Med Surg 2 Exam 3
Old content: A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
Heart rate When a clients circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefor a decreased heart rate indicates adequate fluid replacement.
Old content: Bow tie heart failure
Actions to take: Elevate head of bed, encourage intake of low-sodium diet. Potential complication: Heart failure Parameters to monitor: Urinary output, blood pressure
Old content: A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?
Acute pain
Old content: 30% burns to body, which intervention should be performed first?
Administer IV fluid. Using airway, breathing, circulation framework, priority here is circulation.
Physical injuries after an explosion from slide
Blast lung Tympanic membrane rupture Abdominal and head injuries
Old content: Reviewing medical record of client with extensive burns, which lab result is to be expected?
Hyperkalemia due to release of potassium from damaged cells.
Old content: A nurse is caring for a client who is in shock. As shock worsens the nurse would expect to find what signs and symptoms?
Hypoactive bowel sounds Increased confusion Decreased urine output Cool, clammy skin
Prep U heart review: The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)?
Hypokalemia
Right side heart failure signs and symptoms
Right-sided failure: -JVD -Ascending dependent edema (legs, ankles, sacrum) -Abdominal distention, ascites -Fatigue, weakness -Nausea and anorexia -Polyuria at rest (nocturnal) -Liver enlargement (hepatomegaly) and tenderness -Weight gain
Old content: Rule of 9's review.
Rule of 9's for Adults: 9% for each arm, 18% for each leg, 9% for head,18% for front torso, 18% for back torso. answer 31.5
Old content: The nurse has been identified that the client is in sepsis. Select 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?
Measure lactate level Administer broad-spectrum antibiotic Obtain blood cultures Rapidly administer 30 mL/kg of normal saline
Old content: Expected findings for MI?
Nausea Tachycardia Diaphoresis
Old content: Nursing discharge information post MI:
Need for careful monitoring for cardiac symptoms Need for dietary modifications Need for carefully regulated exercise
Old content: Client states "You are the worst nurse I have ever seen. All you do is hurt me."
Nurse response: "Tell me more about that."
Old content: Peripheral vascular disease and trouble sleeping
Obtain a pair of slipper-socks for the client
Old content: The nurse is caring for a client who has hypovolemic shock. Which is an expected finding?
Oliguria Oliguria (small amounts of urine) is present during hypovolemic shock as a result of decreased blood flow to the kidneys.
Old content: Interventions to promote healing and prevent invention of a venous leg ulcer?
Provide a high-calorie, high protein diet
Old content: What is defined as a partial-thickness burn?
The burned area is mottled in color with blisters present.
Old content: A nurse is evaluating a client who had a myocardial infraction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy?
The client demonstrates ability to tolerate more activity without chest pain.
Emergency and disaster nursing question from Prep U:
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a.) A patient with no pedal pulses b.) A patient with an open femur fracture c.) A patient with bleeding facial lacerations d.) A patient with paradoxical chest movement ANS: D Rationale: Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems.
Old contents: Angina vs myocardial infarction
Treadmill Stress Test: Angina-yes MI-no Provider consult: Angina- yes MI-no Result of nitroglycerin therapy: Angina- yes MI-no Client's report of initial manifestations: Angina-yes MI-yes 12 Lead EKG Report: Angina- yes MI- yes
Anthrax and treatment from slide
-Incubation varies by route. -Skin contact, GI ingestion, inhalation. -Skin lesions, fever, N&V, abdominal pain, diarrhea. -Respiratory symptoms that mimics influenza. -Treatment: Penicillin V, Erythrocin, usually for 60 days.
Small pox and treatment from slide
-Incubation: 12 days -Extremely contagious; spread by direct contact, by contact with clothing or linens, or by droplets person-to-person. -Manifestations: High fever, malaise, headache, backache, and prostration; after 1 to 2 days a maculopapular rash appears on the face, mouth, pharynx, and forearms. -Treatment is supportive care with antibiotics for any additional infection.
Old content: Nurse in the ED caring for a client with partial and full-thickness burns to head, neck and chest. What is the priority for assessment?
Airway obstruction Using ABC's this is most important assessment.
Old content: While assessing the most distal pulse post left femoral cardiac angiography where do you assess?
Assess doralis pedis pulse on left foot extremity.
Asytole
Asystole: Asystole, colloquially referred to as flatline, represents the cessation of electrical and mechanical activity of the heart. Asystole typically occurs as a deterioration of the initial non-perfusing ventricular rhythms: ventricular fibrillation (V-fib) or pulseless ventricular tachycardia (V-tach). -Absence of electrical activity, patient is pulseless -Ventricular standstill Causes: Extensive myocardial damage secondary to acute myocardial infarction, failure of pacemaker, cardiac tamponade, prolonged v-fib, pulmonary embolism Signs and Symptoms: No palpable pulse, no measurable BP, loss of consciousness Risk: Deader - they are already dead Treatment: CPR, ACLS protocol Nursing Interventions: Assess patient, treatment must be aggressive and immediate, start CPR, ACLS
Prep U heart review: A client has an irregular heart rate of around 100 beats/minute and a significant pulse deficit. What component of the client's history would produce such symptoms?
