hypocalcemia low calcium = tetany addisons disease decreased aldosterone & renin cushings disease elevated cortisol hypothyroidism decreased T3 & T4 Diabetes insipidus decreased urine specific gravity Syndrome of inapproprate secreation of antidiuretic hormone increased urine osmolarity diabetes mellitus elevated HbA1c - glycosyated hemoglobin cataracts progressive , painless loss of vission Retina detachment sudden loss of vision open angle glaucoma loss of peripheral Stable angina occurs with exercise, stress but relieved by nitro variant angina due to coronary artery spasm, during periods of rest Unstable angina occurs with exercise, stress but increases in severity over time maclar degeneration central loss of vision angle closure glaucoma increased IOP appendicitis assessment pain at mcburneys point - diagonal from appendices to navel PUD assessment upper eppigastric pain 1-2 hours after eating. Cholecystitis assessment pain at murphy sign = upper right under rib . Pancreatitis assessment turners sign = bruising decorticate rigidity upper extremities flexed , lower rigid decerebrate upper extermeties extended away from cerebrum Hep A transmission ingestion of contaminated food / water - MEXICO Hep B transmission Sex Nonviral Hep Drug toxicity CHF S&S sob, fatigue, DVT, S3 hypovolemic shock position supine with legs elevated continuous bubbling in chest tube water seal chamber indicated there is a leak. find leak, tighten the connections or replace drainage system Stage 3 HIV symptomes -Disseminated or extrapulomonary histoplasmosis . -kaposi sarcoma. -burkitts lymphoma . cardiac injury labs Myoglobin - 24hr marker. troponin - 7day window. PH 7.45 - 7.35 PCO2 35 - 45 HCo3 22 - 28 Pericarditis abnormal finding Report paradoxical pulse Seizure Seizure are abrupt excessive and uncontrolled electrical discharge of neurons within the brain that can cause LOC, or changes in motor / sensory ability and behavior. Dx: EEG for region Interventions = move client to floor, patent airway, suction, turn to side, loosen clothing, document, check vitals, neuro check, reorient. Treatment = AEDs like phenytoin(lessen effects of warfarin & contraceptives) Problems = status epilepticus lasting 30+ mins. Airway, oxygen, IV, ECG, O2 sat, ABG, give loading dose diazepam & IV phenytoin. Parkinsons Parkinsons is a progressive desease affecting motor function due to over stimulation of basal ganglia by acetocoline. Dx: s&S Interventions : meds, monitor swallowing and nutrition, mobility, communication, mental and cog status. Treatment: Increase dopamine or decrease acetocoline. take several weeks. Dopamine agonists - monitor orthostatic hypotension, dyskenesias, hallucinations. Anticcholinergics - monitor dry mouth, constipation, ur. Alzheimers nonreversable dementia charactorized by memory loss, judgment problems, and changes in personality. Dx: apolipoprotien Interventions : asses S&S, sleep/bowel/bladder program, family support group, snacks & fingerfoods, verbal/nonverbal communication options, memory training, avoid overstim, promote consistancy and reorient, speak direct in short concise sentences. Treatment: prevent acetylcholine breakdown (ACH) with donepezil, estrogen, ginko. Multpiple sclerosis MS is an autommune disorder charactoerized by plaque in the white matter of CNS. alyloid plaque damages myelin sheath and interferes with impuse transmission. Dx: MRI shows plaque, CSF shows elevated protien & WBC. Intervnetions: monitor swallowing, vision, activity, skin, speech, coping, encourage fluid to prevent UTIs, bladder/bowel program, communication board, eye patch for diplopia, exercise, grouping ADLS. Treatment: Immunosuppressants & antispasmodics. prednisone= monitor infection, DM, hypok, gi bleeding. Dantrolene= antispasmotic liver and muscle weakness. anticholinergics = bladder dys. ICP interventions ICP intervnetions: elevate head of bed 30 degrees. maintain patent airway. O2 sat 92% and higher. keep PaCO@ 35-38 mm Hain cervical spine stability until cleared by xray. seizure precautions. manitol and monitor osmolality q6 hrs. Stroke CVA involve disruption in cerebral blood flow due to ischemia, hemorrahge or embolism. Dx: MRI, CT, CAT scans. Interventions: vitals q1-2hrs report b/p over 180. monitor temp, maintain co2 92% +, cardiac monitor, LOC, ICP, elevate head of bed 30 degrees, seizure precautions, assist with ADLS, feeding, mobility. TX: low dose aspirin 24-48hrs after stroke, retavase within 4.5 hrs. Pulmonary Embolism PE occurs when a substance enters venous circulation and forms a blockage in the lungs. dx: elevated D-dimer. tachycardia/pnea, hypotension, extra