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153 Cards in this Set
- Front
- Back
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What is the typical compression rate and depth when performing CPR?
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rate 100 per minute
depth 1and 1/2 to 2 inches |
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How long should a responder check the patients breath sounds?
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no more than 5-10 seconds
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What type of dysrhythmia does an AED advise a shock to be delivered for?
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ventricular fibrillation
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What is Coronary Artery Disease?
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a form of atherosclerosis in which lipids and cholesterol collect in the intimal wall of the artery and can cause plaque to form and block the blood flow
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What does HDL do?
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moves fats/lipids away from the heart to be processed by the liver; considered the "good cholesterol"
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What is a heart attack?
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When an artery is blocked and blood (oxygen) is not getting to part of the heart muscle and it dies
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What is an echocardiogram?
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Graphic image of the heart's movement; also shows EF which is how well the heart is pumping (ejection fraction)
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What does Niacin do?
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increase HDL levels
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What can -statins do for the heart?
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keep cholesterol in the liver
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What is angioplasty? what is stenting?
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both insert a catheter to push plaque out of the way. in stenting a "stent" is left in the artery wall in angioplasty nothing is left.
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What is the AV node vs. the SA node?
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SA- the pacemaker of the heart
AV- connection of atria to ventricles |
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What can an ECG tell us?
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-areas of ischemia
-areas of myocardial damage - left ventricular hypertrophy -electrical conductions through the heart! |
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Can arterial lines be used for IV fluids?
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no
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What is normal CO?
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4-6 L/min
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What is prehypertension?
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120-129/80-89
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Korotkoff sounds are auscultated over the _________ artery
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radial
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CCB--What do they do and why are they good for HTN?
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CCB's prevent movement of calcium into cells with allows more sodium to be excreted which lowers BP. orthostatic hypotension and bradycardia can occur though
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The goal amount of salt is...
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less than 2.3 g per day
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What are the four causes of shock?
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cardiogenic: heart (MI)
distributive: massive vasodilation (septic: infection, anaphylactic: allergy, neuro: spinal...) hypovolemic: loss of 10-15% of blood volume (trauma, diuresis, burns, vomiting etc) mechanical: pump failure blockage in vessels |
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What are the stages of shock?
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Initial: failure begins
Compensatory: HR increases to try to perfuse CO increases to oxygenate Progressive: compensatory begins to fail and body goes down hill Refractory: body begins to fail and irreversible damage is done |
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What are classic signs or symptoms of shock?
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Hypotension
tachycardia hypoxia |
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What are the classes of heart failure?
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Class I: no symptoms with activity
Class II: symptoms with strenuous activity Class III: symptoms with normal activity Class IV: symptoms at rest |
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What is the ejection fraction if a client is experiencing systolic heart failure?
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less than 40%
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Pulmonary problems are a risk factor for what type of heart failure?
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right sided! COPD ...
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What are manifestations of left sided heart failure?
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S3 heart sound
dyspnea, orthopnea altered mental status |
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What are manifestations of right sided heart failure?
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jugular vein distention
dependent edema ascites weight gain and polyuria |
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What level of hBnp causes worry?
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over 100 is possible heart failure...
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Normal LVEF and RVEF:
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L: 55-70
R: 45-60 |
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How would you want to position a client with heart failure?
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in high fowlers
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What are manifestations of pulmonary edema?
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anxiety, inability to sleep, pink frothy sputum (cardinal sign!!), cyanosis, hypoxemia, s3
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What are the six p's of ischemia?
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pallor, pain, pulseless, p-coolness, paralysis, parasthesia
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When a PCTA is indicated, client should...
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be kept in bed for 6-8 hours with affected limb kept straight
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Client education following revascularization surgery should include...
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clip toenails straight across and file the rest, wear good shoes, never cross legs, avoid cold temperatures and tight clothing
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What are risk factors for DVT?
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immobility
pregnancy heart failure oral contraceptives hip surgery |
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What is taken to prevent the formation of other clots while a client with a DVT is in the hospital and what will that be switched to when they are discharged?
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heparin; warfarin coumadin--which takes 3-4 days to take effect so may be on them simultaneously for a couple days
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What is an aneurysm?
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a permanent dilation of an artery
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What two diseases are included in the title COPD?
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chronic bronchitus and emphysema
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What are some bronchodilators used for COPD?
