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192 Cards in this Set
- Front
- Back
Third spacing occurs where?
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In the transcellular spaces, including pericardial and peritoneal.
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Ecf consists of what?
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Intravascular space, interstitial space, transcellular
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Edema is considered what type of spacing?
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2nd spacing in the interstitial space.
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Third spacing may present with what symptoms?
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Inc hr, decr bp, decr uo, wt gain rapid, I greater than o.
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how does the pit react to incr osmolality? Decr osmol?
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Secretes adh to retain water to decrease the concentration of blood = less pee. Decr osmo = less adh to increase blood concentration = more pee
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What is the def of dehydration?
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Pure water loss without loss of Na
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Hypovolemia s/sx
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Inc hr, decr bp, incr rr, decr uo, decr skin turgor, sudden wt decr, resstlessness, lethargy
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Nursing int for hypovolemia
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Assess electros, give fluids
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Hypervolemia s/sx
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Incr hr, incr bp, incr wt, incr edema, neck vein distention, crackles, ha, confusion
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Pt presents with crackles in lungs and confusion with ha. Possible dx?
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Hypervolemia
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Pt has vascular dehydration. What orders wood the rn expect?
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Isotonic solution such as normal saline (0.9% nacl), lactated ringers, or dextrose in water (d5w).
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Pt has cellular dehydration, the rn expects the md to order what? Explain
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Hypotonic soltn, ie 0.45% NaCl or 0.33% NaCl. Hypotonic soltn is less concentrated than cells thus fluid enters cells to try and dilute the higher concentrated cells.
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Pt has cellular dehydration, the rn expects the md to order what? Explain
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Hypotonic soltn, ie 0.45% NaCl or 0.33% NaCl. Hypotonic soltn is less concentrated than cells thus fluid enters cells to try and dilute the higher concentrated cells.
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Pt has vascular dehydrarion with edema. Rn expects dr to order what? When would u hold that order and call dr?
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A hypertonic soltn like d5ns (5% dextrose in ns), 5% dextrrose in 0.45% nacl, (d5 1/2 ns), 5% dextrose in lactated ringers (d5lr), or hypertonic saline 3%:::::::: would hold those orders if pt has kidney or heart disease.or if pt is cellular dehydrated.
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Pt has vascular dehydrarion with edema. Rn expects dr to order what? When would u hold that order and call dr?
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A hypertonic soltn like d5ns (5% dextrose in ns), 5% dextrrose in 0.45% nacl, (d5 1/2 ns), 5% dextrose in lactated ringers (d5lr), or hypertonic saline 3%:::::::: would hold those orders if pt has kidney or heart disease.or if pt is cellular dehydrated.
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How do hypertomic soltns work?
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They have greater concentration than in the cells, so fluid leaves the cells to try and dilute the vasculature, causing cells to shrink.
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A pt on lasix loses 4.4 lbs/1 kg in 24 hours. How much fluid loss is this equal to?
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2 liters. One liter of water weighs 2.2 lbs or 1 kg.
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Pt at risk for fluid imbalance. Rn should do what seven thing?
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I&O
Monitor vs, hr, posteral changes in bp of 10% or more Neuro status Daily wt Skin assess Monitor iv fluids |
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The rn knows that ____ is the primary electrolyte in the ecf?
What is the normal range? |
Sodium
135-145 mEq |
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a pt with poorly controlled dm (hyperglycemia) is at risk for what electrolyte imbalance?
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hypernatremia
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when replacing water in hypernatremia, the RN knows that it is important to replace fluids rapidly or slowly?
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slowly, or else cells will swell
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what is the most common electrolyte imbalance seen in hospitalized pts?
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hyponatremia
from n/v/d, ng suctioning, excessive sweating, diuretics, and too much D5W |
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what does SIADH cause?
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syndrom of inappropriate antidiuretic hormone is whe adh is released regardless of plasma osmolality.
Causes hyponatremia because of the increased water retention diluting the na concentration. |
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the nurse knows that the elderly are at increased risk of this electrolyte imbalance because of decreased renal function
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hyponatremia
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as Na is lost, what is reabsorbed?
