adult health final

nasal/facial fracture

displacement of bone or cartilage can cause airway obstruction or cosmetic deformity; potential source of infection CSF may indicate skull fracture Interventions : closed reduction ; rhinoplasty ; nasal septoplasty Priority action is airway assessment Manifestations : Stridor , shortness of breath/dyspnea , anxiety/restlessness , hypoxia & hypercarbia , decreased oxygen saturation , cyanosis, loss of consciousness Collaborative care for facial fracture : Airway assessment Anticipate need for emergency intubation Tracheotomy Cricothyroidotomy - emergent procedure performed on patients experiencing severe respiratory distress in whom orotracheal or nasotracheal intubation has failed Fixed occlusion Debridement Le Forte Fracture classification : I : nasoethmoid complex fracture II : maxillary & nasoethmoid complex fracture III : combination of I & II plus orbital-zygoma fracture ; often called craniofacial disjunction

What is included in the Catheter Related Bloodstream Infection Prevention Bundle? (CRBSI)...

hand hygiene, clip hair-do not shave, ensure skin is clean, wear gloves, prepare skin with 70% alcohol or chlorhexidine, maximal barrier precautions, mask and gown, traffic minimized, do not retouch the proposed insertion site after you clean it meticulous dressing changes as soon as the patient no longer needs it, it should be removed prevents infection or other complications. Ensures asepsis

ondansetron, famotidine, midazolam, morphine

ondansetron - nausea famotidine - nausea midazolan - sedative morphine - pain

Know steps/actions to administering insulin.

***Timing of injection affects blood glucose levels. The interval between pre meal injections and eating, known as "lag time," affects blood glucose levels after meals. Insulin lispro, insulin aspart, and insulin glulisine have rapid onset of action and are to be given within 10 minutes before mealtime when blood glucose is in the target range. If hyperglycemia or hypoglycemia is not present, these insulins can be given at any time from 10 minutes before mealtime to just before eating or even immediately after eating. Regular insulin is given at least 20 to 30 minutes before eating when glucose levels are within the target range. When blood glucose levels are above the target range, the lag time is increased to permit insulin to begin to have a glucose-lowering effect before food enters the stomach. When blood glucose levels are below the target range, injection of regular insulin should be delayed until immediately before eating, and injection of rapid-acting insulin should be delayed until sometime after eating the meal. Mixing insulins can change the time of peak action. Mixtures of short- and intermediate-acting insulins produce a more normal blood glucose response in some patients than does a single dose. The patient's response to mixed insulin may differ from the response to the same insulins given separately STEPS Draw up and administer: Subcutaneous Insulin Administration With Vial and Syringe Wash your hands. Inspect the bottle for the type of insulin and the expiration date. Gently roll the bottle of intermediate-acting insulin in the palms of your hands to mix the insulin. Clean the rubber stopper with an alcohol swab. Remove the needle cover and pull back the plunger to draw air into the syringe. The amount of air should be equal to the insulin dose. Push the needle through the rubber stopper and inject the air into the insulin bottle. Turn the bottle upside down and draw the insulin dose into the syringe. Remove air bubbles in the syringe by tapping on the syringe or injecting air back into the bottle. Redraw the correct amount. Make certain the tip of the plunger is on the line for your dose of insulin. Magnifiers are available to assist in measuring accurate doses of insulin. Remove the needle from the bottle. Recap the needle if the insulin is not to be given immediately. Select a site within your injection area that has not been used in the past month. Clean your skin with an alcohol swab. Lightly grasp an area of skin and insert the needle at a 90-degree angle. Push the plunger all the way down. This will push the insulin into your body. Release the pinched skin. Pull the needle straight out quickly. Do not rub the place where you gave the shot. Dispose of the syringe and needle without recapping in a puncture-proof container. With a Pen Device Wash your hands. Check the drug label to be sure it is what was prescribed. Remove the cap. Look at the insulin to be sure it is evenly mixed if it contains NPH and that there is no clumping of particles. Wipe the tip of the pen where the needle will attach with an alcohol swab. Remove the protective pull tab from the needle and screw it onto the pen until snug. Remove both the plastic outer cap and inner needle cap. Look at the dose window and turn the dosage knob to the appropriate dose. Holding the pen with the needle pointing upward, press the button until at least a drop of insulin appears. This is the "cold shot," "air shot," or "safety shot." Repeat this step if needed until a drop appears. Dial the number of units needed. Hold the pen perpendicular to and against the intended injection site with the thumb on the dosing knob. Press the dosing knob slowly all the way to dispense the dose. Hold the pen in place for 6-10 seconds; then withdraw from the skin. Replace the outer needle cap; unscrew until the needle is removed and dispose of the needle in a hard plastic or metal container. Replace the cap on the insulin pen

What is a normal serum osmolarity

270-300 mOsm/L

How to assess for adequate urine output

400-600 mL/day or at least 30 mL/hour 0.5 mL/kg/hour Daily weight at the same time every day Inspection, percussion, bladder scanner, palpation

asthma

A disease in which reversible airflow obstruction occurs intermittently, causing a reduction in airflow; airway obstruction is caused by inflammation and airway hyperresponsiveness with bronchoconstriction. Asthma- Etiology In asthma, the airways overreact to common stimuli with Bronchospasm Edema of the mucous membranes Production of large amount of thick mucus Inflammation obstructs airways Inflammation: triggered by wBC production in epithelial lining of respiratory tract ex. Eosinophilic asthma: more common in adults- causes inflammation throughout respiratory tract - Aspirin & NSAIDS: can trigger asthma in some adults due to an increase in production of leukotriene Gastroesophageal reflux disease (GERD): can trigger asthma in some when the acidic stomach contents enter the airway Genomic considerations: there are more than 1000 gene variations that can impact drug therapy Diagnostic Tests ABGs Serum Laboratory Tests Pulmonary Function Tests (PFT) Asthma: Assessment Daytime symptoms of wheezing, dyspnea, coughing present more than twice weekly Waking from night sleep with symptoms of wheezing, dyspnea, coughing Relieved (rescue) drug needed more than twice weekly Number of times per week activity was limited or stopped by symptoms Status Asthmaticus Severe, life threatening, acute episode of airway obstruction intensifies once it begins, often does not respond to common therapy Can develop pneumothorax and cardiac or respiratory arrest. Treatment- IV fluids, potent systemic bronchodilator, steroids, epinephrine, oxygen Prepare for emergency intubation Risk Factors, s/sx, nursing care, treatment, patient teaching, use of inhalers, asthma action plan, peak flow monitor, self-management Risk factors: 50 gene variations associated with asthma but has genetic and environmental input needed for expression. Variation in the gene expression of the beta-adrenergic receptors also has an impact on drug therapy Signs and symptoms: intermittent episodes of dyspnea, shortness of breath, chest tightness, coughing, wheezing, and increased mucus production. At first wheezing is on exhalation. Breathing cycle is longer with prolonged exhalation and it requires more effort. Patient may use accessory muscles to breathe. Patients with severe, long standing asthma may have a barrel chest due to air trapping. Hypoxemia in pulse ox- also observe cyanosis in oral mucosa and nailbeds, can change LoC and tachycardia. PaO2 and PaCO2 are both decreased. Later, co2 will rise due to retention. Nursing care: check ABGS, serum labs. Administer O2 and meds Treatment: Control therapy drugs- used to reduce airway sensitivity to prevent asthma attacks from occurring to maintain gas exchange and are used every day regardless of symptoms. Reliever drugs. Medication Management Treatment is based on the step category Uses symptoms, symptom frequency, severity to determine treatment Control therapy Preventive therapy (controller drugs) Change airway responsiveness to prevent asthma attacks Used every day, regardless of symptoms Often combination of a steroid & a LABA Reliever drugs Rescue drugs Used to stop attack once it has started Oxygen Action/Use: correct hypoxemia Goal: Maintain SpO2 93-95% SABA: Short acting Beta 2 agonists (Albuterol, Levalbuterol, Terbutaline) Action/Use: bronchial smooth muscle relaxation, relief of acute symptoms or prevention of exercise induced asthma Side effects: tremor, anxiety, bronchospasm, tachycardia, dysrhythmias, palpitations, hypertension, hypokalemia, refractory asthma, throat irritation Goal: relieve bronchospasm Anticholinergics (Ipratropium bromide, Tiotropium bromide) Action/Use: bronchial smooth muscle relaxation Side effects: dry mouth, bitter taste, bronchoconstriction, palpitations, lower incidence of tachycardia than Beta 2 agonists Goal: relieve bronchospasm Corticosteroids (fluticasone, Beclomethasone, Oral or IV prednisone) Action/Use: reverse airway inflammation Side effects: can cause oral infections (inhaler), oral/IV can cause systemic s.e. Immunosuppression, hyperglycemia, GI ulceration Goal: reduce inflammation to open airways Other med classes include Leukotriene modifiers: blocks inflammatory mediators from stimulating inflammation. Prevents asthma attach triggered by inflammation or allergens. Ex. Montelukast Monoclonal antibodies: bind to and block actions of proinflammatory cytokines (interleukin 5) on cell surface sites of IgE that trigger and maintain asthma attacks. Ex. Benralizumab, Mepolizumab (ends in MAB)- used for patients with eosinophilic asthma. Not for acute symptoms (i.e. not a rescue drug) Anti-inflammatories: they do not cause bronchodilation. Corticosteroids- disrupt production of inflammatory mediators, purpose is to prevent an attack caused by inflammation or allergies. Fluticasone, beclomethasone, budesonide, prednisone (oral). Cromone- stabilize membranes of mast cells- Nedocromil. Leukotriene Modifier- blocks leukotriene receptor - Montelukast Exercise and activity: maintain cardiac health, strengthen muscles, and promote gas exchange and perfusion. Oxygen therapy: used in acute asthma attack when bronchospasms are severe and limit flow of oxygen through the bronchiole tubes Pt teaching: obstruction occurs by both inflammation and airway tissue sensitivity (hyperresponsiveness) with bronchoconstriction. Occurs in response to the presence of specific allergens; general irritants such as cold air, dry air, or fine airborne particles; microorganisms and aspirin and other NSAIDs. Can occur with exercise, upper respiratory illness and for unknown reasons. The airways react with bronchospasm, edematous swelling of the mucous membranes, and copious production of thick mucus Use of inhalers (MDI, DPI, Spacer) correctly: MDI- metered dose inhaler without a spacer: remove the cap and shake according to instructions, tilt your head back slightly and breathe out fully, open your mouth and place the mouthpiece 1-2 inches away, as you breathe in deeply, press down on the canister and breath in one dose of medication, continue to breathe in deeply and slowly, hold your breath for at least 10 seconds and breath out slowly. Wait at least 1 minute between each puff. Replace the cap on the inhaler. At least once a day, remove the canister and clean the plastic case and cap of the inhaler by thoroughly rinsing in warm water DPI- dry powder inhaler: read doctors instructions to determine how fast you should read, exhale fully away from the inhaler, place your lips over the mouthpiece and breathe in forcefully (your breath pulls the drug in), remove the inhaler as soon as you've breathed the drug in. Never exhale into the inhaler due to the moisture, never wash or place inhaler in water, never shake your inhaler. If the inhaler is preloaded, discard it when it is empty, you may not feel, taste, or smell it as you breathe it in Spacer: remove caps from inhaler and spacer, insert the mouthpiece into the non-mouthpiece of the spacer, shake the whole unit vigorously 3-4 times, fully exhale and place the mouthpiece in your mouth over your tongue, press down firmly on the canister to release one dose, breathe in slowly and deeply, the spacer will make a noise if you're breathing too rapidly. Remove the mouthpiece and keep your lips closed and hold your breath for 10 seconds, wait at least 1 minute between puffs, replace caps. Asthma action plan: drugs, oxygen, exercise and activity Peak flow monitor: set the peak flow meter at zero, use a standing position, without leaning or supporting yourself on anything, if possible. Take as deep of a breath as you can, place the mouthpiece in your mouth, making sure to wrap your lips around it. Blow your breath out through the mouthpiece as hard and as fast as you can (reset it if you cough, sneeze or interruption). Reset and perform the test two additional times. The highest reading of the 3 is your current peak flow rate. Record and graph your results to see a trend overtime. Establish a baseline by doing this twice a day for 2-3 weeks when asthma is well-controlled Green zone = stable Your peak flow rate is 80%-100% of your personal best, an indication that your asthma is under control You probably have no asthma signs or symptoms Take your preventative medications as usual If you consistently stay within the green zone, your doctor may recommend reducing your asthma medication Yellow zone = caution Your peak flow rate is 50% to 80% of your personal best, an indication that your asthma is getting worse. You may have signs and symptoms such as coughing, wheezing or chest tightness — but your peak flow rates may decrease before symptoms appear. You may need to increase or change your asthma medication. Red zone = danger Your peak flow rate is less than 50% of your personal best, an indication of a medical emergency. You may have severe coughing, wheezing and shortness of breath. Stop whatever you're doing and use a bronchodilator or other medication to open your airways. Your asthma action plan will help you decide whether to call your doctor, take an oral corticosteroid or seek emergency care Self-management: the prescribed daily controller drug(s) schedule and prescribed reliever drug directions, patient-specific daily asthma control assessment questions, directions for adjusting the daily controller drug schedule, when to contact the primary healthcare provider in addition to regularly scheduled visits, emergency actions to take when asthma is not responding to controller and reliever drugs. Avoid triggers- environmental and drugs, avoid foods that have been prepared with monosodium glutamate or metabisulfite. If exercise is induced, use SABA at least 30 minutes before. Know technique and sequence when using an inhaler. Get adequate rest and sleep. Reduce stress and anxiety. Wash sheets often to destroy dust mites. Monitor peak expiratory flow rates with the flow meter. Know when to seek emergency care

activase, tPA

Activase (alteplase) is an enzyme, which works to break up and dissolve blood clots that can block arteries, used in the treatment of an acute heart attack or pulmonary embolism. Uses: to promote fibrinolysis associated with thrombosis in patients with AMI, PE, ischemic stroke, occluded IV cath Mechanism of action: alteplase promotes conversion of plasminogen to plasmin, an enzyme that digests the fibrin matrix of clots.F Alteplase initiates fibrinolysis

acute coronary syndrome

Acute coronary syndrome (ACS) is used to describe patients who have either unstable angina or an acute myocardial infarction (MI is most severe) In ACS it is believed that the atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation, thrombus, & vasoconstriction In women, commonly indigestion, pain between shoulders, aching jaw, choking sensation that manifest during stressful circumstances or ADLs Many may have no pain at all In patients over 80 the main sign may be confusion

recommended lipid levels and teaching for patient with hyperlipidemia

Cholesterol less than 200 LDLs less than 100 HDLs above 55 for females and 45 for males Teach exercise and lifestyle changes LDL we want low, HDL we want high Teach exercise and lifestyle changes

COPD (emphysema and chronic bronchitis)

Chronic bronchitis: affects only the airways, not the alveoli Complications of COPD Hypoxemia & acidosis Reduced gas exchange and CO2 retention Respiratory infection: increases risk Cardiac failure, especially car pulmonale occurs with both types of COPD Cor pulmonale: Rt. sided heart failure from increase lung tissue pressure & narrow vessels, increase workload of rt. Heart Cardiac dysrhythmias Are common & can result from hypoxemia, cardiac disease, drug effects, acidosis Respiratory failure Assessment History Socioeconomic: role in household, insurance, medications Family history Smoking, occupational exposure, environmental exposure Triggers Cough Sputum Activity tolerance: ADLs, sexual activity, walking, work Nutrition & fluid intake Sleep (Arthopnea) Increase metabolic needs for breathing can lead to a loss of muscle mass in the extremities. Neck muscles may be enlarged. Patient often sits in tripod position. May have short, quick respirations with use of accessory muscles. Wheezes may be present on inspiration and expiration. Reduced breath sounds are common with emphysema. Examine for barrel chest. Chronic bronchitis patients are often cyanotic and have a dusky appearance. Late stages of emphysema= underweight and pallor/cyanosis. Oxygen levels decrease and CO2 levels increase. Hypercapnia is a problem in advanced emphysema not so much chronic bronchitis. Polycythemia occurs (increased h/h). Pulmonary function tests determine severity of disease- 80% and up= mild, 50-79% = moderate, 30-49% = severe, less than 30%= very severe. COPD Assessment test (CAT) determines severity of symptoms rating 8 aspects on a scale of 0-5 with 0 being no symptom. Laboratory / Diagnostic Assessment ABGs, CXR, CBC; sputum analysis, pulmonary function tests Management - non - surgical Teach breathing techniques Positioning: what is tripod positioning Oxygen therapy (how much is too much) Bi-pap or CPAP therapy Activity Hydration Smoking cessation (if indicated) Vaccinations Nutrition Avoid triggers Medical management COPD - Bronchodilators SABA: short acting beta 2 agonists (albuterol, levalbuterol, terbutaline) action/use: bronchial smooth muscle relaxation Relief of acute symptoms or prevention of exercise induced asthma Side effects: tremor, anxiety, bronchospasm, tachycardia, dysrhythmias, palpitations, hypertension, hypokalemia, refractory asthma, throat irritation Nursing implications: assess respiratory & cardiac status, monitor response to treatment, teach correct use, teach proper use of medication for acute exacerbations and prevention LABA: long acting beta 2 agonists (formoterol, salmeterol) action/use: bronchial smooth muscle relaxation, used for long term prevention Nursing implications: assess respiratory & cardiac status, proper teaching, not indicated for acute exacerbation, do not use to treat an acute exacerbation Anticholinergics (ipratropium bromide, tiotropium bromide) action/use: bronchial smooth muscle relaxation Side effects: dry mouth, bitter taste, bronchoconstriction, palpitations, lower incidence of tachycardia than beta 2 agonists. Nursing implications: monitor respiratory status & response to tx, avoid contact with eyes, report any change in vision, provide for relief of dry mouth Surgical Management Lung transplantation: not common Lung reduction surgery Removal of hyperinflated lung tissues that hold & trap stagnant air to improve gas exchange (increase FEV, and decrease TLC & RV) Preoperative care and testing Nursing priorities include pre-op teaching including post operative care and expected post op regimen and maintaining airway Diagnosis: based on signs and symptoms. Determine the FEV1 = forced expiratory volume in the first second and can also be expressed as a percentage of the forced vita capacity. Diffusion test determines how well a test gas diffuses across the alveolar-capillary membrane and combines with hemoglobin Interventions: Nonsurgical management: focused on airway maintenance, monitoring breathing techniques, effective coughing, oxygen therapy, exercise conditioning, suctioning, hydrating, and the use of a vibratory positive-pressure device. Breathing techniques: diaphragmatic or abdominal breathing and pursed lip breathing. Effective coughing: removing mucus especially before meals and bedtime. Oxygen therapy: 2-4 l/min via nasal cannula up to 40% venturi mask. Drug therapy: beta-adrenergic agonists, cholinergic antagonists, xanthines, corticosteroids, and cromones. Exercise conditioning: improve function and endurance. Suctioning: when needed for patients with a weak cough, weak pulmonary muscles and inability to expectorate effectively. Hydration: loosen secretions to help them be expelled easier. Vibratory positive expiratory pressure device: pipe device with steel ball inside, when patient exhales through the device, the vibrations move through the chest and airway causing loosened secretions Surgical management: lung transplantations are rare due to costs. Lung reduction are common for emphysema to improve gas exchange by removing hyperinflated lung tissue. Preventing weight loss: dyspnea management while eating and food selection to increase calories while reducing abdominal bloating and avoiding gas-forming foods Nursing care for exacerbations: oxygen Complications: hypoxemia, acidosis, respiratory infection, cardiac failure, dysrhythmias, and respiratory failure Cor pulmonale: right-sided heart failure caused by pulmonary disease. Air trapping, airway collapse, and stiff alveolar walls increase the lung tissue pressure and narrow lung blood vessels, making blood flow more difficult. This increased pressure causes a greater workload for the right side of the heart which pumps blood into the lungs

tracheostomy

Tracheotomy is the surgical incision into the trachea to create an airway to help maintain gas exchange. Tracheostomy is the tracheal stoma (opening) in the neck that results from the tracheotomy. (note tracheotomy versus tracheostomy) Can be an emergency or scheduled | temporary or permanent Reasons why you would need a trach: acute airway obstruction, the need for airway protection, laryngeal or facial trauma or burns, and airway involvement during head or neck surgery. Used for prolonged unconsciousness, paralysis, or the inability to be weaned from mechanical ventilation. In temporary tracheostomies, the nurse is key in evaluating patient readiness for progression toward decannulation (removal of the tracheostomy tube) Focused Assessment of a pt with a Trach: Note breathing and compare with baseline Tachypnea can indicate hypoxia, and dyspnea can indicate secretions in the airway. Assess for cyanosis, especially around the lips, which could indicate hypoxia Check the pt's O2 sat with pulse ox. if pt is rx'd O2, make sure it's correct amount with correct humidification Assess the trach site for: color, consistency, and amount of secretions in the tube or externally. If the trach is sutured in place, assess for: redness, swelling, or drainage from suture sites. If the trach is secured with ties: assess the condition and security of the ties. Change if they are moist or dirty. Assess the skin around the trach and neck for impaired tissue integrity: including behind the neck, from the ties or from excess secretions. Assess behind the faceplate of the trach and check the patient's tissue and whether any secretions have collected in this area. If the tube is cuffed, check cuff pressure or collaborate with the respiratory therapist to confirm cuff pressure. Auscultate the lungs. Ensure that a second (emergency) tracheostomy tube is available Potential Complications: Tube obstruction can occur as a result of secretions or by cuff displacement. Indicators are difficulty breathing; noisy respirations; difficulty inserting a suction catheter; thick, dry secretions; and high peak pressures (if a mechanical ventilator is used). Assess the patient at least hourly for tube patency. Prevent obstruction by: helping the patient cough and deep breathe, providing inner cannula care, humidifying oxygen, and suctioning. Tube dislodgement and accidental decannulation can occur when the tube is not secure. Prevent this problem by securing the tube in place to reduce movement and traction or accidental pulling by the patient. Tube dislodgement in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. The tube could be in the tissue instead of the trach (called false passage) and the pt won't be able to be ventilated Preventing Aspiration Avoid serving meals when the patient is fatigued. small and more frequent meals have plenty of time to eat closely watch the pt while self feeding Keep suctioning equipment close at hand and turned on. make all liquids thick, including water speech pathologist can determine whether or not they can have thin liquids Avoid foods that generate thin liquids during the chewing process, such as fruit. sit pt in the most upright position deflate the tube cuff during meals Suction after cuff deflation to clear the airway and allow comfort during the meal. Feed each bite or encourage the patient to take each bite slowly. clear residue from throat by double swallowing Avoid consecutive swallows of liquids. Provide controlled small volumes of liquids, using a spoon. Tell the patient to "tuck" the chin down and move the forehead forward while swallowing. let the pt determine when they're ready for next bite If coughing occurs, stop the feeding until the patient indicates that the airway is clear. Assess respiratory rate, ease of swallowing, pulse oximetry, and heart rate during feeding. Suction Properly: Assess the need for suctioning. Wash hands. Wear protective eyewear. Maintain Standard Precautions. Explain to the patient that sensations such as shortness of breath and coughing are to be expected but that any discomfort will be very brief. Check the suction source. Occlude the suction source, and adjust the pressure dial to between 80 and 120 mm Hg to prevent hypoxemia and trauma to the mucosa. STERILE FIELD!!! Preoxygenate the patient with 100% oxygen for 30 seconds to 3 minutes (at least three hyperinflations) to prevent hypoxemia. Synchronize hyperinflations with inhalation. Quickly insert the suction catheter until resistance is met. Do not apply suction during insertion. Withdraw the catheter 0.4 to 0.8 inch and begin to apply suction. Apply continuous suction and use a twirling motion of the catheter during withdrawal to avoid impairing tissue integrity. Never suction for longer than a total of 10 to 15 seconds. Hyperoxygenate for 1 to 5 minutes or until the patient's baseline heart rate and oxygen saturation are within normal limits. Repeat as needed for up to three total suction passes. Document secretion characteristics and patient responses.