Atrial fibrillation
Old content: A nurse is caring for a client in the compensatory stage of shock. Which finding would the nurse expect?
BP of 115/68 The sympathetic nurse system is stimulated, resulting in the release of epinephrine and norepinephrine. This helps maintain BP in compensatory stage.
Prep U heart review: The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse?
Begin CPR!
Blast injury: what happens in an explosion from Prep U:
Blast injury: A blast may result from terrorism but can also occur anywhere at any time if the right (or wrong) circumstances come together (e.g., welding inside of a tank that formerly contained tar but was not properly cleaned can result in an explosion as well as severe tar burns to the worker). Blast lung: Results from the blast wave as it passes through air-filled lungs. The result is hemorrhage and tearing of the lung, ventilation-perfusion mismatch, and possible air emboli. Typical signs and symptoms include dyspnea, hypoxia, tachypnea or apnea (depending on severity), cough, chest pain, and hemodynamic instability. Management involves providing respiratory support that includes administration of supplemental oxygen with nonrebreathing mask but may also require endotracheal intubation and mechanical ventilation. Tympanic membrane rupture: Tympanic membrane (TM) rupture is the most frequent injury after subjection to a pressure wave because TM is the body's most sensitive organ to pressure. Signs and symptoms include hearing loss, tinnitus, pain, dizziness, and otorrhea. The majority of TM ruptures heal spontaneously. Approximately 5% of patients with TM rupture from a blast will require hearing aids. Abdominal and head injuries: Blast abdomen may be evidenced by abdominal hemorrhage and internal organ injury. The typical signs and symptoms of internal abdominal injury can include pain, guarding, rebound tenderness, rectal bleeding, nausea, and vomiting. Head injuries usually minor and just require some follow up with physician.
Old content: A client with severe burns is admitted to ICU to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of shock?
Decreased blood pressure
Old content: The nurse in the ED is caring for a client recently admitted with myocardial infarction. The clients heart is pumping inadequate oxygen and the client is at risk for?
Dysrhythmias
Old content: A nurse is assessing a client who has venous insufficiency. What should the nurse expect?
Edema
Old content: A nurse is developing a plan of care for a client who has cellulitis of the leg. Which intervention should the nurse include in the plan?
Elevate the affected leg on two pillows Elevation of the leg reduces edema
Prep U heart review: A nurse enters a client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client?
Immediate CPR.
Emergency triage priority
In a disaster you have these two patients, who do you take care of first? Breathing issues vs femur fracture. You would move the femur fracture first. Easier transfer. Do the greatest amount of good for the greatest number of people. Opposite of typical ABC'S.
Old content: A finding that indicates to the nurse that the client may be developing hypovolemic shock?
Increase in heart rate from 88 to 110 bpm.
Old content: A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Increased respiratory rate When shock occurs, the body attempts to compensate for decreased level of oxygen and tissue perfusion. Initially, the client will display increased respiratory rate.
Old content: A nurse is caring for a client in shock. What cardiac signs who indicate organ dysfunction?
Mean arterial pressure <65mm Hg. (normal 70-100) Drop of systolic blood pressure of >40 mm Hg from baseline Serum lactate >4 mmol/L
Supraventricular Tachycardia (SVT)
SVT: Supraventricular tachycardia (SVT) is a condition where your heart suddenly beats much faster than normal. It's not usually serious, but some people may need treatment. -Encompasses all fast (tachy) dysrhythmias in which heart rate is greater than 150 bpm -Narrow QRS means conduction is from the atrium -Supra (above the) ventricles Causes: Stimulants, stress or over-exertion, fatigue Signs and Symptoms: Palpitations, chest discomfort (pressure, tightness, pain), lightheadedness or dizziness, syncope, shortness of breath, pounding pulse, sweating, tightness or fullness in the throat, fatigue Risk: Heart failure with prolonged SVT Treatment: Stable patients (asymptomatic): treat cause, vagal maneuvers, medications (adenosine, beta blockers, CCB); unstable patients (symptomatic): cardioversion Nursing Interventions: Assess patient, vagal maneuvers (cough and valsalva), prepare for cardioversion.
Dysrhythmias
Sinus (Bradycardia, Tachycardia, Arrhythmia) Atrial Junctional
Sinus Arrhythmia
Sinus Arrhythmia: Sinus arrhythmia is a variation of normal sinus rhythm that characteristically presents with an irregular rate in which the change in the R-R interval is greater than 0.12 seconds. Causes: May be caused by heart disease, valvular disease. No treatment necessary.