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potassium
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as potassium is lost, what is reabsorbed?
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sodium
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what is the primary route for K loss?
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kidneys
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pt presents with a severe crushing injury to the legs, what does the nurse monitor for in electrolytes? what does the rn expect to be ordered?
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hyperkalemia caused by K released from hemoloyzation.
iv insulin and glucose to drive K+ back into cells |
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pt just had a new ileostomy, what does the rn watch for?
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hypokalemia
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when giving potassium, the RN always assesses what before giving?
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urine output to see if it decreases
and also checks mag levels - if too low the kidneys will excrete K to preserv mag, so replace mag with or before K |
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the nurse knows that as phosporus goes down, what goes up and vice versa?
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Calcium
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how does the parathyroid gland regulate Ca levels in serum?
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releases parathyroid hormone which stims movment of ca from bone to plasma and increases GI absorption of Ca
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what is needed for pth to regulate Ca?
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Vit. D
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pt is hypercalcemic, the nurse expects to do what
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administer diuretics to promote excretion of Ca
admin IVF to hydrate and dilute Ca and increase renal excretion |
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pt is hypocalcemic, the nurse knows this by what s/sx?
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positive chvosteks or trousseau's sign
parestesia, numbness, muscle spasm, hyperreflexia progressing to tetany |
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pt is receiving a blood transfusion, what electrolyte imbalance might he have
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hypocalcemia
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nursing interventions/collaborative care for hypocalcemia
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replace Ca+, treat cause
IV Ca give slowly over time, fall preventions |
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acronym for electrolytes with values:
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Meg's - Mg: 2 (1.5 - 2.5)
Phone - Phosphorus: 2 (2.5-4.5) Keeps - K (Potassium): 3.5 - 5.0 Calling - Calcium: 8-10 Nancy - Na (Sodium) 135-145 |
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pt presents with premature arrhythmias, bradycardia, and heart irritability, fatigue/lethargy, what electrolyte imbalance might he have
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hypokalemia
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the nurse knows to do what when giving potassium iv?
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use a pump and infuse slowly
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decreased clotting time can be caused by what e- imbalance?
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hypercalcemia
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pt presents with slowed cardiac activity and asystole, what e- imbalance could be the cause?
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hyperkalemia
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loss of deep tendon reflexes can be caused by what e- imbalance?
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hypermagnesemia
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pt with new ileostomy and receiving nasogastric suctioning is feeling lethargic, hr 125 and irregular, bp 90-52, ingling in fingers and toes. What imbalances might be going on.
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Hypokalemia - ileostomy and ng suctioning can cause na and k loss through fluid loss.
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Pt on digoxin for arrythmias... what imbalance would you hold his med for?
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hypokalemia because it increases the risk of dig toxicity
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what two imbalances can be caused by ng suctioning?
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hypomagnesemia and
hypokalemia |
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what imbalance can be caused by crushing and burn injuries?
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hyperkalemia - potassium normally is in the icf but burns tumor lysis or crushing injuries release the K into the ECF
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addisons disease increases risk of
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hypomagnesemia
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hypermagnesemia may be treated how?
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with IV calcium to restro Ca-Mag balance
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pt with crushing or burn injury may present with
How treated? |
muscle weakness
bradycardia, asystole Hyperkalemia treated with iv insulin and glucose to drive K back into cells |
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WBC normal values
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5-10
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Hgb normal values
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13 - 17 (15)
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Hct normal values
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42-52%
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Platelet normal values
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140000-400000
Should be above 100,000 |
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normal prothrombin time
normal partial thromboplastin time normal INR |
11-13 sec
24-32 sec 2-3 |
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Normal BUN
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Bunnies less than twunny (less than 20)
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Normal creatine
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creatures blue should be less than two (less than 2)
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acronym for electrolytes with values:
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Meg's - Mg: 2 (1.5 - 2.5)
Phone - Phosphorus: 2 (2.5-4.5) Keeps - K (Potassium): 3.5 - 5.0 Calling - Calcium: 8-10 Nancy - Na (Sodium) 135-145 |
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nursing care for the pt with hyponatremia includes what?