pneumonia

Types (Pathogens vary) Community-acquired (CAP) Develops in pt. who have not been hospitalized or living in long-term care facility for >2 weeks Healthcare acquired (HCAP) Hospital-acquired (HAP) Develops >48h after admission Ventilator-associated (VAP) Develops >48h after intubation Increased risk: elderly, alcoholic, smokers, renal/liver failure, chronic diseases, head injury, immunosuppression Pathophysiology Pneumonia: Pneumonia is excess fluid in the lungs from an inflammatory process. This disease can seriously reduce gas exchange. GAS EXCHANGE is oxygen transport to the cells and carbon dioxide transport away from cells through ventilation and diffusion. Inflammation causing pneumonia can be triggered by infectious organisms and by inhaling irritating agents. S/S: Treatment/ Nursing Care: Assessment: What history would you like to know? What is the patient's general appearance? What assessment findings do you expect? What do you expect to hear upon auscultation? What about the vital signs? What diagnostic test results do you want? Imaging Assessment Chest x-ray is the most common diagnostic test for pneumonia but may not show changes until 2 or more days after symptoms are present. It usually appears on chest x-ray as an area of increased density. It may involve a lung segment, a lobe, one lung, or both lungs. In the older adult, the chest x-ray is essential for early diagnosis because pneumonia symptoms are often vague Other Diagnostic Assessments Pulse oximetry is used to assess for hypoxemia. Thoracentesis is used in patients who have an accompanying pleural effusion. What labs are you going to look at? Gram stain, culture and sensitivity of sputum Sputum is obtained and examined by Gram stain, culture, and sensitivity testing; however, the responsible organism often is not identified. A sputum sample is easily obtained from the patient who can cough into a specimen container. Extremely ill patients may need suctioning to obtain a sputum specimen. CBC A complete blood count (CBC) is obtained to assess for an elevated WBC count, which is a common finding except in older adults. Blood cultures Blood cultures may be performed to determine whether the organism has entered the bloodstream. ABGs: In severely ill patients, arterial blood gases (ABGs) may be assessed to determine baseline arterial oxygen and carbon dioxide levels and to help identify a need for supplemental oxygen. Serum BUN/Creatinine Serum electrolyte, blood urea nitrogen (BUN), and creatinine levels also are assessed. A high BUN level may occur as a result of dehydration. Electrolytes Hypernatremia (high blood sodium levels) occurs with dehydration. Lactate level A lactate level may be ordered to help assess for sepsis What do you expect your ABGs to look like? What treatments do you anticipate? Improve gas exchange Oxygen therapy Incentive spirometry What else could you do? Prevent airway obstruction For pneumonia caused by aspiration of food or stomach contents, interventions focus on preventing lung damage and treating the infection. Aspiration of acidic stomach contents can cause widespread inflammation, leading to acute respiratory distress syndrome (ARDS) and permanent lung damage. Cough & deep breath, Incentive spirometer Hydration- at least 2 L of fluids/24 hours Administer medications as ordered Prevent Sepsis Eliminating the infecting organism is key to treating pneumonia and preventing sepsis. When sepsis occurs with pneumonia, the risk for death is high. Anti-infectives are given for all types of pneumonias except those caused by viruses. Which drugs and the route of delivery prescribed are based on how the pneumonia was acquired (i.e., CAP, HAP, or HCAP), how ill the patient is, which organism is involved, and whether the patient has conditions that increase the risk for complications, especially reduced IMMUNITY. Prevention: Influenza Vaccine Pneumococcal Vaccine Know whether you are at risk for pneumonia (older than 65 years, have a chronic health problem [especially a respiratory problem], or have limited mobility and are confined to a bed or chair during your waking hours). There are two pneumonia vaccines: pneumococcal polysaccharide vaccine (PPSV 23), known as Pneumovax; and pneumococcal conjugate vaccine (PCV-13), known as Prevnar 13. The CDC recommends that adults older than 65 years be vaccinated with both, first with Prevnar 13 followed by Pneumovax about 6 to 12 months later. Adults who have already received the Pneumovax should have Prevnar 13 about a year or more later. These recommendations also apply to adults between 19 and 64 years of age who have specific risk factors such as chronic illnesses Patient Teaching: (Risk Factors) Community-Acquired Pneumonia Is an older adult Has never received the pneumococcal vaccination or received it more than 5 years ago Did not receive the influenza vaccine in the previous year Has a chronic health problem or other coexisting condition that reduces IMMUNITY Has recently been exposed to respiratory viral or influenza infections Uses tobacco or alcohol or is exposed to high amounts of secondhand smoke Health Care-Acquired Pneumonia Is an older adult Has a chronic lung disease Has presence of gram-negative colonization of the mouth, throat, and stomach Has an altered level of consciousness Has had a recent aspiration event Has presence of endotracheal, tracheostomy, or nasogastric tube Has poor nutritional status Has reduced IMMUNITY (from disease or drug therapy) Uses drugs that increase gastric pH (histamine [H2] blockers, antacids) or alkaline tube feedings Is currently receiving mechanical ventilation (ventilator-associated pneumonia [VAP]) TEACHING Review all drugs with the patient and family and emphasize the importance of completing anti-infective therapy Teach the patient to notify the primary health care provider if chills, fever, persistent cough, dyspnea, wheezing, hemoptysis, increased sputum production, chest discomfort, or increasing fatigue returns or fails to go away completely. Instruct him or her to get plenty of rest and increase activity gradually. Teach him or her to avoid crowds (especially in the fall and winter when viruses are prevalent), people who have a cold or flu, and exposure to irritants such as smoke. Smoking is a risk factor for pneumonia. Provide them with information on local smoking-cessation classes and nicotine replacement options Vaccinations will boost IMMUNITY to these diseases. QUESTIONS ABOUT PNEUMONIA/ RESPIRATORY FROM CLASS: The nurse understands that which of the following is the most common manifestation nn of pneumonia in the older adult patient? Confusion Which of the following pt's have an increased risk for developing pneumonia? Patient with closed head injury and is receiving ventilation, patient with dysphagia, patient with aids RN provided education on inh (isoniazid). Which statement by the pt indicates understanding of proper use of this medication? Take it on an empty stomach A nursing student is teaching a 72-year-old pt about the importance of pneumonia vaccination. Which teaching requires intervention by the nurse? You will need one vaccine called pneumovax, if you have had the Prevnar vaccine, then you will not need the pneumovax, since you are 64 yrs old, only the flu vaccine is suggested A pt presents to the primary health care provider's office with fever, ear pressure, sore throat, nasal congestion, and poor response. Which condition does the nurse suspect? Bacterial Rhinosinusitis

Metformin- indications for this medication, when should it be held?

All international guidelines consider metformin and lifestyle intervention as the first-line treatment in adults with T2DM in order to improve glycemic control. Metformin can be used in order to prevent or delay the onset of T2DM Metformin can cause lactic acidosis in patients with kidney impairment and should not be used by anyone with kidney disease. To prevent lactic acidosis and acute kidney injury, the drug is withheld before and after using contrast medium or any surgical procedure requiring anesthesia until adequate kidney function is established. Lactic acidosis is a form of metabolic acidosis that begins when a person overproduces or underutilizes lactic acid, and their body is not able to adjust to these changes. Held before any procedure that they are using the dye & we hold it until there is adequate kidney function. Held before surgery or CT scan- getting contrast because it can damage the kidneys and cause lactic acidosis Inhibits liver glucose production Does not increase insulin secretion, increases sensitivity This brings down your glucose - used for hyperglycemia

amiodarone

Amiodarone Used for atrial and ventricular dysrhythmias. For amiodarone: • Continually monitor ECG rhythm during infusion; bradycardia and AV block can occur. • This drug can cause serious toxicities (lung damage, visual impairment). As a result, approval is limited to use for life-threatening dysrhythmias. However, because of efficacy, use remains very common • Corneal pigmentation occurs in most patients, but it generally does not interfere with vision.

pulmonary embolism

An emboli that obstructs blood flow in a pulmonary vessel(s) Most common cause of a PE Blood clot(s)- a venous thromboembolism (VTE/DVT) Other causes include fatty embolism, air embolism, amniotic fluid, injected particles, foreign body such as a sheared or broken venous catheter A pulmonary emboli is a collection of particulate matter - can be anything, a solid, a liquid, or even air - that enters venous circulation and lodges in pulmonary vessel(s). Most often a PE occurs when a blood clot from a venous thromboembolism (VTE) in the leg or pelvic vein breaks off and travels through the vena cava into the right side of the heart thru the pulmonary artery to the pulmonary vessels. VTE a blood clot forms in a vein-legs, pelvis The clot or a piece of the clot breaks off and travels through the vena cava to the right side of the heart and lodges in the pulmonary artery or one of its branches Platelets form around the embolus, substances are released that constrict the blood vessel limiting blood flow further and gas exchange and tissue perfusion are impaired and allows limited or no blood flow thru the vessel to get to the alveoli to pick up 02 causing hypoxemia The clot obstructs blood flow causing reduced gas exchange → ↓ oxygenation, pulmonary tissue hypoxia, ↓ perfusion and possibly death Risk Factors Prolonged immobilization Central venous catheters Surgery Obesity Advancing age History of thromboembolism Conditions that increase blood clotting Nursing Assessment/ Interventions Signs & Symptoms of PE May be vague but typically are Dyspnea (can be sudden onset) Pleuritic chest pain (worse on inspiration) Sharp & stabbing Cough; Hemoptysis Tachypnea & Tachycardia Anxiety, Apprehension, Restless (may express a feeling of impending doom) Syncope Low grade fever Symptoms of deep venous thrombosis Crackles, wheezes, pleural friction rub Hypoxemia, Decreased Sp02, diaphoresis "Classic" signs of PE are dyspnea, hemoptysis, and chest pain- but they are only present in only 20% of cases. Cardiac symptoms related to decreased tissue PERFUSION include tachycardia, distended neck veins, syncope, cyanosis, and hypotension. Abnormal heart sounds, such as an S3 or S4, may occur. Electrocardiogram (ECG) changes are nonspecific and transient. T-wave and ST-segment changes may occur as can left-axis or right-axis deviations. The patient may have cardiac arrest or frank shock. Interventions Increasing GAS EXCHANGE Improving PERFUSION Reducing risk for further Clot Formation Preventing Complications Treatment ----> PREVENTION IS THE BEST TREATMENT Passive & Active ROM Reposition patient at least q2h Early ambulation Avoid anything constricting- straps, garters, girdles, clothing Prevent pressure under popliteal area no pillow under knees) Elevate affected limb 20 degrees or higher above the heart as appropriate- to promote venous circulation Do not massage leg muscles Instruct pt. not to cross legs Teach pt. to avoid activities that result in Valsalva maneuvers Stool softeners to avoid constipation Encourage smoking cessation Take frequent walking breaks when sitting for long periods of time (flights, car travel, desk job) TREATMENTS NON SURGICAL Anticoagulants therapy Heparin(UFH); LMWH; Warfarin may be started simultaneously HIT (Heparin induced thrombocytopenia) reaction to UFH & LMWH Fibrinolytics/Thrombolytics (dissolve the clots) Based on severity of PE, bleeding risk, prognosis Indicated for treatment of PE with hypotension in the absence of high risk of bleeding Monitor laboratory results Bleeding times (PTT,PT, INR) & Platelets (Thrombocytopenia) Platelet count 40,000-80,000/mm3 may have prolonged bleeding Platelet count <20,000/mm3 at risk for spontaneous bleeding Manage Hypotension IVF therapy to restore plasma volume & prevent shock (isotonic crystalloids) Drug Therapy- vasopressors are used when hypotension does not respond to IVF (Vasopressors- norepinephrine, dopamine) Goal is to restore perfusion- what will you monitor? SURGICAL Embolectomy Surgical or percutaneous removal of the embolus •https://www.youtube.com/watch?v=3OX3-h9zHVo Inferior Vena Cava(IVC) filter (umbrella) (Preventative) Placement of a retrievable vena cava filter to prevent further emboli from reaching the lungs MEDICATIONS Anticoagulants To prevent embolism enlargement & further clotting Heparin sodium Monitor PTT, aPTT, Factor anti-Xa, Platelet count (HIT) Antidote-_____________ Patient Care/Safety Bleeding precautions LMWH- enoxaparin Labs are not usually monitored Partially reversed w/ protamine Warfarin- a Vitamin K Antagonists (VKAs) Monitor w/ PT/INR Antidote-____________ Rivaroxaban- Factor XA inhibitor, a direct thrombin inhibitors aka novel oral anticoagulants (NOACs/DOACs/ TSOACSs) Antidotes vary by agent Fibrinolytics Break up existing clots Determined by Severity (Low-risk, Submassive, Massive) Alteplase (Activase, tPA) Monitor patients CLOSELY! Patient will be in ICU setting Assess hourly, or more frequently, for internal & external bleeding while administering drug and for 8 hours after- hemorrhage is the most common complication Patient should be carefully screened prior to giving Antidotes ______________ NOTES FROM CLASS: CARE OF CRITICALLY ILL PATIENTS WITH RESPIRATORY PROBLEMS RR IS IMPORTANT Low RR or high RR Color: cyanotic or flushed Speed of RR Quality of RR Alkalosis or Acidosis Lung sounds: auscultate---> wheezing, crackles, stridor Coughing: productive or non-productive, when did symptoms start, Hx of smoking Cardiac: increased HR, tightness in chest----> Myocardial Infarction Look @ perfusion Pulmonary Embolism: (PE) clot in the legs Can be solid or liquid; when a DVT in leg or pelvic break off and travel to the right side of the heart, through the vena cava, and lodge in pulmonary vessels IV push: know the medicine is compatible with the fluid that is running Whatever you are giving; make sure it is okay--- refer back to clinical and using Lexi-comp to assess compatibility Pulmonary tissue hypoxia, decreased O2 Oral Birth control--- increased hormones, higher at risk Pg. 587---> literature section Pg 588- key features, s/s SOB, hemoptysis, chest pain Prevention: ROM, reposition Evaluate patient early on for risk factors; then we will see them placed on medications, anticoagulant therapy, position pt to make them comfortable and do not put a pillow under their legs Protamine Vitamin K- Warfarin anti-agent Amicar- Antifibrinolytic agent PTT Know the levels for exam INSTEAD of PTT, some hospitals use antiXA

anaphylaxis reactions

Anaphylaxic reactions Rapid, systemic Can be fatal Angioedema of the face, lips, and mouth Urticaria, wheals, hives

aortic aneurysms

Aneurysms: a permanent dilation or outpouching of a weakened area in the aorta that is classified by region as abdominal, thoracic, or as dissecting Major risk factors: Uncontrolled HTN: high lipid levels, smoking Most aneurysms in the abdominal aorta below the level of the renal arteries Growth of aneurysms in unpredictable Rupture likely when aneurysms greater than 6 cm in size and HTN Assessment Abdominal aortic aneurysms usually asymptomatic, frequently rupture Report of abdominal, flank or back pain Pulsating mass middle or upper abdomen Thoracic aneurysms Assess for back pain, dyspnea, cough, hoarseness, and difficulty swallowing General measures: controlling blood pressure, correcting risk factors Aortic aneurysms Occur when the middle layer (media) of the artery is weakened Risk factors Atherosclerosis, hypertension, hyperlipidemia, cigarette smoking, age, gender, family history S/Sx of ruptured abdominal aortic aneurysm (AAA) vs thoracic aortic aneurysm AAA: hypotension, diaphoresis, decreased LOC, oliguria, loss of pulses distal to the rupture, dysrhythmias, abdominal distention, hematoma in the flanks from retroperitoneal hemorrhage TAA: sudden excruciating back or chest pain, hypovolemic shock

warfarin

Anticoagulant antidote is VITAMIN K, monitor INR Warfarin (Patient Teaching, labs to monitor) Oral anticoagulant Inhibits Vitamin K synthesis which impacts Factors II, VII, IX, & X Patients will often bridge from heparin to Warfarin (Coumadin) therapy Narrow therapeutic range, highly protein bound Frequent monitoring of international normalized ratio (INR) INR levels: Normal: 1.3-2.0 Therapeutic Warfarin range: 2.0-3.0 Higher risk therapeutic Warfarin range 2.5 or > Monitor closely for: Signs of bleeding & drug interactions Patient teaching: Take medication in evening, strict drug compliance & INR monitoring, importance of consistent oral intake of vitamin K, risk of bleeding, avoid falls, contact sports, trauma, use of electric razors, avoid used of NSAIDS Dietary restrictions: Grapefruit, cranberry, green leafy vegetables, garlic, ginger, feverfew, fish oil, turmeric, St Johns Wort, chondroitin sulfate Antidote: Vitamin K (phytonadione)

heparin/lovenox

Anticoagulant antidote protamine sulfate, monitor PTT Low Molecular Weight Heparin (Indications for Use) LMWH = Enoxaparin, Dalteparin, Tinzaparin Lower risk of bleeding Frequent lab monitoring not required Action: inactivates factor Xa Use: Prevent DVT and acute PE after orthopedic or abdominal surgery Can be given at home after discharge Give subcutaneously Precautions: Don't take aspirin concurrently Antidote: protamine sulfate Heparin (antidote, labs to monitor, HIT) Anticoagulant Binds with antithrombin lll Inhibit action of thrombin Inhibit conversion of fibrinogen to fibrin Inhibit clot formation Most commonly to prevent venous thrombosis Administration: subcutaneously, intravenously Weight based dosing protocol Prolongs clotting time--narrow therapeutic range Normal PTT = 25-35 seconds Therapeutic range is 1.5-2x the normal range (37-70 seconds... this varies by heparin protocol) Monitor closely for: Thrombocytopenia (HIT), bleeding, hypotension, pain, and bruising at injection site (ecchymosis, purpura), CNS changes, headache, blood in stool, hematuria Antidote: Protamine sulfate

clopidogrel

Antiplatelets Common examples of antiplatelets: Aspirin P2Y12 Inhibitors: Clopidogrel Prasugrel Ticagrelor Cangrelor PAR-1 inhibitor: Vorapaxar sulfate Inform patients to report any unusual bleeding or bruising because bleeding is a side effect for all medications in this category. Avoid over-the-counter pain medications that contain additional aspirin. With aspirin therapy: • Take with food because gastric irritation may occur. • Assess for ringing in ears because this can be a sign of aspirin toxicity. • Teach patients that aspirin is an important cardiac medication that should not be stopped unless indicated by the provider as studies indicate better survival rates for patients with CAD who receive aspirin. With P2Y12 platelet inhibitors: • Take with food because drugs can cause diarrhea and GI upset. • Do not confuse Plavix with Paxil.

nursing care for anaphylactic reactions

Assess AIRWAY first! Establish or stabilize airway Stay with patient Epinephrine Antihistamines Oxygen Beta-adrenergic agonist Corticosteroids, oral steroids

Role of circulating nurse vs. preop nurse vs. PACU nurse

Circulating nurse: set up operating room, gather supplies, anticipates equipment needed and inspects equipment. Protect privacy, ensure safety, monitors traffic, assesses urinary output and blood loss, monitors sterile field, communicates patient status, documents care, events, interventions, and findings Preop nurse: preop checklist, informed consent, teaching checklist, assess knowledge and education needs, allergies, discharge planning PACU nurse: anticipate, prevent, and manage complications after surgery, airway and pain management, assessment, monitor ABC, cardiac, respiratory status, fluid output, CNS status, wound and pain management

cariogenic shock

Class IV HF, necrosis of more than 40% of the left ventricle Direct pump failure when heart muscle is unhealthy, most commonly due to MI Decreases cardiac output and MAP

Peripheral IV assessment and care and possible complications; treatment/intervention of complications

