110 terms

NUR 105 test #4

stage 2 hypertension
Systolic = or > 160
Diastolic = or > 100
Ace Inhibitors ("Pril" drugs)
What type(s) of drugs causes a dry hacking cough?
Cardio-selective Beta-adrenergic Blocker (generic "lol" family)
- actions: less stimulation, decrease stimulation from beta, beta is excitement, blocks sympathetic nervous system taking away S&S of sympathetic stimulation
- blocks vasoconstriction
- used to treat high BP and to prevent angina
- SE: bradycardia (have to check apical HR before giving), GI upset, lethargy, depression, hypotension, CHF, bronchospasms, impotence, drowsiness, hypoglycemia
-nursing strategies: VS, LOC, monitor EKG, S&S of cardiac failure
- less effective on blacks
- don't quite without consulting a Dr
Lasix dietary needs
Lasix is a loop diuretic and can cause hypokalemia. Need to encourage potassium rich diet and restrict sodium.
- example foods: bananas, nuts, broccoli, carrots, tomatoes, potatoes, peanut butter, oranges, melons, whole grain cereal, bread.
- S&S of hypokalemia: weakness, fatigue, cardiac rhythm disturbance, polyuria, polydipsia
C (risk for skin breakdown r/t immobility)
Which of the following is a nursing DIAGNOSIS?
A. raise HOB to help with breathing
B. goal met, AEB: "pain level is now a 2"
C. risk for skin breakdown r/t immobility
D. assist with ambulation to prevent falls
A (turn patient q 2hrs to prevent skin breakdown)
Which of the following is a nursing INTERVENTION?
A. turn patient q 2hrs to prevent skin breakdown
B. risk for aspiration r/t decreased LOC
C. goal not met, AEB: inability to walk to bathroom without assistance
D. pt states "I can't breathe"
S&S of left sided heart failure
- pink and frothy sputum
- exercise intolerance
- pallor
- anxiety
- tachycardia
- downward trend in BP
- adventitious lung sounds
- S1, S2, S3, S4 heart sounds
S&S of right sided heart failure
- will be really obvious
- increase in CVP (central venous pressure)
- JVD (jugular vein distention)
- abdominal engorgement (ascites)
- fatigue
- weight gain: need to do daily weights
- N/V
- decreased urine output
- dependent edema: only on one side, whichever side is hanging down
- peripheral, abdominal, lubrosacral edema
CHF lab tests
- BUN (blood urea nitrogen): kidney function test, measures concentration of nitrogen in urea, norm is 10-20
- creatinine: kidney function test, creatinine is a waste, norm level is 1-2
- liver function test: hepatomegaly
- hemodynamic monitoring
Medication that slows HR and increases cardiac contractility (also treats atrial fibrillation and atrial flutter)
- nursing considerations: daily weight, I&O, labs, cardiac monitor, VS, best absorbed orally in solution-filled capsule (Lanoxicaps) form, don't change brands without consulting Dr
S&S of digoxin toxicity
sinus bradycardia or bigeminy, heart block, nausea, vomiting, anorexia, visual disturbances (xanthopsia), psych disturbances
What is the therapeutic range of digoxin?
What is the maintenance dose of digoxin
What is the digoxin digitalizing dosage?
ventricular depolarization
What does the QRS stand for on an EKG?
atrial depolarization
What is does the P wave stand for on an EKG?
0.12-0.2 seconds (3-5 boxes)
What is the norm length of a PR interval?
0.04-0.12 seconds (1-3 boxes)
What is the norm length of QRS interval?
0.04 seconds
Each small EKG paper square is worth how much time?
.20 seconds
Each large EKG paper square is worth how much time?
How many large EKG squares equals 1 second?
How many large EKG squares equals 3 seconds?
Pernicious anemia
Vitamin B12 anemia.
- Either lacking in Vitamin B12 or unable to absorb vitamin B12 from the stomach.
- intrinsic factor in stomach is essential for Vit B12 absorption
- B12 is used to make myeline sheaths
- B12 also helps with stem cells and cellular growth
- risk factors: strict vegetarian, elderly (from gastric mucosal atrophy), gastric bypass (reduced stomach surface area)
treatment of pernicious anemia
- B12 IM every month for rest of life
- pretty pinkish red color
S&S of pernicious anemia
- sore tongue is key!
- numbness of hands and feet also key!
