DAY 1 Study

Intermittent Claudication (IC)

"Chest pain" in the leg muscles that occurs during exercise - relieved by rest - associated with peripheral vascular disease.

Diffusion

"Go with the flow" ∙ Movement of solutes from an area of high concentration to an area of lower concentration. ∙ Must be concentrated gradient for diffusion to occur. ∙ Diffusion is affect by: temp, concentration, size of molecules, and surface area of membrane. ∙ Electrical gradient: If + ion moves into the cell - ions will follow.

Left Sided Heart Failure

(Left sided heart failure does not have another name)

Metabolic Acidosis

(base bicarbonate deficit) occurs when an acid other than carbonic acid accumulates in the body or when bicarbonate is lost from body fluids.

Digoxin (Lanoxin) Mechanism of Action

**SLOWS HEART DOWN SO IT HAS TIME TO FILL WITH BLOOD AND INCREASE FORCE OF CONTRACTION** the 3 effects on heart muscle: 1. positive inotropic= increases myocardial contraction 2. negative chronotropic = decrease heart rate (allow for fill time) 3. negative dromotropic = decreased conduction of heart cells ∙ Boosts intracellular calcium and enhances movement of calcium into myocardial cells. This enables stronger heart contractions. ∙ Acts on the CNS to slow the heart rate ∙ Increases the refractory period when cells cannot conduct an impulse

What are some s/s of COPD?

*Note, the patient may be thin in appearance but if they are taking steroids, they will have gained weight.

What is a culture and sensitivity and why is it performed?

A culture is a test to identify the germs that cause have caused the infection. A sensitivity test checks to see what kind of medicine will work best to treat the illness or infection.

Adrenergic Agonist

A drug that stimulates the adrenergic receptors of the sympathetic nervous system, either directly (by reacting with receptor sites) or indirectly (by increasing norepinephrine levels)

What is hypercalcemia and what are the s/sx?

A metabolic emergency that occurs when Ca+ levels rise above 10.5 mg/dl. ・Fatigue ・Confusion, altered mental status, depression, personality changes, lethargy to come ・Muscle weakness, hyporflexia, loss of muscle tone ・Bradycardia, cardiac arrest ・Intestinal(may be first indications noted by patient) Anorexia, n/v, decreased bowel sounds, constipation ・Renal Kidneys work overtime-may lead to renal failure

Trousseau's Sign

A sign of hypocalcemia . Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.

Kaposi Sarcoma (KS)

A type of skin cancer often seen in patients with AIDS; consists of brownish-purple papules that begin in skin and spread to internal organs

Bacille Calmette-Guerin (BCG)

A vaccine against tuberculosis that is prepared from a strain of the attenuated (weakened) live bovine tuberculosis bacillus ∙ Can result in positive PPD reaction

Glucocorticoids & Inflammation

ADRENAL GLAND ❖ Cortex Produces corticosteroids (glucocorticoids, mineralocorticoids, and androgens) ❖ Glucocorticoids ∙ Coristol: most abundant and potent glucocorticoid Cortisol has powerful anti-inflammatory and immunosuppressive properties ❖ Glucocorticoids/Corticosteroids "SONE" or "LONE"

Partial Compensation

ALL values are abnormal

What is an example of a mucolytic?

Acetylcysteine (Mucomyst) ∙ Delivered by inhalation (not OTC) ∙ Adverse effects: severe N/V, bronchospasm ∙ Hepatoprotective when given orally which is why it is the antidote to acetaminophen OD

What is a pH < 7.35?

Acidosis

SLE: Nursing Intervention in Acute Care; Ambulatory Care

Acute Care Nursing Interventions ・Frequent monitoring ・Assess severity of symptoms and response to treatment ・Monitor weight and I&Os ・Promote rest ・Education and emotional support Ambulatory Care Nursing Interventions ・EDUCATION Disease process, meds, pain managment, stress management, heat therapy avoid sick people, avoidance of drying soaps, powders, or household chemicals, use sunscreen and sun avoidance, regular labs ・Pregnancy counseling as needed ・Community resources

Clinical Manifestations of Heart Failure

Acute Decompensated Heart Failure ・ Sudden worsening in symptoms ・ Increase in pulmonary venous pressure ・ Interstitial edema leads to tachypnea ・ Alveolar edema ・ Development of dependent edema or weight gain >3lb in 2 days Chronic ・ Progressive worsening that results in ventricular remodeling.

Treatment of Active TB

Aggressive treatment using 4 drugs (RIPE) ∙ Initial phase = all 4 drugs daily x weeks ∙ Continuation: INH & RIF daily x 126 doses (18 weeks) or twice-weekly INH and RIF doses for 36 doses (18 weeks)

What are some causes of respiratory acidosis?

Airway obstruction, depression of the respiratory center, emphysema, pulmonary edema, sedative overdose, COPD, mechanical hypoventilation, atelactasis, sever pneumonia.

What is pH > 7.45

Alkalosis

Labetalol (Trandate, Normodyne)

Alpha₁ & non-selective Beta Blocker Ends in -alol b/c it also blocks alpha₁ Uses HTN Caution ・May cause BRONCHOSPASM ・Orthostatic hypotension It causes vasoconstriction really quickly

Right Sided Heart Failure

Also known as Cor Pulmonale

Name two protozoal infections and their associated medication treatments.

Amebic Dysentery Metronidazole (Flagyl) Malaria Chloroquine (Aralen)

Isolated Systolic Hypertension (ISH)

An average SBP of 140 mm Hg or more, coupled with an average DBP of less than 90 mm Hg. SBP increases with aging. DBP rises until approximately age 55 and then declines.

Action Potential and Contraction of Contractile Fibers

An impulse in a ventricular contractile fiber is characterized by rapid *depolarization*, *plateau*, and *repolarization*. Cardiac muscle cells undergo twitch-type contractions with long refractory periods followed by brief relaxation periods. *The relaxation is essential so the heart can fill with blood for the next cycle.* The refractory period is very long to prevent the possibility of tetany, a condition in which muscle remains involuntarily contracted. In the heart, tetany is not compatible with life, since it would prevent the heart from pumping blood.

Primary defenses Against Infection

Anatomical features, limit pathogen entry ・Intact skin ・Mucous membranes ・Normal flora in GI tract ・Normal flora in urinary tract Mechanical Clearance ・Tears, coughing, vomiting, urination, defecation

What is the antidote for bethanechol?

Atropine... an anticholinergic.

Why do cancer cells increase with age?

B- and T-lymphocytes decrease as we age. Decreased immune response with increased age.

Why would you avoid performing phlebotomy at a site proximal to a running IV solution?

Because the IV fluids could contaminate and alter the results.