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fluid restriction because water is leaving the ecf and entering the cells causing swelling - we don't want more water adding to the problem
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a pt receiving loop diuretics should be observed for what symptoms?
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weak, irregular pulse,, poor muscle tone
sx of dehydration because loop diuretics cause excretion of NaCl, which causes water to follow |
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a pt with renal failure is at high risk of developing what e- imbalance?
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hypermagnesemia because mag is secreted via kidneys
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a pt who has just undergone a total thyroidectomy must be assessed for what?
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positive chvosteks or trousseaus (hypocalcemia) to see if hyperthyroid is intact
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a pt with hyperphosphatemia will be treated with
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calcium supplements because as Ca rises in serum, it causes exretion of phosphate
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hypokalemia is associated with what ECG changes?
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the presence of a U wave
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hyperactive bowel sounds are a sx of what imbalance?
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hyponatremia
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foods high in potassium include
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avacado, banana, cantaloupe, carrots, fish, mushrooms, oranges, ptoatoes, raisins, spinach, strawberries, and tomatotoes, pork, beef, veal
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foods high in calcium include
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dairy, collard greens, rhubarb, sardines, spinach, tofu
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rn interventions for anemia
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O2 admin
blood/blood product admin if symptomatic drug therapy (iron, erythropoietin) dietary changes to increase iron intake education |
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Hgb measures what?
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the total amount of Hgb in peripheral blood
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Hct measures what?
Normal value should be? |
percentage of total blood volume made up of RBCs'
Should be around 40 males 40-54 females 38-47 |
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what is TRALI
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transfusion related lung injury
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what is TRACO and how does it present differently than TRALI? What common sx does it share with trali?
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transfusion related circulatory overload
no fever or hyptension dyspnea, crackles, change in LOC |
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15 minutes after starting a PRBC transfusion, the pt becomes restless and complains of itching. what should the nurse do FIRST?
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Stop the transfusion!!!!
Then open up saline, get vs and call for help |
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pt has been diagnosed with anemia, what s/sx might the rn expect
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PALENESS #1 sign
glossitis cheilitis (inflam of lips) headache parasthesias burning sensation in tongue |
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when and what might the rn give to a pt with his po iron supplement?
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1 hour before meals with vitamin c/orange juice.
If liquid, give with straw to avoid teeth staining |
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if pt is put on life time iron supplements, what is necessary to monitor?
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liver function because iron is stored in the liver
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pts with chronic kidney disease are susceptible to what blood condition? why?
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anemia, because the kidneys production of erythropoitin is reduced so new blood cell production goes down.
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why does inflammatory chronic disease cause anemia?
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cytokines cause macrophages to uptake and retain Fe, leaving inadequate Fe for RBC production
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definition of thrombocytopenia
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platelets below 150,000
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the nurse notices oozing from iv site on her patient, what might she suspect?
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thrombocytopenia
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define ecchymoses
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large purplish lesions, flat or raised, painful and tender, caused by thrombocytopenia
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thrombotic thrombocytopenic purpura (TTP)
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agglutination of platelets cause microthrombi that depositi in the vasculature accompanied by bleeding from low platelets and clumping of the ones that do exist.
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when might a platelet transfusion be performed in a thrombocytopenic pt?
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when platelets go below 10000
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what meds might be used in a thrombocytopenic pt?
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immunosuppressants such as azathioprine (Imuran) or cyclosporine
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nursing eductation of the thrombocytopenic pt?
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dab nose instead of blowing it
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define neutropenia
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decreased neutrophil count
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pt has been on long term chemotherapy, what are they at high risk for developing?
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neutropenia
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pt presents with an oportunistic infection but has now s/sx of inflammation, no redness, heat, swelling, or puss. What does the nurse suspect?
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neutropenia
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in a neutropenic pt, what is the best indicator of infection?
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fever greater than 100.4
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appropriate nursing actions when caring for a severely neutropenic pt include
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strict hand hygiene and frequent VSs
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pt presents with bleeding gums, petechiae, what does the nurse suspect?