- fatigue, pallor, weakness
Sickle cell anemia
RBC's become sickle shaped
- norm: hemoglobin A
- abnorm: hemoglobin S, causes sickling
- both parents have to carry the trait
- sickled cells are fragile, rupture easily, leaves patient with chronic anemia
- sickled cells only last for 10-20 days and don't carry much oxygen
- during a crisis, sickled cells become lodged in a capillary causing the pain
- 1 in 12 African Americans carry the trait
- 12 million Americans have the disease
- assess for fever, circulation, dehydration, RUQ pain
- nursing strategies: start an IV line
S&S of sickle cell anemia
- maybe jaundice (key!)
- cardiomegaly (key!)
- fatigue
- chronic anemia
- tachycardia
S&S of sickle cell crisis
- mostly pain
- discoloration
- swelling
- priopism (enlargement of penis)
causes of sickle cell crisis
- any stressors (main is dehydration)
- dehydration
- infection
- over exertion
- cold weather changes (causes constriction of vessels)
- anything causing vasoconstriction
- alcohol
- smoking
diagnosis of sickle cell disease
- S&S to diagnose crisis: pain with history of sickle cell
- electrophoresis
- crisis can last up to 10 days, occurs intermittently
- repeated crisis destroy organs (kidneys, etc.)
treatment of sickle cell disease
HOP to it!, also treat underlying stressor
- H: hydrate
- O: oxygenate, don't use as much as used to, only use if O2 sat dropped
- P: pain relief, morphine, toridol really seems to help
- hydroxyurea: decreases incidence of sickle cell crisis
nursing care of sickle cell crisis
- pain management: have describe pain, location, intensity, when it started, precipitating and alleviating factors
- VS q 4 hrs
- be alert for fever and/or dehydration
- watch for S&S of infection
- develop trusting relationship, pt will have anxiety
- protect from injury, pt will be dizzy and light headed
- I&O
- encourage to drink 4-6L of fluid per day
nursing diagnoses for sickle cell anemia
- acute pain
- anxiety
- risk for injury
- fluid volume deficit
- ineffective therapeutic regimen
- management: identify stressors, have regular medical follow-ups, genetic counseling, resources
patient teaching of sickle cell anemia
- maintain hydration
- avoid high altitudes
- drink 4-6L of fluid a day
- avoid smoking and alcohol
- avoid triggers/stressors
- avoid decongestants (they cause vasoconstriction)
- avoid excessive exercise
EKG rhythm analysis
1. calculate rate
2. determine regularity/rhythm
3. assess the P waves
4. assess PR interval
5. determine QRS duration
EKG rate calculation
There are 2 methods
1) Start at an R that falls right on a thick/dark line. Then count each additional dark line until the next R in this fashion...300, 150, 100, 75, 60, 50.
2) count the number of QRS complexes in a 6 second strip and multiply that number by 10
characteristics of normal sinus rhythm
- Rate: 60-100 bpm
- Rhythm: regular
- P waves: uniform in appearance, positive (upright) in lead 2, look alike, 1:1 ratio with QRS
- PR interval: 0.12-0.20 seconds and constant from beat to beat
- QRS interval: less than 0.12
assess the P wave
make sure that there is one P wave before each QRS.
- check for multiples
assess PR interval
- needs to be positive P wave
- measured from beginning of P to beginning of Q
- PR intervals should be even and "march out"
- should last 0.12-0.2 seconds (3-5 boxes)
determine QRS duration
- should last 0.04-0.12 seconds (1-3 boxes)
- measure from beginning of Q to end of S
Characteristics of sinus tachycardia
- Rate: 100-150 bpm
- Rhythm: regular
- P waves: upright, look alike, 1:1 ratio to QRS
- PR interval: between 0.12-0.20
- QRS interval: less than 0.12
characteristics of sinus bradycardia
- Rate: below 60 bpm
- Rhythm: regular
- P waves: upright, look alike, 1:1 ratio to QRS
- PR interval: between 0.12-0.20
- QRS interval: less than 0.12
protamine sulfate
What is antidote for heparin?
- lasts 2 hrs
Vitamin K
What is antidote for coumadin?
Anticoagulant that interferes with the activation of fibrin and keeps it from forming a clot.
- will not break up a clot, just prevents it from growing, or prevents it altogether
- is for short term use, rapid acting
- heparin is given during pregnancy instead of coumadin
- can be given IV or subcut
- watch for S&S of bleeding
- birth control decreases effects
- labs: aPTT (activated partial thromboplastin time) before starting, CBC
coumadin (warfarin)
Anticoagulant that inhibits the action of vitamin K.
