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80 Cards in this Set
- Front
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Endotracheal tube (through nose/mouth then into trachea)
Nursing considerations |
Assess bilat. breath sounds and chest excursions
Mark level of tube touching mouth or nose Secure with tape Enco fluids to ease removal of secretions Move tube on other side of mouth q24h to prevent ulcers |
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Tracheostomy
Nursing considerations |
Cuff inflated to prevent aspiration and facilitate mech. venti.
Maintain cuff press. @ 14-20mmHg Enco fluids Sterile suctioning if necess. Frequent oral hygiene |
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Tracheostomy
Indications for suctioning |
Noisy respirations
Restlessness Increased pulse Increased respirations Mucus in airway |
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Mechanical ventilation
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Prep pt psychologically
Monitor pt's response to venti. Good oral hygiene (>= 2/shift), move endotrach. tube to other side of mouth q24h Assess need for suction q2h Monitor I/O Create alternative methods of communication/assess to call bell Perform and docmt venti and equipmt checks Observe of GI distress (diarrhea, constipation, tarry stools) Docmnt observation/procedure in med rec. |
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Mechanical ventilation
Monitoring response to venti |
VS at least q4h
Listen to breath sounds Assess need for suction Pulse ox monitoring Evaluate ABGs Check for hypoxia (restlessness, cyanosis, anxiety, tachy, increased RR) Check neuro status Check chest for bilat. expansion |
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Rescue breathing
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Infant: 20 breaths/min.
Child: 15 breaths/min. Adult: 12 breaths/min. |
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CPR cycle
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Infant and child: 20 cycles
Adult: 4 cycles |
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Croup syndromes: acute epiglottitis, acute laryngotracheobronchitis
S/Sx |
Bark-like cough
Dyspnea Inspiratory stridor Cyanosis Tripod position |
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Croup syndromes: acute epiglottitis, acute laryngotracheobronchitis
Care at home |
Steamy shower
Sudden exposure to cold air Sleep with humidified air |
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Croup syndromes: acute epiglottitis, acute laryngotracheobronchitis
Requirmnt for hospitalization |
Increasing resp. distress
Hypoxia or depressed sensorium High temp (102F) |
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Croup syndromes: acute epiglottitis, acute laryngotracheobronchitis
Nursing care in hospital |
Maintain airway
Keep tracheostomy set at bedside Croupette or mist tent Monitor HR and RR for early sign of hypoxia O2 with humidification IV fluids Antipyretics (no aspirin) Change linens & clothes often Position in infant seat or prop with pillow |
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Myocardial Infarction
General S/Sx |
Dyspnea, N&V, gastric discomfort, indigestion, apprehension, restless, fear of death.
Cardiac arrest Oliguria (<20ml/hr) low grade fever (100->103in 24h, lasts 3-7 days) Leukocytosis w/in 2 days (disappears in 1 week) Elevated ESR CK-MB: first elevated post MI, peaks 18-24h LDH: peaks 48-72h Troponin: peaks 4-12h |
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Myocardial Infarction
Chest pain related S/Sx |
Severe
Crushing Prolonged Unrelieved by rest or nitroglycerin Radiating to 1-2 arms, jaw, neck and back |
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Myocardial Infarction
Pulmonary edema related S/Sx |
Acute pulmonary edema: sense of suffocation
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Myocardial Infarction
Shock related S/Sx |
sbp < 80mmHg
Gray facial color Lethargy Cold diaphoresis Peripheral cyanosis Tachy or brady Weak pulse |
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Dysrhythmias
S/Sx |
Dizziness, syncope, fainting
Chest pain, palpilations, abnormal heart sounds N&V, dyspnea, abnormal pulse rate (inc, dec, irreg) |
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A-fib
Most common |
Grossly irregular pulse rate
Confusion, syncope and dizziness may occur with severe hypoxia: pump failure may result Causes: chronic lung disease, HF, rheumatic heart disease |
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V-fib
Most severe |
If untreated, death can occur w/in 90s to 5 mins
Potential for cardiac standtill Causes: acute MI, HTN, rheumatic or arteriosclerotic heart disease, hypoxia. |
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Dysrhythmias
Diagnostics |
EKG
ABGs Holter recorder Echocardiogram (structure) Stress test (EKG before, during and after) |
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Holter recorder
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24h continuous EKG tracing
pt keeps diary of activities |
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Defibrillation
Definition |
Use: emergency tx of v-fib
Action: depolarizes all cells so SA node can be re-established as pacemaker |
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Cardioversion
Definition |
Use: elective procedure for dysrhythmias such as a-fib.
