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84 Cards in this Set
- Front
- Back
History of Present Illness
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-Onset, duration, allergies, toxic exposure, lifestyle and dietary habits, smoking habits
-Symptoms patient is reporting: dyspnea, tachypnea, orthopnea, paroxysmalnoctural dyspnea (PND) -Cough: productive, non-productive, sputum (1L with cold) production, hemoptysis (assess mouth and gums first) |
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Cardiopulmonary Symptoms
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-Chest discomfort:
*angina *causes: fluid in the lungs, pneumona, pleurisy, esophogeal, astma -Edema, wght gain (2.2lbs = 1L) -Dizziness, palpitations -Fatigue, pallor -Leg claudication: leg cramps w/activity and goes away when activity is stopped (arterial insufficiency) |
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Cardiopulmonary Assessment
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-Overall appearance of pt
*coloring *vital signs *circumoral pallor (around mouth and nose) -Auscultation of the heart and lungs -*wheezing (constriction of the bronchi), crackles (fluid and air hitting one another), pleural rubs (sand paper) -Respiratory: rate, depth, rhythm, equal expansion -Observe for use of accessory muscles to breath Observe for abnormalities: *clubbing, barrel chest, sternal retractions, nasal flaring, changes in mental status *intercostal retracting and diaphram breathing usually seen in kids -Evaluate the extremeties *Heart murmurs |
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Diagnostic Tests
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-O2 saturation
-ABGs: arterial blood gasses -CBC: complete blood count -PFTs: pulmonary function tests -Chest x-ray -Echocardiogram -Heart catheterization -EKG |
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Upper Airway
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-Anything above the larynx
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Respiratory Conditions
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-Common cold
-Sinusitis (acute or chronic) *Pain over affected sinuses and headache *maxillary (eyes and jaw) *Frontal (forehead) *Ethmoid (whole face) -Tx: antibiotics, analgesics, decongestants, surgery -Causes: deviated septum *hypertrophy of turbinate bones (scrape away at the turbinates) |
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Laryngitis
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-Can be viral (cold) or bacterial or mechanincal (singers, speakers, intubation)
-*Chronic problem due to smoking, vocal abuse, endotracheal intubation, alcohol -Can become severe enough to close off airway |
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Croup
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-Only in young children
-Dry cough -AKA spasmotic laryngitis -partial airway obstruction -Comes on suddenly following a cold (usually in middle of night) -Barking seal cough -Temp seldom elevated -Tx: moist heat to relieve obstruction (shower) (airway for babies dime size, nickle for children) |
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Tracheobronchitits
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-Inflammation of larynx, trachea, bronchi
-Very serious, complications of a cold -Only in children < 4 -Thick sputum, high temp, couphing -Tx: maintain airways, antibiotics, humidified O2 |
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Other Upper Respiratory Problems
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-Sore throat > 3 days: should have a throat culture
*can lead to endocarditis if not treated -Pharyngitis: usually viral, can be bacterial *group B-hemolytic strept: very common -Tonsillitis: if not treated can lead to Peritonsillar abscess |
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Pneumonia
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-AKA PNA
-Causative agents: *bacterial: 1. strept, 2. staph A, 3. pseudomonis (over watering plants) *viral: CMV *Fungal (aspergillus) *Aspiration pneumonia: any dysphagic pt *mycoplasmic, legionnaire's -Pneumnocystitis (common w/HIV) -Symptoms: SOB, extreme fatigue, crackles, wheezing, pleural effusions, increased WBCs -Mortality increases > 70yoa -x-ray: black is air, white is fluid |
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Pneumonia Risk Factors
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-Elderly (more chronic illness... anything respiratory, CHF, diabetes, renal failure)
-Chronic medical condition -Nutritional defects -Alcoholism/drug abusers -Neuro problems: impaired gag reflex, dementia |
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Nursing Management of Pneumonia
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-Assess oxygenation status
-Obtain sputum specimen before antibiotics (in the am before breakfast) -Avoid cough suppressants -Respiratory therapy for mucolytic agents -Ample rest periods (space activities) -Patient teaching *flu vaccine for those at risk *pneumovax shot |
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Pneumonia Classification
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-community acquired (CAP)
-Hospital acquired -pneumonia in the immunocompromised host -aspiration pneumonia |
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Dx of Pneumonia
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-History (especially of recent resp. tract infection)
-chest x-ray -blood culture (bacteremia occurs frequently) -sputum examination |
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Epistaxis
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-Nose bleed
-Causes: *trauma, chronic infection, violent sneezing, blowing, picking *blood thinners *low platelet count *hypertension -Tx: apply pressure on nose, ice packs, FORWARD tilt of head, nasal packing *drugs: neosanerphrine, silver nitrate *surgery: caterize |
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Deviated Septum
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-Submucosal resection
-Nasal septoplasty *both usually done as an out patient procedure |
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Nasal Fractures
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ORIF (open reduction internal fixation) ASAP becuase of swelling makes landmarks hard to see
-Nursing considerations: *watch for covert and overt bleeding *maintain airway *appetite problems |
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Vocal Cord Polyps and Nodules
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-Interference with voice production