- Takes 3-4 days for desired effect.
- Can give with heparin until coumadin takes effect.
- must monitor INR (norm: 2-3) and prothrombin
- give orally
- pt needs to wear medic alert or ID with blood thinner dose
- don't take other meds without Dr approval
- report: faintness, dizziness, increased weakness, severe headaches or abdominal pain, reddish or brown urine, red or black stool, bleeding that won't stop, bruises enlarge, unusual bleeding, avoid injury (use electric razor, soft tooth brush, no alcohol), suspected pregnancy (category X)
coumadin dietary needs
- avoid cranberry juice or products
- limit intake of vitamin K such as...
- asparagus, beans, broccoli, brussel sprouts, cabbage, cauliflower, collards, green tea, kale, milk, mustard greens, spinach, swiss chard, turnips, yogurt, egg yolk, fish liver oils, meats such as pig and beef liver, peas, polyunsaturated oils, mayo, potatoes, salad dressing, lettuce
- basically limit intake of green veggies (anything that's good for you! LOL!)
beuger's disease
Disease of arterial system that only occurs in smokers
- most common in men 20-40 years of age
- inflammation with thrombosis of arteries and veins in both the upper and lower extremities
~ Nursing care:
- smoking cessation: most important
- protection of limbs and affected areas
- goal is to improve circulation
- monitor pulses
- avoid injury to extremities
- medication therapy: calcium channel blockers, antibiotics, anticoagulants
- 40% who continue to smoke will require an amputation
- if pt develops gangrene, amputation is only option
Raynaud's disease/phenomenon
Vasospasms of the arterioles and arteries of upper and lower extremities
- Phenomenon: S&S identical to disease but is associated with connective tissue or collagen vascular diease
- causes coldness, pain and pallor of fingertips and toes
- typically brought on by cold, nicotine or exposure to stress
- white (pallor), blue (cyanosis), red (erythema) sequence of color change
- avoid stimuli: cold, nicotine, stress
- layers of clothing, extra winter caution
- avoid injury
- treatments...
~ Treat with calcium channel blockers
- nifedipine (adalat, procardia): blocks calcium channels in vascular smooth muscle = vasodilation
- flushing, dizziness, headache, peripheral edema, gingival hyperplasia, hypotension
~ sildenafil (viagra)
~ Nitroglycerin patch
intermittent claudication
pain that occurs with movement/exercise and is relieved by rest
venous ulcer characteristics
- ulcer occurs on inner/outer ankle/anterior tibia
- irregular border
- superficial: pink wound bed
- uneven edges
- pain may or may not be present
- no claudication or rest pain
- treatment: promote circulation (elevation, prescribed treatments/dressings, compression stockings), monitor wound for infection
arterial ulcer characteristics
- ulcer occurs on tips of toes, toe webs, heals if bedridden
- circular, even edges
- deep, pale to black, dry gangrene
- very painful
- rest pain usually present
- intermittent claudication
- treatment: restore circulation, protect from injury at gangrenous sites, monitor for infection
characteristics of arterial insufficiency
Wounds occur secondary to ischemia from inadequate circulation of oxygenated blood
- ulcers start at toes
- pain is severe
- pedal pulses diminished or absent
- no edema
- skin is cool and cyanotic
- tissue is thin and shiny
- hair loss on skin
- nails turn yellow
- leg elevation increases pain
characteristics of venous insufficiency
Wounds occur secondary to inadequate functioning of the venous system
- ulcers start at ankles
- pain is mild to moderate
- pedal pulses normal
- edema is increased
- skin temp is normal to warm
- skin is flaky and dry
- has brownish/red discoloration
- leg elevation decreases pain
- treat with compression
PTA (percutaneous transluminal angioplasty
Used to gain access to the arteries in the lower extremities in people who are poor surgical risks. Primary purpose is to relieve arterial stenosis in such areas as the superficial femoral and iliac arteries.
- under local anesthesia, a balloon catheter is passed into the vessel to the stenotic area. Once in the optimal position, the balloon is inflated. Inflated balloon presses against vessel walls, dilating lumen of artery and improving blood flow. Heparin is injected through catheter at time of removal to prevent clot formation.
- pressure applied for 10-20 minutes
hiatal hernia
protrusion of the lower esophagus and stomach upward through the diaphragm into the chest.