What drug interactions do decongestants have?

Beta Blockers May decrease the effect of a beta blocker MAOIs Increased risk of HTN and dysrhythmias Caffeine In large amount may lead to increased restlessness & palpitations

What are some side effects of warfarin (Coumadin)?

Bleeding, bruising.

What is the MOA of spironolactone?

Blocks action of Aldosterone in distal renal tubules thereby increasing excretion of sodium and water and sparing K+

What is the mechanism of action for furosemide (Lasix)?

Blocks reabsorption of sodium, chloride, and water from the Loop of Henle and distal renal tubules in the kidney, resulting in diuresis and mobilization of excess fluid (edema) leading to decreased BP. ◆ K+, Mg+, and Ca++ may also be excreted

Hemothorax

Blood in the plural space

Name the 4 body fluids that can transmit HIV.

Blood, semen, vaginal secretions, perinatal.

If an IV catheter has a green hub, what gauge is it?

18

What are some differences between 1st generation & 2nd generation antihistamines?

1st Generation ∙ Likely to cause drowsiness ∙ Likely to cause anticholinergic symptoms ∙ Ex. diphenhydramine (Benadryl) 2nd Generation ∙ Little to no effect on sedation ∙ Fewer anticholinergic symptoms ∙ Ex. fexofenadine (Allegra), loratadine (Claritin), cetirizine (Zyrtec)

How long must you wait before retying a tourniquet?

2 minutes

If an IV catheter has a pink hub, what gauge is it?

20

What is the smallest gauge catheter that can be used to administer blood?

20

The intrapleural space if filled with _____________ mL of fluid.

20-25 mL. Drained by the lymphatic system.

If an IV catheter has a blue hub, what gauge is it?

22

How long is IV fluid good for once it is spiked?

24 hours

What is the osmolality of an isotonic solution?

250-375 mOsm/kg

Which end of HCO3 is alkaline? Acidic?

26 is alkaline 22 is acidic

What is the normal blood osmolality?

275-295 mOsm/kg

Where do you hear the aortic valve? Which sound is louder?

2nd intercostal space at right sternal margin; S2 > S1

If a client has hypertensive crisis, what is the treatment?

> 180/> 120 Client needs intervention now

What is the osmolality of a hypertonic solution?

> 375 mOsm/kg

Super Bug

A bacteria that can't be killed even if using multiple antibiotics.

Sodium-Potassium Pump

A carrier protein that uses ATP to actively transport sodium ions out of a cell and potassium ions into the cell.

Hematoma

A collection of blood into the tissue

CABG (Coronary Artery Bypass Graft)

Creation of a new blood supply to an area of the heart with a clotted/blocked artery.

What information do you need to include when labeling your primary IV tubing administration set?

Date, time, initials

What do adrenergics that stimulate Alpha₂ receptors do?

Decrease GI motility and tone

How is metabolic alkalosis compensated?

Decreased respiratory rate

PAD (Peripheral Arterial Disease): Definition, S/S, Treatment

Definition Thrombus or embolus which obstructs arterial flow. Caused by plaque build up in the arteries. Progressive narrowing & degeneration of arteries of the neck, abdomen, and extremities. S/S The 4 P's, paralysis, mottled extremities, long cap refill, pain. If chronic skin will be thin and shiny Treatment Heparin, angioplasty, surgery, bypass grafts, catheterizations in lower extremity arteries Teaching Points Walk/rest/walk, avoid leg crossing, avoid exposure to cold, assess ulcer formation/gangrene, good skin care, no caffeine or tobacco, education on meds

Chronic Venous Insufficiency (CVI): Definition, S/S, Interventions

Definition ・Inadequate venous return over a long period due to varicose veins or valvular incompetence ・Prolonged venous HTN which stretches the veins and damages the valves. The resultant edema & venous stasis causes venous leg ulcers, swelling, cellulitis. S/S Hyperpigmented lower extremities, edema, cell death, necrotic tissues Nursing Interventions ・Elevation of legs. Sleep with foot of the bed elevated. ・Nutritional status evaluation ・Encourage walking, no prolonged sitting or standing. Avoid pressure to popliteal area. ・Good skin care ・Graduated compression stockings

Neutrophils

Definition ・Most abundant white blood cell Roughly 2,200-6,000/mcL ・Phagocytic and tend to self-destruct as they destroy foreign invaders, limiting their life span to a few days ・Get to the site quickly. Within 6-12 hours they are working. Two Types Segments The bazookas. Mature neutrophils. Bands The babies. Immature neutrophils; multiply quickly during acute infection Lifespan 2-14 days Never Let Mother Eat Bacon

Fluid Volume Deficit

Dehydration ∙ Loss of water only ∙ Increase in concentration of molecules dissolved in water Hypovolemia (ECF volume deficit) ∙ Loss of water and electrolytes Results from: ∙ Abnormal loss of body fluids ∙ Inadequate intake ∙ Plasma-to-interstitial fluid shift (3rd spacing)

What are the clinical manifestations of SLE in each body system?

Dermatologic Butterfly rash, rashes, lesions Musculoskeletal Arthritis Cardiopulmonary Pleurisy, dysrhythmias Renal Lupus nephritis Hematologic Attack blood cells ⇒ anemia, risk of infections, bleeding Neurological Seizures, cognitive dysfunction, psychosis GI Abdominal pain, dysphagia, N/V/D Reproductive Menstrual abnormalities

Sympathomimetic

Drug that mimics the sympathetic nervous system (SNS) with the signs and symptoms seen when the SNS is stimulated.

Adjuvant Analgesics Drugs

Drugs that are marketed for indications other than pain, but found to be useful for pain as an off-label use. ∙ Corticosteroids ∙ Anti-psychotics ∙ Antiseizure medications ∙ And others...

K+ and H+ exchange during acidosis

During acidosis, H+ ions move into and accumulate in ICF ・To balance the cations, K+ ions shift out of cells to ECF ・Decreased cellular K+ causes kidneys to retain K+ and hyperkalemia results

K+ and H+ exchange during alkalosis

During alkalosis, H+ ions move out of the cell and into ECF ・K+ shifts into the cells ・Kidneys increase secretion of K+ and hypokalemia results

What is the mechanism of action of potassium (KCL)

Electrolyte replacement for acid-base balance, nerve conduction, and muscle contraction. Treatment and prevention of potassium depletion.

Secondary Hypertension

Elevated BP with a specific cause that often can be identified and corrected. Clinical findings that suggest secondary hypertension relate to the underlying cause. For example, an abdominal bruit heard over the renal arteries may indicate renal disease. Treatment of secondary hypertension is aimed at removing or treating the underlying cause. Secondary hypertension is a contributing factor to hypertensive crisis.