Assess: insertion site, work way up, redness, warmth, rate of infusion Complications: air embolism: entry of air into patient's circulatory system, more common with central. Place on left side, Trendelenburg and call physician. Pneumothorax: occurs if the catheter accidentally pierces the lung or pleural membrane catheter breakage or damage: can break and embolize or travel in circulation to the heart or pulmonary artery infiltration: IV solution leaks into the subq tissue-catheter slips out of the vein or if the iv fluids leak infection: if localized, this begins with redness, warmth, purulent drainage. Systemic moves to fever, chills, malaise, increase WBC phlebitis: inflammation of the vascular endothelial wall. Pain warmth and redness at the site extravasation: infiltration of a vesicant drug from an IV line into surrounding tissue- can occur with w peripheral or ventral venous catheter fluid overload: increased BP, HR, and respirations. Dyspnea, crackles, distended neck veins, weight gain thromboembolism: blood clot speed shock: systemic reaction to the rapid infusion of a substance unfamiliar to the patient's circulatory system. Discontinue infusion, hang isotonic solution, monitor VS, call physician sepsis: infection in the blood Treatment/interventions: stop the infusion, warm compress, start infusion in another site,

cystic fibrosis

Autosomal recessive genetic disease interfering with chloride transport in cell membranes CF: thick, sticky mucus causes problems in lungs, pancreas, liver, intestines, testes, salivary glands Management Cornerstone management of CF: Pulmonary hygiene: chest PT Infection prevention (Burkolderia Cepacia and Pseudomonas aeruginosa) and other infections- antibiotic treatment, avoidance of other CF patients Nutritional support: high calorie diet, supplemental pancreatic enzymes (PERT), vitamins Oxygen therapy, BiPap, bronchodilators, Mucolytics Lung transplantation has also become a treatment option Gene therapy: effective only on patients with specific genetic mutations. Ex. Ivacaftor See p. 552 about CTFR gene (controls chloride movement across cell membranes) Warning Signs Persistent cough Blood-streaked or rust-colored sputum Hoarseness or change in respiratory pattern Dyspnea Weight loss, fatigue Recurrent episode of pleural effusions or pneumonia Patho: genetic disease that affects many organs and lethally impairs lung function. Underlying problem is blocked chloride transport in the cell membranes which causes the formation of mucus that has little water content and is thick. The secretions plug the airways in the lungs and the glandular tissues in the nonpulmonary organs, causing atrophy and organ dysfunction. Respiratory failure is the main cause of death. Nonpulmonary problems include pancreatic insufficiency, malnutrition, intestinal obstruction, poor growth, male sterility, and cirrhosis of the liver. In young adults, other complications include diabetes and osteoporosis. Organs affected: lungs, pancreas, liver, salivary glands, and testes. Nursing care: chest PT, antibiotic therapy when infected (B. cepacia), nutritional support, BiPAP and oxygen therapy. Lung transplant and gene therapy are also an option

cardiac related lab values : BNP, electrolytes, lipids

BNP <100 - No heart failure 100-300 - Heart failure present >300 - Heart failure >600 - Moderate Heart failure >900 bad- severe heart failure Electrolytes Possible low sodium, magnesium, and potassium values Lipids Too much LDL (bad fats in your cholesterol) - possible signs of heart failure

ACE inhibitors ex. captopril, lisinopril

BP meds ACE inhibitors make patients more allergic because they enhance sensitivity to histamine. Oral allergy syndrome, caused by a cross-reaction of allergens found in pollen and in raw fruit, vegetables, and tree nuts, typically appears in people with allergic rhinitis, but can also occur in those without it The ACE inhibitors and ARBs suppress the renin-angiotensin system (RAS), which is activated in response to decreased renal blood flow. ACE inhibitors prevent conversion of angiotensin I to angiotensin II, resulting in arterial dilation and increased stroke volume. ARBs block the effect of angiotensin II receptors and thus decrease arterial resistance and arterial dilation. In addition, these drugs block aldosterone, which prevents sodium and water retention, thus decreasing fluid overload. ACEIs include captopril,lisinopril, and enalapril. The most common side effect of this group of drugs is a nagging, dry cough. Teach patients to report this problem to their primary health care provider as soon as possible. If a cough develops, the drug is discontinued. Angiotensin-Converting Enzyme (ACE) Inhibitors Common examples of ACE inhibitors: Lisinopril Enalapril Captopril Report persistent, dry cough to the primary health care provider because this is a common and annoying side effect, and another type of antihypertensive medication may be necessary. Monitor BP carefully, especially orthostatic pressures, because these agents result in vasodilation and decreased BP. Do not give the drug without checking with the health care provider if systolic BP is below 100. Assess for hyperkalemia because ACE inhibitors reduce the excretion of potassium.

epinephrine

Bronchodilator, nonselective adrenergic agonist, cardiac stimulant, vasopressor Action: 1 and 2 agonist causing increased levels of cyclic AMP producing bronchodilation, cardiac and CNS stimulation; large doses cause vasoconstriction via receptors; small doses can cause vasodilation via 2 vascular receptors Therapeutic outcome: vasoconstrictor, cardiac stimulator, bronchodilator, decreased aqueous humor Uses: acute asthmatic attacks, hemostasis, bronchospasm, anaphylaxis, allergic reactions, cardiac arrest, adjunct in anesthesia, shock Nursing considerations: Asthma: monitor respiratory function, ABGs, Lung sounds, heart rate, rhythm, amount & color of sputum Monitor BP Check injection site Monitor for evidence of allergic reactions

CAD

CAD- risk factors Atherosclerosis Metabolic syndrome Genetics Smoking High cholesterol Hypertension Diabetes Obesity High LDL Low HDL Sedentary lifestyle Stress

covid 19

COVID-19: Prevention, medication/treatment S/S: Most Common Symptoms Fever or chills Cough Shortness of breath or difficulty breathinG Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Nausea or vomiting Diarrhea Abdominal pain Unique Features in Some Patients Conjunctivitis Prothrombotic state (venous thromboembolic disease) Neurologic findings (encephalopathy with agitated delirium) Dermatologic findings, especially reddish nodules on distal digits (in young adults) Indications for Emergency Interventions Trouble breathing Persistent pain or pressure in the chest New confusion Inability to wake or stay awake Bluish lips or face (cyanosis) Prevention: AIRBORNE The highly contagious nature of the disease and the need for the use of techniques/interventions that more easily disperse droplets to others (e.g., suctioning, intubation) requires extraordinary containment measures during all aspects of care. PPE: When caring for a patient with COVID-19, it is critical that health care providers wear an N95 respirator mask (with a face shield whenever possible), gowns, shoe covers, gloves, and goggles (if no face shield is available). Inhaled medications should be delivered by metered dose inhalers with spacer devices versus given by nebulizer to avoid aerosolization of COVID-19. Physical distancing between patients and among health care providers, when not providing direct care, is recommended Teach family members to monitor themselves for illness, especially respiratory infection, for at least 2 weeks after the last contact with the patient. Medication/Treatment: One new and not yet approved drug, the IV antiviral agent remdesivir, received emergency use authorization by the U.S. Food and Drug Administration Mixed results have arisen regarding treatment with certain drugs used for other disorders; true and reliable efficacy cannot be determined without large, randomized, and controlled clinical trials. Current evidence shows that dexamethasone, other glucocorticoids, convalescent plasma, and other antibody-based therapies are used in treatment. Other new and existing antiviral drugs are in early-phase trials to measure activity against replication of COVID-19.

Pressure ulcer-care/nursing interventions, prevention, causes, stages of ulcers. Know nursing diagnoses r/t pressure ulcers and how to implement the steps of the nursing process for a patient with a pressure ulcer.

Causes: Compression of skin and underlying soft tissue between bony prominence and external surface for extended period Mechanical forces create ulcers: pressure, friction, and shear Commonly occur over sacrum, hips, and ankles but can occur anywhere. Nasal cannula that is too tight can cause a pressure ulcer Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and oxygenation and, eventually, leading to cell death. Ulcers occur most often in people with limited mobility because they cannot change their position to relieve pressure. Patients who cannot feel or communicate the pain that occurs with unrelieved pressure are more likely to develop pressure ulcers. Once formed, these chronic wounds are slow to heal, resulting in increased morbidity and health care costs. Complications include sepsis, kidney failure, infectious arthritis, and osteomyelitis. Excessive skin moisture, such as urinary or fecal incontinence, also increases the risk for skin damage. Nutrition status is an important concern. Protein malnutrition makes normal tissue more prone to breakdown and also delays healing Pressure is determined by the amount and distribution of weight exerted at the point of contact and the density of the contacting surface Pressure occurs when the patient is positioned on a hard surface that does not diffuse the weight, such as when lying on a hard floor for hours after a fall or when remaining in the same position too long. Unrelieved pressure leads to ischemia, INFLAMMATION, and tissue necrosis. Friction occurs when surfaces rub the skin and irritate or directly pull off epithelial tissue. Such forces are generated when the patient is dragged or pulled across bed linen. Shearing forces are generated when the skin itself is stationary and the tissues below the skin (e.g., fat, muscle) shift or move. A shear injury usually occurs when a patient is in a wheelchair or in bed in a semi-sitting position and gradually slides downward. The skin over the sacrum may not slide down at the same pace as the deeper tissues, mechanically "shearing" the skin, causing blood vessels to stretch and break. Shearing leads to soft-tissue ischemia and deep tissue injury, even though no external break in skin integrity is observed. Prevention: Braden Scale Assesses the risk of developing a pressure ulcer Very high risk: 9 or less High risk: 10-12 Moderate risk: 13-14 Mild Risk: 15-18 No Risk: 19-23 Sensory perception measures a patient's ability to detect and respond to discomfort or pain that is related to pressure on parts of their body Moisture: assesses the degree of moisture the skin is exposed to. Maceration and erosion of the epidermal layer Activity: category looks at a patient's level of physical activity since very little or no activity can encourage atrophy of muscles and breakdown of tissue Mobility: patient's ability to adjust their body independently Nutrition: assessment of a patient's nutritional status looks at their normal patterns of daily nutrition. Eating only portions of meals or having imbalanced nutrition can indicate a high risk in this category Friction and Shear: it looks at the amount of assistance a client needs to move and the degree of sliding on beds or chairs that they experience. Sliding motion can cause shear- skin and bone are moving in opposite directions causing breakdown of cell membranes and capillaries Calazime-Nourishes skin, helps treat and prevent diaper rash, wet and cracked skin Calazime dries light exudates from compromised skin Menthol cools irritated skin and calms inflamed tissue Semi-breathable, long-lasting barrier protects torn or exposed skin against harmful stimuli Nourishes skin with amino acids, antioxidants and pain control ingredients Non-allergenic Non-sensitizing Preventing Pressure Ulcers 2 steps early identification of high-risk patients and implementation of aggressive intervention for prevention w/use of pressure relief and or pressure relieving devices Positioning: Pad contact surfaces with foam, silicone gel, air pads, or other pressure-relieving pads. Do not keep the head of the bed elevated above 30 degrees to prevent shearing. Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her. When positioning a patient on his or her side, do not position directly on the trochanter. Re-position an immobile patient at least every 2 hours while in bed and at least every 1 hour while sitting in a chair. Do not place a rubber ring or donut under the patient's sacral area. May use a waffle cushion When moving an immobile patient from a bed to another surface, use a designated slide board well lubricated with talc or use a mechanical lift. Place pillows or foam wedges between two bony surfaces. Keep the patient's skin directly off plastic surfaces. Keep the patient's heels off the bed surface using bed pillow under ankles. Nutrition: Ensure a fluid intake between 2000 and 3000 mL/day. Help the patient maintain an adequate intake of protein and calories. Skin Care: Perform a daily inspection of the patient's entire skin. Document and report any manifestations of skin infection. Use moisturizers daily on dry skin and apply when skin is damp. Keep moisture from prolonged contact with skin: Dry areas where two skin surfaces touch, such as the axillae and under the breasts. Place absorbent pads under areas where perspiration collects. Use moisture barriers on skin areas where wound drainage or incontinence occurs. Do not massage bony prominences. Humidify the room. Skin Cleaning: Clean the skin as soon as possible after soiling occurs and at routine intervals. Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence. Use tepid rather than hot water. In the perineal area, use a disposable cleaning cloth that contains a skin barrier agent. While cleaning, use the minimum scrubbing force necessary to remove soil. Gently pat rather than rub the skin dry. Do not use powders or talcs directly on the perineum. After cleansing, apply a commercial skin barrier to those areas in frequent contact with urine or feces. Causes: prolonged bedrest, immobility, incontinence, diabetes mellitus, inadequate nutrition or hydration, altered mental status, peripheral vascular disease Stages: Stage 1: skin intact, area does not blanch and is usually over a bony prominence Compare these areas with adjacent or opposite areas to assess skin color, skin temperature, skin consistency, sensation Stage 2: skin is not intact Partial thickness skin loss of epidermis or dermis Ulcer is superficial, may appear as abrasion, blister, or shallow crater Bruising not present Stage 3: full thickness skin loss, subq and underlying fascia may be damaged or necrotic Bone tendon, muscle NOT exposed May have undermining and tunneling Check length, depth, and width Undermining is caused by erosion under the wound edges, resulting in a large wound with a small opening. Much like and iceberg, what you see on the surface is not indicative of what lies below Undermining is in multiple direction Tunneling is one direction Stage 4: full thickness with exposed or palpable muscle, tendon, or bone Undermining and tunneling common with sinus tracts possible Slough and eschar often present slough is a yellow fibrinous tissue that consists of fibrin, pus, and proteinaceous material. Slough can be found on the surface of a previously clean wound bed and it is thought to be associated with bacterial activity. Discharging, blind-ended track that extends from the surface of the skin to an underlying abscess/cavity. May be caused by infection, liquefaction or a foreign body. - Allow cleansing and draining. - Do not plug. - Protection of surrounding skin Unstageable pressure ulcer: full thickness and the base is covered by slough or eschar, obscuring the true depth of the wound Nursing Diagnoses: impaired bed mobility, imbalanced nutrition less than body requirements, acute pain, impaired skin integrity (stage 1 and 2), impaired tissue integrity (stage 3 and 4), risk for infection, risk for pressure ulcer

patient with a chest tubeP

Chest Tube Drainage System The Pleur-evac & Atrium are common chest drainage systems that employ a 3 chamber system 1. Collection (Drainage) Chamber - drainage is monitored & measured closely and is part of I/O ; drainage should never completely fill the chamber and get into the tubes (tension Pneumo) 2. Water Seal- prevents air from moving back up the tubing and reentering the pleural space; should always contain 2cm of water to prevent air from returning to the patient (serves as a one-way valve), 3. Suction - regulates suction, typically -20 cmH20, can be wet or dry suction, may be connected to wall suction Nursing Management Monitor tidaling: movement of water up and down with respirations in water seal chamber (normal) Monitor for continuous bubbling in water seal chamber (means air leak is present) Drainage: varies but look for drastic changes from hour to hour... greater than 70-100 mL per hour call MC, or if very bloody and was not before...could be a problem Pain management: may need meds and splinting to cough and deep breathe Subcutaneous air; palpate for 'rice crispy' feeling around insertion site, chest, neck Troubleshooting If chest tube come disconnected from chest tube drainage system: palace tube in bottle of sterile water, monitor patient, call MD If a chest tube comes out of the patient, cover the chest tube incision site with sterile dressing; tape on three sides, so some air can escape. Monitor pt and call MD Do not clamp or milk tube unless instructed to do so. excessive bubbling in water seal chamber, tube becomes disconnected, system breaks, excessive drainage, patient pulls chest tube out Nursing assessment/monitoring: Nursing care priority is to ensure the integrity of the system, promote comfort, ensure patency, and prevent complications. Bubbling of the water in the water seal indicates air drainage from the patient. Patient: ensure that the dressing on the chest around the tube is tight and intact. Assess for difficulty breathing, assess pulse ox. Listen to the lung sounds in each lung. Check alignment of trachea. Check tube insertion site for the condition of the skin. Observe for signs of infection or excessive bleeding. Check to see if tube eyelets are visible. Assess for pain and its location and intensity. Assist patient to deep breathe, cough, and use incentive spirometry. Reposition patient that reports burning in the chest Drainage system: do not stir up the chest tube. Keep the system lower than the patient's chest. Keep the tubes as straight as possible from the patient to the suction. Ensure it is securely taped to the connector. Assess bubbling in the water-seal chamber-should be gentle bubbling on exhalation, forceful cough, position changes. Assess for tidaling. Check the water level in the seal chamber. Only clamp for brief periods when changing the drainage system or when checking for air leaks. Empty collection chamber or change the system before the drainage makes contact with the bottom of the tube. When a sample of drainage is needed for culture, obtain it from the chest tube. Interventions: oxygen therapy when the patient is hypoxemic, even if it isn't severe, it may be ordered as humidified oxygen to reduce anxiety. Bronchodilators and corticosteroids for the patient with bronchospasm, inflammation, and edema. Sometimes mucolytics can be prescribed and antibiotics in the case of infection. Radiation therapy can relieve hemoptysis, obstruction of the bronchi and great veins, difficulty swallowing from esophageal compression, and pain from bone metastasis. Thoracentesis is performed when pleural effusion is a problem for the patient with lung cancer. It is fluid removal by suction after the placement of a large needle or catheter in the intrapleural space.

thrombolytics

Contraindications: recent abdominal surgery or stroke, prior intracranial hemorrhage, known cerebral vascular lesions, known intracranial neoplasm, suspected aortic dissection, active bleeding or bleeding diathesis, significant closed head or facial trauma in the last 3 months, hx of chronic hypertension, severe uncontrolled hypertension, dementia or known intracranial pathology not covered, traumatic or prolonged CPR or major surgery, recent internal bleeding, noncompressible vascular punctures, prior exposure or allergic reaction to streptokinase/anistreplase, pregnancy, active peptic ulcer, current use of anticoagulant

nitroglycerin

Coronary vasodilator, antianginal Increases collateral blood flow toward the subendocardium, and dilates coronary arteries and decreases myocardial oxygen demand by peripheral vasodilation, which decreases both preload and afterload Monitor BP and watch for hypotension, monitor for headache and lightheadedness, do not give to pt taking ED drugs, for the sublingual tabs and spray, pt should lie down while taking, assess pain: duration, time started, activity being performed, character

Pre-operative factors that increase risks during surgery, and age-related risk factors, medications that may increase risks during surgery

Decreased immunity, diabetes, pulmonary and cardiac diseases, hemodynamic instability, multi-system disease, coagulation defect or disorder, anemia, dehydration, infection, hypertension, hypotension, any chronic disease Malnutrition, obesity, drug, tobacco, or illicit substance use or abuse, altered coping ability, herbal use Malignant hyperthermia, cancer, bleeding disorder, anesthesia reactions or complications Age older than 65: cardiac problem, decreased cardiac output, low blood pressure, sensory deficits, lower reaction time, lower lung elasticity, osteoporosis and arthritis, dry skin, greater risk for damage, greater risk for infection Medications: antihypertensives, tricyclic antidepressants, anticoagulants, NSAIDs, immunosuppresives

cardio version vs defibrillation

Defibrillator can resolve pulseless ventricular tachycardia/fibrillation Cardioverter is implanted for patients with one or more episodes of spontaneous sustained v tach Cardioversion is synchronized countershock, used in emergencies for unstable ventricular/supraventricular tachydysrhythmias, used electively for stable tachydysrhythmias resistant to medical therapies Defibrillation is asynchronous countershock that depolarizes critical mass of myocardium simultaneously to stop reentry circuit and allow sinus node to regain control CLASS Q: Discuss the care of a patient undergoing synchronized cardioversion, when would this be indicated and what is the nursing care involved? 12-lead ECG to obtain baseline Emergencies for unstable tachydysrhythmias like VT and SVT Electively for stable tachydysrhythmias like afib Low-energy shock that is timed to be synchronized to be delivered with the QRS complex Used to depolarize the tissue involved in cardiac contractility

Glucose regulation and homeostasis- review the patho

Diabetes mellitus is a common, chronic, complex disorder of impairment nutrient metabolism, especially glucose Although all nutrients are affected, glucose regulation is impaired first, which then changes protein & fat metabolism Glucose regulation is the process of maintaining optimal blood glucose levels, also known as glycemic control Many problems and life-shortening complications can be due to impaired regulation Patho review : Diabetes has many subtypes, and all have the main feature of chronic hyperglycemia resulting from impaired processes in glucose regulation that include reduced insulin secretion or reduced insulin action or both The disease is classified by the underlying problems causing lack of insulin or its action & the severity of insulin deficiency The pancreas regulates glucose regulation Glucagon is a hormone that has balancing actions opposite those is insulin It prevents hypoglycemia by triggering the release of glucose from storage sites in the liver and skeletal muscle. Sometimes called "hormone of starvation" Insulin prevents hyperglycemia by allowing body cells to take up, use, and store carbohydrate, fat, and protein. Sometimes called "hormone of plenty" bc it is secreted when food intake is high and works to move glucose from blood into cells to keep blood glucose levels in the normal range Insulin is the lock and key for glucose to move into cell membranes Several organs play a role in glucose regulation Glucose is the main fuel for central nervous system cells Brain cannot produce or store much glucose, it needs a continuous supply from the blood to prevent neuron dysfunction and cell death Glucose is stored as glycogen in the liver and skeletal muscles and fatty acids as stores as triglycerides in fat cells Insulin exerts many effects on metabolism and cellular processes in all tissues and organs In the liver, insulin promotes the production and storage of glycogen (glycogenesis) at the same time that it inhibits glycogen breakdown into glucose (glycogenolysis). It increases protein and lipid synthesis and inhibits ketogenesis (conversion of fats to acids) and gluconeogenesis (conversion of proteins of to glucose) In muscle, insulin promotes protein and glycogen synthesis In fat cells, it promotes triglyceride storage Overall, insulin keeps blood glucose levels from beginning too high and helps keep blood lipid levels in the normal range

Diabetic Ketoacidosis vs. hyperosmolar non-ketotic syndrome- differences of each, priorities of treatment and nursing care, labs

Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones Develops when body can't produce enough insulin Without insulin your body begins to break down fat as fuel This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated Diabetic Ketoacidosis (DKA) Hyperglycemic-Hyperosmolar State (HHS) Onset Sudden Gradual Precipitating factors Infection Infection Other stressors Other stressors Inadequate insulin dose Poor fluid intake Symptoms Ketosis: Kussmaul respiration, "rotting fruit" breath, nausea, abdominal pain Altered central nervous system function with neurologic symptoms Dehydration or electrolyte loss: polyuria, polydipsia, weight loss, dry skin, sunken eyes, soft eyeballs, lethargy, coma Dehydration or electrolyte loss: same as for DKA Laboratory Findings Serum glucose >300 mg/dL (16.7 mmol/L) >600 mg/dL (33.3 mmol/L) Osmolarity/osmolality Variable >320 mOsm/L (mOsm/kg) Serum ketones Positive at 1:2 dilutions Negative Serum pH <7.35 >7.4 Serum HCO3 − <15 mEq/L (mmol/L) >20 mEq/L (mmol/L) Serum Na+ Low, normal, or high Normal or low BUN >30 mg/dL (10 mmol/L); elevated because of dehydration Elevated Creatinine >1.5 mg/dL (60 mcmol/L); elevated because of dehydration Elevated Urine ketones Positive (THINK KETOacidosis) Negative

ABG interpretation

Drawn from artery- radial, brachial, or femoral pH measures hydrogen ion concentration, 7.35-7.45 PCO2: partial pressure of co2 in arteries. 35-45 Bicarb: serum bicarbonate, 22-26 PaO2: arterial oxygen level, 80-100 Partial compensation when pH is still outside of range Full compensation if pH is within normal range

complications of MI to include heart failure

Dysrhythmias, heart failure, cardiogenic shock Assessment/lab values Evaluate reports of pain, obtain vital signs, ensure IC access Normal Cardiac Troponin T <0.10ng/mL Normal cardiac troponin I <0.03ng.mL Treatment - PCI, CABG and TPA, and Activase PCI: percutaneous coronary intervention can remove clot and deliver thrombolytics, it can reopen the clotted coronary artery and restore perfusion, performed within 2-3 hrs of onset of symptoms Can be an angioplasty (forces plaque against vessel wall to increase diameter of the vessel) Stent: expandable mesh is placed to hold the vessel open, post-op requires antiplatelet therapy CABG: most common type of cardiac surgery and most common procedure for older adults The pts occluded arteries are bypassed using their own vessels (internal mammary gland is popular) or synthetic grafts, it is indicated when pts do not respond to management of CAD or when progression is evident Angina w >50% occlusion of left main coronary artery that cannot be stented, unstable angina with severe two vessel disease, ischemia with HF, acute MI w cardiogenic shock, valvular disease, coronary vessels unsuitable for PCI TPA Activase

labs and abg's

Electrolytes: Sodium (Na): 135-145 mEq/L Potassium (K): 3.8-5 mEq/L Calcium ( C): 8.6-10.2 mEq/L Magnesium (Mg): 1.3-2.3 mEq/L ABGs: pH 7.35-7.45 PCO2 35-45mmHg HCO3 22-26 mEq/L PaO2 80-100 mmHg Lactate 3-7 mg/dL (0.3-0.8 mmol/L) CBC: Hemoglobin Males 13-18 g/dL blood Females 12-16 g/dL Hematocrit Males 42-50% Females 40-48% WBC: normal count is between 5000 and 10,000 cells RBC: 4-6 million cells/ microLiter of blood PTT: PT: INR: 1 mg = 1000 mcg 5 ml = 1 tsp 3 tsp = 1 tbsp 15 ml = 1 tbsp 30 mL = 1 oz 8 oz = 1 cup 1 kg = 2.2 lb

hypertension

Elevated: 120-129, and diastolic greater than 80 Stage 1 HTN: S 130-139, and D greater than 80 Stage 2 HTN: S greater than 140 or D greater than 90 Hypertensive crisis: S greater than 180 or D greater than 120 In the US, one in every three adults has HTN. It can lead to stroke, MI, PVD, and kidney failure. Hypertensive crisis Patients who stop taking meds or not treated adequately BP greater than 180/120 Can cause organ damage in kidneys or heart May have symptoms: HA, dizziness, nose bleed, anxiety, blurred vision, neuro sx, chest pain Want to lower BP slowly (no more than 25% in 2-6 hrs) Hypertensive emergency drugs: usually IV Nitroprusside Nicardipine Labetalol Risk factors and possible causes of HTN, possible complications of HTN, patient teaching Essential Hypertension Most common type: not caused by an existing health problem Results in damage to vital organs Causes hyperplasia (thickening) or arterioles Etiology: Obesity Smoking Stress Family history Increased age (over 60 or post menopausal) Physical inactivity Excessive ETOH intake African-American ethnicity (very high prevalence) Secondary Hypertension Common causes: Renal disease Primary aldosteronism Pheochromocytoma Cushing's syndrome Drugs ex. Oral contraceptives, glucocorticoids Assessment Patient and family history Et two readings per visit if elevated, both arms Physical assessment: think about end organ damage (eyes, kidneys, heart) laboratory/diagnostic tests: urinalysis, electrolytes, BUN/Cr, lipid levels, echo, ECG Lifestyle, diet, smoking, stress, ETOH Assess risk factors, age, ethnicity, family history diet history, alcohol consumption, drug use, history of renal or CV disease Increased BP in both arms with accurate cuff (determines orthostatic changes, increased incidence of hypertension in pt with atherosclerosis), palpate all pulses and note differences, palpate each carotid separately, check temperature differences in lower extremities, check cap refill Health Teaching Sodium restriction Weight reduction Reduced alcohol intake Exercise Decrease stress levels Quit smoking Risk Factors: Age, ethnicity, family and diet history, alcohol consumption, drug use, history of renal/CV disease Possible Causes: kidney disease, aldosteronism, pheochromocytoma, Cushing's disease, coarctation of the aortas, brain tumors, encephalitis, pregnancy, oral contraceptives/drugs, smoking, hyperlipidemia, >60/postmenopausal, excessive sodium and caffeine, obesity, excessive/continuous stress Pt teaching: Emphasize intake of vegetables, fruits, and whole grains, low-fat dairy products, poultry, fish, legumes, nontropical veg oils, nuts, limit sweets, sugary beverages, red meats, lower sodium, engage in aerobic physical activity 3-4 times a week, reduce weight, decrease stress, stop smoking and tobacco Possible complications: hypertensive urgency/crisis, stroke, heart disease, plaque formation (atherosclerosis) and hardening of the arteries (arteriosclerosis) -> MI, PE, and stroke

What is important to cover in pre-operative teaching?

Fears and anxieties Surgical procedure Preoperative routine- NPO, blood samples, showering Invasive procedures (lines, catheters) Coughing, turning, deep breathing Incentive spirometer How to use How to tell when used correctly Lower extremity exercises Stockings and pneumatic compression devices Early ambulation Splinting Pain management

corticosteroids: inhaled corticosteroids and IV/oral ex. fluticasone and prednisone/solumedrol

Fluticasone : Class : corticosteroids , inhalation Action : decreases inflammation by inhibiting mast cells, macrophages, and leukotrienes ; anti inflammatory & vasoconstrictor properties Therapeutic outcome : decreased severity of asthma Uses : prevention of chronic asthma during maintenance treatment in those requiring oral corticosteroids ; nasal symptoms of seasonal/ perennial & allergic/nonallergic rhinitis Prednisone : Class : corticosteroids Action : decrease inflammation by increasing capillary permeability & lysosomal stabilization, minimal mineralocorticosteroid activity Therapeutic outcome : decreased inflammation, decreased adrenal insufficiency Uses : severe inflammation, neoplasms, multiple sclerosis, collagen disorders, dermatologic disorders Contraindications : hypersensitivity

Skin infections: know the main differences between fungal, bacterial, and viral infections, along with the names of the main ones

Fungal: Dermatophyte infections, especially superficial infections, differ in lesion appearance, body location, and species of the organism. Itching it common. Can be moist, red, irritated appearance. Anywhere on the body- common areas are perineum, vagina, axillae, under the breasts, scaling, and central clearing Tinea capitis, can be transmitted by inanimate objects, combs, hats, pillowcases, and other objects and also poor hygiene Tinea corporis (ringworm) Candida albicans fungal infection of the mouth. Easily grown in warm, moist environments. Bacterial: Faruncle- (boil) can be bacterial or fungal infections of hair follicle. small, tender, erythematous nodules become pus filled and more tender over time. Lesions may be single or multiple and also recurrent. Regional lymphadenopathy is sometimes present; fever is rare. Occasional scarring results. Typically caused by staph aureus- mostly communal like dorms or prisons Folliculitis- Isolated erythematous pustules occur singly or in groups; hairs grow from centers of many of the lesions. Occasional papules are present. There is little or no associated discomfort. There is no residual scarring. Areas of hair-bearing skin, especially buttocks, thighs, beard, scalp, abdomen, posterior neck regions, and axillae Cellulitis- Localized area of inflammation may enlarge rapidly if not treated. Redness, warmth, edema, tenderness, and pain are present. On rare occasions, blisters are present. Cellulitis is often accompanied by lymphadenopathy and fever. Lower legs, areas of persistent lymphedema, and areas of skin trauma (e.g., leg ulcer, puncture wound) Viral: *Herpes zoster (shingles). most often in older people or in anyone who is immunosuppressed for any reason. The disorder can be accompanied by fever and malaise. It is contagious to people who have not previously had chickenpox and have not been vaccinated against the disease. Keeping patients with fluid-filled blisters separated from other patients until the lesions have crusted reduces the risk for transmitting the virus to others. Complications include full-thickness skin necrosis, Bell's palsy, or eye infection, and scarring if the virus is introduced into the eye. Pathway of a spinal or cranial nerve. Occurs on anterior and posterior trunk following involved dermatone *Postherpetic neuralgia: severe pain persisting after the lesions have resolved. is common in older patients. Early diagnosis of shingles and prompt treatment with antiviral drugs help decrease the duration and severity of postherpetic neuralgia. Antiseisure meds that can used for pain, Gabapentin (Neurontin), Pregabalin (Lyrica) *Chronic herpes simplex infection. Grouped vesicles are present on an erythematous base. Vesicles evolve to pustules, which rupture, weep, and crust. Older lesions may appear as punched-out, shallow erosions with well-defined borders. Lesions are associated with itching, stinging, or pain. Secondary bacterial infection with necrosis is possible in immunocompromised patients. Type 1 classically on the face and type 2 on the genitalia, but either may develop in any area where inoculation has occurred; recurrent infections occur repeatedly in the same skin area Herpetic whitlow is a form of herpes simplex that occurs on the fingertips of health care personnel who come into contact with viral secretions. It can be spread easily to patients and can become severe in immunosuppressed patients. Herpes simplex 1. Grouped vesicles are present on an erythematous base. Vesicles evolve to pustules, which rupture, weep, and crust. Older lesions may appear as punched-out, shallow erosions with well-defined borders. Lesions are associated with itching, stinging, or pain. Secondary bacterial infection with necrosis is possible in immunocompromised patients. Type 1 classically on the face and type 2 on the genitalia, but either may develop in any area where inoculation has occurred; recurrent infections occur repeatedly in the same skin area

Basics about the types of anesthesia; patient safety for local, vs regional vs general

General: reversible loss of consciousness induced by inhibiting neuronal impulses in areas of the CNS. Results in analgesia, amnesia, muscle relaxation, and unconsciousness. Through IV or inhaled Complications: malignant hyperthermia, overdose, unrecognized hypoventilation, intubation complications Local: topically- skin or mucous membranes of the area and by local infiltration- injected into the tissue Regional: type of local anesthesia that blocks multiple peripheral nerves and reduces sensation in a specific body region. Field block, nerve block, spinal and epidural Complications of local or regional: patient sensitivity to anesthetic agent, incorrect delivery technique, systemic absorption, and overdose. Abscesses from contamination. Necrosis and gangrene from prolonged blood vessel constriction

Diabetic patient teaching-examinations (eyes, feet, A1C, blood glucose) how often needed, normal vs abnormal lab values

Goal is to normalize blood glucose To maintain ADA Treatment Goals of A1C ≤ 7% Pre-prandial BG 70-130 mg/dL Post prandial BG <180 mg/dL Nutrition: Individualized Plan General Recommendations <10% of daily calories from saturated fat; minimize trans fat; have a source of Omega 3 fatty acids 2-3x/week Limit dietary cholesterol to ≤ 300mg CHO- avoid empty calories, get at least 25g fiber; carb counting/ratios Alcohol Limit 1/day for women and 2/day for men with meals, can cause hypoglycemia Exercise: Regular exercise is essential & the most beneficial Recommend at least 150 min/week of moderate-intensive (50-70% MHR) aerobic activity divided into 3 days or 75 min/week of vigorous aerobic activity (avoid >2d between) Exercise in the adult with diabetes can cause hypoglycemia because of increased muscle glucose uptake and inhibited glucose release from the liver Teach patient about relationship b/w regularly scheduled exercise and blood glucose levels, blood lipid levels, and complications with diabetes Reinforce level of exercise based on physical health Wear appropriate footwear during exercise Stay hydrated Not to exercise in extreme heat or cold Don't exercise w/in 1 hour of insulin injection Do not exercise unless blood glucose is at least 80 and less than 250 Have a carbohydrate snack before exercising Carry simple sugar to during exercise Always have diabetes identification with them Check blood glucose frequently Medication teaching : Drug therapy is indicated when a patient w/ type 2 diabetes does not achieve glucose control w/ diet, exercise, and stress management Patients with type 1 diabetes require insulin therapy to control blood glucose The choice for antidiabetic drugs is based on cost, the patient's ability to manage multiple drug dosages, age, & response to other drugs Short-acting are preferred in older patients, those with irregular eating schedules, or those with liver, kidney, or cardiac dysfunction Long-acting agents w/ once-a-day dosing are better for adherence Beta-cell function in type 2 often declines over time, reducing effectiveness of some drugs Treatment with type 2 may require insulin therapy either alone or with antidiabetic drugs Metformin : All international guidelines consider metformin & lifestyle intervention as first-line treatment for type 2 to improve glycemic control Metformin can cause lactic acidosis in patient w/ kidney impairment & should not be used by anyone w/ kidney disease To prevent lactic acidosis & acute kidney injury, the drug is withheld before and after using contrast medium or surgical procedures Lactic acidosis is a form of metabolic acidosis that begins when a person overproduces or underutilized lactic acid, and cannot adjust to changes Foot care : all diabetic patients should receive full foot exams yearly to assess for sensation, foot structure, vascular status & skin integrity Inspect between the toes specifically See HCP immediately if you see a blister, skin breakdown, or infection : wrap in dry sterile dressing, do not use adhesive tape , do not treat with home remedies , do not smoke Do not use excessively cold or hot water for bathing Don't treat problems on your own Wear clean cotton socks daily and change often : protects feet and keeps them warm and dry Don't wear same shoes 2 days in a row and wear breathable shoes Do not cross legs or wear garters or tight stockings that constrict blood flow Eyes/ blind patients : There are insulin syringe options that allow for blind or those with vision problems to accurately administer the medication themselves at home Different colors for those who have vision impairments Bands on the syringes for certain types of insulins for those who are blind A thumb-wheel insulin draw up that clicks for every unit that the patient draws up to know how many they are getting To avoid air bubbles, teach the patient to move the plunger up and down three times when drawing up medication to hopefully avoid getting air bubbles in the syringe

Disorders of the adrenal gland- hyper/hypo adrenalism (Addison's vs. Cushing's disease), pheochromocytoma

HyperAdrenalism: Cushing's Disease | Manifestations Cushings: an excess of cortisol Excessive glucocorticoids are excreted from the adrenal cortex. The most common cause of Cushing syndrome is either adrenocortical hyperplasia or adrenocortical adenoma (tumor). Hyperglycemia which may develop into diabetes weight gain central type obesity with "buffalo hump," heavy trunk and thin extremities fragile thin skin ecchymosis Striae weakness Lassitude sleep disturbances Osteoporosis muscle wasting Hypertension "Moon-face" Acne More likely to get infection slow healing virilization in women loss of libido mood changes Labs: ↑ Na+ ↑ glucose, ↓ K+ and Ca, serum cortisol increased HypoAdrenalism: Addison's Disease | Manifestations Adrenal insufficiency; lack of cortisol and aldosterone Pheochromocytomas are tumors that originate most commonly in the adrenal medulla and result in excessive secretion of catecholamines, resulting in life-threatening high blood pressure.

20% dextrose and insulin IV...when would this be used?

Hyperkalemia because it pulls potassium back into the cell

Most common signs/sx of electrolyte imbalances: hyper/hypokalemia

Hyperkalemia: above 5 Increases cell excitability Cardiac problems are most severe Bradycardia, hypotension, tall peaked T waves, prolonged PR intervals, flat or absent P waves, wide QRS complexes Twitching of muscles, burning and tingling sensations in the early phases. Weakness of legs and arms in the later stages Increased bowel motility including diarrhea If caused by kidney failure, elevated serum creatinine and blood urea nitrogen, decreased blood pH, and low or normal hematocrit and hemoglobin Hypokalemia: below 3.5 Reduces excitability of cells Weakness- hand grip, standing, deep tendon reflexes Threaded pulse, arrythmias/irregular heartbeat, Flat T waves and U waves develop Decreased bowel motility Paralytic ileus

Most common signs/sx of electrolyte imbalances: hyper/hypomagnesemia

Hypermagnesemia: above 2.6 Bradycardia, peripheral vasodilation, and hypotension Prolonged PR interval and a widened QRS complex Cardiac arrest is possible Depressed nerve impulse transmission Drowsiness and lethargic Reduced or absent deep tendon reflexes Voluntary skeletal muscle contractions become progressively weaker and finally stop Hypomagnesemia: below 1.8 Linked with hypocalcemia Increased membrane excitability and accompanying serum calcium and potassium imbalances Risk for hypertension, atherosclerosis, hypertrophic left ventricle, and dysrhythmias Potassium levels are low Increased nerve impulse transmission from nerve to nerve or nerve to muscle Decreased peristalsis

Most common signs/sx of electrolyte imbalances: hyper/hyponatremia

Hypernatremia: above 145 Decreased excitability of cells Attention span and cognition function, agitated, confused, lethargic Muscle twitching and irregular contractions, as it progresses, muscles become weaker CV: decreased contractility, pulses increased with hypovolemia Decreased BP, thread pulse, tachycardia Hyponatremia: below 135 Increased excitability of cells Changes in behavior, LoC, and cognition. Seizure, irritable, lethargic Neuromuscular: muscle weakness, deep tendon reflexes diminish GI: increased motility causing nausea, diarrhea, and abdominal cramping CV: (with hypovolemia) rapid, weak pulse, decreased BP. With hypervolemia- bounding pulse, with normal or high BP

Disorders of the thyroid and parathyroid gland (i.e. hypo/hyper of each)- associated labs, symptoms and treatment (surgery vs. radioactive iodine vs. medication)

Hyperthyroidism is the second most prevalent endocrine disorder, after diabetes mellitus. Graves' disease: the most common type of hyperthyroidism, results from an excessive output of thyroid hormones (autoimmune) May appear after an emotional shock, stress, or an infection Other causes: thyroiditis and excessive ingestion of thyroid hormone Affects women 8X more frequently than men (appears between second and fourth decade) Clinical Manifestations (thyrotoxicosis): 1. Heat intolerance. 2. Palpitations, tachycardia, elevated systolic BP. 3. Increased appetite but with weight loss. 4. Menstrual irregularities and decreased libido. 5. Increased serum T4, T3, decreased TSH (Lab) 6. Exophthalmos (bulging eyes) 7. Perspiration, skin moist and flushed ; however, elders' skin may be dry and pruritic 8. Insomnia. 9. Fatigue and muscle weakness 10. Nervousness, irritability, can't sit quietly. 11. Diarrhea. Treatment: They may start with Thionamide medications. PTU is used if woman is pregnant (although still has risks to fetus); monitor for drop in WBC's and liver toxicity. Methaimazole- do not use in pregnant women, will also monitor WBC's and liver fx. If medication is not effective, the pt. then may opt for radioactive iodine therapy OR surgery to remove the thyroid. Radioactive iodine treatment cannot be used in pregnant women. A dose of radioactive iodine is given to the patient The radioactive iodine wipes out the thyroid tissue and may result in a lifelong hypothyroidism in the patient (then they would take levothyroxine for the remainder of their life...but easier to give that then treat hyperthyroidism for life). Thyroid storm: lifethreatening event that occurs in patients with uncontrolled hyperthyroidism. Can be triggered by some stressor; trauma, surgery, infection, pregnancy, vigorous palpation of a goiter. Key manifestations: fever, tachycardia, HTN, confusion, restlessness, seizures. Hypothyroidism is the disease state caused by insufficient production of thyroid hormone by the thyroid gland. Main cause of hypothyroidism is an autoimmune disorder called Hashimoto's thyroiditis, where antibodies destroy the thyroid gland. Other causes of hypothyroidism are a result of treatment for hyperthyroidism, so surgery, radiation, or medications like lithium or PTU. Hyperparathyroidism Primary hyperparathyroidism is 2-4 X more frequent in women. Manifestations include: elevated serum calcium, bone decalcification, renal calculi, apathy, fatigue, muscle weakness, nausea, vomiting, constipation, hypertension, cardiac dysrhythmias, psychological manifestations Treatment: Parathyroidectomy, Hydration therapy Encourage mobility reduce calcium excretion Diet: encourage fluid, avoid excess or restricted calcium Hyperparathyroidism will cause hypercalcemia and hypophosphatemia Hypoparathyroidism Deficiency of parathormone usually due to surgery Results in hypocalcemia and hyperphosphatemia Manifestations include tetany, numbness and tingling in extremities, stiffness of hands and feet, bronchospasm, laryngeal spasm, carpopedal spasm, anxiety, irritability, depression, delirium, ECG changes Trousseau's sign and Chvostek's sign Managing it: Increase serum calcium level to 9—10 mg/dL / Calcium gluconate IV and magnesium IV / Cardiac monitoring / Neuromuscular activity monitoring / Diet high in calcium and low in phosphorus/ Vitamin D