Sinus Bradycardia
Sinus bradycardia is a cardiac rhythm with appropriate cardiac muscular depolarization initiating from the sinus node and a rate of fewer than 60 beats per minute (bpm). The diagnosis of this condition requires an ECG showing a normal sinus rhythm at a rate lower than 60 bpm. Causes: Athletic patient, hypothyroidism, vagal stimulation Signs and Symptoms: Syncope, dizziness, chest pain, shortness of breath, exercise intolerance, cool, clammy skin Risk: Reduced cardiac output Treatment: Based on whether patient is symptomatic, atropine 0.5 mg IVP, q 3-5 minutes for max of 3 mg, pacing if the patient is hemodynamically compromised Nursing Interventions: Assess patient, monitor vital signs, IV access, prepare for medications, pacing
Sinus Tachycardia
Sinus tachycardia is a regular cardiac rhythm in which the heart beats faster than normal. While it is common to have tachycardia as a physiological response to exercise or stress, it causes concern when it occurs at rest. Causes: Heart disease, hypertension, fever, stress, exercise, excess alcohol, caffeine, nicotine, or recreational drugs such as cocaine, side effect of medications, response to pain, electrolyte imbalance, hyperthyroidism, autonomic dysfunction (postural orthostatic tachycardia syndrome [POTS]) Signs and Symptoms: Dizziness, shortness of breath, lightheadedness, rapid pulse rate, heart palpitations, chest pain, syncope Risk: Cardiac output may fall due to inadequate ventricular filling time, myocardial oxygen demand increases, can precipitate myocardial ischemia or infarct Treatment: Aimed at finding and treating cause, beta blockers (Lopressor or Atenolol), synchronized cardioversion, adenosine 6 mg, rapid IVP if unstable, second dose 12 mg rapid IVP Nursing Interventions: Assess patient, monitor vital signs, IV access, ACLS protocol
Small pox and Management Prep U:
Small Pox: Smallpox (variola) is classified as a deoxyribonucleic acid (DNA) virus. It has an incubation period that ranges from 7 to 17 days. It is extremely contagious and spread by direct contact, by contact with clothing or linens, or by droplets from person to person only after the fever has decreased and the rash phase has begun. Aerosolization of the virus would result in widespread dissemination. Management: Antivirals and immune globulin may aid in treatment; however, vaccination remains the most effective method of prevention. The patient should be isolated in a negative-pressure environment, using strict airborne and contact precautions. Laundry and biologic wastes should be autoclaved before being washed with hot water and bleach. All people who have household or face-to-face contact with the patient after the fever begins should be vaccinated within 4 days to prevent infection and death. A patient with a temperature of 38°C (101°F) or higher within 17 days after exposure must be placed in isolation. Cremation is preferred for all deaths, because the virus can survive in scabs for up to 13 years.
Old content: A nurse is closely monitoring a client who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture od the client's aneurysm?
Sudden onset of severe back or abdominal pain
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?
Talk with the client during would care
Emergency and disaster nursing question from Prep U:
The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? a.) A 74-yr-old patient with palpitations and chest pain. b.) A 43-yr-old patient complaining of 7/10 abdominal pain. c.)A 21-yr-old patient with multiple fractures of the face and jaw. d.) A 37-yr-old patient with a misaligned lower left leg with intact pulses. ANS: C, A, B, D
Prep U heart review: The client has just been diagnosed with a dysrhythmia. The client asks the nurse to explain normal sinus rhythm. What would the nurse explain is the characteristic of normal sinus rhythm?
The sinoatrial (SA) node initiates the impulse.
Triage
The sorting of patients to determine priority health care needs and the proper site of treatment. In non-disaster situations, health care workers assign highest priority and allocate most resources to the most critically ill patients. In disaster situations with large numbers of casualties, decisions are based on the likelihood of survival and the consumption of resources.
Old content: What characteristic of the burn will primarily determine if client will experience a systemic response to the injury?
The total body surface area (TBSA) affected by the burn.
Old content: Statement by nurse why cardiac rehab should be done.
"Cardiac rehabilitation cannon undo the damage to your heart but it can help you get back to your previous level of activity safely"
Old content: Explaining cardiac enzymes to partner of client:
"These tests help determine the degree of damage to the heart tissue."
Prep U heart review: A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best?
"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."
Preparing a client for EKG from slide
-Apply electrodes on clean, dry skin -If amount of chest hair prevents the electrode from having good contact with the skin, the hair may need to be clipped. -Poor electrode adhesion will cause significant artifact (distorted, irrelevant, and extraneous ECG waveforms)
Shock review
-As you go into shock, your blood pressure, pulse rate, and breathing rate drop abruptly. Because the body's temperature is not regulated, the skin gets cold and sweaty. A rapid fall in blood pressure reduces the supply of oxygen and nutrients to vital organs in the body. -Alterations in mental state -Increased capillary refill time (usually less than 3 seconds) -Urine output less than 30 mL/hr -Rapid elevations of temperature -Decreased bowel sounds (body shutting down) -Blood pressure may remain normal, even in hypovolemic shock, or low, but all vitals to be evaluated.
Old content: A nurse is preparing to administer 0.9% sodium chloride 1,000 ml IV to infuse over 8 hours. The nurse should set the pump to deliver how many ml an hr?
125 ml/hr
Old content: Prescription for vancomycin 1 g in 250 ml dextrose 5% over 2 hr by IV intermittent bolus. The nurse should set the pump to deliver how many ml/hr?
125 ml/hr
First sign of increased ICP
1st: Altered mental status followed by: headache, nausea / vomiting.
Old content: A client in acute phase of recovery and has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs?
