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122 Cards in this Set
- Front
- Back
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What physical assessments would indicate that a patient has fluid volume excess
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increased bounding pulse, jugular vein distention, presence of crackles, elevated bp and cool pale skin
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what intervention would be appropriate to correct hypotonic overhydration
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restriction of free water
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What should nurse monitor for worsening of hydrotonic state?
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urine outpu
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What is the compensatory mechanism in a patient with dehydration?
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rapid pulse (sympathetic impulse)
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What interventions expect in patient with fluids in patient with dehydration?
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DW5
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What is most important to monitor in client with corrective measures to dehydration?
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urine output
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What would indicate a negative response to an intervention for dehydration?
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crackles in lungs
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What is third spacing?
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fluid in interstitial space
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What is normal urinary output?
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30-50 cc/hr
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How can a clients weight be used to ass fluid status?
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every 1pnd equal 500 ml
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What is antidiuretic hormone?
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a hormone released by the pituitary gland in response to an increase in blood osmolarity which results in decreased urine production and increased water in the blood
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What is aldosterone?
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A hormone released by the adrenal cortex in response to high potassium in blood. The hormone cause the kidneys to reabsorb sodium and release potassium.
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What is a normal urinary output in 8 hours?
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240 mL
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A doctor may ordered for a patient with too much fluid in interstitial fluid?
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albumin followed by lasix
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What are the symptoms of fluid overload?
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Mental Status changes, weight gain, edema, jugular vein distension, bounding pulse, congested breathing sounds
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What is a isotonic solution?
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Has the same osmolarity and serum and body fluids. Used by hypotensive patients due to hypovolemia. LR. 0.9NS
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What must assess in patient with excessive production of ADH?
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hyponatremia
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What is main use for a central line?
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To dilute antibiotic or medication with large amounts of blood.
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What is purpose of reverse isolation?
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to protect patient from outside infection
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What antibiotic is a treatment choice for MRSA
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vancomycin
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What isolation expected for patient with TB
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airborne
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What lab result is reflective of hypernatremia?
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greater than 145 sodium level
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What patient is at risk for developing hypokalemia?
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metabolic acidosis
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A patient who has three days diarrhea has what potassium level?
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3.0 mEq/L
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What expect see in patient with hypercalcemia?
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muscle weakness
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A nurse considered magnesium levels normal if they fall within what range?
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1.4 - 2.1
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Wha tis the trigger for most asthma attacks?
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inflammation (reversible)
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What should you ask when assessing a patient with asthma?
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Family history of asthma
Did have in childhood, response to a specific antigen? Are you or anyone a smoker? |
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What are symptoms of asthma?
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Coughing, Dyspnea, Increased Respiration Rate, Audible Wheezing
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What educate patient with asthma?
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Avoid asthma triggers in environment
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What are some medications for someone with asthma?
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albuterol (beta agonist) bronchodilator), ipatroprium or atropine(anticholinergic)(antagonist of parasympathetic nervous system) (bronchodilator)
long lasting Theophylline(methelxanthine)(works like caffeine) bronchodilator anti-inflammation corticosteroids(baclomethasone) (prevention of inflammation of bronchioles) zileuton(leukotriene modifier(reduce edama, inflammation and bronchoconstriction cromolyn(mast cell stabiler) reduce mast cells releasing histamine) methylxanines(bronchodilator), corticosteroids(bronchodilator) |
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What are non medical treatments for asthma?
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oxygen therapy and excercise
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What relaxes smooth muscles with no effect on inflammation?
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bronchodilaters
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What happens with COPD patient whose lungs lose elasticity and are hyper inflated?
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emphysema
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What are some effects of emphysema?
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Decreased oxygen in blood to respiratory acidosis with increased CO2 in blood
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What are signs and symptoms of URI?
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Increased mucous and decreased oxygen.
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What does cor pulmonale?
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Right Side Heart Failure
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What assess in patient with COPD?
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smoking
family history exposure to toxins in environment |
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What also assess to see if have COPD?
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sputum in cough, how are breathing, trouble sleeping, weight loss, finger clubbing due to respiratory distress
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What are some tests on patient with COPD?
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ABGs and PFT
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COPD patients with high CO2 and low oxygen need what?
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O2 at 1-2/L per minute to give oxygen and not overload.
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What is maximum amount of air for someone with COPD?
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2 L 02
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What are some ways to increase oxygen in patient with COPD?
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pursed lips, high fowler, diaghramitic breathing
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What are some ways can clear airways of secretions?
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postural drainage, Chest Physiotherapy, suctioning, nebulizer
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What are some ways nursing inteventions for patients with COPD?