Action: same as defibrillation |
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Defibrillation
Nursing considerations |
Start CPR before defibrillation
3 shocks given in a row 200 joules 1st attempt 200-300 joules 2nd attempt 360 joules 3rd attempt Check monitor between shocks for rhythm Don't stop to check pulse after shocks, continue CPR, intubate, start IV. Epinephrine: 1mg IVP q3-5mins Sodium bicarbonate: to treat acidosis |
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Cardioversion
Nursing considerations |
Informed consent
IV Valium for anxiety Digoxin withheld for 48h prior to procedure Synchronizer turned on, check at the R-wave O2 discontinued Assess airway patency 25-360 joules Check monitor between shocks for rhythm After procedure, assess VS: q15mins for 1h, q30mins for 2h, then q4h |
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Head injury
Skull fracture S/Sx |
Battle's sign (ecchymosis over mastoid bone)
Raccoon eyes (bilat. periorbital ecchymosis) |
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Head injury
Concussion S/Sx |
Transient mental confusion or loss of consciousness
HA No residual neurologic deficit Possible loss of memory surrounding event |
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Head injury
Contusion S/Sx |
Varies from slight depression of consciousness to coma
Decorticate posturing (flexion and internal rotation of forearms and hands) Or decerebrate posturing (extension and external rotation of forearms and hands) generalized cerebral edema |
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Head injury
Laceration S/Sx |
Penetrating trauma with bleeding
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Head injury
Hematoma S/Sx |
Epidural: short period of unconsciousness, followed by lucid interval with ipsilateral (same side) pupillary edema, weakness of contralateral extremities
Subdural: decreased level of consciousness, ipsilateral pupillary dilation, contralateral weakness, personality changes. |
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Head injury
Nursing interventions |
Eval. level of consciousness
VS, pupil size, shape, equality and reaction to light. Check nose and ears for CSF leakage Neurological assessment Careful I/O Seizure precautions,prophylactic anticonvulsants Elevate HOB 30 deg. to decrease ICP Regulate hydration according to I/O Prevent infection if open wound Manage increased ICP and cerebral edema, administer glucocorticoids (i.e. Decadron) Hypothermia to decrease metabolic demands Barbiturate therapy to decrease cerebral metabolic rate Minimal procedure (suction, turning, positioning) Prevent complications of immobility |
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Flail chest
S/Sx |
affected side down with inspiration, up during expiration (paradoxycal).
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Sucking chest wound
S/Sx |
Sucking sound on inspiration and expiration
Pain Hyperresonance Decreased resp. excursion Diminished/absent breath sounds on affected side Weak/rapid pulse Anxiety Diaphoresis Altered ABGs |
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Pneumothorax
S/Sx |
Dyspnea
Pleuritic pain Absent or restricted movement on affected side Decreased or absent breath sounds Cyanosis Cough and fever Hypotension |
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Flail chest
Nursing interventions |
Monitor for shock
Humidified O2 Pain management Monitor ABGs Enco turning, deep breathing and coughing |
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Sucking chest wound, pneumothorax
Nursing interventions |
Thoracentesis
Cuest tubes |
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Abdominal injuries
S/Sx |
Penetrating: symptoms of hemorrhage; increase risk of infection (peritonitis)from rupture of bowel.