A patient controlled analgesia (PCA) system
Air embolism
Air embolism: The risk of air embolism is rare but ever-present. It is most often associated with cannulation of central veins and directly related to the size of the embolus and the rate of entry. Air entering into central veins gets to the right ventricle, where it lodges against the pulmonary valve and blocks the flow of blood from the ventricle into the pulmonary arteries. Manifestations: Manifestations of air embolism include palpitations, dyspnea, continued coughing, jugular venous distention, wheezing, and cyanosis; hypotension; weak, rapid pulse; altered mental status; and chest, shoulder, and low back pain. Treatment: Treatment calls for immediately clamping the cannula and replacing a leaking or open infusion system, placing the patient on the left side in the Trendelenburg position, assessing vital signs and breath sounds, and administering oxygen. Prevention: Air embolism can be prevented by using locking adapters on all lines, filling all tubing completely with solution, and using an air detection alarm on an IV infusion pump. Complications of air embolism include shock and death. The amount of air necessary to induce death in humans is not known; however, the rate of entry is probably as important as the actual volume of air.
Depolarization and Repolarization
Depolarization = stimulation = systole Repolarization = relaxation = diastole
ECG Trace
ECG Trace attached
Old content: A nurse is providing teaching for a client with new diagnosis of angina pectoris. The nurse should give the client the following information about angina pain:
Exertion and anxiety can trigger the pain
Determining heart rate on ECG
In a 6-second strip, count the number of R-R intervals and multiply by 10.
Old content: Which action is used to determine MI?
Perform a 12-lead-ECG
Normal sinus rhythm
Photo attached Normal sinus rhythm
Sinus pause or arrest
Sinus pause: A sinus pause or arrest is defined as the transient absence of sinus P waves that last from 2 seconds to several minutes. Causes: May occur in individuals with healthy hearts during sleep, myocarditis, cardiomyopathy, MI, digitalis toxicity, age- elderly, vagal stimulation Signs and Symptoms: Sometimes asymptomatic, syncope, dizziness, LOC, bradycardia Risk: Sudden cardiac death (rare), syncope, fall, thromboembolic events including stroke, CHF, atrial tachyarrhythmias - such as atrial flutter or fibrillation Treatment: Only treated if patient symptomatic, atropine, pacemaker Nursing Interventions: Assess patient, monitor vital signs
Old content: New diagnosis of venous insufficiency, instructions to include:
Use elastic stockings
Dysrhythmias defined
-Disorders of formation or conduction (or both) of electrical impulses within heart. -Can cause disturbances of Rate, Rhythm, Both rate and rhythm. -Potentially can alter blood flow and cause hemodynamic changes -Diagnosed by analysis of electrographic waveform. Types of dysthymias: Atrial: Premature atrial complex Atrial flutter Atrial fibrillation ------------------------------------------ Ventricular: Premature ventricular complex Ventricular tachycardia Ventricular fibrillation Ventricular asystole
Constipation treatment
-Encourage the patient to increase fluid intake of 1.5 to 2 L/day as tolerated. -Advised patients to take the recommended dose of dietary fiber of at least 20 to 30 g daily. -Assist the patient in doing physical activity and exercise. -Laxative if needed. *ICP patient, and give stool softener so they do not bear down. Constipation and Sinus Brady you do not want to bear down either.
Junctional Rhythm
-Occurs when the AV node becomes the pacemaker of the heart -Discharges an impulse at a rate of 40 - 60 bpm -May have absent or inverted P waves -HR > 60 bpm, accelerated junctional rhythm
Preparing a client for 12 lead EKG
-Position the client in supine position with chest exposed. -Wash the clients skin to remove oils. -The electrode application site should be clean and dry. -Hair on chest may need to be clipped or chest may need to be shaved for mail clients.
MI vs Angina
-The key difference between angina and a heart attack is that angina is the result of narrowed (rather than blocked) coronary arteries. This is why, unlike a heart attack, angina does not cause permanent heart damage. -Heart attack is due to a block that does cause damage. -Angina can be relieved with rest and NTG.
Shockable rhythms
-The two shockable rhythms are ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). -While the non-shockable rhythms include sinus rhythm (SR), supraventricular tachycardia (SVT), premature ventricualr contraction (PVC), atrial fibrilation (AF) and so on.
Diarrhea treatment
-Weigh daily and note decreased weight. -Have the patient keep a diary of their bowel movements. -Avoid using medications that slow peristalsis. -Give antidiarrheal drugs as ordered. -Provide bulk fiber (e.g., cereal, grains, psyllium) in the diet.
Old content: A nurse is preparing to administer lidocaine 50 mg IV bolus. Available is lidocaine 200/mg/ml. How many ml should the nurse administer per dose?
0.3 ml
Old content: A nurse is preparing to administer heparin 2,000 units by IV bolus. Available is 5,000 units/ml. How many ml should the nurse administer?
0.4
Old content: Client with heart failure. Prescription which needs additional clarification?
0.9 % normal saline IV at 150 ml/hr continuous. Not indicated for heart failure.
Old content: Bow tie on worsening of congestive heart failure
Actions to take: Apply 02 at 2/L min nasal cannula, Elevate head of bed Potential condition: Worsening of congestive heart failure Parameters to monitor: O2 saturation, Respiratory rate.