Primary Hypertension

Elevated BP without an identified cause (90% to 95% of all cases). Although the exact cause of primary hypertension is unknown, there are several contributing factors. These include changes in endothelial function related to either vasoconstricting or vasodilating agents, increased SNS activity, overproduction of sodium-retaining hormones, increased sodium intake, greater-than-ideal body weight, diabetes, tobacco use, and excessive alcohol intake.

Three Layers of the Heart

Epicardium, myocardium, endocardium

Name some opportunistic infections and opportunistic cancers associated with AIDS

Fungal ・Candidiasis of bronchi, trachea, lungs, or esophagus ・Pneumocystis Pneumonia (PCP) Viral ・Cytomegalovirus (CMV) ・Herpes Simplex w/chronic ulcers Protozoal ・Toxoplasmosis of the brain ・Chronic intestinal cryptosporidiosis Bacterial ・Mycobacterium TB ・Recurrent Pneumonia Cancer ・Invasive cervical cancer ・Kaposi Sarcoma (KS) ・Burkitt's Lymphoma ・Immunoblasti Lymphoma ・Primary Lymphoma of the brain ・HIV Associated Wasting Syndrome

What are some side effects of potassium (KCL)?

GI upset, confusion, restlessness, ARRHYTHMIAS.

Why is digoxin (Lanoxin) given?

Given to treat atrial fibrillation and atrial flutter, CHF, and paroxysmal atrial tachycardia.

When would you hold nitroglycerin?

Hold for SBP < 90

When would you hold nystatin (Mycostatin)?

Hold for mucosal irritation (inspect oral mucous membranes before and frequently throughout therapy)

When should you hold potassium (KCL)?

Hold if K⁺ is elevated (normal is 3.5-5 mEq/L)

Antidiuretic Hormone(ADH)

Hormone of posterior pituitary. Chemical class: Peptide *Stimulates water reabsorption by kidneys*.

PR Interval

How long it takes for electricity to go from the SA (atria) Node to the AV Node. 0.12-0.2 seconds Contraction occurs (we hope) Measure from beginning of the P wave to the end of the PR segment (beginning of QRS complex).

If a patient has brain swelling, what type of fluid do you give them?

Hypertonic solutions.

What are some causes of respiratory alkalosis?

Hyperventilation, severe anxiety, hysteria, high altitude, early aspirin overdose, hypoxemia from acute pulmonary disorders, fever or sepsis, brain lesion or injury, excessive mechanical ventilation, PE

Chvostek's Sign

Hypocalcemia (facial muscle spasm upon tapping)

Drug Interactions of Digoxin

Hypokalemia and Hypokalemia causing drugs: ∙ Increase digoxin effect = increase risk of toxicity ∙ Digoxin and K+ use the same receptors Beta Blockers and Calcium Channel Blockers ∙ Taken with digoxin may cause an excessively slow heart rate St. John's Wart ∙ May speed up digoxin metabolism = increase risk of toxicity

What patients might benefit from receiving isotonic IV fluids?

Hypotensive or hypovolemic patients. ***Use with caution as clients will be at risk of fluid volume excess***

If a patient is dehydrated, what types of fluids do you give them?

Hypotonic solutions.

What patients might benefit from receiving hypertonic IV fluids?

Hypovolemia or hyponatremia

What fluids should a hypovolemic hyponatremic patient receive?

IV sodium chloride: 0.9% NaCl, 3% NaCl

What are the 5 types of Antibodies/immunoglobulins? Which is the most abundant?

IgG (76%) Principle in human serum. Moves across placenta giving the infant the mother's immunity. Secondary immune response. IgA (15%) Found in breast milk, respiratory and GI mucous, saliva, tears. IgM (8%) Controls ABO blood groups, primary immune response IgD (1%) Present on surface of B-lymphocytes and serves as antigen receptors IgE (0.002%) Attaches to mast cells in respiratory and GI tract. Major role in allergic reactions and parasitic infections.

Innate Immunity

Immunity that is present before exposure and effective from birth. Responds to a broad range of pathogens.

Acquired Immunity

Immunity that is present only after exposure and is highly specific.

Who is COPD different from asthma at a bronchial level?

In COPD there is an increased number of mucous glands.

What is the action of cholinergic agonists?

Induce rest & digest.

Who is more at risk of fluid and electrolyte imbalances?

Infants and the elderly.

Thrombophlebitis

Inflammation of vein with clot formation and danger of embolism.

Secondary Defenses Against Infection

Inflammatory Response The external barriers have been breached and pathogens have entered. They release harmful wastes and secretions causing damage to cells and tissue. Chemicals released trigger the secondary defenses. ・Phagocytosis ・Compliment cascade ・Inflammation ・Fever ・Nonspecific

Purkinje Fibers

Large diameter myocardial conductive fibers that conduct signals quickly. Spread the impulse to the myocardial contractile cells in the ventricles. Extend through the myocardium from the apex of the heart toward the atrioventricular septum and the base of the heart. Because of this the contraction also begins at the apex and moves towards the base allowing blood to be pumped out of the ventricles and into the aorta and pulmonary trunk.

Which color vacutainer tube top is needed for CBC with diff?

Lavender

Where do you hear the pulmonic valve? Which sound is louder?

Left sternal border, 2nd intercostal space; S2 > S1

Where do you hear Erb's Point? Which sound is louder?

Left sternal border, 3rd intercostal space; S1 = S2

Where do you hear the tricuspid valve? Which sound is louder?

Left sternal border, 4th intercostal space; S1 > S2

Which color vacutainer tube top is needed for a PT/INR/PTT?

Light blue

Local vs Systemic Anaphylaxis

Local ❖ Itching, tearing, burning of eyes ❖ Nose stuffiness ❖ Cutaneous response Wheal-and-flare- reaction Systemic Anaphylaxis

In atrial septum, transmits signal to bundle of His. Located in the inferior portion of the right atrium within the atrioventricular septum.

Location of AV Node.

What is the pharmacologic classification of furosemide (Lasix)?

Loop diuretic

What are some causes of metabolic alkalosis?

Loss of acids, such as repeated vomiting; excessive intake of alkaline substances, such as antacids, gains of HCO3-, gastric suction, hypokalemia, use of potassium wasting diuretics, excessive corticosteroids, hyperaldosteronism.

What are some causes of metabolic acidosis?

Loss of bicarbonate ions through sever diarrhea or renal dysfunction; increased metabolic acids (diabetes mellitus), retained acids in blood, conditions that decrease bicarbonate, excessive intake of acids, ketoacidosis, lactic acid accumulation (shock), kidney disease

How can you treat COPD?