Blunt: usually injury to solid organ; ab pain, rigidity, distension; N&V; shock. Cullen's sign (ecchymosis around umbilicus), Turner's sign (ecchymosis in either flank)=retroperitoneal bleeding. Bruits = renal artery injury. Balance's sign (resonance over spleen with patient on left side) = rupture of spleen. Resonance over liver indicates pathology. |
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Penetrating abdominal injuries
Nursing interventions |
NPO, NG tube,
Monitor drainage, bowel sounds Indwelling catheter Monitor output carefully Assess for hematuria |
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Blunt abdominal injuries
Nursing interventions |
IV with large-bore needle in upper extremities
Monitor CVP Check hematological values and clotting studies ABGs Serum lytes Liver and kidney function Cardiac monitor Indwelling catheter |
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Shock
S/Sx |
Cool, clammy skin, cyanosis
Restlessness, decreased alertness Tachy, weak or absent pulse Acidosis Oliguria Respirations shallow, rapid Hypotension |
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Shock
Types |
Hypovolemic: hemorrhagic shock, cutaneous shock, diabetic shock, GI obstruction (vomiting and diarrhea), diabetes insipidus, excess use of diuretics, internal sequestration (fractures, hemothorax, ascites).
Cardiogenic (dec CO): MI, dysrhythmiass, pump failure. Distributive (inadeq. vascular tone): neural-induced (anesthesia, barbi inject., insulin shock, spinal cord injury); Sepsis (toxic shock); anaphylaxis. |
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Shock
Nursing interventions |
Maintain adequate oxygenation, increase tissue perfusion, keep warm (maintain body temp)
Maintain sbp > 90mmHg Assess ABGs, treat acidosis Maintain patient airway Indwelling catheter, hourly outputs Monitor CVP (3-11) Bedrest with extremities elevated 20 deg., knees straight, head slightly elevated (no Trendelenburg). IV blood or other fluids Abx Meds to improve myocardial contraction [digitalis, isuprel, quinidine, atropine] Meds to maintain adequate urine output [mannitol, lasix] Meds to restore BP [adrenergics/sympathomimetics: dobutrex, intropin]. |
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Increased intracranial pressure
S/sx |
Altered LOC - often earliest sign
GCS (<7 = coma; >15 = AO) Early signs: confusion, restlessness, pupillary changes. Increased BP, decreased pulse Widening pulse pressure |
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Increased intracranial pressure
Complications |
Cerebral hypoxia
Decreased cerebral perfusion Herniation - pupil constriction |
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Increased intracranial pressure
Nursing interventions |
VS hourly - be alert for widening pulse
Monitor muscle strength, pupillary reactions, verbal response, GCS. Maintain resp. function Elev. head 30-45deg to promote venous drainage from brain. Avoid neck flexion/head rotation - support in cervical collar or neck rolls Reduce environmental stimuli Prevent Vasalva maneuver, teach to exhale while turning or moving in bed. Administer stool softener (colace). Restrict fluids to 1200-1500 per day Osmotic diuretics to reduce fluid volume (mannitol) corticosteroid therapy to reduce cerebral edema (decadron) Antiseizure meds (valium, dilantin, phenobarbital). |
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Seizures
Causes |
Epilepsy
Fever in child Head injury Hypertension CNS infection Brain tumor or metastasis Drug withdrawal Stroke |
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Seizures
Nursing interventions (during) |
Protect from injury
Do not restrain Do not try to insert a bite block, padded tongue blade, or oral airway. Place pt on side with head flexed forward Monitor onset, duration, pattern of seizure |
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Seizures
Nursing interventions (after) |
Position on side to prevent aspiration
Reduce environmental stimuli If needed, provide oxygen and suction equipment Reorient as needed |
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Seizures
Prevention |
Administer anticonvulsant: don't discontinue abruptly, avoid alcohol, good oral hygiene, carry med id.