Medications to know: Adenosine and Atropine
Adenosine (Adenocard): Drug class: Antidysrhythmics Pharm action: Used to convert supraventricular tachycardia to sinus rhythm when vagal maneuvers have been ineffective. In the heart adenosine decreases heart rate and also decreases the speed with which impulses flow between the heart muscles to bring about a contraction. Therapeutic: Restore heart to normal sinus rhythm. Example of uses: Adenosine can be useful in treating wide QRS tachycardia that is hemodynamically stable when it is difficult to differentiate between supraventricular tachycardia and ventricular tachycardia. Adenosine can be used diagnostically for patients with narrow QRS complex tachycardia. Side effects: The side-effects of adenosine are unpleasant, but usually transient and tolerable. Chest pain, dyspnoea, cutaneous flushing and a sense of impending doom are well known. The most significant adverse effects are bronchospasm and arrhythmogenesis (heart structure becomes weak). Contraindications: Do not take if unstable heart or blood vessel problem. Nursing intervention: Monitor heart rate, BP, and EKG. Assess respiratory status. Client education: Move positions slowly do to orthostatic hypotension, avoid caffeine. Evaluation of medication: Proper profusion, heart restored to normal rhythm. *Ways to remember: Adenosine = Think D and decreases. ---------------------------------------------------------------------- Atropine Sulfate: Drug class: Anticholinergics Pharm action: Inhibits the action of acteylcholine at postganglionic sites located in the smooth muscle, secretory glands, CNS. Low doses decrease sweating, salivation, respiratory secretion. Therapeutic: Atropine increases the heart rate and improves the atrioventricular conduction by blocking the parasympathetic influences on the heart. Examples of use: The use of atropine in cardiovascular disorders is mainly in the management of patients with bradycardia. Atropine increases the heart rate and improves the atrioventricular conduction by blocking the parasympathetic influences on the heart. Side effects: Side effects include the following: Bigger, dilated or enlarged pupils, eye pain, dry eyes, blurred vision, chest pain/discomfort/tightness, decreased urine output, tachycardia. Contraindications: Individuals who should not take atropine: overactive thyroid gland, myasthenia gravis (a skeletal muscle disorder), closed angle glaucoma, high blood pressure. Nursing interventions: Assess vitals signs such as HR and BP. EKG monitoring. Client education: Caution with activities that require alertness, oral care due to dry mouth. Evaluation of medication: Increase in heart rate, dry mouth present, muscarinic effects.
Anthrax and Management from Prep U:
Anthrax: Anthrax is recognized as the most likely weaponized biologic agent available and has been recognized as a highly debilitating agent for centuries. Bacillus anthracis is a naturally occurring gram-positive, encapsulated rod-shaped bacterium. Anthrax is caused by replicating bacteria that release toxin, resulting in hemorrhage, edema, and necrosis (cell death). Management: At present, anthrax is penicillin sensitive; however, strains of penicillin-resistant anthrax are thought to exist. Recommended treatment includes penicillin, ciprofloxacin, levofloxacin, and doxycycline. If antibiotic treatment begins within 24 hours after exposure, death can be prevented. Treatment is continued for 60 days. For patients who have been directly exposed to anthrax but have no signs and symptoms of disease, ciprofloxacin or doxycycline is used for prophylaxis for 60 days. Standard precautions are needed when caring for a patient infected with anthrax. The patient is not contagious, and the disease cannot spread from person to person. Equipment should be cleaned using standard hospital disinfectant. After death, cremation is recommended because the spores can survive for decades and represent a threat to morticians and forensic medicine personnel. A vaccination, which includes six doses is available for the Department of Defense, and the CDC is in the process of developing a civilian vaccination protocol.
Prep U heart review: Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?
Anticoagulant
Aspirin
Aspirin: From Hughes: Aspirin is an antiplatelet, makes platelets less sticky and prevents clots for this reason. Rationale: Taking aspirin helps prevent blood clots from forming in your arteries and may help lower your risk for a stroke or heart attack. Your provider may recommend to take daily aspirin if: You do not have a history of heart disease or stroke, but you are at high risk for a heart attack or stroke. Aspirin slows the blood's clotting action by reducing the clumping of platelets. Platelets are cells that clump together and help to form blood clots. Aspirin keeps platelets from clumping together, thus helping to prevent or reduce blood clots.
Old content: Patient suffers from claudication related to peripheral artery disease. What is the priority assessment?
Asses pulses in extremities
What is atrial fibrillation?