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atrovent, albuterol and theophylline
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What are some anti-inflammatories that are commonly used for clients with COPD?
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mast cell stabilizers-intal
leukotrine-singulair corticosteroids-flovent |
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What are some nursing interventions for clients with COPD?
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encourage pursed lip and diaphragmatic breathing, smoking cessation, include rest times, promote good nutrition
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What are some complications of COPD?
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right sided heart failure due to air trapping, thickening of the aveolar wall along with respiratory infection due to thick mucus
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What is the most common pulmonary perfusion abnormality?
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thrombotic embolism--dislodged clot (systemic) usually DVT
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What is typically ordered if someone has a positive Mantoux skin test?
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a chest x ray also a sputum smear
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If a patient with TB is being transported out of the room what does the nurse need to make sure is done?
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have the client wear a HEPA mask
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When are clients considered TB free?
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After three negative sputum cultures
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What assessment findings are associated with appendicitus?
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early: cramping, periumbilical pain
late: rebound tenderness (mcburney's point) nausea vomiting anorexia |
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What labs do you do to diagnose appendicitus?
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elevated WBC- 11000-18000 is typical (mild to moderate elevation)
ultrasound of abdomen |
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What position would you want a client with an appendicitus in? Also, what interventions are you going to avoid?
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semi fowlers to keep abdominal drainage in lower stomach
do not apply heat because this could encourage perforation |
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What is cholecystitis?
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inflammation of the gall bladder --usually caused by gall stones
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What are some risk factors for cholecystitis?
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female, over 60, high fat diet, rapid weight loss,
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How is cholecystitus typically diagnosed?
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right upper quadrant ultrasound
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What are signs of gall bladder attack
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right upper quadrant pain, pain radiating up to the shoulder, murphy's sign (pain with deep inhalation), jaundice, anorexia, vomiting,
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A client with a t-tube following a cholecystectomy should have the tube clamped...
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1-2 hours before and after eating
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What is expected for a stoma in the post-op period?
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should be moist, pink, and may have a little bit of blood during the post op period
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What is GERD?
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Gastroespophageal reflux disease where enzymes and acids leak into the esophagus and cause damage
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What is the chief symptom of GERD?
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dyspepsia (heart burn) or regurgitation (acid reflux) in relation to eating or activities
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What are some diet precautions to take for a client who may have GERD?
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a diet that avoids foods that relax the LES. Those foods would include: caffeine, chocolate, citrus fruits, tomatoes, mint, and alcohol
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What is a procedure that can be done if drugs taken for GERD are ineffective?
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wrap the Fundus around the bottom of the esophagus or stimulate sphincter to contract.
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What are some medications that can be taken for GERD?
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antacids (at least an hour away from other medications)
PPIs (omneprozole) work better than histamine 2... histamine 2 agonists (cimetadine) |
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What are some educational topics to bring up with a client who has GERD?
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-avoid offensive food
-sit up after eating for at least 30 min -lose weight (if applicable) -eat smaller meals -use of pillows is not advised because it pushes stomach contents up |
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What is typically the first sign (and sometimes only) of liver failure?
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jaundice
excessive breakdown of bilirubin in infants causes RBCs to go down sclera of eyes even turns yellow urine can be discolored as well |
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What is the most common cause of malnutrition and damage to the liver?
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alcohol
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What is cholestasis?
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When blood flow to the liver is stopped
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What is hepatomegaly?
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enlarged liver; clients "feel full"
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What is portal hypertension? What are the causes and what can it lead to?
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Portal hypertension is when flow of blood through the liver is stopped either by high blood pressure in the portal vein or no flow through the liver. This can cause collateral veins to develop which means blood is no longer filtered by the liver. Toxins can then build up and varicose veins in esophagus and stomach lining can bleed
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What are S&S of liver failure?
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jaundice, ascites, bruising, fatigue, nausea, confusion
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The higher up an ostomy is placed in the sm. intestine...
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the more liquid and acidic the output will be
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When should an ostomy bag be emptied?
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when it is 1/4-1/2 full
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An iliostomy will have what type of output and complications?
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constant liquid output. fluid and electrolyte imbalance is a concern
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What type of output comes from a sigmoid colostomy? transverse colostomy?urostomy?