- hiatus: opening in the diaphragm through which the esophagus passes
S&S of hiatal hernia
- dysphagia
- eructation (belching)
- regurgitation
- heartburn
- many don't have S&S
treatment of hiatal hernia
- antacids
- H2 receptor blockers
- proton pump inhibitors
- surgery - fundoplication: strengthens lower esophageal sphincter
nursing care of hiatal hernia
- look for triggers
- history
- administer medications
- small frequent meals, avoid eating a few hours before bedtime
- avoid caffeine, alcohol, smoking
- no meat for a while, nothing fibrous (texture)
- elevate HOB 6-12 inches
- stress management, avoid straining
- turning, coughing, deep breathing post-op
decompression, feeding
Post-op tubes are used for _____________ and _______.
Can the nurse reposition a tube?
- only reposition the patient
upper GI series
Barium swallow detects abnormalities of esophagus and stomach
- patient preparation: inform that pt will drink a contrast solution. radiographs will be taken of esophagus, stomach, and duodenum via fluoroscope. films will be repeated 6 hrs later to see how much barium has passes through the stomach. patient should be NPO 6-8 hrs before procedure, per agency protocol
- post procedure nursing care: monitor stools for at least 2 days for passage of white stools that show that barium is being eliminated (norm stools return in 3 days). Laxative agents may be ordered to promote elimination. provide food, extra fluids, and rest
Do you do oral care on a person with an oral infection with inflammation?
- soft bristle tooth brush, ordered mouth washes, soft food, read directions carefully
peptic ulcer disease
loss of protective lining of stomach, gastric secretions eating a hole in stomach
- injury to tissues
- may be acute or chronic, duodenal or gastric
- tell to be on bland soft diet, eat things that don't aggravate
- stay away from caffeine, alcohol, nicotine, acidic foods
- avoid aspirin and NSAIDs, use tylenol
- east several small frequent meals to avoid stomach being empty, don't skip meals
complications of peptic ulcer disease
- hemorrhage
- perforation: fluid can leak into peritoneum, treat with fluids, antibiotics, can close spontaneously but if not have to do surgery.
- obstruction
treatment of peptic ulcer disease
Goals: promote healing, prevent complications, prevent any recurrence of complications
- drugs: most commonly anti-ulcer drugs, H-2 receptor blockers, pepsid, proton pump inhibitors
- diet: discourage alcohol, discourage meat broth, don't skip a meal, small frequent meals, don't chew gum, can eat pretty much what they want as long as it doesn't irritate their stomach, milk
- saline lavage
- vasopressin
- surgery
surgeries for peptic ulcer disease
- vagotomy: vagus nerve severed
- pyloroplasty: widen pyloris, involves passage of stomach contents into the duodenum
- antrectomy: removal of the antrum of the stomach
- subtotal gastrectomy: part of distal portion of the stomach including the antrum is removed - billroth 1 (remaining attached to duodenum) and 2 (remaining attached to jejunum)
- total gastrectomy: removal of entire stomach
complications from peptic ulcer surgery
- delayed stomach emptying
- dumping syndrome
- diarrhea
- anemia
- weight loss
rest pain
persistent pain in the foot or digits when the patient is resting, indicating severe degree of arterial insufficiency
- pain is not relieved by resting
ventricular repolarization
What does the T wave represent?
lead 2
Which EKG lead is used/looked at most often?
DASH eating plan
Dietary Approach to Stop Hypertension helps to lower BP in those with hypertension, and it decreases the risk of developing hypertension in those who currently have BP in the healthy range.
- adopt a diet rich in fruits, vegetables, and low-fat dairy products, whole grains, poultry and fish, nuts, potassium, calcium, magnesium, protein, and fiber
- low in: saturated fat, total fat, cholesterol, red meats, sugared beverages, salt and sodium
This drug stimulates bone marrow to produce RBCs
aplastic anemia
Basically a complete failure of the bone marrow.
- lacking everything (RBCs, WBCs, platelets)
- causes: chemotherapy, radiation, exposure to chemicals, infections, autoimmune disorders, medications, gold compounds, instriptomycin
S&S of aplastic anemia
- spontaneous bleeding (key!)