Atrial fibrillation, often called AFib or AF, is the most common type of treated heart arrhythmia. An arrhythmia is when the heart beats too slowly, too fast, or in an irregular way. -Electrical signal circles uncoordinated through the muscles of the atria causing them to quiver (sometimes more than 400 times per minute) without contracting. -Ventricles do not receive regular impulses and contract out of rhythm, and the heartbeat becomes uncontrolled and irregular. -Hallmark sign of a-fib: irregularly irregular. Causes: Hypoxia, hypertension, CHF, CAD, dysfunction of the sinus node, mitral valve disorders, rheumatic heart disease, pericarditis, hyperthyroidism, excessive alcohol or caffeine consumption Signs and Symptoms: Can be asymptomatic, heart palpitations, irregular pulse, dizziness or light-headedness, fainting, confusion, fatigue, trouble breathing, sensation of tightness in the chest Risk: Heart failure, myocardial ischemia, clot formation in atria (atria not completely emptying), stroke, pulmonary embolism, dramatic drop in cardiac output Treatment: Rate control, beta blockers, calcium channel blockers, antithrombotic therapy, TEE, synchronized cardioversion, ablation
Atrial flutter
Atrial flutter: Atrial flutter is a type of abnormal heart rhythm, or arrhythmia. It occurs when a short circuit in the heart causes the upper chambers (atria) to pump very rapidly. Atrial flutter is important not only because of its symptoms but because it can cause a stroke that may result in permanent disability or death. *saw like -Conduction deficit in the atrium which causes a rapid, regular atrial impulse at a rate of 250 - 400 bpm -Atrial rate is faster than the AV node can conduct so not all impulses are conducted into the ventricle, causing a therapeutic block at the AV node; otherwise the ventricular rate would also be 250 - 400 bpm, leading to v-fib. Causes: Age > 60 years old, valve disorder (mitral), thickening of the heart muscle, ischemia, cardiomyopathy, COPD, emphysema, hyperthyroidism Signs and Symptoms: Chest pain, palpitations, SOB, anxiety, weakness, angina, syncope Risk: Clot formation in atria (atria not completely emptying), stroke, pulmonary embolism, dramatic drop in cardiac output Treatment: Vagal maneuvers, adenosine, antithrombotic therapy, rate control, rhythm control, cardioversion - if hemodynamically unstable Nursing Interventions: Assess patient, monitor vital signs, prepare for cardioversion
Prep U heart review: The nurse knows that electrocardiogram (ECG) characteristics of atrial fibrillation include what?
Atrial rate of 300 to 400
Prep U heart review: A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Which medication does the nurse anticipate administering to treat bradycardia?
Atropine
Old content: Client who is experiencing anaphylactic shock, which medication to be administered first?
Epinephrine
Burn review
First-degree (superficial-thickness) burns - These burns only involve the top layer of skin. They are painful, dry, and red; and blanch when pressed. These burns do not form a blister and generally heal within a week. *A sunburn is superficial. Second-degree (partial-thickness) burns - These burns involve the top two layers of skin. These burns form blisters, are very painful, may seep fluid, and blanch when pressed. Take a couple weeks to heal. Third-degree (Full-thickness) - These burns extend through and destroy all layers of the dermis and often injure the underlying subcutaneous tissue. Burn eschar, the dead and denatured dermis, is usually intact. The eschar can compromise the viability of a limb or torso if circumferential. Fourth-degree burns go through both layers of the skin and underlying tissue as well as deeper tissue, possibly involving muscle and bone. There is no feeling in the area since the nerve endings are destroyed. Key points: Lactated ringer for burns, asses airway first, fluid and electrolyte imbalances (Hyperkalemia, hyponatremia, Metabolic acidosis) so fluid resuscitation ASAP, monitor edema, wound infection monitoring, muscle and joint mobility. Hypovolemic shock is the most common shock with burns.
Furosemide
Fusosemide (Lasix): Furosemide is a loop diuretic. Inhibits the reabsorption of sodium and chloride at the proximal and distal tubule and in the loop of Henle. Therapeutic use: Pulmonary edema, edema with CHF, hepatic disease, renal disease, ascites, hypertension. Adverse effects: Circulatory collapse, hypokalemia (low potassium) other electrolytes low as well, polyuria, Renal issues, thrombocytopenia, agranulocytosis, rash, Steven Johnson syndrome. Contraindications: Hypovolemia, electrolyte depletion, breastfeeding. Precautions: Diabetes mellitus, dehydration, severe renal failure, cirrhosis, ascites. Client education: Rise slowly due to orthostatic hypotension, high potassium diet as risk for hypokalemia with furosemide. Nursing intervention: Monitor BP due to orthostatic hypotension, monitor electrolyte levels such as potassium, take in morning to avoid any sleep disturbances. Medication effectiveness: Decrease in edema, BP, Calcium levels (hypercalcemia) Increase urine.
Old content: A nurse is monitoring a client who has a leaking cerebral aneurysm. Which manifestations indicate increased intracranial pressure ICP?
Headache Slurred speech Pupillary changes Disorientation/confusion
Emergency operation plan (EOP)
Health care facilities are required by The Joint Commission to create a plan for emergency preparedness and to practice this plan twice a year.
Old content: Manifestations that suggest cardiac tamponade?
Hypotension Muffled heart sounds Tachycardia Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle and the outer covering sac (pericardium) of the heart. These would be the suggested manifestations.
Old content: Patient in shock, blood pressure remains low, interventions are not working, acidosis is worsening, all organs are failing. Type of shock?
Irreversible shock
Old content: Fluid used in first 24 hours for a burn?