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sigmoid:semi formed stool
transverse: mushy or formed urostomy: drains urine |
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What is inflammation of the intestines that results in ulcerations?
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Crohn's disease
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What are S&S of Crohn's disease?
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chronic diarrhea, abdominal pain, nausea cramping and flatulence
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What is a barium enema?
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rectal instillation of opaque solution to allow visualization of the colon
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What does hemodyalisis do?
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shunts clients blood from the body, through a dializer, and back into the body. vascular access is required.
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How often will the typical patient go through hemodyalisis?
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three times a week for 3-5 hrs.
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If there is no thrill or bruit over the hemodialysis site, the nurse should...
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contact the provider..this could mean impaired clotting etc.
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What color is the outflow of dialisate for peritoneal dialysis supposed to be?
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clear light yellow
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What needs to be done to the dialysate prior to infusion?
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warm without using microwave--uneven heating
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What types of foods should a client who participates in peritoneal dialysis be aware to avoid?
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high fiber and stool softeners
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What are risks to contracting Guillan Barre?
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recent immunization, GI disease, and recent surgery
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What does Guillan Barre present like?
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ascending flaccid paralysis, distal to proximal, can lose muscle function in 24-72 hours--RAPID!
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What is the earliest indication of neurologic deterioration?
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decreased LOC
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What are some medications that might be indicated for a client with increased intracranial pressure?
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mannitol
dilantin-seizure precautions antibiotics for infectious agents that might be causing more pressure |
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What are three priority signs that intracranial pressure is rising?
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pupil changes, LOC changes, and nausea/vomiting
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Nuchal Rigidity and a red macular ash are both unique signs of what?
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meningitus- swelling of the meninges into the subarachnoid space
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What is Brudzinski's sign?
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flexing of neck causes flexion of hips and knees (sign of meningitus)
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What is Kernig's sign?
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flexing the hip 90 degrees and then extending the leg causes pain
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After a CSF specimen is collected what should the nurse be sure the client does?
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lay for 4-8 hours so there is no leakage of fluid (layflat) or H/A
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When looking at CSF--what does cloudy and clear indicate?
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cloudy-bacterial
clear-viral other indications in CSF are elevated WBC and elevated protein |
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What is Myasthenia Gravis?
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striated muscles are easily fatigueable due to a lack of acetylcholine (autoimmune disorder)
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How do you diagnose Myasthenia Gravis and what indicates a positive test?
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with the TENSILON test. if the muscles work much better after administration it is a positive test.
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How does Myasthenia Gravis present itself?
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worsens as the day progresses
can't maintain position without support ineffective cough, dysphagia, ptsosis |
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What is MS?
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autoimmune disorder characterized by the development of white plaque on the neurons in the CNS
can be acute or chronic or relapsing |
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What is the common suction pressure on a chest tube machine?
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20
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If there seems to be a clot in the tubing what should the nurse NOT do?
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strip the tubing!
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When the doctor is preparing to remove the chest tube what should the nurse advise the client do?
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the nurse should advise the client to perform the valsalva maneuver
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What is thoracentesis?
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perferation of the chest wall and pleural space
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How much fluid can be removed when performing a thoracentesis?
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1L/ time to prevent cardio collapse
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Post procedure following a thoracentesis how should the nurse position the client?
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on the unaffected side for at least one hour
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When is an uncuffed fenestrated tracheostomy tube indicated?
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for when a client is weaning off of mechanical ventilation
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What is an important hint for someone caring for patients that need mechanical ventilation?
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NEVER TURN ALARMS OFF! oral care q2hrs
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What should a trach be cleaned with?
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Hydrogen peroxide followed by normal saline
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If a client was experiencing an asthma attack and needed rapid relief, what medication would you anticipate administering?
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albuterol
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What medications decrease airway inflammation?
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flovent, singulair, intal
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What is pneumonia?
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an inflmmatory process of the lungs that causes the production of access fluid
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What medications would you anticipate administering for a patient with pneumonia?
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penicillin or cephalosporins
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What is the most common manifestation of pneumonia in older adults?
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confusion as a result of hypoxia
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What is considered a postive Mantoux skin test?
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10mm
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What are dysphagia, hoarseness, sore throat and unilatural ear pain all S&S of?
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Laryngeal Cancer
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What is an important contraindication to fibrinolytic therapy (altepase, streptokinase)?