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thrombocytopenia
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neutrophil count in normal and neutropenic conditions
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Normal = 4000 - 10000
neutropenia = <500 or an absolute neutrophil count (ANC) of less than 1000 |
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neutropenic precautions and education
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reverse isolation,
limited visitors, no kids or sick positive pressure or HEPA filter no fresh fruits/veg, flowers no sunburn, avoid public places and animal |
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describe the RBCs in iron-deficiency anemia
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microcytic and hypochromic
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what deficiency might result in macrocytic yet normochromic RBCs?
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Vit B12 or folic acid
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what is the most important, mature form of WBCs?
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neutrophils
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pt presents with splenomegaly, jaundice and pruritus, pallor, tachycardia, and fatigue. What does the nurse suspect?
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anemia with hemolysis occuring
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polycythemic pts are at high risk of what?
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thrombosis
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describe the RBCs in iron-deficiency anemia
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microcytic and hypochromic
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polycythemia
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stem cell mutation leads to increased productionof rbcs, wbc, and platelets
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s/sx of polycythemia vera
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htn, ha, vertigo, tinnitus, visual disturbances,
pruritis (itchiness), parethesias and redness of hands and feet, thrombophlebitis, intermittant claudication |
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tx for polycythemia vera?
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phlebotomy to reduce Hct to less than 45%, removal of 300-500 mL, iv hydration, myelosuppression (bone marrow activity suppression with drugs), I&O, thrombus prevention
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Normal arterial blood pH should be between
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7.35 and 7.45
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normal PaO2
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65 - 100
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nsg interventions for atelectasis
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prevention
cough/deepbreathing/incentive spriometer (CDB/IS) turning ambulation pain mgmt |
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if PN is hospital acquired, then it occured when
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greater than 48 hours after hospitalization
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risk of aspiration increases with what?
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a decrease in LOC
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pt presents with coughing of purulent sputum and hemoptysis, decreased bs and crackles, fever, chills pleuratic pain, what does the RN suspect?
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Lung abscess
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who is at highest risk of lung abcess?
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anyone with increased aspiration risk ie from lowered LOC from anesthesia, etc. because most lung abcesses are caused by aspiration of material from the GI tract
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definition of pulmonary hypertension (PPH)
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mean pulmonary arterial pressure > 25 mmHg at rest
Normal pressure is 12-15 |
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Pulmonary Hypertension mimics what disorder?
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right sided heart (right ventricular) failure
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Upon cardiac assessment, what might the RN hear in a pt with pulmonary hypertension?
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the RN detects an S4 gallop,
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pt presents with white fingertips which turn blue and then red with tingling and burning. What does the RN suspect?
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Raynauds syndrome, which could be associated with pulmonary hypertension
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during a status asthmaticus attack, what might the nurse request to add to the treatment regimen of bronchodilators?
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Lorazepam
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Normal Cardiac output.
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4-8 L/min
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general cardiac symptoms
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SOB, dyspea, rales, wt gain, nocturnal diuresi, generalized fatigue.
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Arterioles are resistance vessels that change diameter under what stimulation
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Autonomic nervous system (ANS
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pulse pressure is what?
what is normal |
systolic - distolic
30-40 mmHG |
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your patient's pulse pressure is 20 mmHG, what does this indicated
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90/70 pp = 20mmHg (patient is vasoconstricted b/c of BP; trying to compensate)
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blunted baroreceptor response is a clinical implication of what?
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normal aging in the CV system
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preload definition
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The volume blood in the ventricles at end diastole before the next contraction begins.
↑preload: more fluid is left in the ventricle so, the harder the heart has to pump, to move it forward (↑ O2 consumption) If preload stretches the myocardium beyond its physiological limits, contractile force ↓, SV is reduced, therefore cardiac output is reduced |
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afterload definition
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The resistance against which the left ventricle must pump against to eject the volume. (open the aortic valve)
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what is a physical change that occurs in the heart r/t increased afterload?
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left ventricular hypertrophy
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LDL is considered "_____? and should be at what level?
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BAD
less than 130 |
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HDL is considered "__? and should be at what level?
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GOOD
35-85 |
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triglycerides should be at what level?
homosysteines? |
less than 150
4-15 |
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what is MAP?