Lacated ringer
Left and right heart failure
Left side heart failure: A reduction in the output from the left ventricle. The pressure in the left atrium increases as the oxygen-rich blood from the lungs is backed up. Right side heart failure: A reduction in the blood output from the right ventricle. The pressure in the right atrium may be increased depending on the return of blood from the rest of the body. Left sided heart failure is more common, but both left-side or right-sided heart failure will lead to reduced cardiac output from both ventricles. If left untreated left-sided heart failure will result in right sided heart failure as well.
Left side heart failure signs and symptoms
Left-sided failure: -Dyspnea -Orthopnea -Nocturnal dyspnea -Fatigue -Displaces apical pulse (b/c of hypertrophy) -S3 heart sound (gallop) -Pulmonary congestion (dyspnea, cough, crackles) -Frothy sputum (can be blood-tinged) -Altered mental status -Manifestations of organ failure (ex: oliguria)
Fluid volume deficit- treatment of dehydration
Nursing interventions for treatment of dehydration: -Fluid volume replacement: Start intravenous therapy as prescribed. Electrolytes may need to be replaced intravenously. Ringer's lactate IV fluid is preferred. If not available, use normal saline or dextrose solution. Encourage oral fluid intake of at least 2000 mL per day if not contraindicated. -Monitor the patients vitals, especially BP. Heart rate important to monitor as well. -Medications such as Ondansetron may possibly be used to prevent nausea and vomiting. -Monitor I & O's. -If FVD due to blood loss, administer blood products.
Old contents: Food that has best source of protein for wound healing?
One cup of lentils
Normal heart beat
P Wave Represents the electrical impulse starting in SA node and spreading through the atria; atrial depolarization (contraction) PR Interval = Time for impulse to travel from the SA node to AV node (0.12 - 0.20 seconds) QRS complex represents ventricular depolarization (contraction); (0.06 - 0.12 seconds) T wave represents repolarization of the ventricles ST Segment is the time between contractions and the relaxation of the ventricles QT interval is the total time for ventricular depolarization and repolarization (0.36 - 0.44 seconds)
Premature Ventricular Complex (PVC)
PVC's: Premature ventricular contractions (PVCs) occur in most people at some point. Causes may include certain medications, alcohol, some illegal drugs, caffeine, tobacco, exercise, or anxiety. PVCs often cause no symptoms. When symptoms do occur, they feel like a flip-flop or skipped-beat sensation in the chest. Most people with isolated PVCs and an otherwise normal heart don't need treatment. PVCs occurring continuously for longer than 30 seconds is a potentially serious cardiac condition known as ventricular tachycardia. -A PVC is not a rhythm, but an ectopic beat that arises from an irritable site in the ventricles. -PVCs appear in many different patterns and shapes, but are always wide and bizarre compared to a "normal" beat. Causes: Exercise, stress, caffeine, alcohol, heart disease, MI, CHF, cardiomyopathy, mitral valve prolapse, electrolyte imbalances, hypoxia, digitalis toxicity, acidosis Signs and Symptoms: May be asymptomatic, palpitations, weakness, dizziness, hypotension Risk: Reduced cardiac output, heart failure Treatment: Treat the cause, antiarrhythmic Nursing Interventions: Assess patient, monitor for frequent PVC's and deterioration to more serious rhythms.
Pacemakers
Pacemaker: Electronic device that provides electrical stimuli to heart muscle. Types: Permanent or Temporary Pacemaker generator functions: NASPE-BPEG code for pacemaker function. The most common reason people get a pacemaker is their heart beats too slowly (called bradycardia), or it pauses, causing fainting spells or other symptoms. In some cases, the pacemaker may also be used to prevent or treat a heartbeat that is too fast (tachycardia) or irregular. Complications of pacemakers: Infection, bleeding or hematoma formation, dislocation of lead, skeletal muscle or phrenic nerve stimulation, cardiac tamponade, pacemaker malfunction.
Old content: A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?
Packed RBC'S
Parkinson's disease
Parkinson's disease: A brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination which may increase risks of falls. People with Parkinson have symptoms that usually begin gradually and worsen over time. As the disease progresses, people may have difficulty walking and talking. Dopamine production low with Parkinson's disease. To know: Rocks back and forth to start movement with bradykinesia (slowness of movement and speed or progressive hesitations/halts) as movements are continued. The client with Parkinson's disease should exercise in the morning when energy levels are highest. The client should avoid sitting in soft deep chairs because they are difficult to get up from. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to support the ability to dress self. Preventing falls: Exercise plays an essential role in keeping a person with Parkinson's disease healthy and able to participate in activities of daily living. For reducing the risk of falls, exercises that specifically challenge and strengthen a person's balance, address axial rigidity and improve flexibility are ideal. Taking medication on time, walking to a rhythm, focus on long steps when walking are all helpful at preventing falls. General nursing interventions for fall prevention: Familiarize patient with environment, Bed in lowest position, call light on, rails, well lit room, walker if needed, patient possessions with patient, handrails in bathroom, room, hallway.
Pericarditis
Pericarditis: A swelling and irritation of the thin saclike membrane surrounding the heart (pericardium). Manifestations: Chest pressure/pain aggravated by breathing (mainly inspiration), coughing, and swallowing-pericardial friction rub auscultated at left lower sternal border, general shortness of breath and patient may have relief when sitting forward due to pressure relieved. To Know: Commonly follows a respiratory infection, can be due to a myocardial infarction, cardiac temponade is a risk Treatment: Pericarditis pain can usually be treated with over-the-counter pain relievers, such as aspirin or ibuprofen (Advil, Motrin IB, others). Prescription-strength pain relievers also may be used. Colchicine (Colcrys, Mitigare). Treatment of over-all inflammation.