Low flow O₂, SVN, medication, activity management, nutrition, hydration, health maintenance More advanced: bronchoscopy

Lipoproteins Produced in the Liver

Low-density lipoproteins (LDL) ・Enter circulation as tightly packed cholesterol, triglycerides, and lipids ・Carried by proteins that enter circulation; broken down for energy or stored for future as energy High-density lipoproteins (HDL) ・Enter circulation as loosely packed lipids ・Used for energy; pick up remnants of fats and cholesterol left in the periphery by LDL breakdown

Mean Arterial Pressure (MAP)

MAP = (SBP + 2DBP) ÷ 3 Need > 60 mmHg under most conditions When treating hypertensive emergencies, the mean arterial pressure (MAP) is often used instead of BP readings to guide and evaluate drug therapy. The initial goal is to decrease MAP by no more than 20% to 25%, or to decrease MAP to 110 to 115 mm Hg. If the patient is clinically stable, drugs can be titrated to gradually lower BP over the next 24 hours. Lowering the BP too quickly or too much may decrease cerebral, coronary, or renal perfusion. This could cause a stroke, MI, or renal failure. *** Anytime you see a BP listed on the NCLEX calculate the MAP

NSAIDs

MOA ∙ Inhibits prostaglandin synthesis. ∙ COX-1 & COX-2 enzymes produce prostaglandins. ∙ Prostaglandins promote inflammation, pain, and fever Non-Selective NSAIDS: block COX-1 & COX-2 enzymes ∙ Indomethacin (Indocin) ∙ Ibuprofen (Motrin, Advil) ∙ Ketorolac (Toradol) ∙ Naproxen (Aleve) *** These should only be used for a short period of time. Otherwise, use a selective one. Selective NSAIDS: block only COX-2 enzymes ∙ Produces effect without the adverse effects associated with COX-1 inhibition (GI upset/ulceration, renal impairment, bleeding tendencies) ∙ Celecoxib (Celebrex) ∙ Concern: increased risk of CV effects (MI, CVA, heart failure)

What circumstances warrant an 18 gauge IV?

Major trauma or surgery, blood administration

Angle of Louis (sternal angle)

Manubriosternal angle, the articulation of the manubrium and body of the sternum, continuous with the second intercostal space.

Besides the kidneys and Vitamin D, how else are serum calcium levels regulated?

Parathyroid Hormone (PULLS) Excreted by cells of parathyroid gland when there is a decrease in Ca+ levels. Helps Ca+ levels by drawing Ca+ from the bones and promotes transfer of Ca+ and phosphorus into plasma = increase in serum Ca+ levels. Calcitonin (KEEPS) When Ca+ levels are elevated, the thyroid gland excretes calcitonin. The calcitonin then tells the bones to reabsorb Ca+ or, it could also tell the kidneys to start excreting additional Ca+. Phosphorus & pH -- BOTH HAVE INVERSE RELATIONSHIP WITH Ca++

What is the mechanism of action of warfarin (Coumadin)?

Prevents thromboembolic events by inhibiting the livers ability to make vitamin K dependent clotting factors.

Atherosclerosis: Process, S/S, Treatment Goals

Process 1. Injury to artery endothelial cells HTN, DM, increased lipids, infection ➨ Inflammation 2. Macrophages rush to injured area, release enzymes & O₂ radicals, oxidized LDL 3. Macrophages eat oxidized LDL -- Foam cell 4. Fatty streaks develop over time 5. Fibrous plaque w/platelet adhesion S/S Inadequate tissue perfusion, chest pain associate with stress or exercise Treatment Goals Lower LDL cholesterol, control BP, blood sugar

What does epinephrine do when it stimulates Beta₂?

Promotes bronchodilation

What does antidiuretic hormone (ADH) do?

Promotes retention of water by kidneys, secreted by the pituitary. This makes the body hold onto water, then the kidneys tell the body to produce more RBC's which will increase blood volume and it was also tell the body to increases sodium and water which will also increase blood volume.

What is the function of the cardiovascular system?

Provides blood supply to itself first and then the rest of the body, then to take the old blood and get rid of it as necessary.

What does albuterol do?

Bronchodilator. Stimulation of B₂ adrenergic receptors in the lungs (SABA). It relaxes the smooth muscle and dilates the bronchi and bronchioles. Beta₂ → to lungs

What are some s/s of hyposxemia?

RAT ↑ Restlessness Tachycardia Tachypnea

What are some side effects of RIF?

RIF is a first line TB drug. Side effects include: Cutaneous reactions, GI disturbance, hepatotoxicity, orange discoloration of body fluids (sputum, urine, sweat, tears)

What are the actions of epinephrine?

Reacts at alpha- and beta-receptor sites in the sympathetic nervous system to cause bronchodilation, increased HR, increased RR, and increased BP.

Beta-Adrenergic Receptors

Receptors located on postsynaptic cells that are stimulated by specific autonomic nerve fibers. Beta1-adrenergic receptors are located primarily in the heart, whereas beta2-adrenergic receptors are located in the smooth muscle fibers of the bronchioles, arterioles, and visceral organs.

HIV: Assess/Monitoring HIV disease progression and immune function

CD4+ T-cell counts Normal CD4+ count: 800=1200/mcL Problems: < 500 AIDS: < 200 (The body can no longer keep up with the destruction) Viral Load: HIV RNA ・Reported as real numbers ・"Undetectable" ・Tests performed every 3-6 months

How does COPD lead to Cor Pulmonale?

COPD causes the right pulmonary artery to constrict so the right ventricle has to work harder to push fluid forward, but the fluid cannot go through so it goes back to the right atrium and then back into the body.

Ischemia EKG Characteristics

Can be an ST segment depress or an inverted T wave.

AV Node(Atrioventricular Node)

Second clump of myocardial cells located in the inferior portion of the right atrium within the atrioventricular septum; receives the impulse from the SA node, pauses, and then transmits it into specialized conducting cells within the interventricular septum.

What is the action of doxazosin?

Selective Alpha₁ adrenergic antagonist drug that blocks NE from stimulating the alpha₁ receptors leading to decreased BP.

Mechanoreceptors

Sensory receptors responsible for sensing distortion in body tissues.

First Dose Phenomenon

Severe and sudden drop in blood pressure after the administration of the first dose of an alpha-adrenergic blocker.

Type I IgE Mediated Allergy/Anaphylaxis

Severe type I hypersensitivity reaction in which IgE antibodies attached to mast cells, previously sensitized to an antigen, are reactivated. Examples Allergic Rhinitis - Seasonal allergies Asthma Atopic dermatitis - Eczema Urticaria - Hives Angioedema - ACE inhibitors cause it Anaphylaxis

What are the side effects & adverse reactions of decongestants?

