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80 Cards in this Set

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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
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
Tracheostomy
Indications for suctioning
Noisy respirations
Restlessness
Increased pulse
Increased respirations
Mucus in airway
Mechanical ventilation
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.
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
Rescue breathing
Infant: 20 breaths/min.
Child: 15 breaths/min.
Adult: 12 breaths/min.
CPR cycle
Infant and child: 20 cycles
Adult: 4 cycles
Croup syndromes: acute epiglottitis, acute laryngotracheobronchitis

S/Sx
Bark-like cough
Dyspnea
Inspiratory stridor
Cyanosis
Tripod position
Croup syndromes: acute epiglottitis, acute laryngotracheobronchitis

Care at home
Steamy shower
Sudden exposure to cold air
Sleep with humidified air
Croup syndromes: acute epiglottitis, acute laryngotracheobronchitis

Requirmnt for hospitalization
Increasing resp. distress
Hypoxia or depressed sensorium
High temp (102F)
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
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
Myocardial Infarction

Chest pain related S/Sx
Severe
Crushing
Prolonged
Unrelieved by rest or nitroglycerin
Radiating to 1-2 arms, jaw, neck and back
Myocardial Infarction

Pulmonary edema related S/Sx
Acute pulmonary edema: sense of suffocation
Myocardial Infarction

Shock related S/Sx
sbp < 80mmHg
Gray facial color
Lethargy
Cold diaphoresis
Peripheral cyanosis
Tachy or brady
Weak pulse
Dysrhythmias

S/Sx
Dizziness, syncope, fainting
Chest pain, palpilations, abnormal heart sounds
N&V, dyspnea, abnormal pulse rate (inc, dec, irreg)
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
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.
Dysrhythmias

Diagnostics
EKG
ABGs
Holter recorder
Echocardiogram (structure)
Stress test (EKG before, during and after)
Holter recorder
24h continuous EKG tracing
pt keeps diary of activities
Defibrillation

Definition
Use: emergency tx of v-fib
Action: depolarizes all cells so SA node can be re-established as pacemaker
Cardioversion

Definition
Use: elective procedure for dysrhythmias such as a-fib.
Action: same as defibrillation
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
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
Head injury

Skull fracture S/Sx
Battle's sign (ecchymosis over mastoid bone)
Raccoon eyes (bilat. periorbital ecchymosis)
Head injury

Concussion S/Sx
Transient mental confusion or loss of consciousness
HA
No residual neurologic deficit
Possible loss of memory surrounding event
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
Head injury

Laceration S/Sx
Penetrating trauma with bleeding
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.
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
Flail chest

S/Sx
affected side down with inspiration, up during expiration (paradoxycal).
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
Pneumothorax

S/Sx
Dyspnea
Pleuritic pain
Absent or restricted movement on affected side
Decreased or absent breath sounds
Cyanosis
Cough and fever
Hypotension
Flail chest

Nursing interventions
Monitor for shock
Humidified O2
Pain management
Monitor ABGs
Enco turning, deep breathing and coughing
Sucking chest wound, pneumothorax

Nursing interventions
Thoracentesis
Cuest tubes
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.
Penetrating abdominal injuries

Nursing interventions
NPO, NG tube,
Monitor drainage, bowel sounds
Indwelling catheter
Monitor output carefully
Assess for hematuria
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
Shock

S/Sx
Cool, clammy skin, cyanosis
Restlessness, decreased alertness
Tachy, weak or absent pulse
Acidosis
Oliguria
Respirations shallow, rapid
Hypotension
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.
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].
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
Increased intracranial pressure

Complications
Cerebral hypoxia
Decreased cerebral perfusion
Herniation - pupil constriction
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).
Seizures

Causes
Epilepsy
Fever in child
Head injury
Hypertension
CNS infection
Brain tumor or metastasis
Drug withdrawal
Stroke
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
Seizures

Nursing interventions (after)
Position on side to prevent aspiration
Reduce environmental stimuli
If needed, provide oxygen and suction equipment
Reorient as needed
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).
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)
CVA or stroke

Risk factors
Advanced age
HTN, TIAs
DM
Smoking, obesity, elevated blood lipids
Oral contraceptives
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
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)
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
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
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)
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.
Hypokalemia

S/Sx
<3.5 mEq/L
Muscle weakness
Paresthesias
Dysrhythmias
Increased sensitivity to digitalis
Hypokalemia

Causes
Vomiting
Gastic suction
Diarrhea
Diuretics and steroids
Inadequate intake
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
Hyperkalemia

S/Sx
> 5mEq/L
EKG changes, dysrhythmias, cardiac arrest
Paralysis
Nausea and diarrhea
Hyperkalemia

Causes
Renal failure
Use of potassium supplements
Burns
Crushing injuries
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
Hyponatremia

S/Sx
< 135mEq/L
Nausea
Muscle cramps, muscular twitching
Increased ICP, confusion, convulsions
Hyponatremia

Causes
Vomiting
Diuretics
Excess. admin of dextrose and water IVs
Prolonged low-sodium diet
Excess. water intake
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
Hypernatremia

S/Sx
> 145 mEq/L
Disorientation, delusion and hallucinations
Thirst, dry swollen tongue, sticky mucous mb
Hypotension, tachy, elevated temp
Weakness
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
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
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
Hypocalcemia

Causes
Hypoparathyroidism
Pancreatitis
Renal failure
Steroids and loop diuretics
Inadequate intake
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
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
Hypercalcemia

Causes
Malignant neoplastic diseases
Hyperparathyroidism
Excessive intake
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
Hypomagnesemia

S/Sx
< 1.5 mEq/L
Increased neuromuscular irritability, tremors, tetany, seizures
Dysrhythmias
Depression, confusion
Dysphagia
Hypomagnesemia

Causes
Alcoholism
GI suction, diarrhea, intestinal fistulas, abuse of diuretics or laxatives
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
Hypermagnesemia

S/Sx
> 2.5 mEq/L
CNS depressed
Depresses cardiac impulse transmission
Hypotension
Absent deep tendon reflexes
Paralysis
Shallow respirations
Hypermagnesemia

Causes
Renal failure
Excessive magnesium
Admin of antacids, cathartics
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