Most common signs/sx of electrolyte imbalances: hypo/hypercalemia

Hypocalcemia: below 9 Overstimulation of nerves and muscles Charley horses, palmar flexion = positive Trousseau's sign, positive Chvostek's sign Paresthesia of hands and feet, worsening to twitching and numbness HR may be slower or slightly faster with a weak, thread pulse. If severe, hypotension and ECG changes of a prolonged ST and QT interval Increased peristalsis, may report cramping and diarrhea Bones are less dense, more brittle and fragile Hypercalcemia: above 10.5 Increased HR and BP but if very severe, slowed HR Cyanosis and pallor Dysrhythmias and a shortened QT interval More likely for blood clots and kidney stones Impaired perfusion- assess temperature, color, cap refill of feet Decreased deep tendon reflexes, muscle weakness without paresthesia Decreased peristalsis. Constipation, anorexia, nausea, vomiting, abdominal distention, and pain

Most likely causes of hypo/hypercalcemia and interventions to treat

Hypocalcemia: inadequate intake, lactose intolerance, malabsorption syndromes (celiac and chon's), inadequate intake of Vitamin D, kidney disease, diarrhea, wound drainage. Alkalosis, hyperproteinemia, removal or destruction of parathyroid Give calcium PO, IV, increase in food and increase vitamin D, low stimulating environment Hypercalcemia: excessive intake of calcium or vitamin D, kidney failure, hyperparathyroidism, immobility, hyperthyroidism, malignancy, dehydration Interventions: saline fluids to get rid of calcium by kidneys, cardiac monitoring, discontinue diuretics

Most likely causes of hypokalemia and interventions to treat

Hypokalemia: Inappropriate or excessive use of drugs: Loop Diuretics, Digitalis-like drugs, Corticosteroids, Increased secretion of aldosterone, Cushing's syndrome, Diarrhea, Vomiting, Wound drainage (especially GI), Prolonged nasogastric suction, Heat-induced excessive diaphoresis, Kidney disease impairing reabsorption of potassium, NPO. Alkalosis, hyperinsulinism, hyperalimentation, total parenteral nutrition, water intoxication, IV therapy with potassium poor solutions Interventions: Bananas, spinach, oranges, avocados. Potassium IV or PO (infuse slowly with pump), fall precautions

Most likely causes of hyponatremia and interventions to treat

Hyponatremia: Actual sodium deficits: excessive diaphoresis, diuretics, wound drainage, decreased secretion of aldosterone, hyperlipidemia, kidney disease, NPO, low-salt diet, cerebral salt-wasting syndrome, hyperglycemia. Dilution: excessive ingestion of hypotonic fluids, psychogenic polydipsia, freshwater submersion accident, kidney failure, irrigation with hypotonic fluids, heart failure Interventions: drug and nutrition therapy, IV saline infusions, fluid restriction, reduce diuretics, reduce oral fluid intake

Signs and symptoms of hypovolemia and dehydration vs. hypervolemia; sources of fluid loss and intake

Hypovolemia and Dehydration BP would be low (dizziness and light-headedness), HR increases, Respirations increase, temperature depends Specific gravity is elevated (above 1.03) Dark amber urine with a strong odor Elevated hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes Neck veins distended when laying down and flat when sitting Poor skin turgor, skin and oral mucosa is dry Neurologic: changes in mental status Urine output below 500 mL per day is concerning and weight loss of ½ of a pound Diarrhea, hemorrhage, vomiting, burns, diuretic, hyperventilation, difficulty swallowing, impaired thirst, unconsciousness, fever, impaired motor function Hypervolemia Increase in extracellular fluid and vascular volume Increase in BP, increased/pounding pulse, increased in respiratory rate, shallow respirations, shortness of breath Pitting edema, skin is cool to the touch Altered LOC, headache, visual disturbances, paresthesia, skeletal muscle weakness Increased GI motility, enlarged liver Serum electrolyte values are normal Decreased hemoglobin, hematocrit, and serum protein levels Excess fluid replacement, kidney failure, heart failure, long term corticosteroid therapy, syndrome of inappropriate antidiuretic hormone, psychiatric disorders with polydipsia, water intoxication Sources of fluid loss/intake Fluid loss: kidneys through urine, emesis, feces, drainage, blood loss, perspiration, vaporized through the lungs. Fluid Intake: oral fluids, parenteral fluids, enemas, irrigation fluids, solid foods, metabolism

KCl IV...how is it to be given?

IV very slowly Large bore needle Check for extravasation After diluting, give slowly- pump Never crush pills, give with or after meals

What is included in preoperative checklist?

Identification Belongings- in place or removed Stockings, voided, advance directives, iv started by, permission to speak to the family, pager #, informed consent signed and witnessed, site of surgery verified by surgeon and patient, history and physical on chart, pregnancy test date, type and screen verified with blood bank, test results, latex allergy, ID plate on chart, NPO List allergies Pre op meds and dosages Vital signs Risk for falls, communication barrier

hypersensitivity

Increased/excessive response to presence of antigen exposure Degree of reaction ranges from uncomfortable (itchy, watery eyes, sneezing) to life threatening (allergy asthma, anaphylaxis, bronchoconstriction, circulatory collapse) Type 1: Rapid Also called atopic allergy, most common type Some reactions occur only in areas of antigen exposure Caused by increased production of immunoglobulin E (IgE) antibody class Allergens contracted by inhalation (pollens, spores, animal dander, dust, grass, ragweed), ingestion (foods, food additives, drugs, biologic), injection (bee venom, drugs, biologic substances), contraction (latex, pollens, foods, environmental proteins) Anaphylaxis- blood vessel dilation, decreased cardiac output, bronchoconstriction Angioedema: severe reaction that involves all layers of the skin, mucous membranes, and subq tissues in the affected area

assessment of a patient with infective endocarditis

Infective endocarditis, also called bacterial endocarditis, is an infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve or a blood vessel. IE is uncommon, but people with some heart conditions have a greater risk of developing it ASSESSMENT: New Murmur, S3/S4 Fever assoc. with chills, night sweats, malaise and fatigue (infection s/s) *Heart failure - most common-- most common cause of infective endocarditis Anorexia, weight loss Arterial embolization (catheter inserted to help the blocked artery) Splenic infarction (blood flow to the spleen is lost, causing necrosis of spleen) Neurologic changes Petechiae Splinter hemorrhages (small black or red streaks in nail beds) INTERVENTIONS/TREATMENT: Diagnostics Positive Blood culture-- because it is caused by a bacterium Labs Echocardiography - evidence of endocardial involvement Interventions Antibiotic therapy - usu. 4-6 weeks (CVC) Penicillins and Cephalosporins Need to promptly recognize and treat "strep" throat to prevent rheumatic fever Repair of injured valve, removal of infected valve, draining of abscess

Phases of wound healing and mechanisms of wound healing

Inflammatory Phase: begins at the time of injury/cell death and lasts 3-5 days (reepithelization is 5-7 days) Characterized by vasoconstriction and clot formation At 10 minutes, vasodilation with increased capillary permeability and leakage of plasma into the surrounding tissue. WBCs migrate to the wound Clinical manifestations- local edema, erythema, and warmth are present Inflammation serves to control bleeding and prevent infection and sets the stage for healing because it signals cells that are responsible for repair and regeneration to come to the site of the injury Proliferative Phase: mitotic fibroblast cells migrate into the wound, attach to the framework, divide, and stimulate the secretion of collagen Begins about the 4th day and lasts 2-4 weeks Collagen together with ground substance builds tough and inflexible scar tissue Capillaries in areas surrounding the wound form "buds" that grow into new blood vessels Capillary buds and collagen deposits form the "granulation" tissue in the wound, and the wound contracts Epithelial cells grow over the granulation tissue bed Maturation Phase: Collagen is reorganized to provide greater tensile strength Begins as early as 3 weeks after injury and may continue for a year or longer Scar tissue gradually becomes thinner and paler in color The mature scar is firm and inelastic when palpated The remodeling phase completes the wound healing process and often takes several years. Beginning and overlapping with the proliferation phase, remodeling works to form and lyse collagen within a scar to help increase strength and skin integrity. It is during this phase that the initial 15%-strength scar eventually regains 80% of the skin's original strength. During the remodeling phase, scar tissue changes in appearance. In light-skinned individuals, the scar's color changes from pink or red to a white color as vascular changes occur. The diminished need for additional worker cells to repair the site reduces the need for additional vascular support. Scar tissue also becomes more flexible as it ages First intention: made by surgeon, edges are brought together Second intention: granulation and contraction, deeper tissue or wound, open wound with prolonged healing and scar tissue formation Third intention: delayed closure, high risk for infection with resulting scar, may leave wound open because of infection Mechanisms of wound healing: Say When skin injury occurs, the body restores tissue integrity through three processes: re-epithelialization, granulation, and wound contraction. The depth of injury and extent of tissue integrity loss determine to what degree each process contributes to wound healing. Partial Thickness Wound: damage to the epidermis, upper layers of the dermis Heal by re-epithelialization within 5-7 days Skin injury immediately followed by local inflammation Superficial with minimal loss of tissue integrity from damage to the epidermis and upper dermal layers. Heals by reepithelization and contraction of wound margins In a healthy person, healing of a partial-thickness wound takes about 5-7 days. This process is more rapid in skin that is hydrated, well oxygenated, and has few microorganisms Examples include skin tears, blisters, and stage 2 pressure ulcers Full-Thickness Wound: damage extends into lower layers of dermis, underlying subcutaneous tissue Must be filled with granulation tissue to heal Contraction develops in healing process Most of the epithelial cells at the base of the wound are destroyed and the wound cannot heal by re-epithelialization alone. Removal of damage tissue results in a defect that must be filled with scar tissue (granulation) for healing to occur During the second phase of healing, new blood vessels form at the base of the wound and the fibroblast cells begin moving into the wound space. These cells deposit new collagen to replace the lost tissue Heals by granulation, wound contraction, and epithelialization, take longer to heal and cannot be sutured

influenza

Influenza: s/s, Treatment, nursing care of the patient, prevention Seasonal influenza, or "flu," is a highly contagious acute viral respiratory infection that can occur at any age. Epidemics are common and lead to complications of pneumonia or death, especially in older adults or immunocompromised patients. Influenza A causes a moderate to severe infection. Influenza B usually causes mild illness in children. Droplets enter into the respiratory tract of the unaffected person and begin replication 24 hours before the appearance of symptoms. S/S: Rapid onset of severe headache, muscle aches, fever, chills, fatigue, and weakness. Adults are contagious from 24 hours before symptoms occur and up to 5 days after they begin. Sore throat, cough, and watery nasal discharge can also occur. Infection with influenza strain B can lead to nausea, vomiting, and diarrhea. Most patients feel fatigued for 1 to 2 weeks after the acute episode has resolved. Nursing Care of the Patient: Nurses need to perform an assessment of the patient with influenza include: History. Assess the patient's travel history, if any. Physical examination. Assess respiratory status for rate, depth, ease, use of accessory muscles, and work of breathing; auscultate the lung fields for the presence of wheezes, crackles (rales), rhonchi, or decreased breath sounds. Maintain patent airway- Administer oxygen as ordered; monitor oxygen saturation by pulse oximetry, and notify the physician of readings <90% or as prescribed by the physician Position patient in high Fowler's or semi-Fowler's position, if possible Administer bronchodilators as ordered Perform postural drainage and percussion, as ordered Encourage fluids, up to 3-4 L/day unless contraindicated Encourage deep breathing exercises and coughing exercises every 2 hours. Maintain a normal breathing pattern- Perform chest physiotherapy, chest percussion, and postural drainage as ordered Encourage patient to change position every 2 hours and as needed, and assist as needed Provide and encourage fluid intake of at least 2 L/day unless contraindicated. Achieve normal temperature- Monitor VS especially temperature, every 2-4 hours and as needed; utilize the same methods of temperature reading with each measurement Administer antipyretics as ordered Provide tepid sponge baths; and instruct patient/family in use of hypothermia blanket, reasons for use, signs, and symptoms of complications, etc. Achieve relief from pain- Administer analgesics as ordered Provide warm baths or heating pad to aching muscles Encourage gargling with warm water; provide throat lozenges as necessary Instruct patients or SO in deep breathing, relaxation techniques, guided imagery, massage, and other non pharmacological aids. Educate patients- Use limited amounts of time for teaching, with the provision of a quiet environment Inform people receiving the vaccine of the possible adverse effects and report them immediately Instruct patient and/or SO about influenza types, when typical outbreaks occur, and methods to avoid infection Instruct patient and/or SO about newer antiviral drugs, their effects, when to seek immediate medical attention, and side effects of medications Influenza Antivirals: Current recommendations for the treatment of influenza type A and B are oseltamivir or zanamivir. Zanamivir and oseltamivir should be taken within 48 hours of flu symptoms, but they are not substitutes for the influenza vaccines. PT TEACHING: Side Effects and Adverse Reactions of these two neuraminidase inhibitors include dizziness, headache, insomnia, vertigo, fatigue, and GI disturbances such as nausea, vomiting, and diarrhea. Prevention: Vaccinations for the prevention of influenza are widely available Although handwashing is a good way to prevent transmitting the virus, many people cannot wash their hands immediately after sneezing. The technique recommended by the CDC for controlling flu spread is to sneeze or cough into the upper sleeve rather than into the hand Pandemic Influenza: Many viral infections in animals and birds are not usually transmitted to humans. A few historic exceptions have occurred when these animal and bird viruses mutated and became highly infectious to humans. These infections are termed pandemic because they have the potential to spread globally and because the virus is new to humans who have no IMMUNITY to it.

What is informed consent, and the nurses' role?

Informed and involved in the decisions of their healthcare Patient has sufficient information to understand: the nature and reason of surgery, who will be performing surgery and whether others will be present All available options and the benefits and risks associated The risks associated and potential outcomes Risks associated with anesthesia Risks, benefits, and alternatives to blood or blood products used during the procedure Patient asks questions As a nurse, make sure the patient understands, even if it means having the surgeon come back Nurse witnesses the form, cannot get consent for the doctor Phone consent is appropriate if it is the only thing available

What is malignant hyperthermia? What are risk factors and triggers for it?

Inherited autosomal dominant muscle disorder that is an acute life-threatening complication of certain drugs used for general anesthesia. Inadequate thermoregulation. Causes increased calcium levels in muscle cells and increased muscle metabolism with leads to acidosis, cardiac dysrhythmias, and a high body temperature Tachycardia, dysrhythmias, tachypnea, muscle proteins in urine, jaw rigidity, body temp above 105 Dantrolene sodium is the medication of choice

common causes and interventions

Injection of bee venoms and drugs. Inhalation of pollen, dust, spores, animal dander, dust, grass, ragweed, ingestion of foods, food additives, drugs. Touched by latex

Types of insulin- use for different types, peak action, how to administer

Insulin is a hormone -carries insulin into the cell; without insulin, glucose cannot be used by the cells. Insulin "opens" the receptors to allow the glucose from the blood into the cells Overall, insulin keeps blood glucose levels from becoming too high and helps keep blood lipid levels in the normal range. When more glucose is present in liver cells than can be used for energy or stored as glycogen, insulin causes the excess glucose to be converted to free fatty acids (FFAs). Rapid acting Insulin Aspart (Novolog) Insulin Glulisine (Apidra) Human Lispro (Humalog) there is U-100 & U-200 Short acting Regular (Humulin R, Novolin R, ReliOn R) Humulin R (Concentrated U-500) Intermediate acting NPH (Humulin N, Novolin N, ReliOn N) There are also 70/30 & 75/25 mixes Long acting Insulin Glargine (Lantus) Insulin Glargine U-300 (Toujeo) Insulin Detemir (Levemir) Insulin Degludec U-100 & U-200 (Tresiba) Pharmacokinetics of Insulin Onset - Length of time before insulin reaches the bloodstream and begins lowering the blood glucose Peak time - Time during which insulin is at maximum strength in terms of lowering blood glucose Duration of Action - How long insulin continues to lower blood glucose Type Name Onset Peak Duration Rapid acting Aspart (Novolog) Glulisine (Apidra) Lispro (Humalog) Lispro U-200 ~15 min 30 minutes- 1 ½ hours 2 ½- 5 hrs -varies by type Short acting Regular human (HumulinR, Novolin R, ReliOn R) 30 min. 2-5 hrs 5-12 hrs -varies by type Humulin R (concentrated U-500) U-500 is 1 ½ hrs U-500 4-12 hrs U-500 24 hrs Intermediate Isophane insulin NPH (Humulin NPH, Novolin NPH, ReliOnNPH) 1 ½-4 hrs 4-14 hrs 10-24+ hrs 70/30 (N & R) 75/25 (N & R) 15-30 min 1-4 hrs 24 hrs Long acting Glargine (Lantus) Glargine U-300 (Toujeo) 2-4 hrs None 12 hrs 24 Detemir (Levemir) 1 hr 6-8 hrs 6-24 hrs Degludec U-100 & U-200 (Tresiba U-100,U-300) 1 hr 9 hrs 42 hrs

most likely clinical causes of metabolic acidosis. most common symptoms & basic interventions

Metabolic acidosis: pH below 7.35, bicarb below 22 Causes: over ingestion of acids or not enough production of bicarb. Lactic acidosis from shock, sepsis, or cardiac arrest. Decreased kidney function and not secreting enough hydrogen ions/conserve bicarb. Oxidation of fatty acids Symptoms: cardiac dysrhythmias and CNS dysfunction, headache, diarrhea, tremors. Lungs try to compensate by increasing rate and depth of respirations in order to get rid of some carbonic acid Interventions: sodium bicarb given for lactic acidosis secondary to shock. Hydration and drugs to treat underlying cause

Types of IV fluids: isotonic vs. hypo vs. hypertonic and when/why is that type of fluid chosen, risks associated with fluids

Isotonic: 0.9% NS, LR (lactated ringer's) Osmolarity 250-375 Causes no fluid shift Increase intravascular volume Remain in intravascular space - used for hypovolemia/dehydration, replacing electrolytes lost from vomiting and diarrhea Hypotonic: 0.45% NS, D5W- after in the body osmolarity less than 250 Causes fluid to shift into the cell Used for cellular hydration - used for treatments such as dialysis or diuretics for patients with DKA Risk for cardiac collapse, elevated ICP, third spacing Hypertonic: D5NS, 3% NS Osmolarity greater than 375 Causes shift out of the cell Used in correcting hypotonic hyponatremia and decreasing edema VERY high risk, can cause extreme harm if cells are dehydrated Can cause circulatory overload

What tests/labs are used to monitor/diagnose Diabetes? Desired levels?

LABS: Main causes of DKA are decreased or missed insulin doses, illness or infections and untreated or undiagnosed diabetes Glucose >300 Metabolic Acidosis- With insulin deficiency, the body turns to stored fat for energy, releasing free fatty acids. When this stored fat is used for energy, ketone bodies (small acids) provide a backup energy source. Ketone bodies ("ketones") are abnormal breakdown products that collect in the blood when insulin is not available, leading to the ACID-BASE BALANCE problem of metabolic acidosis. pH <7.35 K+ Potassium imbalance- Insulin lack initially causes potassium depletion. With the increased fluid loss from hyperglycemia, excessive potassium is excreted in the urine, leading to low serum potassium levels. High serum potassium levels may occur in acidosis because of the shift of potassium from inside the cells to the blood. Serum potassium levels in DM, then, may be low (hypokalemia), high (hyperkalemia), or normal, depending on hydration, the severity of acidosis, and the patient's response to treatment. Dehydration contributes to the acidosis as well- Dehydration with DM leads to hemoconcentration (increased blood concentration); hypovolemia (decreased blood volume); poor tissue PERFUSION; and hypoxia (poor tissue oxygenation), especially to the brain. Hypoxic cells do not metabolize glucose efficiently, the Krebs' cycle is blocked, and lactic acid production increases, causing more acidosis. (excess acids from lack of insulin cause hydrogen ions and C)2 levels in the blood to increase causing an anion-gap metabolic acidosis) BUN & Creatinine- Dehydration with DM leads to hemoconcentration (increased blood concentration);

signs/symptoms of right and left sided heart failure

Left sided: Weakness Fatigue Dizziness Acute confusion Pulmonary congestion Breathlessness Oliguria (little urine output) Angina Tachycardia, palpitations Pallor Weak peripheral pulses Cool extremities Fatigue Hacking cough, worse at night Crackles or wheezes in lungs Frothy, pink-tinged sputum Tachypnea S3/S4 gallop Right Sided: Distended neck veins and measure abdominal girth (measures buildup of fluid in abdomen) Hepatomegaly (large liver) ascites may also be assessed. Large amount of abdominal fluid Malnutrition due to large amounts of fluid (anorexia) Dependent Edema (in ankles in legs for pt's that can walk/sacrum for pt's that can't walk) Systemic congestion Swollen hands and fingers Polyuria at night Weight gain Increased blood pressure (from excess volume) or decreased blood pressure (from failure)

loop diuretics ex. furosemide

Loop diuretics ex. Furosemide Used for acute HF, continue to work even after excess fluid is removed, monitor for dehydration especially in older patients, monitor for decreased urinary output, confusion, and dizziness

types of O2 delivery devices

Low-flow systems: ordinary nasal cannula, simple facemask, partial rebreather mask, and non rebreather mask High-flow systems: include the Venturi mask, aerosol mask, face tent, high-flow nasal cannula (HFNC), tracheostomy collar, and T-piece. They deliver precise oxygen concentrations from 24% to 100% at 8 to 15 L/min. High flow systems are made to adjust depending on the amount of room air available These systems are used for critically ill patients and when delivery of precise levels of oxygen is needed. Nasal Cannula: The nasal cannula is used at flow rates of 1 to 6 L/min. Oxygen concentrations of 24% (at 1 L/min) to 44% (at 6 L/min) can be achieved. Flow rates greater than 6 L/min do not increase gas exchange. High flow rates with a nasal cannula also increase mucosal irritation and injury to tissue integrity. The nasal cannula is often used for chronic lung disease and for any patient needing long-term oxygen therapy. Place the nasal prongs in the nostrils, with the openings facing the patient, following the natural anatomic curve of the nares. Venturi Mask: Venturi masks deliver the most accurate oxygen concentration without intubation. Adapters (located on the bottom of the mask) let room air mix with the oxygen Each adapter requires a different flow rate. For example, to deliver 24% of oxygen, the flow rate must be 4 L/min. CPAP: Goal: open collapsed alveoli. Patients who may benefit from this form of oxygen or air delivery include those with atelectasis after surgery, those with cardiac-induced pulmonary edema, and those with COPD. Delivers a set positive airway pressure throughout each cycle of inhalation and exhalation Non rebreather masks: provide the highest oxygen level of the low-flow systems This mask is often used with patients whose respiratory status is unstable and who may require intubation. During exhalation, air leaves through these exhalation ports while the one-way valve prevents exhaled air from re-entering the reservoir bag. The flow rate is kept high (10 to 15 L/min) to keep the bag inflated during inhalation. Assess for this safety feature at least hourly.