-Usually develops because of voice abuse, smoking, allergies -Tx: *surgical stripping (bronchoscopy) *watch for bleeding and airway |
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*Lung Abscesses*
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-Encapsulated infections
-Causes: *TB, pulmonary embolus, CA, COPD, open trauma -Tx: bronchoscopy to drain it -Hard to treat d/t being encapsulated -High doses of antibacterial (antibiotics) |
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Pleural Effusions
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-Accumulation of fluid in the pleural space
-Causes: fluid overload, chest CA, CABG, TB, pneumonia, thoracotmy: open up of the chest (open heart surgery) -Common Terms: *hemothorax: bloody fluid *Chylothorax: Chyle is usually a milky fluid comprised of lymph drainage *Empyema: accumulation of pus in the pleural space. |
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Pleural Effusions Symptoms
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-SOB
-Absent or decreased breath sounds -Assymetrical chest expansion -Dullness with percussion -3rd spacing fluid (can't be removed easily) |
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Pleural Effusions Treatment
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-Thoracentis (complication includes pneumothorax)
*Positioning pt *done at the bedside *stat x-ray after *reassure pt that they should feel much better after procedure |
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Pleurisy
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-Inflammation of the pleura
-Symptoms: pleural friction rub, pain on inspiration, gaurded breathing -Often follows resp. infection or occurs where chest tubes were inserted -Tx: NSAIDs or steroids |
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Chronic Obstructive Pulmonary Disease (COPD)
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-Broad term used to describe conditions with a chronic obstruction to EXPIRATORY airflow
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COPD
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-Emphysema
-Chronic Bronchitis -Asthma -Bronchiectasis *saO2 often clouds status of pt (need ABGs for accurate assessment) -Air remains trapped in the lungs -CO2 is usually the driving mechanism for breathing |
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Emphysema
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-D/t cigarette smoking
*which causes connective tissue damage to the alveoli *the alveoli overinflate and lose their elasticity then aren't able to deflate enough to expel the air -Other causes: chronic infections, asthma, dust, age *occurs more in men and those with reduced income and lack of education |
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Treatment for Emphysema
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-Purpose is to improve the quality of life
-NO CURE -Bronchodilators -Steroids (anti-inflammatory) -Antibiotic prophylaxis |
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O2 therapy for Empysema
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-Because of the high levels of CO2 in the blood over a long period of time, the primary stimulus to breath is from a reduction in O2 rather than an increase in CO2 in normal patients
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Effects of Smoking
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-Increases blood pressure and heart rate (vasoconstriction of vessels)
-Carbon monoxide damages arterial wall encouraging fatty build up of cholesterol -It increases the adhesiveness of platelets -Increases the thickness of blood -Damage of alveoli (butterfly to brocolli) -Causes CA, heart disease, and lung disease |
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How To Quit
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-Cold turkey (with help): best results
*Bupropion (zyban) and nicotine patch: taken 7-12 weeks is highly effective -Nicotine fading: not effective just inhale more -Nicoting patch or gum: s/e similar to smoking |
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Asthma
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-AKA airway reactive disease
-Airways react to allergens, exposure to irritants, exercise *cause increase mucus production which causes a cough *Bronchi narrow, dyspnea occurs *Wheezing can occur with bronchospasm -Not all asthmatics wheeze -Secretions form with inflammation |
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Asthma Etiology
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-Allergies
-Infections: asthma exacerbates an infection in the lungs -Drugs -Exercise -Family hx -Stress -Temperature changes: bronchospasms |
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Treatment of Asthma
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-Inhaler for pt to use in respiratory distress
-Rescue inhaler: beta agonist *albuterol (prevention), alupent, maxair, tornalate, brethaire, -Epinephrine: SQ (potent pulmonary dilator) -Steroid use: not a rescue medication *prednisone, medrol, prelone, pediapred orally, IVP (solumedrol), inhaled, syrup *with inhaled steroids: rinse mouth after use to avoid infection from candida albicans *types: vanceril, azmacort, flovent -NSAIDs: intal, tilade -Leukotriene Inhibitors: accolate, singulair |
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Other COPD
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-Chronic Bronchitis
*inflammation of the bronchi *excessive mucus at least 3 months out of the year -Bronchiectasis: *pockets in main stem bronchus where mucus and bacteria love to flourish |
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Sleep Apnea
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-Characterized by excessive daytime sleepiness, increased incidence with obesity, snoring
-Usually upper airway obstruction of soft palate and tongue -C-PAP machine to control: continuous positive airway pressure -Sleep study -Monitor EEG, O2, as it can be related to pulmonary heart issues, Ears, nose, throat problems |
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Restrictive Lung Disease
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-AKA stiff lung
-Irreversible -No cure -Tx with O2 only -permanent damage to the lung tissue -Examples: coal miner's lung (silicosis), asbestosis |
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Arterioslcerosis
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-AKA: arterialsclerotic heart disease (ASHD), Coronary artery disease (CAD), Peripheral vascular disease (PVD), renal artery disease, aortic aneurysm...