Side Effects ∙ Jittery ∙ Nervous ∙ Restlessness Adverse Reactions ∙ HTN ∙ Hyperglycemia EXTREME CAUTION IN PATIENTS WITH: ∙ HTN ∙ Hyperthyroidism ∙ Cardiac disease ∙ DM

What are the side effects of albuterol? Adverse reactions?

Side Effects ・Nervousness ・Restlessness ・Tremor ・Dizziness Adverse Reactions ・Chest pain ・Tachycardia/palpitations ・Cardiac dysrhythmias

What are some side effects/adverse reaction of Captopril?

Side Effects: ・Metallic taste in mouth ・HA ・Dizziness ・Rash ・ACE Cough (dry cough, like that annoying dry tickle in the back of your throat) Adverse Reactions: ・Hypotension Orthostatic - First Dose Phenomenon ・Hyperkalemia Does not allow aldosterone to do it's thing ・Angioedema Life threatening ・Neutropenia Low white blood cell count

Hemoptysis

Small amount of blood mixed with sputum

What particles have pull power?

Sodium, sugar, protein (albumin)

Crystalloids

Solutes that dissolve readily into true solutions

Alpha-agonist

Specifically stimulating to the alpha-receptors within the SNS, causing body responses seen when the alpha-receptors are stimulated.

Beta-agonist

Specifically stimulating to the beta-receptors within the sympathetic nervous system, causing body responses seen when the beta-receptors are stimulated.

Virchow's Triad

Stasis, hypercoagulability, endothelial damage

How do decongestants work?

Stimulate alpha-adrenergic receptors causing vasoconstriction of the capillaries.

Colloids

Substances such as large protein molecules that do not readily dissolve into true solutions

Heart Blood Flow Order

Superior and Inferior Vena Cava ➟ Right Atrium ➟ Tricuspid Valve ➟ Right Ventricle ➟Pulmonic Valve ➟ Pulmonary Artery ➟ Lungs ➟ Pulmonary Vein ➟ Left Atrium ➟ Mitral Valve ➟ Left Ventricle ➟ Aortic Valve ➟ Aorta ➟ Body

What drug therapy would you educate an allergic/anaphylactic pt on?

Sympathomimetic (Adrenergic Agents)/Decongestant Drugs ❖ Pseudoephedrine (Sudafed) Antihistamines ❖ Fexofenadine (Allegra) ❖ Diphenhydramine (Benadryl) Anti-inflammatory Medications ❖ Mast Cell Stabilizers Cromolyn (NasalCrom) ❖ Leukotriene Receptor Antagonists Montelukast (Singulair) ❖ Corticosteroids Prednisone, nasal spray ❖ Antipruritic Calamine lotion

Respiratory Alkalosis

Carbonic acid deficit

What are signs and symptoms of hypokalemia?

Cardiac Weak, irregular heart rate, orthostatic hypotension, palpitations EKG Flat or inverted T wave, U wave, ventricular arrhythmias, cardiac arrest Watch closely if patient is on digoxin Can potentiate action and cause toxicity Skeletal muscle weakness (especially in legs) Paresthesias, leg cramps, decreased reflexes Respiratory muscles may weaken Tachypnea (shallow) GI (smooth muscle) alterations Decreased bowel sounds, constipation, ilieus

How do you take orthostatic vitals?

Take vitals while pt is supine, sitting, and standing; waiting 2 minutes in between BEFORE moving from one position to the next.

Hyperkalemia EKG Changes

Tall T wave Flat P wave Wide QRS Prolonged PR

Muscle Relaxants

Centrally acting. They work on all muscles. Not just one. MOA not fully known. Examples ∙ cyclobenzaprine (Flexeril) ∙ carisoprodol (Soma) *more likely to be habit forming ∙ methocarbamol (Robaxin) Side Effects ∙ Drowsiness ∙ Dizziness ∙ Lightheadedness ∙ HA ∙ GI upset ∙ Possible Anticholinergic effects Adverse Effects ∙ Angioedema ∙ MI ∙ Seizures ∙ Ileus (possible inhibition of rest and digest which could lead to an ileus that could rupture the bowel) ***If on a muscle relaxant or opioid take a stool softener, drink more water, increase fiber.

Ventricular Tachycardia

The ECG shows multiple QRS complexes without visible P or T waves. This rhythm indicates damage to the ventricles.

Exetimibe (Zetia)

Cholesterol Absorption Inhibitor MOA ・Inhibits absorption of cholesterol in small intestine ・Decrease dietary cholesterol to liver ・decrease in total cholesterol Adjunctive Treatment Used in combo with statins

Name two meds approved for intermittent claudication and how do they work?

Cilostazol (pletal) ・Platelet aggregation inhibitor. ・Inhibits enzyme CAMP PDE III ➨ vasodilation and inhibition of platelet aggregation. ・Reduces symptoms of IC with improved walking distances Pentoxifylline (Trental) ・Blood viscosity reducing agent ・Therapeutic management of symptomatic PVD & IC ・Inhibits platelet aggregation & fibrinogen ・Reduces blood viscosity ・Increases RBC flexibility

Cephalosporins

Class Anti-infective/cephalosporins Action ◇ Binds to the bacterial cell wall membrane, causing cell death. ◇Spectrum varies depending on drug generation. Third generation is more effective against more organisms. ◇ Work a lot like penicillin Allergies 5-10% of people allergic to penicillin are also allergic to cephalosporins Side Effects Rash, GI pain, anorexia, anaphylaxis, hypersensitivity Names ◇ cephalexin (Keflex) (1st generation) ◇ ceftriaxone (Rocephin) (3rd generation) ◇ cefepime ◇ cefazolin

Raltegravir (Isentress): Class, Action, Dose, Adverse Effects

Class Antiretroviral/Integrase Inhibitors/Integrase Strand Transfer Inhibitors (INSTIs) Action Inhibits the activity of HIV-1 integrase, which is required for viral replication. Blocking this prevents HIV-1 provirus formation and leads to a decrease in viral load and an increase in active CD4 cells. Route Oral Adverse Effects HA, dizziness, N/V/D, fever, rhabdomyolysis, suicidal thoughts

Enfuviritide (Fuzeon): Class, Actions, Dose, Adverse Effects

Class Antiretroviral/fusion inhibitor Action Prevents the entry of HIV-1 into cells by interfering with the fusion of the virus with cellular membranes Dose Sub-q, 2x/day Adverse Effects Pancreatitis, hypersensitivity reactions, HA, N/V/D, rash, anorexia, pneumonia, chills, injection-site reactions