Patient teaching for low-sodium diet, and good sources of potassium in the diet

Low-sodium diet: adequate water intake. Low sodium foods, beverages, and drugs, fish and poultry, avoid snack foods, condiments, and pickled or fried foods Potassium: bananas, spinach, oranges, avocados, dairy, kiwi, broccoli, potatoes, mushrooms, lima beans

anti cholinergic drugs

Medication: Ipratropium bromide & Tiotropium bromide action/use: bronchial smooth muscle relaxation Side effects: dry mouth, bitter taste, bronchoconstriction, palpitations, lower incidence of tachycardia than Beta 2 agonists Goal: relieve bronchospasm Nursing implications: monitor respiratory status & response to tx, avoid contact with eyes, report any change in vision, provide for relief of dry mouth Cholinergic blocking agents block the effects of PNS neurotransmitter by occupying the receptor sites INHIBIT ACETYLCHOLINE Used to treat: irritable bowel syndrome, peptic ulcers, urinary frequency, reduce secretion pre-op, motion sickness, induce pupil dilation for eye exams Parkinson's disease COPD

patient education with heart failure

Medications: Take medications as prescribed and do not run out. Know the purpose and side effects of each drug. Avoid NSAIDs to prevent sodium and fluid retention. Activity: Stay as active as possible but don't overdo it. Know your limits. Be able to carry on a conversation while exercising. Weight: Weigh each day at the same time on the same scale to monitor for fluid retention. Diet: Limit daily sodium intake to 2 to 3 g as prescribed. Limit daily fluid intake to 2 L Symptoms: Note any new or worsening symptoms and notify the health care provider immediately

chest trauma: rib fractures, flail chest, pneumo/hemothorax, tension pneumothorax

Rib fractures: Most common injury with chest trauma | Can cause respiratory dysfunction | Diagnosis- CXR Assessment: Need to assess for injury to organs/structures below Clavicle & 1st rib fractures indicate a high impact injury Assess for hemodynamic instability (Aorta, Subclavian artery injury) Fracture of ribs 10-12? Assess for secondary organ injury to the liver, spleen, kidney Management- chest is usually not splinted by taped Assessment of Ventilation & Oxygenation Pain management!!! To allow maximal participation in pulmonary exercises Patient education Pillow splinting, Incentive spirometry, cough & deep breathing, early ambulation Prevention of pneumonia or other complications Flail Chest: Fractured ribs may result in flail chest, gas exchange, coughing, and clearance of secretions are impaired Two or more adjacent ribs fracture in more than one location creates a free-floating segment of the rib cage & can cause flail chest Results in: Paradoxical chest wall movement- "Sucking inward" of loose chest area during inspiration, "puffing out" of same area during expiration S/S: Increased work of breathing, Tachypnea, Hypoxemia Management Treated with intubation, ventilation, and pain management Position patient to enhance ventilation & oxygenation Frequent pulmonary care The patient is often anxious, short of breath, and in pain. Pneumo/Hemothorax: A Pneumothorax is air (pneumo) in pleural space Occurs when air escapes from the injured lung into the pleural space altering the negative intrapleural pressure causing a partial or complete lung collapse S/S: respiratory distress, tachypnea, tachycardia, decreased or absent breath sounds on affected side, chest pain Dx: Confirmed with CXR Tx: 02 and Chest tube Hemo: Hemothorax is a collection of blood in the pleural space resulting from injuries to the heart, great vessels, or the pulmonary parenchyma. Bleeding can be moderate (from intercostal vessels) or massive (from the aorta or from subclavian or pulmonary vessels). Decreased breath sounds, dullness to percussion on the affected side, hypotension, and respiratory distress may be seen. Placement of a chest tube facilitates removal of blood from the pleural space with resolution of ventilation and gas exchange abnormalities. Tension Pneumothorax: BAD! Medical emergency- Life-threatening An injury to the chest allows air to enter the pleural cavity without a route for escape S/S: mediastinal shift & distended neck veins Each inspiration allows additional air to enter the pleural space causing increased intrapleural and intrathoracic pressures which can then cause compression of heart and great vessels to shift toward the unaffected side Cardiovascular collapse can occur if not treated immediately Decreased cardiac output and alteration in gas exchange causes patients to experience anxiety, severe respiratory distress, absence of BS on the affected side, hypotension, distended neck veins and tracheal deviation (shift from midline toward unaffected side) Diagnosis is made on clinical presentation, tx is not delayed for x-ray Cyanosis: Late manifestation Emergent treatment with needle thoracostomy | Chest tube inserted after needle decompression

most likely clinical causes of metabolic alkalosis. most common symptoms & basic interventions

Metabolic alkalosis: pH above 7.45, bicarb above 26 Causes: ingestion of antacids, prolonged vomiting (loss of HCl), thiazide diuretics and prolonged gastric suctions. Hypokalemia Symptoms: cardiac dysrhythmias, seizures, confusion, muscle twitching, agitation. Lungs attempt to compensate by decreasing rate and depth to conserve carbonic acid Interventions: renal excretion of bicarb, treat underlying losses, replacing fluids and electrolytes

Critical rescue for hypoglycemia? Signs/sx and nursing interventions for hypoglycemia

Monitor BG before administering hypoglycemic agents, before meals, at bedtime and when patient is symptomatic Treatment for mild hypoglycemia (hungry, irritable, shaky, weak, headache, fully conscious, BG﹤60 and who is able to swallow) 15/15 Rule or Rule of 15 Treatment for moderate hypoglycemia (cold clammy skin, pale, rapid pulse, drowsy, marked change in mood, BG﹤40) treat with: 15-30 g rapidly absorbed CHO and additional food such as low fat milk or cheese after 15 minute (generally give 30 g) Treatment for severe hypoglycemia (unable to swallow; unconsciousness or convulsions; blood glucose usually less than 20 mg/dL Glucagon 1mg given subcutaneously or IM; MR in 10 min; call HCP If Glucagon is unavailable, a small amount of glucose gel may be inserted in buccal pouch 50% dextrose IV carefully to avoid extravasation because it is hyperosmolar and can damage tissue If patient remains unresponsive transport to ED After patient is responsive give a simple sugar and a small snack or meal *FROM POWERPOINT NOTES* Prevention Strategies. Teach the patient how to prevent hypoglycemia by avoiding its four common causes: (1) excess insulin, (2) deficient intake or absorption of food, (3) exercise when insulin action is peaking, and (4) alcohol intake. Insulin excess from variable absorption of insulin can cause hypoglycemia even when insulin is injected correctly. Increased insulin sensitivity can occur with weight loss, exercise programs, and resolution of an infection. Differences in insulin formulation can result in hypoglycemia. Teach the patient to not change insulin brands without medical supervision. Deficient food intake from inadequate or incorrectly timed meals can result in hypoglycemia. Changes in gastric absorption may cause hypoglycemia in patients with delayed gastric emptying, which is more severe with solid meals and is made worse by illness or poor glucose control. Teach the patient the importance of Exercise often causes blood glucose levels to fall in a patient with Type 1 DM. Prolonged exercise increases muscle glucose uptake for several hours after exercise. Teach the patient about blood glucose monitoring and carbohydrate consumption before and during exercise. Also teach him or her to exercise at times when insulin activity is not peaking. Alcohol inhibits liver glucose production and leads to hypoglycemia. It interferes with the counterregulatory response to hypoglycemia and impairs glycogen breakdown, making exercise-induced hypoglycemia more severe. Teach the patient to ingest alcohol only with or shortly after eating a meal with enough carbohydrate to prevent hypoglycemia. Warn patients to avoid excess alcohol at bedtime to prevent nighttime hypoglycemia Treating with CHO intake ( Give simple Carbs, no complex) 5 gms of CHO should raise blood glucose (BG) ~ 20 mg/dL 10 grams of CHO should raise BG ~40 mg in 30 minutes; 20 grams about 60 mg over 45 min 50% dextrose given IV is used for patients who cannot swallow Glucagon is the main counterregulatory hormone and is used as therapy for severe hypoglycemia in DM. It converts liver glycogen to glucose but is not effective in starved patients who have little liver glycogen. Take care to prevent aspiration in patients receiving glucagon, because it often causes vomiting. The effects of glucagon and dextrose are temporary. After the patient responds and is no longer nauseated, give a simple sugar followed by a small snack or meal. IV glucose is used to maintain mild hyperglycemia. Diazoxide (Proglycem) or octreotide (Sandostatin) may be required to treat sulfonylurea-induced hypoglycemia. Evaluate response by monitoring blood glucose levels for several hours. Symptoms may persist for an hour or more after treatment. A target blood glucose level is 70 to 110 mg/dL (3.9 to 6.2 mmol/L). *FROM ANOTHER BP* Plasma glucose <70 mg/dL May not see signs and symptoms until 50-60 Prevention/causes: Can be caused by excess insulin, some oral diabetic drugs, insufficient food intake, skipping meals, poor timing of insulin, alcohol, and an increase in physical activity Symptoms: early warning signs - irritability, shaky/tremors, anxiety, tachycardia, hunger, sweating. Later signs - confusion, slurred speech, seizures, loss of consciousness, brain damage, coma Classic signs and symptoms may not appear in the older adult patient with DM - changes in LOC may be slow and progress through confusion and bizarre behavior. Coma may come w/out warning Treatment: carbohydrate replacement, Glucagon 1 mg IM or SQ, 25-50 mL 50% dextrose solution IV, if pt is responsive and not nauseous - give simple sugar followed by small snack or meal and IV glucose to maintain mild hyperglycemia Treatment must be immediate

beta blockers ex. metoprolol, atenolol

Monitor BP and HR , bradycardia and decreased BP are expected effects, assess for wheezing or dyspnea, can cause bronchospasm, assess for insomnia, fatigue, and dizziness Class II: Beta Blockers Only 4 beta blockers are approved for the treatment of dysrhythmias Common examples of beta blockers: • Propranolol • Acebutolol • Esmolol • Sotalol Sotalol is a class II dysrhythmic and a class III drug because of its effect on the QT interval and delay of repolarization. Assess ventricular arrhythmias because this drug can have proarrhythmic effects. Monitor HR and BP; bradycardia and decreased BP are expected effects. Assess for wheezing or shortness of breath; beta2-blocking effects on the lungs can cause bronchospasm. Assess for insomnia, fatigue, and dizziness; side effects may require a decrease in dosage or discontinuation of the drug.

calcium channel blocker ex. amlodipine, nifidipine

Monitor BP and HR, hypotension and bradycardia can occur, monitor for arrhythmias, postural hypotension (**HF can occur) Teach patients to avoid grapefruit juice and grapefruit while taking calcium channel blockers because grapefruit and its juice can enhance the action of the drug, causing organ dysfunction or death The calcium channel blocker nifedipine can also be used to decrease pulmonary vascular resistance.

Care of patient post thyroidectomy/parathyroidectomy

Monitor dressing for potential bleeding and hematoma formation; check posterior dressing (behind the neck) Monitor respirations; potential airway impairment Assess pain and provide pain relief measures Semi-Fowler's position, support head Assess voice but discourage talking Potential hypocalcaemia related to injury or removal of parathyroid glands; monitor for hypocalcaemia Monitor for stridor Keep emergency tracheostomy equipment at bedside... will go up to pt's room with them. Keep suction available too.

Nursing care of pt. post hypophysectomy

Monitor the patient's neurologic status hourly for the first 24 hours and then every 4 hours. • Monitor fluid balance, especially for output greater than intake. • Encourage the patient to perform deep-breathing exercises. • Instruct the patient not to cough, blow the nose, or sneeze. • Instruct the patient to use dental floss and oral mouth rinses rather than toothbrushing until the surgeon gives permission. • Instruct the patient to avoid bending at the waist to prevent increasing intracranial pressure. • Monitor the nasal drip pad for the type and amount of drainage. • Teach the patient methods to avoid constipation and subsequent "straining." • Teach the patient self-administration of the prescribed hormones.

CABG

NPO before surgery, could be emergency or planned, could be minimally invasive or thoracotomy, teach that meds will change after surgery Shower w 4% chlorhexidine gluconate before surgery, teach splinting, arm/leg exercises, report any post op pain, analgesics, coughing/deep breathing/early ambulation After traditional surgery the pt will be moved to a post-open-heart unit and undergo mechanical ventilation for 3-6 hrs

Normal ranges of Na, K, Ca, Mg

Na: 135-145 K: 3.5-5 Ca: 9-10.5 Mg: 1.8-2.6

What are the most common post-operative complications and how can they be prevented?

Nausea, vomiting, thirst, urinary retention, constipation, ileus, obstructive sleep apnea, coping issue, change in body image, change in mental status Monitor ABCs, cardiac, pain, fluid, antiemetics, gum chewing, non-opioid pain management, mouth swabs for thirst, scheduled urination, drugs for constipation, counseling for coping

epistaxis

Nosebleed; common problem b/c of the many capillaries w/in the nose Occur as a result of loss of tissue integrity from trauma to the nasal mucosa, hypertension, blood dyscrasia (leukemia), inflammation, tumor, decreased humidity, nose blowing, nose picking, chronic cocaine use, & procedures such as NG suctioning Older adults bleed most often from the posterior portion of the nose Nursing care : Assess for respiratory distress, tolerance of the packing, assess packing or tubes Intervention : humidification, oxygen, bedrest, antibiotics, pain meds (opioids may be prescribed : assess for gagging & coughing reflexes) For anterior nosebleed ; use a nasal plug that contains agent to promote clotting Use pulse oximeter to monitor for hypoxemia Tubes & pacing usually removed after 1-3 days Posterior nasal bleeding is an emergency!!! b/c it can't be easily reached & the patient may lose a lot of blood Posterior packing ; epistaxis catheters (nasal pressure tubes) ; or gel tampons are placed through the nose w/in the posterior nasal region Placement is uncomfortable & the airway may be obstructed w/ reduced gas exchange if the pack slips Cauterization or ligating the blood vessels or performing an embolization of the bleeding arteries may be needed if packing doesn't work Embolization risk factors : loss of tissues integrity w/ necrosis ; facial nerve paralysis ; & blindness At home interventions: Apply petroleum jelly Use saline nasal spray - moisture & prevent bleeding Avoid vigorous nasal blowing

teaching for a patient who had a heart valve replaced

Notify PCP and all specialists of replacement, notify dentist, request prophylactic antibiotics, clean wounds w antibiotic ointment, notify PCP of fever, petechiae, dyspnea (SOB) Diuretics, beta blockers, ACEI, digoxin, nitrates, vasodilators, anticoagulation, O2 Dental exam should be performed before surgery, and taken care of Avoid foods high in vitamin K, esp dark green leafy vegetables

Nursing care of pt. getting a central venous; possible complications of a central venous line

Nursing Care: education, nursing infection assessment, chest x-ray, monitor and document condition, flush with saline before and after medications. Hand hygiene, clip hair-do not shave, ensure skin is clean, wear gloves, prepare skin with 70% alcohol or chlorhexidine Possible complications: extravasation, air embolism, pneumothorax, infection, sepsis, dislodgement, migration, rupture, lumen occlusion

Kussmaul respirations with ketoacidosis, nursing actions

Nursing Interventions for Respiratory Acidosis Administer oxygen. encourage coughing and deep breathing. suction (pneumonia) may need respiratory treatment (asthma) hold respiratory depression drugs (know the category of drugs used opioids, sedatives etc) Kussmaul respirations are very deep and rapid- attempting to cause respiratory alkalosis in an attempt to correct the metabolic acidosis Dehydration with DM leads to hemoconcentration (increased blood concentration); hypovolemia (decreased blood volume); poor tissue PERFUSION; and hypoxia (poor tissue oxygenation), especially to the brain. Hypoxic cells do not metabolize glucose efficiently, the Krebs' cycle is blocked, and lactic acid production increases, causing more acidosis. The excess acids caused by absence of insulin increase hydrogen ion (H+) and carbon dioxide (CO2) levels in the blood, causing anion-gap metabolic acidosis. These products trigger the brain to increase the rate and depth of respiration in an attempt to "blow off" carbon dioxide and acid. This type of breathing is known as Kussmaul respiration. Treatment Goals: Restore circulating Volume and Tissue perfusion Decrease Blood Glucose Correct Acidosis Correct Electrolyte Imbalances Interventions Blood glucose and renal function/Urinary output hourly EKG and electrolyte levels- K/+ May use sodium bicarbonate if severe acidosis pH< 7.0 VS, lung assessments, signs of fluid overload Watch patient closely for hypoglycemia & hypokalemia

post femoral popliteal bypass

Nursing care/assessment of patient- post femoral-popliteal bypass procedures The pt must keep the leg still, no ambulation for 24 hrs post op, HOB at 20-25 degrees Monitor for lower limb ischemia- 6 P's Palpate pulses below the graft to assess graft patency Doppler ultrasonography may be used to assess blood flow when pulses are non palpable

obstructive sleep apnea

OSA is a type of breathing pattern disruption during sleep that lasts at least 10 seconds & occurs minimum of 5 times in an hour Usually occurs with sleep time hypopnea (lower than normal respiratory rate & depth insufficient for gas exchange) During sleep the head & neck muscles relax, allowing the tongue, soft palate, & neck structures to be displaced Upper airway is obstructed but neural control of chest movement is unimpaired The apnea decreased gas exchange ; increases CO2 levels ; & decreases pH & stimulates neural centers The sleeper wakes after 10 seconds or longer of apnea & corrects the obstruction & respirations resume. They go back to sleep & the cycle starts again sometimes as often as every 5 minutes Can cause many issues due to body not getting rest & physiologic restoration : O2 sat will go down ; sleepiness ; headaches ; decreased concentration ; hypertension ; weight gain ; cognitive deficits ; pulmonary & cardiovascular disease Risk factors : Obesity ; large uvula ; short neck ; smoking ; enlarged tonsils ; enlarged adenoids ; oropharyngeal edema ; congenital variation in oral cavity structures, pharynx, or neck Those who have the genetic disorder achondroplasia have a higher incidence of sudden infant death syndrome (SIDS) & OSA as older children & adults Patient teaching regarding ways to improve sleep apnea : Change in sleep position is the first nursing intervention to try & usually helps some Weight loss Positive pressure ventilation - either nasal mask , nasal pillows, or normal face mask Sedatives to promote sleep may make OSA worse Stimulants to promote wakefulness during the day may have side effects & don't help sleep at night Use of CPAP : Continuous positive airway pressure (CPAP) : to hold open airways Most common nonsurgical management for OSA Delivers continuously during each cycle of inhalation & exhalation w/ compressor Surgical management : adenoidectomy ; uvulectomy ; or uvulopalatopharyngoplasty

Wound care: s/s of infection and types of wound exudate (what does each type of exudate mean?

Odor, fever, tenderness, erythema, purulent drainage, approximation of edges, necrosis, elevated white blood cell levels Serosanguinous: blood tinged amber fluid consisting of serum and red blood cells. Normal for the first 48 hours after surgery. A sudden increase precedes wound dehiscence Purulent: creamy yellow pus= colonization with staphylococcus Greenish blue with a fruity odor- colonization with pseudomonas Beige pus with fishy odor- colonization with proteus Brownish pus with fecal odor- colonization with aerobic coliform and Bacteroides. Usually occurs after intestinal surgery

components of normal EKG rhythm, including normal PR, QRS, QT

One complete cardiac cycle is P, Q, R, S, (QRS complex), T wave P wave indicates atrial contraction (depolarization) QRS Complex is ventricular contraction (depolarization), atrial repolarization T wave ventricular repolarization (resting phase) Assess the patient, read the strip from left to right, starting at the beginning

PAD VS PVD

PAD Affects arteries that carry blood away from the heart Arteries: walls are thick, have extra strength to endure high pressure No "valves" stage II includes claudication with muscle pain, cramping, or burning occurs with exercise and is relieved w rest, reproducible with exercise stage III pain while resting that wakes the patient at night, described as numbness, burning, toothache-type pain, usually occurs in the distal part of the extremity (toes, arch, forefoot, or heel), rarely in the calf or the ankle, relieved by placing the extremity in the dependent position stage IV ulcers and blackened tissue occur on the toes, forefoot, and heel, distinctive gangrenous odor skin will be cool to touch, thin dry/scaly skin, hairless, thick toenails circulation to the extremity poor, pulses may not be present, no edema PVD Affects veins that carry blood to the heart Veins: thinner and less muscular allowing for more distention Less pressure Allows blood to collect Dull throbbing pain, pt will prefer to elevate legs to alleviate pain and pressure, Skin can have brownish color, thick skin Pulse will be present and normal, edema common and present, worse at the end of the day Vascular Assessment Compare: bilateral, distal/proximal, upper/lower, supine/dependent Circulation Sensation Movement Color Pain PAD: disorders that interrupt or impede arterial peripheral blood flow due to vessel compression, vasospasm, and/or structural defects in the vessel wall Usually result of: atherosclerosis Clinical symptoms of PAD Intermittent claudication Numbness or burning sensation Loss of hair on lower extremity Diminished or absent pulses Thickened toenails Pallor or dependent rubor Acute arterial occlusion "surgical emergency" "6 P's" of ischemia Promote vasodilation in PAD, avoid direct heat, avoid crossing legs, wearing restrictive clothing, garters, inspect feet daily PVD Stop smoking, adhere to anticoagulant therapy Keep feet clean and dry. Avoid injury to feet and ankles. Keep toenails clean and filed. Apply a lubricating lotion. Avoid constricting garments. Avoid extended pressure on feet and toes

pancreatic enzyme replacement

PERT may be needed for CF Pancreatic enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss. Pancreatic enzymes are usually prescribed in the form of capsules or tablets that contain varying amounts of amylase, lipase, and protease. Teach patients not to chew or crush pancreatic enzyme replacements that are available as delayed-release capsules or enteric tablets. Teach them to take the enzymes with all meals and snacks. The dosage of pancreatic enzymes depends on the severity of the malabsorption. Record the number and consistency of stools per day to monitor the effectiveness of enzyme therapy. If pancreatic enzyme treatment is effective, the stools should become less frequent and less fatty.