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mean arterial pressure:(SBP+2DBP)÷3 (avg BP in arterial system felt by organs
adequate arterial pressure is needed for cap perfusion |
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describe the two theories of HTN cause:
hemodynamic vasoconstrictor |
Hemodynamic hypothesis: ↑SNS activity, inappropriate renin-angiotension-aldosterone system (RAAS) stimulation
Vasoconstrictor hypothesis: inappropriate Ca+2 in smooth muscles |
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the sympathetic nervous system stimulates the renin angiotensi system to do what
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increase Na and increase h2o, which increase preload and cardiac output.
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baroreceptors sense low BP and cause the secreation of what hormone?
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ADH
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vasoconstriction does what?
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increases preload AND afterlowad, which increases o2 consumption and stresses heart muscle/
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what is the single biggest problem resulting from HTN>
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end organ damage
heart: lv hypertrophy kidneys: increased RAAS stim perpetuates HN Brain: increased risk of hemorrhage Retinas: hemorrhage Aorta: aneurysm and rupture |
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the RN knows to question orders for what type of diuretic for a heart pt with renal failure?
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potassium sparing duretics
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what nursing concern should you monitor for for anyone on any type of diuretic?
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hypostatic hyptension and electrolyte imbalances
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you pt presents with obesity, triglycerides over 150, HDL less than 40, fasting BG over 100, and HTN. What do you expect his diagnosis will be? What is needed to prevent a cardiovascular event?
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Metabolic syndrome
Heart Healthy Life Style Education Exercise Tight BG management Management with medications antihypertensives, statins, insulin, |
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a pt with a HR of 180 bpm, what is your concern and why?
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coronoary arteries receive o2 during diastole, which is not happening with that high of a HR. Concern is MI
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what is number one modifiable risk factor for all CAD/MI pts?
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smoking cessation
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If chest pain occurs with activity, lasts 3-5 min but is relieved by rest and/or nitrates, what might the dx be?
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chronic stable angina
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a diabetic pt presents with increased blood glucose and fatigue - what would the nurse be concerned about?
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angina - neuropathies may be present, lowering sensitivity to pain.
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your female pt has been diagnosed with panic/anxiety disorder and complains of an aching jaw/choking sensation, what would the RN be concerned about?
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angina
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over the age of 70, chest pain does not aloways occur. what might you see instead?
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dyspnea and indigestion, confusion or disorientation
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in your pt with chronic stable angina, what medications would you expect?
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Nitrates, sublingual nitroglycerin
Beta blockers Low dose ASA Calcium channel blockers |
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how does nitroglycerin help in angina or ischemic events?
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Vasodilates coronary veins and arteries
Relaxes systemic arteriolar bed, decreasing SVR |
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your pt is on nitroglycerin what must you monitor for?
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orthostatilc hypotension
and tolerance over long term |
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how do beta blockers work?
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block the excitation of beta receptors which lowers o2 consumption, lowers HR, lowers BP, lowers contractility. This all increases stroke volume and increase o2 to myocardial tissues by slowing the heart down (more blood to coronary arteries during diastole)
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your pt is on beta blockers, what must you watch for?
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Hypotension
Hyperglycemia (drug specific) Bronchoconstriction Hyperlipidemia |
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calcium channel blockers work how?
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block mvment of Ca into cells, causing vasodilation, decreased HR, decr contractility and systemic vascular resistance . Reduces O2 demand by the heart.
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Your pt is on Ca channel blockers, what must you watch for?
|
Cardiac arrhythmias
Hypotension Constipation Gastric distress |
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ACE inhibitors work how?