Nevirapine (Viramune): Class, Action, Dose, Adverse Effects

Class Antiretroviral/nonnucleoside reverse transcriptase inhibitors (NNRTIs) Action Binds to HIV-1 reverse transcriptase and blocks replication of the HIV by changing the structure of the HIV enzyme. The chain is seen as corrupt and is terminated. Dose Oral, 2x/day Adverse Effects HA, N/V/D, rash, liver dysfunction, chills, fever

Zidovudine (Retrovir, AZT): Class, Action, Dose, Adverse Effects

Class Antiretroviral/nucleoside reverse transcriptase inhibitors (NRTIs) Action Inhibits the activity of HIV-1 reverse transcriptase, interfering with the order of transcription, which in turn terminates viral DNA replication. The first HIV med. Dose Oral or IV. May need to take up to 6x/day Adverse Effects Lactic acidosis, hypersensitivity reactions, hepatotoxicity, HA, insomnia, dizziness, N/D, fever, rash, bone marrow suppression

Fosamprenavir (Lexiva): Class, Action, Dose, Adverse Effects

Class Antiretroviral/protease inhibitor Action Inhibits protease activity, leading to the formation of immature, noninfectious virus particles Dose Oral Adverse Effects HA, mood changes, N/D, fatigue, rash, Stevens-Johnson syndrom, redistribution of body fat (buffalo hump, thin arms and legs).

Maraviroc (Selzentry): Class, Action, Dose, Adverse Effects

Class Antretroviral/CCR5 Coreceptor Agonist Action Blocks a specific receptor (CCR5) on CD4 and T-cell surfaces that prevents CCR5-tropic HIV-1 from entering the cell and multiplying Dose Oral, 2x/day Adverse Effects Dizziness, paresthesias, N/V/D, cough, upper respiratory infection, fever, musculoskeletal symptoms, hapatotoxicity

Biologic Response Modifiers (BRMs): Class, action, when used, names, common side effect, teaching

Class DMARD/TNF blocker Action Binds to TNF, making it inactive. TNF is a mediator of the anti-inflammatory response When Used Use when pts have failed other DMARDs The Inhibitors etanercept (Enbrel) infliximab (Remicade) adalimumab (Humira) Other BRMs anakinra (Kineret) abatacept (Orencia) tocilizumab (Actemra) rithximab (Rituxan) Side Effects TB, bone marrow suppression, infections Teaching ・Watch for s/s of infection ・Importance of labs monitoring (CBC with diff and ANA) ・Action and s/e of drug prescribed ・Balance of activity and rest ・Joint protection ・Non-pharm relief of pain

Methotrexate (Rheumatrex): Classification, action, side effects

Classification Antineoplastic; DMARD; immunosuppresant/antimetabolite, anti-rheumatic Action Interferes with folic acid metabolism. Result is inhibits DNA synthesis and cell reproduction in rapidly dividing cells. Side Effects Pulmonary fibrosis/toxicity, bone marrow suppression, hepatotoxicity Considerations ・Inexpensive and lower toxicity ・Can be used alone or in combination with other drugs ・Need frequent labs ・Report SOB, bruising, or sore throat

When are hypotonic solutions contraindicated and why?

Contraindicated in acute brain injury b/c cerebrals cells absorb water rapidly leading to cellular edema.

SA Node(Sinoatrial Node)

The highest inherent rate of depolarization and is known as the *pacemaker* of the heart. Initiates the *sinus rhythm*, or normal electrical pattern followed by contraction of the heart. *Begins heart activity that spreads to both atria through specialized internodal pathways*. Excitation spreads to AV node via these pathways.

How do the kidneys regulate phosphate?

The kidneys are the primary regulator of phosphate.

Atheromatous Plaque (Atheroma)

The lumen has gotten so small, enough O₂ has gotten cut off and chest pain is experienced.

How do the lungs remove CO2 if PH is too acidic?

The lungs increase the rate of breathing

Aldosterone

The major mineralocorticoid. Important in the regulation of the concentration of sodium and potassium ions in urine, sweat, and saliva. Released in response to *elevated blood K+, low blood Na+, low blood pressure, or low blood volume*. In response it increases the excretion of K+ and the *retention of Na+*(which *increases water aborption*), which in turn increases blood volume and blood pressure. Its secretion is prompted when CRH from the hypothalamus triggers ACTH release from the anterior pituitary.

Nifedipine (Procardia): Therapeutic Effects, Side/Adverse Effects

Therapeutic Effects/Uses HTN, angina, *dysrhythmias/arrhythmia* Side/Adverse Effects ・R/T Vasodilation Dizziness, HA, peripheral edema, facial flushing ・Constipation Smooth muscle is relaxed ・HF May decrease the contractility of the heart too much ・Dysrhythmia/Arrhythmia Could lead to sinus bradycardia

Nitroglycerin (Nitro-Dur, Nitrostat): Effect/Uses, Admin, SE, Contraindications

Therapeutic Effects/Uses ・Control of angina pectoris ・Acute MI ・Management of HF Long acting nitrates Administration ・Can be given multiple routes ・Use gloves when applying the paste or ointment Side Effects/Adverse Effects ・Side effects due to vasodilation Hypotension, dizziness, reflex tachycardia, flush, HA ・Life threatening Hypotension and CV collapse when given with ED meds (Viagra, Cialis, & Levitra) Contraindications Severe anemia H&H low, they need RBC. Chest pain due to low H&H. Already not enough blood volume, nitrates could make it worse.

Why is using a 25+ gauge needle for phlebotomy not best practice?

There is a much higher risk of hemolysis (rupture of RBCs), leading to inaccurate test results.

Ventricular Fibrillation

There is no organized wave of stimulation spreading through the heart muscle. As a result, individual heart cells contract independently leading to a quivering of the heart muscle. Since there is no coordinated contraction of the ventricles, blood is not effectively ejected from the heart. *If V-fib continues, cardiac arrest follows*.

How are calcium and phosphorus related?

They have an inverse relationship. When calcium is high, phosphorus is low and vice versa. Phosphorus inhibits Ca+ absorption in the intestines.

Indications of atropine

To decrease secretions before surgery, treatment of parkinsonism, restoration of cardiac rate and arterial pressure following vagal stimulation, relief of bradycardia and syncope due to hyperactive carotid sinus reflex, relief of pylorospasm, relaxation of the spasm of biliary and ureteral colic and bronchspasm, control of crying and laughing episodes associated with brain lesions, relaxation of uterine hypertonicity, management of peptic ulcer, control of rhinorrhea associated with hay fever, antidote for cholinergic overdose and poisoning from various mushrooms.