-Hardening of the arteries -Minor risk factors: *obesity, exercise, diabetes -Major: cholesterol, smoking, high blood pressure -Male higher than women until menopause -Family hx |
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Cholesterol Management
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-First obtain fasting lipid panel
*total cholesterol *triglycerides *HDL (high density lipoprotein) *LDL (low density lipoprotein) -Homocysteine levels -C-reactive protein levels < 1.0mg/L *any inflammation in the body will cause this |
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Cholesterol Management
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-Nutritional Education: mono/polyunsaturated fats
*avoid red meat and dairy -Medical Therapy: *mevacor, pravachol, zocor, lipitor, lescol, crestor, zeita: statins inhibit cholesterol production (liver panel fx should be done) *Lopid: decreases triglycerides *Folic Acid: decreases Homocysteine *Anti-oxidants: nyacin (causes more liver damage than statins), vitamin B |
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Diagnostic Tests for ASHD
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-Angiogram: infection of Dye into an artery (femoral)
-Treadmill -Thallium treadmill -Doppler Study: carotid artery disease -Echocardiogram: structure of the heart (resting and with exercise) -12 lead EKG -TEE: Transesophogeal echocardiogram |
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Angiogram Complications
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-Allergic reaction to the dye
-Hematoma -Hemorrhage -Occlusion (most common): check distal pusles |
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Peripheral Vascular Disease
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-Any form of artery disease not pertaining to the heart
-Arterial vascular insufficiency -A form of ASHD which includes all vascular structures: *ateries, veins, arterioles, venules -PVD Assessment: *pulses *color *temperature *edema *skin changes |
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Chronic Arterial Insufficiency
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-Pulses: decreased or absent
-Color: pale, dusky, red on depression -Temp: cool -Edema: absent/mild -Skin: *thin/shiny *atrophic/loss of hair over foot *toe nails thickened and rigid *Ulceration: if present involves toes or points of trauma *gangrene may develop |
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Chronic Venous Insufficiency
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-Pulses: normal (may be difficult to feel d/t edema)
-Color: normal or cyanotic -Temp: normal -Edema: present -Skin: brown pigmentation around ankles, stasis dermatitis -Ulceration: does not develop -Gangrene: does not develop |
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Assessing Edema
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-Go up the bone to determine edema score
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PVD Symptoms and Nursing Dx
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-Intermittent claudication pain
-Burning pain -leg cramps -deformed nails, hair changes -bruits -necrosis -decreased cap. refill -cyanosis -RN Dx: altered tissue profusion, activity intolerance, sleep pattern disturbance, pain |
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PVD Medical Management
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-Drug therapy
-Angoiplasty -Surgical manangement *aorto-illiac bypass *aorto-bifemoral bypass *endarterectomy: cleaning of the carotids (c/p STROKE) *Amputation -Neurogenic Pain: *tricyclic antidepressants (Elavil: amitriptyline, Pamelor: nortriptyline) *antisiezure: neurontin, tegretol |
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Acute Arterial Occlusion
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-Usually thrombosis or embolus (always an emergency)
-Symptoms: acute ischemia, pain, cool to touch, discolored -Tx: anticoagulation and/or surgical embolectomy |
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Aneursyms
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-Out-pouching of vessels
*abdominal aorta most common *ASHD main cause *2.5cm normal *5cm palpable *blow out at 6cm |
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Raynaud's Disease
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-Spasms of the arteries
-Leads to ischemia -Usually fingers and toes -Medical therapy -Pt education -Avoid cold climates and smoking -Tx: calcium channel blockers *diltiazem, procardia XL |
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Thrombophlepbitis
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-Superficial vs deep vein thrombosis (DVT) (leads to pulmonary embolism)
-Venous stasis (bedrest, hypovolemia, tissue injury, a-fib) -Hypercoagulability of blood *smoking, birth control, hormone replacement Risk factors: post-op, irregular heart beat, infection in general -Thrombus: stay put -Embolus: travels -Tx: *thrombus: keep clot where it is |
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DVT Symptoms
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-Unilateral: redness, pain, edema, +Homan's sign, inflammation
-Diagnostic Tests: veinogram, ultrasounds -Tx: *prevention is ideal: early ambulation, pneumatic stockings, prophylactic anticoagulation *antigoagulatoin for a clot |
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Normal Clotting Cycle
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Platelets-thromboplastin-prothrombin-fibrinogen-fibrin-formed elements (wbcs, rbcs) = clot
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Anticoagulation Therapy
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-Coumadin: works by blocking the formation of prothrombin
-Heparin & Lovenox: work by preventing the conversion of fibrinogen to fibrin -None of these drugs dissolve the clot, just keeps them from getting bigger |
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Heparin
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-Advantages: *consistant results across all patients