heart sounds mumor. Interventions: Watch for hemorrhage and hypotension. oxy, high fowlers 90%, IV, meds, LOC. Tx: enoxaprin, heparin, warfarin, activase & streptase. MI & Angina imbalance btween mycardial oxgen supply and demand. MI is pain lasting over 30mins only relieved by opioids, Angina is pain lasting less than 15 mins relieved by nitro. Dx: myoglobin - marker 24hrs , CK 3days , troponin I 7 days , troponin T 14-21days. Interventions: vitals Q15mins until stable, then every hour. ECG and continuous monitoring. Output 30ml/hr. admin oxygen 2-4 L/min. IV site. Heart Failure Heart Failure is when the heart muscle is unable to pump effectivlely resulting in inadequate cardiac output , hypertrophy, and congestion. MADD DOG. Dx: hBNP over 100 = heart failure . Interventions: daily weight , I&O. assess sob, dyspnea & admin oxy. monitor vitals. high fowlers 90%. monitor agb, electrolytes(hypokalemia), o2. restrict h20 & sodium. Tx: Diuretics -watch for low potassium. ACE - watch for hypotension, dry cough normal, b/p 2hrs after dose. digoxin - toxicity, 60bpm. Beta blocker - hypotension, brady, weight. nitro - headache, dizziness. anticoagulants - bleeding. Peripheral Arterial Disease (PAD) Peripheral Arterial disease is atherosclerosis of the arteries in the lower extremities which causes inadequate blood flow. Dx: pulseless, hairless, cold cynotic lower extremities. white when elevated, red when lowered, bruit over femoral. interventions: promote movement. elevate legs slightly. avoid crossing or restrictive clothes. promote vasodialation: heat, socks. avoid caffeine, smoking, stress, cold. Tx: aspirin, clopidogrel, pentoxifylline, statins - watch for bleeding, and muscle pain. Hypertension Hypertension is systalic over 140 or diastolic over 90. Hypovolemic shock Low blood pressure and inadequate tissue perfusion that leads to oragan failure. Due to cardiogenic (MI), Hypovolemic(dehydration/bleeding), Septic (UTI), Anaphylactic (reaction). Dx: hemodynamic monitoring, pulm cath. Interventions: Monitor Oxygen(priority), vitals, Cardiac rhythm, output, LOC, skin color, temp, turgor, cap refil. High flow 100% oxy mask. emergency equiptment ready, IV access. supine, elevate legs. Complications= MODs (monitor organs) & DIC (monitor bleeding). aneurysm an aneurysm is a weakness in a dilated artery that causes widening or "balloning" in the wall of the blood vessel. Dx: xray for eggshell shape. Aortic aneurysm = gnawing abd/flank pain, bruit, hypertension. Aortic dissension = sudden tearing/ripping abd/back pain. Tx = lower B/P if aneurysm, Increase if rupture! Surgery for graft. keep hob below 45 degrees, report output under 50ml/hr, admin antiplatelet. Interventions: Vitals Q15min then Q1hr when stable. pain, temp, circ, ROM, ABG, o2 sat, CBC. Output 30ml/hr. admin oxy, maintain IV, admin meds. Complications: hypovolemic shock = diaphoresis, nausea, vomiting, faintness, apprehension, pulseless, LOC, hypotension & tackycardia. BLOOD LABS RBC - Females 4.2-5.4 million/ul. males 4.7 - 6.1 million/ul. WBC - 5,000-10,000/ul. Platelets - 150,000-400,000 mm. HGB - Females 12-16. Males 14- 18 . HCT - Females 37-47%. Males 42 - 52%. PT - 11-12.5 seconds 85-100%. aPTT - 30-40 seconds (or 1.5-2x with therapy). INR - 2-3 on warfarin. Fluid Volume Deficit FVD is a imbalance due to hypovememia (loss of water and electrolytes) or dehydration -osmolar (loss of water only). Dx: High Hct, osmolarity 300. High BUN, protien. Interventions: urinalysis, o2 sat, CBC, elect. admin oxy, monitor vitals. Lung sounds, LOC. IV access, shock posisiton (legs elevated). fluid replacement (LR, NS, blood). report output 30ml/hr. Tx: oxygen, coloids(blood products), crystalloids(LR,NS), dopamine and other vasoconstrictors. Goal= Vasoconstrict to increase B/P. Fluid volume excess Excess fluid creating imbalance that can leat to pulmonary edema, and heart failure. DX: Hct = decreased concentration due to excess fluid. overhydration = decreased osmolarity (270). BUN, elect and creatinine = decreased concentration. Resp alkalosis. S&S: tachypnea, tachycardia, hypertension, confusion, edema, crachles, dyspnea. Interventions : Vitals, ABGs, CBC, Sat, xray. Semi fowlers sup oxy. weigh daily, monitor I&O. diuretics, and reduce IV flow. limit sodium and fluids. lung sounds for crackles. Complication - pulm edema - admin morphine & diuretic, high fowlers and oxy. electrolyte labs Sodium 136-145. potassium 3.5-5. chloride 98-106. calcium 9-10.5. magnesium 1.3-2.1. phosphrous 3-4.5. ABG ACID BASE 7.35 7.45 PH 45 35 PaCO2 - resp 26 22 HCO3 - metabolic Acute pancreatitis The highest