Before you start the phlebotomy procedure on a patient how do you correctly identify the patient?

To the order and their specimen labels.

Helpful Hints to Remember Hypercalcemia

Too much CALciuM = Too calm Groans (constipation) Moans (fatigue, lethargy) Bones (bone pain) Stones (kidney stones) Psychiatric Undertones (depression, confusion)

The 4 Types of Hypersensitivity Reactions

Type I ❖ IgE-mediated allergic reactions ❖ Allergic/anaphylactic reactions Type II (Block 4) ❖ IgG or IgM antibodies ❖ Cytotoxic & Cytolytic Reactions ❖ Tissue specific reactions ❖ ABO blood types Type III ❖ IgG or IgM antibodies + antigen ❖ Immune-complex-mediated reactions ❖ Autoimmune Type IV ❖ Cell-mediated reactions/delayed hypersensitivity. Sensitized T cells ❖ Contact dermatitis

Extravasation

Unintended discharge or leakage of a vesicant solution or medication into surrounding tissue as a result of cannula dislodgment or inflitration.

Allergy Skin Testing

What It Is Antigen liquid shots are given to a patient to see if there's a reaction Nursing Interventions ❖ D/C corticosteroids and antihistamines 5 days prior b/c corticosteroids ⬇︎ the immune response & antihistamines would prevent a reaction ❖ Consent ❖ Administer allergens to skin surface ❖ Risk of anaphylaxis Post procedure Interventions ❖ Have pt. remain in office for 30 minutes ❖ Resuscitation equipment available ❖ Inspection of sites, measure and document ❖ Identify allergen and educate about lifestyle modifications to avoid exposure ❖ Desensitization programs & immunotherapy

S1: Valves, Sound, Represent

Valves The sound created by the closing of the atrioventricular valves (triscuspid & mitral) and the opening of the aortic and pulmonic valves during ventricular contraction. Sound A "lub". Represent Systole. Blood pumping out.

S2: Valves, Sound, Represent

Valves The sound of the closing of the semilunar (aortic & pulmonic) and the opening of the atrioventricular (tricuspid & mitral) valves during ventricular diastole. Sound Described as a "dub". Represent Heart at rest

Sinus Bradycardia

The ECG wave is normal, but the heart rate is usually less than 60 bpm. This occurs when the SA node does not initiate the wave of stimulation often enough. What does the nurse do? ・Assess client If not symptomatic ... monitor If symptomatic... need treatment ・Clinical Manifestations Moving slow, dizziness, fatigue, decreased BP, decreased CO, hypotension, SOB, decreased LOC, chest pain ・Notify MD ・Treatment of choice - Oxygen and atropine to get HR above 60 BPM - IV fluids - Be ready to apply trancutaneous pacemaker - May need permanent pacemaker ・Attempt to determine cause ・Medications that could cause SB? Beta Blockers, CCB, Digoxin ・What else could cause SB? Constipation. Encourage stool softeners, water, and fiber.

Tertiary Defenses Against Infection

The Immune Response ・Specific Look for antigens. Slower than the inflammatory response.

Cardiac Output

The amount of blood pumped by each ventricle in one minute.

Stroke Volume

The amount of blood pumped by each ventricle.

Raynaud's Disease

Vasospasms of vessels serving the fingers and toes that can lead to intermittent pain and cyanosis of the digits then rubor as blood flow returns.

What is the "window period" of HIV?

The amount of time between when the pt. is infected and the body has made enough antibodies to be detected by the screening tests available to them at that point. Basically, a person can be infected with HIV but their body has not produced enough antibodies yet against it, so it is still undetectable by tests. Can last around 2 months

Why are cholinergic agonists prone to many undesirable systemic effects?

The are not limited to a specific site.

What are two key measures for weight reduction when it come to HTN lifestyle modifications?

Waist Measurement < 35 inches for women < 40 inches for men BMI: < 25 > 25 = overweight > 30 = obesity

When do we treat a fever?

We treat if the temperature rises above 101.5℉ because we want the immune system to fight it. Some infection control doctors will even wait till the temperature hits 102.5℉.

Cholestyramine (Questran): What are they? How do they work? Treatment?

What They Are & How They Work ・Bile Acid Sequestrant ・Bile acids contain high levels of cholesterol ・Bile acid sequestrants bind with bile acids in the intestine and are excreted in feces Treatment ・Used to be first line drug, may now be used in combo with statins ・Powder mixed with liquid up to 6x/day ・Decreases total cholesterol

- In the brain: Medulla oblongata, hypothalamus, and cerebrum. - In the vessels: Baroreceptors(sensory neurons in blood vessel walls) that pick up info about blood pressure and send it to the medulla. - Body temperature changes - Electrolyte imbalances (K+, Ca2+, Na+)

What can alter the heart rate?

Mineralcorticoids(e.g. *aldosterone*); regulate mineral balance.

What hormones are released from the zona glomerulosa of the adrenal cortex and what are their functions?

Bundle of His(Atrioventricular[AV] Bundle)

The connection between the atria and ventricles. Divides into two AV bundle branches and purkinje fibers.

Afterload

The force the ventricles must generate in order to pump blood against the resistance in the vessels. Any condition that increases resistance requires a greater afterload to force open the semilunar valves and pump the blood. Damage to the valves, such as stenosis, which makes them harder to open will also increase afterload. Any decrease in resistance decreases the afterload.

Type I Alveolar Cells

The gas exchange cells

What is an example of an intranasal glucocorticoid?

fluticasone (Flovent/Flonase)

What are some examples of expectorants?

guaifenesin (Mucinex & Robitussin)

Vasculitis

inflammation of blood vessels

What are some examples of nasal decongestants?

oxymetazoline (Afrin 12hour); phenylephrine (Afrin)

Acid Base Mnemonic (ROME)

• Acid-Base Mnemonic to interpret blood gas values. R: Respiratory O: Opposite: pH ↑ PCO₂ ↓ Alkalosis pH ↓ PCO₂ ↑ Acidosis M: Metabolic E: Equal: pH ↑ HCO₃⁻ ↑ Alkalosis pH ↓ HCO₃⁻ ↓ Acidosis

Surfactant

∙ A lipoprotein that lowers the surface tension within alveoli to allow them to inflate during breathing. ∙ Produced by type II alveolar cells

Hypertonic Solution

∙ A solution in which the concentration of solutes is greater than that of the cell that resides in the solution. ∙ Higher ( ) than blood

Hypotonic Solution

∙ A solution in which the concentration of solutes is less than that of the cell that resides in the solution. ∙ Lower ( ) than blood.