TB

PULMONARY TB Highly communicable; caused by Mycobacterium tuberculosis Many more people are infected with the bacteria then ever develop the disease Transmitted via DROPLETS In the hospital patient will be on ____________ precautions---> AIRBORNE Risk of transmission is reduced after pt. has been treated for 2-3 weeks. Initial infection is seen more often in the middle or lower lobes of the lung The local lymph nodes are infected and enlarged. An asymptomatic period usually follows the primary infection and can last for years or decades before clinical symptoms develop. This is called latent TB. An infected person is not contagious to others until symptoms of disease occur. Secondary TB is a reactivation of the disease in a previously infected person It is more likely when defenses are lowered and IMMUNITY is reduced. This is seen in older adults, those with chronic diseases, and especially those with HIV disease. The upper lobes are common sites of reactivation. Miliary or Hematogenous TB Spread of TB outside of the lungs throughout the body Many tiny nodules scattered throughout the lung are seen on chest x-ray. Other body areas can become infected as a result of this spread. Risk factors Those in constant, frequent contact with an untreated person Those who have reduced IMMUNITY or HIV Adults who live in crowded areas such as long-term care facilities, prisons, homeless shelters, and mental health facilities Older homeless adults Abusers of injection drugs or alcohol Lower socioeconomic groups Foreign immigrants Blood Tests for TB and PPD Skin Testing Interpretation: Blood analysis can be done with interferon-gamma release assays, or IGRAs. The two available tests are the QuantiFERON-TB Gold In-Tube test and the T-SPOT TB test (most common) Both tests show how the patient's immune system responds to the TB bacterium. A positive result means that the person is infected with TB but does not indicate whether the infection is latent or active. Asmall amount (0.1 mL) of purified protein derivative (PPD) is placed intradermally in the forearm. The test is "read" in 48 to 72 hours. An area of induration (localized swelling with hardness of soft tissue), not just redness, measuring 10 mm or greater in diameter, indicates exposure to and possible infection with TB A positive reaction indicates exposure to TB or the presence of inactive (dormant) disease, not active disease. A reduced skin reaction or a negative skin test does not rule out TB disease or infection of the very old or anyone who has severely reduced IMMUNITY. Failure to have a skin response because of reduced immunity when infection is present is called anergy. PPD SKIN TEST A Positive reaction does not mean that active disease is present, but does indicate exposure to TB or dormant disease S/S: Progressive FATIGUE Lethargy Nausea Anorexia Weight LOSS Irregular menses LOW GRADE-grade fever, night sweats Cough Mucopurulent sputum, blood streaked Chest tightness Treatment/ Nursing Care: DOT (directly observed therapy)- tx can be from 26 weeks up to 2 years Combination drug therapy with strict adherence: Isoniazid (INH)----> Take on empty stomach (1 hr before or 2 hrs after meals) Avoid antacids, No alcohol Take a daily MVI with B vitamins while on drug (depletes B) Rifampin Teach pt about orange red staining of skin and urine and contacts Reduces effectiveness of oral contraceptives Pyrazinamide Hx. Gout- drug increases uric acid levels ; photosensitivity Take with at least 8oz water, increase fluid intake Ethambutol Hx gout- drug increases uric acid levels, report any changes if vision! (can cause optic neuritis leading to blindness) ***With all these teach patient to avoid alcohol and to report any signs of liver toxicity or failure- darkening of urine, jaundice, increased tendency to bruise or bleed Patient Teaching: Remain in your home and avoid contact with others. Take your TB medicines as directed, eat healthy foods, and get plenty of rest. Wear a mask that covers your nose and mouth if you must go to medical appointments and when health care providers come to your home. Nursing Care in Hospital: Promoting airway clearance Adherence to the treatment regimen Promoting activity and adequate nutrition Preventing spreading of tuberculosis infection Acid-fast bacillus isolation Monitor adverse effects AIRBORNE precautions They must ensure procurement of good quality personal protective materials such as N95 respiratory masks, gloves, and aprons and also follow their usage protocol

pacemaker and AICD

Pacemaker: indicated in conduction disorders that are not temporary, including complete heart block Monitor EKG after placement, initial activity restrictions, risk of pericardial effusion/tamponade Teach pt to report any pulse rate lower than the set rate, teach care of site, avoid lifting 10lbs CLASS Q: Discuss the care of a patient with a pacemaker and indications for a pacemaker, what would you teach the patient? Care: monitor ECG rhythm to make sure the pacemaker is working properly, assess the implantation site for bleeding, swelling, redness, tenderness, and infection. The patient should be afebrile and have stable v.s. Teach: avoid sources of strong electromagnetic fields (magnets) because it can lead to malfunction. Cary a pacemaker i.d. card and always wear medical alert bracelet Indications: bradycardia, third degree heart blocks, and treat conduction disorders

assessment of patient with pericarditis, and nursing interventions/treatment

Pericarditis is inflammation of the pericardium, a sac-like structure with two thin layers of tissue that surround the heart to hold it in place and help it work. A small amount of fluid keeps the layers separate so there's less friction between them as the heart beats ASSESSMENT: Substernal precordial pain (​​Symptoms are worse with inspiration, supine position, coughing, or swallowing, are relieved with sitting up or bending forward.) Radiating to left side of neck, shoulder, or back Grating, oppressive pain, aggravated by breathing (inspiration) because of the inflammation and friction with heart beating--- coughing, swallowing Pain worsened by supine position; relieved by sitting up and leaning forward Pericardial friction rub (grating sound of heart against the pericardium) because the inflammation makes it hard for the fluid to prevent friction and the heart is "rubbing" INTERVENTIONS/TREATMENT: Relieving pain - NSAIDS Positioning - sitting up/leaning forward Monitoring and managing potential complications (Pericardial effusion & Cardiac tamponade)

Nursing care of: disorders of the posterior pituitary gland (SIADH and DI)

Pituitary gland Sits beneath the hypothalamus Termed the "master gland" Basically it sends hormones to signal the release or inhibition of other hormones in the pituitary gland, and then the pituitary gland releases another hormone which will influence other parts of the body. Divided into: anterior pituitary gland & posterior pituitary gland Hormones of the posterior pituitary are: Antidiuretic hormone (acts one the collecting duct of the kidneys to retain water) and Oxytocin (acts on uterus to initiate contractions). The anterior pituitary hormones are "all the rest" including: follicle stimulating hormone, luteinizing hormone, growth hormone, thyroid stimulating hormone, prolactin, adrenocorticotropic hormone, melanocyte-stimulating hormone The hypothalamus communicates with the Anterior pituitary gland via the hypothalamic-hypophyseal portal system, and communicates with the posterior pituitary gland via the nerve fibers in the hypophyseal stalk. The hormones of the posterior pituitary are produced in the hypothalamus and delivered to the posterior pituitary where they are stored, and then released when needed in the body. Posterior pituitary gland controls: fluid balance, uterine contraction, milk let-down ADH (vasopressin) and oxytocin (love hormone, uterin contraction) Anterior pituitary gland controls: growth, metabolism, sexual development Hormones secreted: Growth hormone Tyrotropin (TSH) Corticotropin (ACTH) Follicle stimulating hormone Lutenizing hormone (LH) Melanocyte stimulating hormone Prolactin Primary pituitary disorders - problems with pituitary itself Secondary pituitary disorders - problems originating in hypothalamus When discussing problems of the pituitary gland, it can be either a primary or secondary problem If it is a primary problem, then there is a problem with the pituitary itself, such as a pituitary adenoma (mass) that is interfering with release of one or more hormones of the pituitary gland. If it is a secondary problem, then it is originating somewhere else, such as in the hypothalamus, which is then affecting which hormones are released to the pituitary gland. For example, if a child has a growth problem; there may need to be extensive tests done including measuring hormone levels, CT/MRI to see if there is a problem with either the hypothalamus or the pituitary gland. This is beyond the scope of what we are learning in this lesson. Pituitary problems: diabetes insipidus (DI) and SIADH (problem of posterior pituitary and ADH) Posterior pituitary: diabetes insipidus Loss of water due to ADH deficiency or the inability of kidneys to respond to ADH Kidney tubules and collecting ducts are not able to reabsorb water Large volumes of urine are excreted Dehydration and fluid & electrolyte imbalance DI is a water loss problem caused by either deficiency of ADH or an inability of the kidneys to respond to ADH properly. The result is a large loss of water via the kidneys; urine will be in large amounts, very dilute. Priorities of care will be to monitor for dehydration (replace the fluid), monitor electrolyte imbalances (watch for hypernatremia). Central diabetes insipidus - caused by a problem in the hypothalamus or pituitary gland Lack of production and release of ADH (vasopressin) Could be caused by tumors, infection, trauma, brain surgery Nephrogenic diabetes insipidus - kidneys fail to respond to ADH and cannot concentrate urine Can be caused by some medications such as lithium carbonate and demeclocycline DI can be acute or chronic...chronic would require life long treatment Assessment Increased urination Excessive thirst Hypotension Tachycardia Dry mucous membranes Increased and rapid dehydration Decreased cognition Irritability Diagnosis CT/MRI to determine underlying cause Low urine specific gravity (﹤1.005) Low urine osmolarity (50-200 mOsm/kg) Serum electrolytes - usually increasing serum sodium, hematocrit due to hemoconcentration Water deprivation test: will see serum osmolality continue to increase and no increase in urine osmolality Most important points in assessment are noted: large amounts of dilute urine is lost and can lead to hypovolemia. Specific gravity and urine osmolality are usually low, where in the serum, the sodium will rise, as well as hematocrit, due to hemoconcentration of the blood. Interventions: Medication: for central DI - Desmopressin acetate (DDAVP) and Pitressin - synthetic vasopressin (oral, nasal, IV/IM, SQ) For central DI, the preferred drug for treatment is desmopressin acetate (DDAVP), which comes in IV, Sq, oral, intranasal. For acute cases, IV is used. In chronic DI, nasal spray or oral used. Irritation of the mucous membranes may occur with the spray. For exam purposes, please look up desmopressin (DDAVP)..used most commonly. For nephrogenic DI: NSAIDs like indomethacin and thiazide diuretics. Not as common. Measure I&O, labs Closely monitor for fluid volume losses - replace with hypotonic fluid like D5W or 0.45 NS to decrease sodium slowly (0.5 mmol/L every hour) Closely watch patient's weight Medical alert bracelet for permanent DI SIADH (syndrome of inappropriate antidiuretic syndrome) Over secretion of ADH even when plasma osmolarity is low or normal Results in fluid electrolyte imbalance Water retention which leads to delusional hyponatremia Due to increased blood volume kidneys inhibit the release of renin and aldosterone On the flip side to DI is SIADH. Remember it with "too many letters, too much ADH" If they have too much ANTI-diuretic hormone, then they are going to (NOT DIURESE), so will hold on to fluid. They may have sx of fluid overload or hypervolemia, and sodium levels decrease due to dilution of the blood (not due to loss of sodium). Assessment: Obtain detailed history: recent head trauma, cardiovascular disease, TB, CA, drug use. More likely seen in certain tumors that cause increased release of ADH, such as small cell lung cancer. Signs/symptoms GI disturbances: nausea, vomiting, decreased appetite due to fluid retention Lethargy, headache, disorientation, change in LOC...potentially seizures, coma...due to fluid shifts and hyponatremia Full bounding pulse; hypervolemia Related to fluid overload and hyponatremia. With hyponatremia, there may be neurological changes. Urine will be decreased in amount, and will be more concentrated, thus a high specific gravity and high urine osmolality Interventions: Fluid restrictions (500-1000 mL/day) Patient on tube feedings dilute food with NS not H2O Weight monitoring Hypertonic solutions ex. 3% NaCl only when sodium is very low Medications: vasopressin antagonist (tolvaptan, conivaptan) - promote water excretion without losing sodium Diuretics only when sodium levels are back to normal Fluid overload: neck vein distention, crackles, increased peripheral edema Water for pulmonary edema Treatment will include getting rid of fluid and may do this with a severe fluid restriction, as well as replacing sodium, but will bring sodium up very slowly. Watch for neurological signs when sodium gets in the low 120's. Normal 135-145. NCLEX Question Which urine properties indicate to the nurse that the client with SIADH is responding to interventions? Urine output volume increased, urine specific gravity decreased

possible causes of heart failure right & left sided

Possible causes of heart failure: Right sided v. Left sided Left Sided (also known as congestive heart failure) Hypertension, coronary artery disease, valvular disease Can be diastolic or systolic Right sided Left ventricular failure, right ventricular MI, pulmonary hypertension, right ventricle cannot empty completely, increased volume and pressure in venous system and peripheral edema

Chronic complications of Diabetes- how to prevent, patient teaching, assessment

Priority nursing action focuses on interventions to reduce modifiable risk factors associated with CVD such as : smoking cessation, diet, exercise, blood pressure control, maintaining prescribed aspirin use, & maintaining prescribed lipid-lowering drug therapy Teach patient to report indications of ischemia, such as dyspnea with or without cough, extreme fatigue, & sudden onset of nausea & vomiting Risk for stroke is 4X higher in adults w/ DM compared w/ those who do not have the disease Diabetes causes increased risk for severe carotid atherosclerosis Chronic high blood glucose levels can cause damage to the kidneys Chronic hyperglycemia can cause hypertension in the kidney blood vessels & excess kidney perfusion & thicken the basement membrane which causes organ damage Increased pressure damages the kidney in many ways The blood vessels become leakier, especially in the glomerulus The leakiness allows filtration of larger particles including albumin and other proteins (albuminuria) & which then form deposits in the kidney tissue & blood vessels The blood vessels narrow, decreasing kidney oxygenation & leading to kidney hypoxia * cell death Over time, scarring of the glomerulus occurs and loss of urine filtration ability leading to kidney failure (chronic hyperglycemia thickens basement membranes, which causes organ damage) Kidney damage is also related to HTN patients with diabetes & cardiovascular disease Both systolic & diastolic HTN speed the progression of diabetic nephropathy PT TEACH*** annual testing for microalbuminuria is recommended for patients who have had type 1 diabetes for at least 5 years and in everyone with type 2 diabetes Damage to nerve fibers in the autonomic nervous system can cause dysfunction in every part of the body. Factors that cause nerve damage in diabetic neuropathy : Hyperglycemia, chronic diabetes, hyperlipidemia, damaged blood vessels, increased genetic susceptibility, smoke and alcohol use Hyperglycemia can also cause blindness. After about 20 years all patients with diabetes will have some degree of retinopathy Two types : NON-PROLIFERATIVE - causes structural problems in retinal vessels : areas of poor retinal circulation, edema, hard fatty deposits in the eye, and retinal hemorrhages Fluid and blood leak from vessels and cause retinal edema PROLIFERATIVE - growth of new retinal vessels, also known as neurovascularization When retinal blood flow is poor & hypoxia develops, retinal cells secrete vascular endothelial growth factors that stimulate formation of new blood vessels in the eye The new vessels are fragile, thin, and bleed easily leading to vision loss The combination of vascular changes and hyperglycemia reduce immunity by reducing white blood cell activity, inhibiting gas exchange, & promoting the growth of microorganisms Increased risk for infection and active infections are worse and there are more complications & sepsis

Be familiar with SCIP

Prophylactic antibiotic received within one hour prior to surgical incision Prophylactic antibiotic selection for surgical patients Prophylactic antibiotics discontinued within 24 hours after surgery end time Cardiac surgery patients with controlled 6 am postoperative blood glucose: avoid hyperglycemia Surgery patients with appropriate hair removal Urinary catheter removed postoperative day 1 or post op day 2 if day of surgery being 0 Surgery patients with perioperative temperature management Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period Surgery patients with recommended venous thromboembolism prophylaxis ordered Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery

PCI

Pt is on bedrest, HOB no higher than 30 degrees Monitor for bleeding at the insertion site, pulses/extremity color/temp distal to insertion site, chest pain, acute closure of vessel (ST elevation), vital signs, electrolytes, renal function, dysrhythmias, contrast reaction

respiratory infections

Pulmonary Empyema When pulmonary empyema occurs as a result of pneumonia, further interventions are needed. Collection of pus in pleural space Most common cause: Pulmonary infection, lung abscess, infected pleural effusion Pulmonary empyema is a collection of pus in the pleural space most commonly caused by pulmonary infection. When empyema is present, GAS EXCHANGE can be impaired by both reduced lung diffusion and reduced effective ventilation. Empyema is suspected when chest wall motion is reduced, fremitus is reduced or absent, percussion is flat, and breath sounds are decreased. S/S Abnormal breath sounds, including bronchial breath sounds, egophony, and whispered pectoriloquy, also may be present Diagnosis made by chest x-ray or CT scan and a sample of the pleural fluid (obtained via thoracentesis). Empyema fluid is thick, opaque, exudative, and foul smelling Treatment includes draining the empyema cavity, re-expanding the lung, and controlling the infection Appropriate antibiotics are prescribed A chest tube(s) to closed-chest drainage is used to promote lung expansion and drainage The tube is removed when the lung is fully expanded and the infection is under control Chest surgery may be needed for thick pus or excessive pleural thickening Nursing interventions similar to those for patients with a pleural effusion, pneumothorax, or infection Empty empyema cavity Re-expand lung Control infection Sinusitis/Rhinosinusitis Rhinosinusitis is an inflammation of the mucous membranes of one or more of the sinuses and is usually seen with rhinitis, especially the common cold (coryza). Anything that interferes with sinus drainage (e.g., deviated nasal septum, nasal polyps or tumors, inhaled air pollutants or cocaine, allergies, facial trauma, and dental infection) can lead to rhinosinusitis Inflammation of sinus mucous membranes Rhinitis - inflammation of _____ mucosa Symptoms: Viral vs Bacterial Facial or dental pain Purulent nasal drainage Fever Swelling Most often viral can develop into bacterial if Purulent drainage, fever, and lack of response to decongestants can indicate a bacterial infection Complications include cellulitis, abscess, and meningitis Treatment Antihistamines: Block the production of histamine in the body Diphenhydramine, Chlorpheniramine (1st generation) Side Effects: dry mouth, drowsiness, dizziness N&V, blurred vision Loratadine, Cetirizine, Fexofenadine (2nd generation)---> Less side effects Decongestants: relieve the swelling of mucous membranes Pseudoephedrine, Phenylephrine Should not be taken if patient has irregular heart rate, hypertension, heart disease or glaucoma Tonsillitis Inflammation/infection of tonsils and lymphatic tissues Contagious airborne infection, usually bacterial Treatment Antibiotics for 7-10 days Surgical intervention Symptoms: Sudden mild to severe sore throat Fever Aches, Chills Dysphagia, odynophagia Assessment: Tonsils visually swollen & red Covered with white or yellow exudate Purulent drainage Inflamed cervical lymph nodes Peritonsillar Abscess (PTA) Complication of acute tonsillitis The infection spreads from the tonsil to the surrounding tissue and forms an abscess. The most common cause of PTA is group A beta-hemolytic Streptococcus, although the abscess often contains multiple organisms Manifestations: Pus causing one-sided swelling with deviation of the uvula Trismus and difficulty breathing Hot potato speech Bad breath, swollen lymph nodes Severe throat pain radiating to the ear or teeth, a muffled voice, fever, and difficulty swallowing Diagnosis usually made based on the patient's symptoms, but needle aspiration and culture of pus collected is the preferred test Treatment Percutaneous needle aspiration of abscess Antibiotics Patient Teaching The nurse is providing teaching to a client who has been diagnosed with bacterial rhinosinusitis. Which instruction does the nurse include when teaching this client about his diagnosis Teach patients with any bacterial infection the importance of completing the entire antibiotic prescription, even when symptoms improve or subside. This will help eradicate the organism and prevent development of resistant bacterial strains. Inhalation anthrax Because inhalation anthrax is so rare, any occurrence in a person who does not have an occupational risk is considered an intentional act of bioterrorism Report the presence of symptoms consistent with inhalation anthrax to hospital authorities immediately. Inhalation anthrax (respiratory anthrax) is a bacterial infection caused by the gram-positive organism Bacillus anthracis. This organism lives as a spore in soil where grass-eating animals live and graze. Most cases of anthrax are on the skin (cutaneous) Inhalation anthrax accounts for only about 5% of cases, and GI anthrax accounts for about 1% of cases of the disease. When infection occurs through the lungs, the disease is nearly 100% fatal without treatment Inhalation anthrax is rare in North America and is not spread by person-to-person contact. It is an occupational hazard of veterinarians; farmers; taxidermists; and others who frequently contact animal wool, hides, bone meal, and skin Early stage Fever Fatigue Mild chest pain Dry cough No signs or symptoms of upper respiratory infection Mediastinal "widening" on chest x-ray Late Sudden onset of breathlessness Dyspnea Diaphoresis Stridor on inhalation and exhalation Hypoxia High fever Mediastinitis Pleural effusion Hypotension Septic shock Treatment/ NSG Interventions: Proper nursing intervention can assist in the reduction of nosocomial respiratory tract infections. Maintaining the integrity of the patient's respiratory defense mechanisms and/or augmenting those that are impaired helps to control endogenous factors that can contribute to infection Nursing implications in controlling endogenous factors include mobilization of secretions, prevention of aspiration, and reduction of oral resident microorganisms. Strict aseptic technique in caring for artificial airways and respiratory assistance equipment is essential. Advocacy of a patient's right to protection from harm should be exercised if breaks in proper technique by others are observed. The care that nurses provide is relevant to infection control. Viral/Bacterial: Bacterial infections are caused by bacteria, while viral infections are caused by viruses Often viral cases of pneumonia begin as congestion and cough with or without fever in the first few days. When a doctor listens to the lungs and finds breathing sounds are not clear on either side of the chest, a viral cause over bacteria is even more highly suspected ​​As you might think, bacterial infections are caused by bacteria, and viral infections are caused by viruses. Perhaps the most important distinction between bacteria and viruses is that antibiotic drugs usually kill bacteria, but they aren't effective against viruses Patient Teaching: Drinking plenty of clear fluids and rest. Vitamin-C may help boost your immune system. Over-the-counter pain relievers such as acetaminophen and ibuprofen can be helpful for fevers and to ease any aches. Saline (salt) nose drops, lozenges, and vapor rubs can also help symptoms when used as directed by your physician Using a humidifier to breathe warm, moist air may provide relief Be sure to avoid cigarette smoke and other pollutants, such as chemical fumes.