*fast acting *reverses in seconds -Disadvantages: *kill pt if given to much IV or SC *Illness called Heparin Induced Thrombocytopenia -Test Used: PTT (partial thromboplastin time): measured in seconds (1.5-2.5 secs longer than normal) -Reversal drug: protamine sulfate -Complications: hematoma, hemorrhage, HIT -Administer: *subcut. same as lovenox *IV: needs to be on pump, to RNs to be present during changes in programming (critical drip) |
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Coumadin
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-Advantages: oral, inexpensive
-Disadvantages: inconsistant across pts, 2-5 days to reach therapeutic blood levels, pts are often on 2 blood thinners -Test Used: PT (protime): measured in seconds (1.3-2.0 times the normal, INR of 1.5-2.5) -Reversal drug: vitamin K -Complications: hemorrhage pregnancy deformities, long metabolic time (in system long after it has been d/c) -Administer: oral: ask why is pt getting this, and what is their PT, given at 1800 so the MD can be notified of the daily INR |
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Lovenox
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-Advantages: consistant results
-Disadvantages: Subcut. admin -Lab work: don't need daily labs, Platelet count -How to admin: -Complications: hemorrhage |
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Thrombolytic Therapy
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-Actually dissolves the clot
-Streptokinase, Urokinase (aslo used to declot a central line), Activase, TPA, Repro *all IV critical drip infusions *heparin is given after thrombolytics -Given for: *acute stroke *acute coronary syndrome(Acute myocardial ischemia) *embolism -TPA most common: tissue plasmainogen activator |
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DVT: surgical management
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-Thrombectomy
-Home care education on coumadin: *s/s of bleeding (black tary stool) *outpatient visits *Don't change dose or skip, or double-up on a dose *Call MD if forgot dose *Informing other MDs on coumadin *don't get pregnant *Dietary considerations (don't change diet) *talk with MD before taking any supplements |
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Pulmonary Emboli
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-Obstruction of blood flow to a pulmonary artery causing necrosis (life-threatening event)
-Most commonly from a DVT -S/S: *dyspnea *hemoptysis *pleural friction rub *chest pain *tachycardia -Risk factors: *DVT, veinastatsis, hypercoagulability -Tx: anticoagulation therapy (coumadin for rest of lifes) -Surgical Intervention: *vena cava umbrella (interruption) |
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Hypertension
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-1 in 4 develop HTN
-#1 reason people go to MDs and for prescription drugs -Mostly without symptoms -95% unknown cause -5%: pheochromocytoma 240/140, tumor on the adrenal gland, 24h urine test for catecholamine) or renal artery stenosis (BP can't be controlled) -Pregnancy induced, white coat hypertension -Women with toxemia increased risk for HTN later in life -Systolic BP influenced by emotions |
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Factors Which Influence HTN
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-Family hx
-Ethnicity: increased in blacks (usually requires multiple drug therapy) -Age -Gender: men get it at slightly earlier age -Personality type A -wght -Exercise -Alcohol (especially with excessive drinking) -Caffeine |
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S/S of HTN
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-retinal changes
-arteriol narrowing -asymptomatic |
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Management of HTN
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-Modify risk factors
-dietary considerations: *modify salt intake (2g normal) *don't eat: milk, cheese, breads, canned soups |
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Medical Management of HTN
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-Diuretics
-Beta Blockers: end in olol -Alpha 1 blockers: mine -Calcium channel blockers: pine -ACE inhibitors: pril -Angiotension II receptor blockers: artan -Vasodilators: -Adrenergic inhibitors: |
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Heart Failure
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-The inability of the heart to pump enough blood to meet tissue needs
-Wide range of severity: mild to cardiogenic shock (80% mortality) -Causes: CAD, myocardial infarction, cardiomyopathy, valvular or congenital disease, HTN |
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Pathophysiology of CHF
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-Problem with muscle contractility
-Muscle tone (illness where muscle becomes stiff and unfunctioning) -Fluid volume overload |
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Left-Sided Heart Failure
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-Most common
-D/t impaired ejection of blood from left ventricle -Blood backs up into lungs *can back up into right side of heart -S/S: *pulmonary congestion (Crackles, listen at bases) *repiratory distress *PND (paroxysimal nocturnal dyspnea) *wght gain *increased heart rate *right sided heart failure symptoms -Pt dx w/CHF needs to be weighed daily |
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Right-Sided Heart Failure
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-Due to impaired ejection of blood from the right ventricle
-Often due to left-sided HF or pulmonary disease -Backs up into systemic circulation -S/S: *peripheral edema *distended neck veins (JVD) *Liver enlargement *wght gain *increased heart failure *lethargy, fatigue, activity intolerance *pedal edema while standing *generalized edema while lying down |
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Cor pulmonale
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-an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system.