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ACE is in blood vessel lumens and converts angiotensin I IIpreload andBP
ACE inhibitors BLOCK this mechanism decreases BP decreases SVR decrease myocardial work during systole Causes Diuresis |
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your pt has been admitted to the ER with anxiety, increased HR, increase RR, diaphorsis and fever, arrhythmias, n/v and
FEELINGS OF DOOM What is the probable diagnosis? |
Acute Coronary Syndrome
|
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your pt who has had a h/o chronic stable angina complains that his chest pain has "changed". What are you thinking?
|
Unstable angina: acute coronary syndrome
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your pt has just had a cardia catheterization procedure. What are you doing and watching for?
|
Assess circulation in extremity used for catheter insertion
Observe insertion site for hematoma and bleeding Place compression device over catheter insertion site Monitor VS and cardiac rhythm Monitor for s/s of PE Affected leg should remain straight |
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Pt presents in the ER with severe CP unrelieved by rest, pressure, tightness radiation to jaw, neck, down arms, weakness, SOB
what is probable diagnosis |
myocardial infarction
|
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what labs would you expect to see rising 3-12 hours and peak 24 hours after an MI?
|
Creatine kinase myocardial bands (Ck-MB)
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it has been 4 days since your pt says he experienced chest pain but didn't come in for it. What labs are you interested in seeing?
|
cardiac-specific tronponin I (cTni) because they rise 3 hours after an MI but don't return to baseline until 5-14 days after. Ck-MB would not be a good lab for indicating MI this far after because it returns to normal after 48 hours
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your pt has a Ck-MB level of 1.0 - what is your expectation of dx?
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that an MI has not occurred. Levels of more than 2.5–3 are more indicative of an MI.
|
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What cTni levels are you looking for to indicated an MI has occurred?
|
over five or any detection at all really
|
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in a pt with a 40 year history of diabetes with newly diagnosed angina, how will an MI most likely present?
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Malaise, hyperglycemia, nausea and vomiting
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you have a pt in your ER who has suffered a non-STEMI. The nurse would question orders for what?
|
Clot buster medications such as:
tissue plasminogen activator recominant plasminogen activator streptokinase ONLY USED IN STEMI |
|
What would you see as a sign that the clot buster is working when given to a pt with STEMI/
|
reduced ST elevation and improved cardiac enzyme level
|
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you would monitor the effectiveness of Heparin with what lab?
|
therapeutic PTT value should be 65 to 95 seconds, but this varies by the hospital.
If the PTT shortens to below the therapeutic range, danger of having a second heart attack. Often second attacks are fatal. PTT results that are longer than the high limit indicate a risk of bleeding. |
|
how would you monitor the effectiveness of coumadin?
|
Most people taking Coumadin should have an INR between 2 and 3. An (PT) INR below 2 signals the danger of a new clot, whereas an INR over 4 means a risk of dangerous bleeding.
|
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what does the RN do post-op for a pt who has just had an artery bypass surgery?
|
Ambulation
Sternal precautions Pain control IS/deep breathing Incision care Manage chest tubes/pacer wires. Monitor hemodynamics, urine output, heart rhythm, fluid & e-lytes |
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your pt's ejection fraction has just been determined to be 30%. what might your patient's diagnosis be? Define it.
|
Low Output Heart Failure (systolic dysfunction): LV is unable to eject normal blood volume with each beat
Normal EF = 60-75% |
|
what are some causes of low output HF
|
LV or RV failure
PHTN (pulmonary hypertension) Valve stenosis |
|
define high output heart failure and list some causes
|
Too much blood for the LV to eject
Excessive volume leads to LV dilatation and fluid backup into the Pul vasculature Causes; valve regurgitation, hyperthyroidism, anemia, hypervolemia, lack of inotropic ventricular force |
|
what are some compensatory mechanisms with HF?
|
increased HR to increase CO
increased rennin to cause vasocxn and volume retention to increase stroke volume vasopressin released to increase vasocxn when sv is adequate BNP/ANP are relased to stop these processes and decrease bp. |
|
describe dilated cardiomyopathy
|
most common
increased dilated ventricle= decreased contraction & decreased SV, increased diastolic volume in V= increased stretch (dilate) |
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describe hypertrophic cardiomyopathy
|
size, mass, esp septum
incrase mass = decreased ventricle size = longer diastole, poor passive fill, increased septal mass = increased O2 consumption |
|
restrictive cardiomyopathy
|
least common
ventricle can’t stretch Amyloidosis (F>M |
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in HF that results in poor forward flow, what doess the RN assess for and what are the treatment goals?
|
Assess for cause of poor CO and treatment goals are:
Maximize CO Improve tissue perfusion Minimize symptoms |
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what are some s/sx of decreased cardiac output?