- pallor
- extreme fatigue
- tachycardia
- hypotension
- frequent infections that do not resolve
treatment of aplastic anemia
- identify and treat cause
- transfuse blood products
- put them in reverse isolation
- corticosteroids if autoimmune
- bone marrow transplant
nursing actions of aplastic anemia
- constant VS and assessments
- administer blood transfusion
- reverse isolation
- minimize # of invasive procedures
- hold pressure for 5-10 minutes
- try to avoid IM injections, avoid prolonged turnicate use (use BP cuff)
- don't damage rectal mucosa: stool softeners, encourage fluids, increase fiber
- instruct to use electric razor
- need rest periods, prevent injury
- avoid aspirin and aspirin containing drugs (i.e. peptobismol) and NSAIDs
- educate to minimize risks
hematocrit should be __ times the hemoglobin value
fusiform aneurysm
Aneurysm that kinda looks like a snake that just swallowed an egg. :) Just a bulging/stretching of the vessel
Where is most common location for an aneurysm?
urine output
Most important post-op nursing assessment once patient is stable is hourly _____ ______.
- doesn't matter what the surgery is for, this rings true for all
Histamine H2 antagonist/antiulcer agent that causes healing and prevention of ulcers. Decreased symptoms of gastroesophageal reflux. Decreased secretion of gastric acid
vincent infection
"Trench mouth" - often developed among soldiers in the field in WW 1. Bacterial infection that causes a metallic taste and bleeding ulcers in the mouth, foul breath, and increased salivation. Pt also may have S&S of general infection, such as fever, enlarged lymph nodes, and anorexia.
- treatment: Topical antibiotic agents and mouthwashes. Rest, nutritious diet, good oral hygiene are also helpful
Can/should you give drugs through a TPN line?
PH, x-ray
2 methods of checking NG tube placement... __ and __-____.
diabetes mellitus
What illness will most likely have side effects from hypertension
pulsating mass
Sign of abdominal aneurysm?
complication of angioplasty, arteriography and surgery that needs assessing?
decrease cardiac workload
Why give medication for CHF?
procedure done for CHF?
leave air bubble in tube
Something to remember when giving Levinox or levaquin?
side effect of beta blockers?
60-100 bpm
rate of sinoatrial (SA) node?
40-60 bpm
rate of atrioventricular (AV) node?
20-40 bpm
rate of perkinje fibers?
electronic equipment that provides visual images of varying electrical quantities
- EKG monitor
B natriuretic peptide
What is secreted in response to ventricular stretching?
in morning before getting out of bed
When is best time to apply TED hose?
SCD's mimic ______ pumping of lower extremities to prevent clots.
Should you use heat therapy on a pt with PVD?
- have decreased sensation
5 p's
Post-op assessment
- pain
- pulse
- pallor
- paresthesia
- paralysis
antihypertensive drugs
- ace inhibitors ("pril")
- beta-blockers ("olol")
- calcium channel blockers (Very Nice Drugs)
beta blockers
"OLOL" family. Blocks beta-receptors in the heart causing: decreased HR, decreased force of contraction, decreased rate of AV conduction
- SE: bradycardia, lethargy, GI disturbance, CHF, decreased BP, depression
- examples: propranolol (non-selective), atenolol (cardio-selective)
ace inhibitors
"pril" family. Decreases peripheral vascular resistance without: increasing cardiac output, increasing cardiac rate, increasing cardiac contractility
- side effects: dizziness, orthostatic hypotension, GI distress, cough, headache
- examples: captopril, lisinopril
calcium channel blockers
"Very Nice Drugs" (Verapamil, Nifedipine, Diltiazem, also atorvastatin). Blocks calcium access to cells causing: decreased contractility and conductivity of the heart, decreased demand for oxygen
- side effects: decreased BP, bradycardia, may precipitate AV block, headache, abdominal discomfort (constipation, nausea), peripheral edema
Causes vasodilation.
- routes: transdermal, PO, sublingual, IV
- quick acting: NTG-IV (onset in 2-5 minutes), sublingual tabs, translingual spray
- slow acting (10-30 minutes): nitro-bid (patch), nitro ointments, sustained-release tablets
- side effects: severe hypotension, tachycardia, dizziness, headache, syncope
angiotensin 2 receptor antagonists
"sartan" family. Prevents vasoconstriciton
- side effects: dizziness but not too bad
- nurses: prevent injury
- examples: losartan
central adrenergic blockers
Blocks vasoconstriction, reduces anxiety, vasodilator
- side effects: orthostatic hypotension, dry mouth, water retention
- nurses: safety, VS, hygiene, fluid retention
- examples: clonidine, methyldopa
alpha-adrenergic receptor blockers
"zosin" family. Causes vasodilation.
- side effects: reflex tachycardia (just happens suddenly), palpitations, orthostatic hypotension
- nurses: check VS
- examples: prazosin
Direct vasodilator
- side effect: hair growth