Nursing assessment for dysrhythmias
Physical assessment include: -Skin (pale and cool) -Signs of fluid retention (JVD, lung auscultation) -Rate, rhythm of apical, peripheral pulses -Heart sounds -Blood pressure, pulse pressure.
Emergency triage colors
Triage category priority: 1 Triage color: Red Immediate: Injuries are life-threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. Typical conditions: Sucking chest wound, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abdominal wounds, incomplete amputations, open fractures of long bones, and second/third-degree burns of 15-40% total body surface area Triage category priority: 2 Triage color: Yellow Delayed: Injuries are significant and require medical care but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated. Typical conditions: Stable abdominal wounds without evidence of significant hemorrhage; soft tissue injuries; maxillofacial wounds without airway compromise; vascular injuries with adequate collateral circulation; genitourinary tract disruption; fractures requiring open reduction, débridement, and external fixation; most eye and central nervous system injuries. Triage category priority: 3 Triage color: Green Minimal: Injuries are minor, and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. Typical conditions: Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances. Triage category priority: 4 Triage color: Black Expectant: Injuries are extensive, and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties, but not abandoned. Comfort measures should be provided when possible. Typical conditions: Patients who are unresponsive with penetrating head wounds, high spinal cord injuries, wounds involving multiple anatomic sites and organs, second/third-degree burns in excess of 60% of body surface area, seizures or vomiting within 24 h after radiation exposure, profound shock with multiple injuries, agonal respirations, no pulse, no blood pressure, pupils fixed and dilated
Ventricular Dysrhythmias
Ventricular Dysrhythmias: Ventricular arrhythmias are abnormal heart rhythms that make the lower chambers of your heart twitch instead of pump. -When the sinoatrial (SA) node and the AV junctional tissues fail to generate an impulse, the ventricles will assume the role of pacing the heart, at a rate of 20-40 bpm. -Ventricular rhythms will display QRS complexes that are wide (greater than or equal to 0.12 seconds) and bizarre in appearance. -Premature Ventricular Complex (PVC) -Ventricular Tachycardia (VT) -Ventricular Fibrillation -Idioventricular rhythms
Ventricular Fibrillation
Ventricular Fibrillation: Ventricular fibrillation is a type of irregular heart rhythm (arrhythmia). During ventricular fibrillation, the lower heart chambers contract in a very rapid and uncoordinated manner. As a result, the heart doesn't pump blood to the rest of the body. -Coarse and fine -Occurs as a result of multiple weak ectopic foci in the ventricles. -No coordinated atrial or ventricular contraction -Electrical impulses initiated by multiple ventricular sites; impulses are not transmitted through normal conduction pathway Causes: CAD, MI, untreated VT, electrolyte imbalance, hypothermia, myocardial ischemia, drug toxicity or overdose, trauma, Brugada syndrome Signs and Symptoms: Loss of consciousness, absent pulse Risk: Death Treatment: CPR with immediate defibrillation, ACLS Nursing Interventions: CPR, defibrillate, ACLS *Shockable rhythm
Ventricular Tachycardia (VT)
Ventricular Tachycardia (VT): A condition in which the lower chambers of the heart (ventricles) beat very quickly. Ventricular tachycardia occurs due to a problem with the heart's electrical impulses. The condition may develop as a complication of a heart attack or may occur in people with certain conditions, such as valvular heart disease. -Defined as 3 or more PVCs in a row at a rate > 100 bpm. -Patient is almost always unresponsive and pulseless. -Sustained VT lasts for more than 20 seconds and requires immediate treatment to prevent death. -VT can quickly deteriorate into ventricular fibrillation. -Lethal dysrhythmia, patient is usually pulseless. -Pulseless V-Tach is a shockable rhythm. *Pulseless Ventricular Tachycardia (VT) is a shockable rhythm. Causes: Usually occurs with underlying heart disease, and with myocardial ischemia or infarction, certain medications may prolong the QT interval predisposing the patient to ventricular tachycardia, electrolyte imbalance, digitalis toxicity, congestive heart failure Signs and Symptoms: Chest discomfort (angina), syncope, light-headedness or dizziness, palpitations, shortness of breath, absent or rapid pulse, loss of consciousness, hypotension Risk: Major cause of sudden cardiac death Treatment: No pulse: begin CPR, follow ACLS protocol; pulse and unstable - cardioversion and drug therapy, long term may need ICD placed, ablation Nursing Interventions: Assess patient, pulseless-begin CPR, ACLS; pulse.
Old content: The nurse is preparing a client for a cardiac cauterization. Which actions should the nurse take?
Witness client sign consent form Obtain client vitals Confirm client allergies
Old content: A worker has sustained a flash burn to the right arm. After flames have been extinguished, what is the next step to cool the burn?
Wrap cool towels around the affected extremity