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Goal of Medical Management
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-Blood test to dx: BNP (type B natiuretic Peptide)
-To restore balance between oxygen supply and demand by: *improving heart contractility *reducing heart rate *improving activity tolerance *reducing afterload (blood pressure) -Done using: *antihypertensive drugs: so the heart can pump the blood out against less pressure |
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Treatment of CHF
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-Optimize oxygen of pt
-Vasodilation drugs: *nitrate therapy -Inotropic Drugs: to improve the contractility of the heart *Digoxin, dopamine, dobutamine) -Drugs to reduce HR: *Beta blockers (Cardioselective) -Drugs to reduce B/P: -Drugs to reduce blood volume *diuretics |
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Non-Pharmological Approach to CHF
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-Reduce:
*oral intake of fluids *IV fluids *sodium and alcohol intake -Treat underlying problem -Avoid: *altitude *overexertion *prolonged traveling *extreme weather |
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Nursing Interventions for CHF
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-Assess Resp. status often
-Keep HOB elevated -Avoid stenuous activity -Daily wght -I&O -Assess for postural hypotension -Urinal close by (diuretics) -Discharge teaching: palpations of heart, extra ankle edema, sleeping with more pillows |
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Digitalis Toxicity
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-Anorexia (usually first sign)
-N/V -Blurred vision (halo/rings around lights) -EKG changes, arrhythmias -Abdominal pain -Fatigue/disorientation -Normal dig serum level: *0.8-2.0ng/ml -Tx: d/c or reduce dose |
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Cardiomyopathy
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-Any abnormality of the heart muscle:
*dilated (congestive) *hypertropic *Restrictive |
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Dilated Cardiomyopathy
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-idiopathic
-postpardum -drugs from chemotherapy -virus -Medical management same as CHF |
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Hypertropic Cardiomyopathy
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-heart is contracting too much
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Restrictive Cardiomyopathy
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-Makes the heart stiff
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Rheumatic Heart Disease
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-pt's who have untreated strept
-Mitral stenosis main problem |
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Anemias and other abnormalities
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-hypoproliferative
*reduced # of RBCs d/t bone marrow malfunction *iron deficiency: RBCs have decreased level of HGB, caused by bleeding, elderly fixed income, pregnancy, side effects of meds: black stool, constipation, must be z-tracked in IM, allergy rx -Excessive destruction or loss: *hemolytic anemia: antibodies developed against RBCs, jaundice, tx corticosteroids *sickle cell anemia: |
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Common disorders of WBCs
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infectious mononucleosis
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Normal Lab Values
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-Hematoglobin: m(13.5-17.5 g/dl)
f(11.5-15.5 g/dl) -Hematocrit: m(44-52%) f(39-47%) -Albumin: (3.5-5.5 g/dl) -Electrolytes: *Sodium: 136-145 *Potassium: 3.5-5.2 *Chloride: 96-106 -Glucose: 70-110 mg/dl -Total Cholesterol: <200 mg/dl *HDL: 35-85 mg/dl *LDL: <130 mg/dl -BUN: 8-28 mg/dl -Calcium: 8.5-10.5 mg.dl -Creatine: 0.6-1.2 mg/dl -Uric Acid: 2.5-8 mg/dl -Magnesium: 1.8-3.0 mg/dl -Phosphorus: 2.3-4.7 mg/dl |