Care of patient after radioactive iodine for hyperthyroidism

Radioactive iodine (RAI) therapy is not used in pregnant women because it crosses the placenta and can damage the fetal thyroid gland. • Use a toilet that is not used by others for at least 2 weeks after receiving the radioactive iodine. • Sit to urinate (males and females) to avoid splashing urine on the seat, walls, and floor. • Flush the toilet (with the lid closed) three times after each use. • If urine is spilled on the toilet seat or floor, use paper tissues or towels to clean it up, bag them in sealable plastic bags, and take them to the hospital's radiation therapy department. • Men with urinary incontinence should use condom catheters and a drainage bag rather than absorbent gel-filled briefs or pads. • Women with urinary incontinence should use facial tissue layers in their clothing to catch the urine rather than absorbent gel-filled briefs or pads. These tissues should then be flushed down the toilet exclusively used by the patient. • Using a laxative on the second and third days after receiving the radioactive drug helps you excrete the contaminated stool faster • Wear only machine-washable clothing and wash these items separately from others in your household. • After washing your clothing, run the washing machine for a full cycle on empty before it is used to wash the clothing of others. • Avoid close contact with pregnant women, infants, and young children for the first week after therapy. Remain at least 3 feet (about 1 m) away from these people and limit your exposure to them to no more than 1 hour daily • Not sharing toothbrushes or toothpaste tubes • Using disposable tissues rather than cloth handkerchiefs

laryngectomy

Removal of part or all of the larynx (voice box) Partial laryngectomy : smaller cancers of the larynx often can be treated by removing only part of the voice box There are different types of partial laryngectomies but all have the same goal of removing the cancer while leaving behind as much larynx as possible Supraglottic laryngectomy : part of larynx above the vocal cords is removed Hemilaryngectomy : small cancers of the vocal cords are removed by taking out one side of the larynx Total laryngectomy : entire larynx is removed and then the trachea is brought up through the skin to the front of the neck and you breath through the hole (tracheostomy) After the surgery, the air you breathe is not naturally filtrated by the nose as normally & you can't speak normally

most likely clinical causes of respiratory acidosis. most common symptoms & basic interventions

Respiratory acidosis: pH below 7.35, carbonic acid above 45 Causes: hypoventilation, respiratory problems leading to respiratory depression, inadequate chest expansion, airway obstruction, poor gas exchange Symptoms: hypercapnia. Lethargy and confusion, delayed electrical conduction (CV), hypotension, thread peripheral pulses, hyporeflexia, skeletal muscle weakness, flaccid paralysis, Kussmaul respirations, pale-cyanotic and dry skin Interventions: improving gas exchange through drug and oxygen therapy, positions and breathing techniques, ventilatory support if needed

most likely clinical causes of respiratory alkalosis. most common symptoms & basic interventions

Respiratory alkalosis: pH above 7.45, carbonic acid below 35 Causes: increased ventilatory elimination of carbon dioxide, pneumonia, shock, severe anemia Symptoms: nausea, vomiting, tingling of fingers. hypoxemia causing rate and depth of ventilation are increased Interventions: breathing into a paper bag, same interventions as metabolic alkalosis

DVT

Risk factors: obesity, smoking, immobilization, plane rides, older than 40, spinal cord injury-paralysis, oral contraceptives, diabetes Signs/symptoms: warm, swelling, dull ache, worse when ambulate Prevention: smoking cessation, ambulate, stockings, compression device Treatment: thrombolytics, heparin, anticoagulants, fibrinolytics Complications: breaking off and moving to heart, lungs, and brain. Decreased circulation

STEMI vs NSTEMI

STEMI has ST elevation visible on an ECG

Short acting/long acting (SABA/LABA) bronchodilator ex. albuterol and salmeterol

Short-acting bronchodilators (albuterol) relieve or stop asthma symptoms. You use your "rescue inhaler" to stop an asthma attack These medications work quickly (within 15-20 minutes) to help decrease shortness of breath. Your doctor may prescribe these as-needed to decrease shortness of breath. They may also be prescribed before exercise Albuterol Long-acting bronchodilators help control asthma symptoms by keeping the airways open for 12 hours. You use these inhalers every day to prevent asthma attacks These medications are long-acting. Long-acting bronchodilators are used regularly to open the airways and keep them open. Long-acting bronchodilators can be either LABAs (long-acting beta2 agonists) or LAMAs (long-acting muscarinic antagonists). LABA and LAMA are types of bronchodilators. Salmeterol

Sick-day rules for diabetics

Sick Days: Monitor BG q4h Test urine for ketones when BG >240 mg/dL Continue to take insulin and/or other antidiabetic agents To prevent dehydration- drink 8-12 oz (240-360 mL) of sugar free liquids every hour during the day. If BG < target-drink fluids that are not sugar free Continue regular meals If unable to tolerates solid foods, consume foods or liquids equal to CHO content of meals Call PCP for Persistent n/v Moderate or lg ketones BG that remains elevated after 2 supplemental doses of insulin Temp 101.5 or higher and/or increasing or fever for >24 hrs

ST, SB, Afib, VT, Vfib, asystole

Sinus Bradycardia (below 60 bpm): discuss potential causes, what to assess, and interventions Causes: hypoglycemia, hypothermia, hypothyroidism, previous cardiac history, medications, toxic exposure, MI (inferior wall involving right coronary artery), or maybe athletes with low resting heart rates→ for athletes you do not need to intervene since that is their "normal" Assessments: syncope, dizziness, chest pain, shortness of breath, exercise intolerance, cool and clammy skin, decreased LOC Interventions: atropine to increase heart rate, pacing if patient is hemodynamically compromised, depending on whether patient is symptomatic or not Sinus Tachycardia (above 100 bpm): discuss potential causes, what to assess, and interventions Causes: damage to heart tissues from disease, hypertension, fever (high temperature), stress, excess alcohol, caffeine, nicotine, recreational drugs (cocaine, amphetamines), medications, pain, electrolyte imbalance, hyperthyroidism----> things that stimulate the body or elevate normal body response Assessments: dizziness, SOB, Lightheadedness, rapid pulse rate, palpitations, chest pain, syncope Interventions: aimed at finding and treating the cause Fever- antipyretics Stimulants- stop use (caffeine, OTC meds, herbs, drugs) Anxiety- reassurance or anxiolytics Narrow QRS complexes- vagal maneuvers, adenosine, beta blockers, calcium channel blockers, synchronized cardioversion Wide QRS complexes- antiarrhythmics like procainamide, amiodarone, or sotalol Atrial Fibrillation : discuss potential causes, what to assess, and interventions Causes: Hypoxia, hypertension, congestive heart failure, coronary artery disease, dysfunction of sinus node, mitral valve disorders, rheumatic heart disease, pericarditis, hyperthyroidism, excessive alcohol or caffeine consumption Assess: For heart palpitations, irregular pulse (too rapid or too slow/ racing/ fluttering/pounding), dizziness/lightheadedness, fainting, confusion, fatigue, trouble breathing Interventions: Collaborative care risk for PE and VTE, medication admin, cardioversion, percutaneous radiofrequency catheter ablation, bi-ventricular pacing, maze procedure, left atrial appendage closure. Supraventricular Tachycardia: discuss potential causes, what to assess, and interventions Causes: anxiety, caffeine, cocaine, stimulant drugs, hypoxia, stress or overexertion, hypokalemia, atherosclerotic disease Assessments: SOB, chest pain, anxiety, dizziness, vital signs, palpitations, chest pressure or tightness, syncope, pounding pulse, sweating, tightness or fullness in throat, fatigue, excessive urine production Interventions: vagal maneuvers (carotid massage), synchronized cardioversion, adenosine*, calcium channel blockers, beta blockers, 12 lead EKG to get better look Ventricular Tachycardia: SHOCK discuss potential causes, what to assess, and interventions Causes: underlying heart disease, myocardial ischemia or infarction, medications that prolong QT interval, electrolyte imbalance, digoxin toxicity, congestive heart failure ---> when the heart is weak Assessments: chest discomfort (angina), syncope, lightheadedness or dizziness, palpitations, shortness of breath, absent or rapid pulse, loss of consciousness, hypotension, Interventions: if no pulse- begin CPR and follow ACLS protocols, if pulse and patient is unstable- cardiovert and begin drug therapy, amiodarone, lidocaine, antiarrhythmics, long term Ventricular fibrillation: SHOCK discuss potential causes, what to assess, and interventions Causes: AMI, untreated VT, electrolyte imbalance, hypothermia, myocardial ischemia, drug toxicity or overdose, trauma Assessments: loss of consciousness, absent pulse, check patient to see if artifact, patient is awake and alert or unconscious Interventions: Check pulse, call code, start CPR, get on defibrillator (or AED if that's all you have) immediately, initiate ACLS protocols Asystole: discuss potential causes, what to assess, and interventions→ ***Asystole (ay-sis-stuh-lee) is when there's no electricity or movement in your heart. That means you don't have a heartbeat. It's also known as flatline. Potential causes: suffocation, massive pulmonary embolism, hyperkalemia, myocardial infarction (MI) complicated by VF or ventricular tachycardia (VT) that deteriorates to asystole, post defibrillation, hypothermia, hypoxia, near drowning, direct lightning strike, and sedative or opioid overdoses leading to respiratory failure. (things that cut off oxygen or cause your heart to stop beating) Assess: vital signs (pulse, oxygen, skin color) Interventions: begin CPR, don't shock, check carotid pulse, push EPI, maintain patent airway, ventilate with ambu bag ***FROM OLDER BP AND BOOK: Sinus Tachycardia Fast heartbeat related to rapid firing of the sinoatrial node Caused by: damage to heart tissues from heart disease, hypertension, fever, stress, excess alcohol/caffeine/nicotine/recreational drugs (cocaine), side effect of meds, response to pain, imbalance of electrolytes, hyperthyroidism, exercise Interventions: avoid nicotine, caffeine, alcohol, bedrest if tachy is causing hypotension, stress management, Sinus Bradycardia Regular but unusually slow heart rate, can be a normal variation in athletes, during sleep, or in response to vagal maneuver Caused by: hypoglycemia, hypothermia, hypothyroidism, previous cardiac history, medications, toxic exposure, MI - inferior right wall involving right coronary artery Interventions: treating underlying cause, atropine, increase intravascular volume, D/C drugs suspected of causing bradycardia, transcutaneous or transvenous pacing, Atrial Fibrillation Electrical signal that circles uncoordinated through the muscles of the atria causing them to quiver without contracting, ventricles do not receive regular impulses and contract out of rhythm, and the heartbeat becomes uncontrolled and irregular, most common arrhythmia Caused by: hypoxia, hypertension, congestive heart failure, coronary artery disease, dysfunction of the sinus node, mitral valve disorders, rheumatic heart disease, pericarditis, hyperthyroidism, excessive alcohol or caffeine S/Sx: heart palpitations, irregular pulse that feels too rapid or too slow, racing, pounding, or fluttering, dizziness/light-headedness, fainting, confusion, fatigue, trouble breathing, difficulty breathing when lying, tightness in the chest Assess if the patient is stable, if it is new, CHADS2 score Interventions: control rate and rhythm of heart, poss anticoagulants, biventricular pacing, radiofrequency ablation, electrical cardioversion Ventricular Tachycardia Rhythm in which three or more PVCs arise in sequence at a rate greater than 100 beats per minute, can occur in short bursts less than 30 seconds, causing few or no symptoms, sustained v-tach lasts for more than 30s and requires intervention and immediate treatment Can quickly lead to vfib Caused by: underlying heart disease, myocardial ischemia or infarction, certain medications may prolong the Q T interval predisposing the pt to vtach, electrolyte imbalance, digitalis toxicity, congestive heart failure S/Sx: angina, syncope, light-headedness, palpitations, dyspnea, absent or rapid pulse, loss of consciousness, hypotension Interventions: antidysrhythmic, cardioversion, radiofrequency ablation Ventricular Fibrillation *** Asystole A state of cardiac standstill with no cardiac output and no ventricular depolarization, eventually occurs in all dying patients Caused by: suffocation, massive PE, hyperkalemia, myocardial infarction complicated by VF or Vtach that deteriorates to asystole, post defibrillation, hypothermia, hypoxia, near drowning, direct lightning strike, and sedative or opioid overdoses leading to respiratory failure Start CPR

Basic lab values associated with fluid balance

Sodium: 135-145 K: 3.5-5 Ca: 9-10.5 Mg: 1.8-2.6 Glucose: 90-100 BUN: 10-20 mg/100 mL Creatinine: 0.7-1.4 mg/100 mL Hemoglobin: 13-18 gr/dL for males and 12-16 females Hematocrit: 42-50% males, 40-48% female Platelets: 100,000 to 400,000 PT: 9.5-12 seconds (time it takes plasma to clot) PTT: 20-45 seconds (partial thromboplastin time) (how long it takes the blood to clot) INR: 1 Total protein: 6-8 g/100 mL Albumin: 3.5-5 g/100 mL Osmolarity: 270-300 mOsm/L pH urine: 4.6-8.2 specific gravity: 1.005-1.030

Skin cancer prevention and identification.

Squamous cell carcinoma: epidermis, caused by repeated injury or irritation Basal cell carcinoma: it often goes unnoticed, metastasis is rare, genetic predisposition, can be caused by irritation and UV exposure Melanoma: pigmented cancer growth, also known as a nevus growth or mole. Asymmetric, borders are irregular, color, diameter, evolving Any skin cancer occurs as a result of failure of cellular regulation over cell division Overexposure to sunlight is the major cause of skin cancer, although other factors also are associated. Because sun damage is an age-related skin finding, screening for suspicious lesions is an important part of physical assessment of the older adult. The most common skin cancers are actinic or solar keratosis, squamous cell carcinoma, basal cell, and melanoma Table 25-5 page 458 Prevention: sunscreen, avoid tanning bed, inspect skin monthly, hats

respiratory failure & ARDS

The inability respiratory system to provide oxygenation and/or remove carbon dioxide from the body The acute respiratory failure develops over minutes to hours vs chronic failure which develops over time A patient with Chronic respiratory failure can develop ARF (acute-on-chronic) Can be caused by : Oxygenation failure Ventilatory failure Or combination : occur in patients w/ COPD, cystic fibrosis, asthma attack, heart failure along w/ ventilatory failure PaO2 < 60 mmHg Pa CO2 > 45 mmHg (PH <7.35) Arterial oxygen saturation: SaO2 <90% in both cases Assessment : Symptoms : hypoxia, hypercapnia, acidosis Dyspnea is the hallmark sign of respiratory failure Assess rate & lung sounds LOC - drowsiness , lethargic ABG's Monitor SpO2 & end-tidal CO2 Assess agitation , tachycardia , tachypnea , cyanotic ARDS : Acute Respiratory Distress Syndrome : Most severe form of respiratory failure w/ hypoxemia despite 100% O2 (classic hallmark sign) ; decreased pulmonary compliance ; non-cardiac bilateral pulmonary edema ; CXR-dense pulmonary infiltrates described as a "ground glass appearance" The trigger is a systemic inflammatory response Alveolar capillary membrane is the main site of injury Patient develops a fluid filled alveoli due to damage Surfactant activity is reduced causing loss of lung compliance & alveolar collapse 3 phases of ARDS : Exudative fluid moves into the alveoli ; atelectasis develops Fibroproliferative - lung injury ; pulmonary hypertension ; fibrosis ; MODS (multi organ dysfunction syndrome) can occur Resolution - begins after ~2 weeks ; resolution of injury can occur, if patient survives may have permanent lung damage ARDS often occurs after an acute lung injury (ALI) Symptoms : Dyspnea & tachycardia / increased WOB Early hyperventilation w/ normal breath sounds & respiratory alkalosis that develops to crackles & respiratory acidosis Restlessness , anxiety , change in LOC Hypoxia that worsens despite O2 (refractory hypoxemia) Causes : Sepsis Pulmonary infections Shock Trauma Pancreatitis Multiple blood transfusions Cardiopulmonary bypass Drug ingestion Interventions / management : Oxygenation & ventilation Primary goal is adequate oxygenation NPPV (non-invasive positive pressure ventilation) - CPAP / BiPap Pressure control ventilation or volume control Positive end-expiratory pressure (PEEP) **** basically any way to restore function & lung capacity and prevent alveolar collapse

atropine

Unclassified for dysrhythmias, is used for bradycardia Monitor HR and rhythm after administration, increased HR is expected Atropine sulfate Used for bradycardia. • Teach patients to report nausea, vomiting, diarrhea, paresthesias, confusion, or visual disturbance; these can indicate digoxin toxicity. • Monitor HR and rhythm after administration; increased heart rate is expected.

unstable vs stable angina

Unstable Angina Chest pain or discomfort that occurs at rest or with exertion that causes a severe activity limitation An increase in # of attacks and intensity indicates unstable angina Pressure may be longer than 15 minutes or may be poorly relieved by rest or nitroglycerin May present w ST changes on a 12 Lead ECG, but normal troponin, some ischemia present but not enough to cause detectable myocardial damage or cell death As the assays for troponins become more sensitive, the diagnosis of UA is decreasing Unstable Angina includes: New onset angina - patient having their first angina symptoms variant angina - pain resulting from coronary artery spasms & typically occurs after rest preinfarction angina - chest pain that occurs in the days or weeks before a myocardial infarction Stable Angina Chest pain/discomfort The frequency, duration, & intensity of symptoms remain the same over several months Occurs w moderate to prolonged exertion in a pattern that is familiar to the patient Results in slight limitation of activity & is usually associated with a fixed atherosclerotic plaque Usually relieved by nitroglycerin or rest / rarely requires aggressive treatment Occurs in a familiar pattern, frequency/duration/intensity of the attacks remain the same, causes only a slight limitation in activity, usually relieved by nitroglycerin or rest, managed w drugs and rarely needs aggressive treatment

digoxin/lanoxin

Used for Afib and atrial flutter, assess apical HR before administration, decreased HR is expected response Teach pt to report nausea, vomiting, diarrhea, paresthesias, confusion, or visual disturbance Monitor pulse rate

adenosine

Used for paroxysmal SVT have crash cart available because short period of asystole is common after administration, bradycardia and hypotension may occur Facial flushing, dyspnea, and angina are common side effects Adenosine Used for paroxysmal SVT. • Have emergency equipment available because a short period of asystole is common after administration; bradycardia and hypotension may occur. • Facial flushing, shortness of breath, and chest pain are common side effects.

loop diuretics ex. furosemide

Used to treat fluid overload, heart failure, edema, nephrotic syndrome, ascites, hepatic disease, hypertension Can also treat hypercalcemia in malignancy Conivaptan: euvolemia hyponatremia, not indicated for HF, hypervolemia Hydrochlorothiazide: edema, hypertension, heart failure Bumetanide: edema in congestive heart failure, ascites

Kayexalate (Sodium Polystyrene)

Used to treat high levels of potassium in the blood Removes potassium, calcium, and sodium Primarily in large intestine PO or rectal

anticoagulants; warfarin, heparin/enoxaparin

WARFARIN: Vitamin K Antagonists (VKAs) Warfarin is used for people with a history of PE or DVT for preventative measures Monitor w/ PT/INR Antidote-Vitamin K INR: indicating a derived measure of prothrombin is used to monitor the effectiveness of warfarin. INR should be about 2-3 when taking heparin or warfarin Teach adults the importance of obtaining these tests (PT, PTT, INR) and monitor results to ensure that they are within the desired range to ensure patient safety. HEPARIN: Heparin sodium Heparin is used to prevent blood clots from forming Monitor PTT, aPTT, Factor anti-Xa, Platelet count Antidote-Protamine Patient Care/Safety Bleeding precautions Teaching: Drink adequate fluids to prevent dehydration. Avoid crossing the legs. Ambulate frequently and avoid prolonged sitting. Explore smoking cessation programs as needed. Call your primary health care provider if redness, pain, swelling, and warmth occur in the lower extremity.