Avoid triggers: alcohol, stress, caffeine, fever, hyperventilation. Alternative/complementary therapy: ketogenic diet (high in fat, low carb). |
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CVA or stroke
S/Sx |
Confusion/disorientation
Changes in VS and neuro signs Change in level of consciousness, seizures Aphasia (inability to speak, write, comprehend). Hemiplegia (paralysis on one side) Bladder and/or bowel incontinence HA, vomiting Hemianopsia (loss of half of visual field) Dysphagia (difficulty swallowing) |
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CVA or stroke
Risk factors |
Advanced age
HTN, TIAs DM Smoking, obesity, elevated blood lipids Oral contraceptives |
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CVA or stroke
Nursing interventions (immediate) |
Maintain patent airway
Minimize activity Keep HOB elev. 15-30 deg to prevent increased ICP. Maintain proper body alignment Keep side rails up |
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CVA or stroke
Nursing interventions (intermediate and rehabilitative) |
Institute measures that facilitate swallowing
Good body alignment and comfort Monitor elimination patterns (prone to constipation) Provide skin care Perform passive and/or active ROM exercises Orient to person, time and place Address communication needs (facing, speaking cleary and slowly) |
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CVA or stroke
Measures that facilitate swallowing |
Sit upright with head slightly flexed
Use tongue actively Administer liquid slowly Avoid milk-based products Place food on unaffected side of mouth Semisolid foods Swallow while eating Upright position 30-45 mins after eating |
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Spinal cord injury
S/Sx |
Motor and sensory deficit below level of injury
Spinal shock syndrome (flaccid paralysis, complete loss of all sensation, decreased pulses, suppression of somatic and visceral reflexes) Postural hypotension Circulatory pb (edema) Alteration in normal thermoregulation |
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Spinal cord injury
Nursing interventions |
Assessment (triage): ABC, stabilization of VS, head to toe assessmnt.
Immobilize cervical spine Steroid therapy to dec inflammation Hyperbaric oxygen therapy to inc. tissue oxygenation Move by log-rolling, use turning frames Skin care, emotional support Adequate nutrition Reduce aggravating factors that cause spasticity Bladder/bowel training, catheterization Pt and family education to cope with detailed care at home Prevent complication of autonomic hyperreflexia (dysreflexia) |
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Spinal cord injury
Autonomic dysreflexia |
Usually caused by bladder/bowel distention; other causes: pain, tactile stimulation
In pt w/ lesions above T6 after spinal shock has subsided S/Sx: pounding HA, profuse sweating (forehead), nasal congestion, piloerection (goose flesh), brady, HTN, change in pt's color. NI: Place in sitting position, catheterize or irrigate existing catheter to re-establish patency, check rectum for fecal mass, apresoline (for HTN) may be given slowly IV. |
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Hypokalemia
S/Sx |
<3.5 mEq/L
Muscle weakness Paresthesias Dysrhythmias Increased sensitivity to digitalis |
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Hypokalemia
Causes |
Vomiting
Gastic suction Diarrhea Diuretics and steroids Inadequate intake |
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Hypokalemia
Nursing interventions |
Oral potassium supplements
Increase dietary intake: rasins, bananas, apricots, oranges, beans, potatoes, carrots, celery. IV supplements: no more than 40mEq/L in peripheral IV or w/o cardiac monitor |
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Hyperkalemia
S/Sx |
> 5mEq/L
EKG changes, dysrhythmias, cardiac arrest Paralysis Nausea and diarrhea |
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Hyperkalemia
Causes |
Renal failure
Use of potassium supplements Burns Crushing injuries |
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Hyperkalemia
Nursing interventions |
Restrict dietary potassium and potassium containing meds.