|
increased HR
****decrease Urine output/decreased renal function****** arrhythmias, ppor nutrition ****increased Diastolic BP (chronic vasoconstriction)***** POOR ACTIVITY TOLERANCE |
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your pt has SOB, rales/crackles, wet cough, nocturnal dyspnea, confusion/restlessness
WHAT DO YOU SUSPECT? |
left sided HF
|
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your pt has systemic edema, weight gain, hepatomegaly, ascites, peripheral edema, JVD, anorexia
What do you suspect? |
Right sided HF
|
|
what is the goal of Nursing and collaborative care for Heart Failure?
|
TO MAXIMIZE CO
|
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what are the ways we maximize CO in HF?
|
Diuretics
ACE inhibitors (ARBs if ACE intolerant) Beta and Ca channel blockers Digoxin Nitrates Synthetic BNP (Natrecor) Manage dyspnea Monitor labs and treat electrolytes Renal function tests, BNP, K, Ca, Mg, Na Exercise programs; manage fatigue Diet mgmt Cardiac transplantation |
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In a pt with HF, the nurse knows to establish what in order to track progress.
|
establish baselines
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frequently, actue heart failure presents what?
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acute pulmonary edema, usually associated with LV failure
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your pt presents with SOB, increased RR, decreased spO2, agitation/anxiety, wheezing, wet cough, and rales. What do you suspect and what is your priority?
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Left sided heart failure causing pulmonary edema.
Priority is to improve O2, and move the fluid out of the lungs with diuretics. |
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How does the nurse assess for Peripheral vascular disease?
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CMS checks: Circulation, Motion, Sensation.
Peripheral pulses Motor function Numbness? Tingling? Pain? Loss of sensation? Color, tempreture, swelling, hair loss? Skin integrety Ankle-brachial index (ABI) Doppler probe |
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your pt presents with severe pain in lower extremities, especially with activity, intermittent claudication (impairment in walking, or a "painful, aching, cramping, uncomfortable, or tired feeling in the legs that occurs during walking and is relieved by rest)
decreased to absent pedal pulses, and deep ulcers on toes and heels. No edema WHat do you suspect? |
Peripheral Arterial Disease
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your pt presents with dull aching craming pain in lower extremities. Pulses are +1, and there is uneven pigmentation with a blue hue in the toughened skin. Moderate edema with medial and lateral ulcers are present.
What do you suspect? |
Peripheral Venous Disease
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what are your nursing interventions in PVD?
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pain relief with meds,
position pt to relieve pressure and edema in Lower extremities Wound healing Keep kin clean, dry, moisturized ENCOURAGE Mobility antiplatelet agents |
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your pt has venous stasis, immobility, hypercoagulability and is dehydrated. What is he at risk for?
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Deep vein thrombosis
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your pt has dull aching pain in his leg. you pull back the covers to reveal erythema and incrased temperature in the leg. He has a + Homan's sign.
What do you suspect? |
Deep vein thrombosis
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interventions once a DVT develops
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Bed Rest
Elevate extremity Heparin or Warfarin Monitor for s/sx clot migration |
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what are aortic aneurysms caused by?
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CAD leading to atherosclerosis: plaques lead to degeneration of vessel walls weaken and dilate
HTN Genetics Congenital abnormalities Trauma Infxn |
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in a pt with thoracic aortic aneurysm, (TAA) what is your sign and what is your priority when diagnosed?
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embolic showers may be first s/sx in brain and fingers.
back pain, SOB, hoarsenes, difficulty swallowing control BP (HTN) control pain |
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what is the usual primary s/sx of abdominal aoritic aneurysms?
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Renal compromise
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your pt states that it feels like her heart is in her abdomen, what do you suspect?
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abdominal aortic aneurysm
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renal and Lower extremity embolic showers could be indicative of what
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abdominal aortic aneurysm
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what do elevated levels of homocystine tell you? What 's elevated?
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+ for presence of CV disease
15-30 micromoles per liter as moderate 30-100 micromoles per liter as intermediate Greater than 100 micromoles per liter as severe |