priority finding is absent bowel sounds Nontunneled percutaneous central venous catheter (CVC) Nurse should place pt in Trendelenburg position Conscious sedation Nurse should intervene if pt's O2 is 90% because respiratory depression is a side effect of the meds used during conscious sedation Increased ICP Indicated by sleepiness, widening pulse pressure and decerebrate/decorticate posturing Diabetes and illness Patient should continue medication regimen (insulin) when ill to prevent hyperglycemia Tracheostomy suctioning Nurse should pre oxygenate the pt with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia Cholecystitis Indicated by pain that radiates to the right shoulder Hepatitis A Eating contaminated food increases the risk of contracting Hep A SBO and NG tube Nurse should assess for the passage of flatus because that indicates that the intestines are resuming appropriate function IV with discomfort and coolness First action the nurse should take is to compare the site to the opposite extremity Hormone replacement Pt should notify provider of calf pain (indication of DVT), numbness in the arms (indication of a CVA) and intense headache (indication of CVA) Left sided heart failure Nurse should expect to see oliguria during the day because of decreased blood flow to the kidneys Peritoneal dialysis If the fluid is sluggish in draining, nurse should turn the pt onto their side to reposition the catheter (if it's against the peritoneal wall) or move the catheter (if it's kinked) Diabetic ketoacidosis Improvement in condition would be a glucose of under 300mg/dL COPD If pt has SOB, cough and fatigue along with thick mucus secretions, nurse should administer guaifenesin (mucolytic med that thins secretions and promotes airway clearance) as prescribed Pt should be drinking 2-3L/day to thin mucus secretions Hypoglycemia Cool, clammy skin is an indication of hypoglycemia Pericardial friction rub Scratchy, high-pitched sound associated with acute pericarditis Tension pneumothorax Indicated by chest asymmetry. The air that is forced into the chest cavity causes the affected lung to collapse, and the air that enters the pleural space during inspiration does not exit during expiration. HIV treatment A decreased viral load indicates a positive response to prescribed HIV treatment, because viral load testing measures the presence of HIV viral genetic material Detached retina Pts who have a retinal detachment typically report the sensation of a curtain being pulled over part of the visual field External fixation device Pt should use crutches with a rubber tip. The device is applied by the surgeon directly to the bone to form a rigid structure on the affected extremity. Rheumatoid arthritis Application of heat and cold decreases joint inflammation and pain Right hemisphere stroke Impulsive behavior is an indication Chemo Nurse should report a high temp. because it can indicate an infection due to myelosuppression Radical mastectomy Nurse should include the presence of one or more surgical drains the the plan of care. Pt should start exercise of the arm 24hr after surgery Above-the-knee amputation with temporary prosthesis Pt should sleep on a firm mattress. Pt should keep the residual limb in extension to prevent hip flexion contracture Hearing aids The amplification of background noise is often a challenging aspect of adjusting the a hearing aid Fluid volume overload Indicated by distended neck veins Pacemaker The pacemaker should discharge to maintain the programmed heart rate Tonic-clonic seizure It is not unusual for a pt to become cyanotic and it is generally selflimiting. In the event of a tonic-clonic seizure, nurse should turn the pt onto their side Skin breakdown A 5% loss of total body weight in 30 days or a 10% loss of total body weight in 6 month indicates poor nutrition which places a pt at risk for skin breakdown. A pre albumin level of 5mg/dL also places a pt at risk for skin breakdown. Magnesium sulfate Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate Ibuprofen A common side effect of ibuprofen is GI bleeding Prednisone inhaler Pt should wait at least 20-30 seconds between puffs Morphine Nausea and vomiting are common adverse effects IV blood transfusion Should be done with 0.9% sodium chloride Gastric lavage Pt should lie on the left side to decrease the amount of 0.9% sodium chloride that leaves the stomach and to prevent aspiration. Nurse should insert a large-bore NG tube Lactulose Works by stimulating the production of excess stools to rid the body of excess ammonia- these excessive stools can result in hypokalemia and dehydration