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DVT/pulm embolism
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A tracheal deviation could be a sign of...
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tension pneumothorax
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What is the purpose of a CABG?
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to restore vascularization to the myocardium
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What is the plan of movement for a CABG patient post-op?
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dangle feet in 1st 2 hrs.
walk 25-100 ft. in 1st 24 hours sit in 24-48 |
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Volume greater than 150ml/hr post CABG could mean...
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hemmorrhage
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What is the universal donor? recipient?
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donor: O
recipient: AB |
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What are some important considerations for the administration of iron?
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fiber/fluids to prevent constipation
vit c helps absorption turns stool black |
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What is Reed Sternburg associated with?
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hodgkins lymphoma
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How many g of Sodium should you ingest/day?
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2.3
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For what disease would you advise a client to walk until it hurts and then walk a little bit further? Also, elevate legs but not above level of heart...
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peripheral artery disease
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Cigs cause
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vasoconstriction
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What is compartment syndrome?
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increase pressure in confined body space (irreversible tissue damage ensues in 4-6 hrs.)
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For what disease would you see pallor on elevation of limbs and rubor when limbs are dependent?
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PAD
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What is Homan's sign?
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pain on dorsiflexion of calf--NOT a good indicator of DVT because it only happens in 10% of cases
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If a nures consistantly measure/recorded the circumference of a R and L thigh what would you guess she was monitoring?
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the progression of a DVT
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What should LVEF and RVEF be?
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LVEF:55-70%
RVEF:45-60% |
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Peripheral edema, JVD, Ascites, weight gain and fatigue are all signs of
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Right sided heart failure
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Dyspnea, orthopnea, crackles, S3 heart sounds, frothy sputum and cough are all signs of
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Left sided heart failure
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What side heart failure?
-Weight gain -peripheral edema |
Right sided
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What side heart failure?
-cough -crackles -dyspnea |
Left sided
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Increased HR and hypotension are signs of...
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SHOCK
legs up...shunt blood to vital organs! |
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Normal HCO3
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22-26
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Suction pressure should typically be at...
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80-120
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If a client undergoes a Bronchoscopy should he/she notify the primary care provider if a fever is developed?
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depends on when the fever is developed
mild fever is expected in the first 24 hours... |
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What is a normal PaO2
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80-100
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What cardiac enzyme first is detectable?
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Myoglobin (but it only lasts 24 hours)
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When can you first detect CK or Troponin I or T?
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CK: 4-6hrs
I/T: 3 hrs |
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TPN administration is typically through
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a central line
this is to allow for rapid dilution |
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What is PPN?
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peripheral parenteral nutrition which is less hypertonic and used for short term
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How often should you hang a new solution and tubing?
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q 24 hrs
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Standard IV therapy is equivalent to what calorie amount?
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<700
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When should a nurse seriously consider administering TPN?
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5 day rule (hasn't eaten in 5 and isn't expected to eat in 5) or 7-10 d.
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If you were administering TPN and a sudden air embolism (dyspnea, chest pain, hypoxia) occured, what would your first set of actions be?
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trendelenburg, or left side and administer oxygen
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What are some functions of dialysis?
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rid body of excess fluid and electrolytes
eliminate waste products restore homeostasis |
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For Peritoneal Dialysis what color should the outflow be?
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light yellow and clear
infection would be indicated by bloody, frothy, cloudy |
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Does the size of a donor kidney matter?
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no
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What is urge incontinence?
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the inability to stop urine flow long enough to get to the toilet
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What is stress incontinence?
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loss of small amounts of urine with sneezing laughing or lifting
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Urinary incontinence is a contributing factor to... (2) ?
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1. altered skin integrity
2. falls |
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What is postvoid residual urine?
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a way to look at urinary retention (if it's greater than 100mL post voiding)
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Frequency of catheterization when performed intermittanty is adjusted to maintain an output of...
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300 mL or less
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What is pyelonephritis?
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an infection and inflammation of the renal pelvis, calyces, and medulla (usually begins in the lower urinary tract with organisms ascending into the renal pelvis)
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Urinalysis and urine culture and sensitivity for pyelonephritis would most likely show what symptoms?
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dark, cloudy, foul odor, WBCs, RBCs, positive leukocyte esterase, nitrate BUN elevated
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What is a nephrectomy?
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removal of the kidney
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