Kayexalate: cation exchange resin (causes diarrhea) orally dilute to make more palatable Rectally give with sorbitol to avoid fecal impaction EMERGENCY: calcium gluconate IV, sodium bicarbonate IV Peritoneal or hemodialysis |
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Hyponatremia
S/Sx |
< 135mEq/L
Nausea Muscle cramps, muscular twitching Increased ICP, confusion, convulsions |
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Hyponatremia
Causes |
Vomiting
Diuretics Excess. admin of dextrose and water IVs Prolonged low-sodium diet Excess. water intake |
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Hyponatremia
Nursing interventions |
Sodium PO: beef broth, tomato juice
IV lactated ringer's or 0.9% NaCl Water restriction method (safer method) I/O, daily weight |
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Hypernatremia
S/Sx |
> 145 mEq/L
Disorientation, delusion and hallucinations Thirst, dry swollen tongue, sticky mucous mb Hypotension, tachy, elevated temp Weakness |
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Hypernatremia
Causes |
Hypertonic tube feedings w/o water supplements
Diarrhea Hyperventilation DI Ingestion of OTC drugs Inhaling large amount of salt water Inadequate water ingestion |
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Hypernatremia
Nursing interventions |
IV admin of hypotonic solution (0.3% NaCl or 0.45% NaCl, 5% dextrose in water)
Offer fluids at regular intervals Decrease sodium in diet I/O, daily weight |
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Hypocalcemia
S/Sx |
Ionized serum ca < 4.5 mg/dL or total serum ca < 8.5 mg/dL
Increased excitability of nervous system Tetany detected by Trousseau's sign (BP) and Chvostek's sign (facial nerve). Seizures, confusion, irritability, paresthesia |
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Hypocalcemia
Causes |
Hypoparathyroidism
Pancreatitis Renal failure Steroids and loop diuretics Inadequate intake |
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Hypocalcemia
Nursing interventions |
Oral calcium gluconate or calcium chloride (admin with orange juice to maximize absorption).
Parenteral calcium gluconate may be transitory and more doses may be necessary. Caution with digitalized patients (both situation are cardiac depressants) Avoid infiltration Administer at slow rate to avoid high serum concentration and cardiac depression Seizures precautions Maintain airway as laryngeal stridor can occur Increase diet intake of Ca Regular exercise |
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Hypercalcemia
S/Sx |
Ionized serum Ca > 5.2 mEq/L or total serum calcium > 10.5 mg/dL
Central and peripheral nervous system sedated Muscle weakness, lack of coordination Constipation, ab pain, distension Confusion Depressed or absent tendon reflexes Dysrhythmias |
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Hypercalcemia
Causes |
Malignant neoplastic diseases
Hyperparathyroidism Excessive intake |
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Hypercalcemia
Nursing interventions |
IV admin of 0.45% or 0.9% NaCl
Enco fluids Lasix Calcitonin to decrease Ca level Mobilize patient Restrict diet intake Maintain acidic urine Surgical tx may be indicated for hyperparathyroidism |
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Hypomagnesemia
S/Sx |
< 1.5 mEq/L
Increased neuromuscular irritability, tremors, tetany, seizures Dysrhythmias Depression, confusion Dysphagia |
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Hypomagnesemia
Causes |
Alcoholism
GI suction, diarrhea, intestinal fistulas, abuse of diuretics or laxatives |
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Hypomagnesemia
Nursing interventions |
Increase diet intake: green veg, nuts, bananas, oranges, peanut butter, chocolate.
Parenteral mag sulfate Monitor cardiac rhythm and reflexes to detect depressive effects Monitor resp. status, keep self-inflating breathing bag Calcium for magnesim intoxication from rapid infusions Monitor for digitalis toxicity Maintain seizure precautions Test ability to swallow before PO fluids/food |
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Hypermagnesemia
S/Sx |
> 2.5 mEq/L
CNS depressed Depresses cardiac impulse transmission Hypotension Absent deep tendon reflexes Paralysis Shallow respirations |
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Hypermagnesemia
Causes |
Renal failure
Excessive magnesium Admin of antacids, cathartics |
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Hypermagnesemia
Nursing interventions |
Discontinue oral and IV Mg
Support venti IV calcium for hyperMg and to antagonize cardiac depressant effect Hemodialysis Monitor reflexes Teach about OTC drugs containing Mg Monitor cardiac rhythm |