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increase calories, bronchodilator before meals, small frequent feedings
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What is inflammation of nasal mucosa?
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rhinitis
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what term used for inflammation of sinuses?
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sinusitis
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What term is for inflammation of the mucous membranes of the pharynx
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pharyngitis
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This is a build up of fluid in the lungs due to an inflammatory response in the lungs triggered by infection.
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pneumonia
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What are some symptoms of pneumonia?
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ill flushed skin, uncomfortable, joint pain, chest/pleuritic pain, tachycardia with weak pulse,
dyspnea, tachypnea, need to sit up, hypotension |
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What are usual lab tests for pneumonia?
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CBC, ABGS, Radiographic Tests CXR, pulse oximetry
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What are some interventions for pneumonia?
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Assess chest movement and rate
Give coughing excercises frequently Give at least 2500 fluid daily |
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Beta agonists can be administered by?
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MDI or DPI
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What are rescue medications?
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short acting beta agonist (last 4 to 6 hours)
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How long are long lasting beta-agonists?
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12 hours
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What are some long lasting beta-agonists?
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salmetero l(Serevent)
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Which beta agonist is better for prophylaxis of asthma attacks?
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long lasting
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What is a anticholinergic?
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ipratropiun(atropine) anti cholinergic(parasympathetic inhibitor) bronchodilater
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What does ipratropiun (atropine) do?
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short acting bronchodilator and stop secretions
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What medication used when beta-agonist and anticholinergic do not work?
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methylxanthines (theoyphylline)
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methylxanthines(theoyphilline) have what?
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narrow safety margin and side effects
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What are side effects of methylxanthine(theoyphilline)
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tachycardia, restlessness, dysrhythmias
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What are some corticosteroids?
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Beclomethasone
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What does corticosteroids do?
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Anti-inflammatory by stopping synthesis of enzymes and genes for inflammation.
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What is a side effect of corticosteroids?
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More susceptible to oral infections.
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What is a mast cell stabilizer?
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cromolyn
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What does Cromylin do?
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Stops release of histamines from mast cells.
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What is a type of luekotrine modifier?
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montelukast(singular)
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What is the normal blood ph?
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7.4
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What is considered acidosis and alkalosis?
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7.35; 7.45
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WHAT DOES increased CO2 from hypoventilation create?
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More H+ ions in the blood.
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When PCO2 is greater than 45 what occurs?
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Respiratory Acidos
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What is the PH in respiratory acidosis?
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The PH is 7.35.
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What happens to the blood when hyperventilation occurs?
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The CO2 decreases in blood creating Respiratory Alkalosis with CO2 below 35.
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What is HCO3?
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This is an alkaline in the body.
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Where is bicarbonate formed?
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kidneys, liver, and pancreas
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What do kidneys do with H+?
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Secrete in urine.
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What happens when kidneys not working?
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Blood builds with H+ and becomes acidic.
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When a patient vomits they are losing H+ and become what?
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Metabolic alkaline
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A patient is metabolic alkaline when their blood has increased bicarbonate and less Hydogen.
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HCO3 greater than 26 is metabolic alkalosis and ph is greater than 7.45
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When body has low HCO3 (less than 22)
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metabolic acidosis when HCO3 <26 and ph<7.35
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What is treatment for patient undergoing respiratory alkalosis.
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Breath into a bag or hold breath. underlying cause must be treated.
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GI tack bleeding loses a lot of what?
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bicarconate
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nasograstric suctioning or severe diarrhea can cause what?
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metabolic acidosis
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Respiratory problems create which acid or bicarbonate problem?
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Respiratory acidosis
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Why does respiratory create respiratory acidosis?
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Not enough CO2 is blown off during exhale and remains building up in blood.
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Respiration slows under respiratory acidosis from chronic lung disease and cause lung muscles to do what?
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weaken
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PH problems come from two sources?
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Respiratory or metabolic (liver, kidneys)
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What test is used to evaluate blood PH?
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ABG's
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What is a common form of dehydration?
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hypovolemia
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What is dehydration?
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occurs when a patient is hemorrhaging or when fluids from other parts of the body are lost, like vomiting, diarrhea, severely draining wounds, profuse diaphoresis
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Signs and Symptoms of dehydration are?
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thirst, rapid weak pulse, low blood pressure, decreased tears, dry skin, dry mucous membranes, poor skin turgor, increased temp, decreased urine output, darker urine, constipation, WEIGHT LOSS, also increased BUN, hematocrit and specific gravity
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What give if someone has dehydration?
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push isotonic fluids that have the same osmolarity as blood
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Most reliable indicator of fluid gain or loss
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weight gain or loss
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What O2 administration restrictions are there for a patient w/ a history of COPD because otherwise they may loose the stimulus to breathe and suffer respiratory arrest
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2 L/ min
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What is the peak flow rate?
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Maximum expiratory airflow
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what is tidal volume
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air volume of each breath
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What are signs of respiratory distress?
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restlessness, irritability and confusion
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What teach patient about Rhinitis?
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Help reduce allergen & irritant exposure; teach pt to read drug label and about OTC meds; teach HAND HYGIENE; encourage appropriate IMMUNIZATIONS.
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What is pharyngitis?
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Inflammation of pharynx.
More common in pts younger than 25 years; Primary symptom is sore throat Pathophys – usu caused by viral infection; may be bacterial (strep); body triggers an inflammatory response to the invading organism |
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How do nurses manage pharyngitis?
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Viral=supportive measures only; Tylenol or aspirin; antitussives; cool/warm drinks; increase fluid intake to AT LEAST 2-3 L/day
Bacterial=antibiotic agents (usu. Penicillin) |
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What do nurses teach patients about pharyngitis?
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Teach pt when to contact physician: with dyspnea; drooling; inability to swallow and inability to fully open mouth; rest during febrile stage of illness; frequent handwashing and proper disposal of tissues; warm saline gargles
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What do with patient post op tonsillitis?
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Continuous observation.
if pt vomits large amounts of dark blood or bright red blood at frequent intervals or if the pulse rate and temp rise & pt is restless NURSE NOTIFIES SURGEON IMMEDIATELY!! |
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Teaching patient post op tonsillitis?
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Teach s/s hemorrhage; liquid or semiliquid diet for several days; avoid SPICY HOT ACIDIC OR ROUGH FOODS; limited MILK products; avoid vigorous tooth brushing or gargling
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Treatment of epistaxis?
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Anterior septum
Treatment of epistaxis? Initially apply direct pressure w/ pt sitting upright with head tilted FORWARD pinching the nose for 5-10 MINUTES |
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Symptoms of Atelectasis
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Cough
Sputum production Low-grade fever Decreased tactile fremitus Dull percussion over affected area; Decreased chest movement toward the involved side (b/c alveoli are collapsed); Respiratory distress, anxiety and symptoms of hypoxia occur if large areas of the lung are affected |
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What does left shift mean?
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An unusually high number of immature neutrophils.
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patient teaching to a patient who has a nose bleed?
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avoid blowing nose
strenuous activity lifting straining 4-6W sneeze with mouth open avoid ASA and NSAID |
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Nurse Management allergic rhinitis?
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identify trigger
reduce inflam and symp antihistamine intranasal corticosteriods increase fluid intake immunotherapy |
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What are signs and symptoms of respiratory detoration?
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Dyspnea, Tachypnea, cough, increase sputum, sputum discoloration, fluid retention, cyanosis,
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Bronchiectasis management
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◦Monitor the frequency of respiration. Note the ratio of inspiration and expiration.
◦Auscultation of breath sounds and record breath sounds. ◦Assess the patient to a comfortable position, height headboard and sat on the back of the bed. ◦Help the abdominal breathing exercise or lip. ◦Observations karakteriktik cough and Auxiliary measures for effectiveness cough efforts. ◦Depth of fluid intake till 3000ml/day appropriate cardiac tolerance and provide a warm and fluid intake between meals in lieu. ◦Give the drug as indicated. |
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What need to know when empting folly?
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volume, color, odor and if blood in it. (need to know if what taking out if taking in) (edema in legs, ankle pitting edema)
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In order to form urine nephron must do what?
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filtration, reabsorption and secretion
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How manage anxiety and stress?
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environment(work, home)
nutrional sleep internal factors alcohol good social supports parent or teen |
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OCD
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urgent repetive motion
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ptsd
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reaction to terrifying event that brings returning memories of the event
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GAD
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abnormal number of neurotransmitters in brain not working properly
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SSRI
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work on long term depression and anxiety
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Benzo
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work fast but highly addictive
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side effects of anxiety drugs
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a. Drowsiness, confusion, lethargy; tolerance; physical and psychological dependence; potentiation of other CNS depressants; aggravation of depression; orthostatic hypotension; paradoxical excitement; dry mouth; nausea and vomiting; blood dyscrasias; delayed onset (with buspirone only)
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Nursing intervention for OCD
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Ensure Basic Needs
Explain expectations Provide Time Reinforce Positive Behaviors Empathy Provide Alternative Activities Connect Feelings and Behaviors |
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Medication for OCD
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SSRI
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