Isotonic Solution

∙ A solution whose solute concentration is equal to the solute concentration inside a cell. ∙ Same ( ) as blood

Intravascular Fluid

∙ A type of ECF ∙ Fluid in the blood (plasma)

Transcellular Fluid

∙ A type of ECF ∙ Specialized fluids

Interstitial Fluid

∙ A type of extracellular fluid ∙ Fluid in the space between cells

Second Spacing

∙ Abnormal accumulation of interstitial fluid ∙ Fluid overload

Define ECF; What is the % of TBW?

∙ Extracellular Fluid ∙ Fluid outside the cells of the body ∙ Carries water, electrolytes, nutrients, and oxygen to cells ∙ Removes waste products of cell metabolism ∙ 20% of TBW (1/3 of total body fluid)

When it comes to dehydration, what are we gonna do as nurses?

∙ First, identify high risk patients (older adults, children, conditions with fluid loss) ∙ Correct underlying cause ∙ Encourage adequate fluid intake ∙ May need IVFs ∙ Monitor VS, skin, neurological status ∙ Daily weights (low weight if dehydrated) ∙ Accurate I&O ∙ Oral hydration ∙ IV hydration ∙ Monitor labs ∙ Skin and oral care ∙ Provide safe environment (fall risk, side rails) ∙ Foley (if meets criteria, if we need accurate I&Os) Remember when your patient is dehydrated, they are hypertonic.

Third Spacing

∙ Fluid is trapped and unavailable for functional use ∙ Can cause a relative hypovolemia/dehydration Ascites, burns, pericardial effusion (fluids around the heart), pleural effusion (fluid around the lungs).

Hydrostatic Pressure

∙ Force within a fluid compartment ∙ Pressure created by the pull of gravity, pressure can also be created by the pull of gravity, pressure can also be created by blood against the surface of out vessels, BLOOD PRESSURE-created by heart pumping.

What are some NSAIDS & ASA considerations?

∙ Give meds with food to avoid GI upset ∙ Immediately report signs of GI bleeding ∙ Stop ASA 5-7 days prior to surgery (if OK'd by HCP) ∙ Do not crush enteric coated tablets ∙ Minimize ETOH intake Monitor for S/Sx of liver toxicity: ∙ N/V ∙ Lethargy, fatigue ∙ Itching ∙ RUQ pain

When would you hold furosemide (Lasix)?

∙ Hold for SBP < 90 ∙ Hold if K⁺is low (<3.5 mEq/L) ∙ Hold if patient is dehydrated

Aldosterone

∙ Hormone made by kidneys ∙ Works to increase sodium and water reabsorption ∙ Produced as a result of Renin-Angiotensin system ∙ BP and flood balance Angiotensin II stimulates adrenal gland to release aldosterone ➞ Aldosterone causes kidneys to RETAIN Na+ and H2O ➞ Na+ AND H2O retention ➞ increased blood volume and Na+ levels

What do nurses do in patients with acid-base imbalances?

∙ Hydration status ∙ Lung sounds ∙ Level of consciousness ∙ Daily weights ∙ VS ∙ Intake and output ∙ Skin moisture/turgor ∙ Tongue/mouth ∙ GI system ∙ Heart sounds: S3/fluid overload ∙ Laboratory studies ∙ Dysrhythmias (block 2/4)

What is potassium contraindicated in?

∙ Hyperkalemia ∙ Severe renal impairment ∙ Untreated Addison's disease ∙ Some products may contain tartazine (yellow dye #5) or alcohol; avoid using in patients with an intolerance ∙ Hyperkalemic familial periodic paralysis

What are some contraindications for nitroglycerin?

∙ Hypersensitivity ∙ Increased intracranial pressure ∙ Severe anemia ∙ Pericardial tamponade ∙ Constrictive pericarditis ∙ Uncorrected hypovolemia ∙ Alcohol intolerance (large IV doses only)

What is furosemide (Lasix) contraindicated in?

∙ Hypersensitivity ∙ Some liquid products may contain alcohol, avoid patients with alcohol intolerance ∙ Hepatic coma or anuria ∙ Cross sensitivity with thiazides and sulfonamides may occur.

What is nystatin (Mycostatin) contraindicated in?

∙ Hypersensitivity ∙ Some products may contain alcohol-- avoid patients who may be hypersensitive or intolerant ∙ Use cautiously in denture wearers (dentures require soaking in nystatin suspension)

What is digoxin (Lanoxin) contraindicated in?

∙ Hypersensitivity ∙ Uncontrolled ventricular arrhythmias ∙ AV block ∙ Idiopathic hypertrophic subaortic stenosis ∙ Constrictive pericarditis ∙ Known alcohol intolerance (elixir only)

What lab results would you have with a dehydrated patient?

∙ Increased BUN ∙ Elevated HCT ∙ Elevated serum osmolality ∙ Increased urine specific gravity ∙ Elevated sodium *Remember patient is hypertonic*

What is the overall effect of Digoxin (Lanoxin)?

∙ Increased myocardial contractility ∙ Reduced HR ∙ Increased SV ∙ Reduced heart size during diastole ∙ Decrease in venous BP ∙ Increased coronary circulation ∙ Promotion of diuresis as the result of improved circulation

Pneumonia

∙ Infection of the lung tissue ∙ Enters the lungs by aspiration, inhalation, spread of other infection.

Aspirin: MOA

∙ Inhibits prostaglandin synthesis and release. ∙ Inhibits platelet aggregation (for a longer period than NSAIDs) ∙ Used to enhance blood flow during an MI and to prevent MI ∙ Competes with many other protein-bound drugs.

Extracellular Fluid Components

∙ Interstitial Fluid: 2/3 of ECF ∙ Intravascular Fluid (plasma): 1/3 of ECF ∙ Transcellular Fluid (spinal fluid, digestive, eyes): 1 L of ECF

Define ICF; What is the % of TBW?

∙ Intracellular Fluid ∙ Fluid within the cells of the body ∙ Essential for cell function and metabolism ∙ 40% of TBW (2/3 of total body fluid)

What lab results would we expect to see with a patient who has fluid volume excess?

∙ Low hematocrit, K+, and BUN ∙ BNP: Increased (the only lab that will increase) ∙ Decreased urine specific gravity ∙ Decreased serum osmolality ∙ Decreased serum sodium (if overhydration) Your patient will be hypotonic.

What do nurses do with a patient who has fluid volume excess?

∙ Monitor I&O hourly (Foley if needed) ∙ Monitor daily weight (1 kg wt gain = 1 L fluid gain) ∙ Observe for s/s of fluid overload ∙ Use IV pumps to control the rate of infusion ∙ Elevate HOB to facilitate breathing ∙ Monitor ABGs ∙ Assess breath sounds regularly to check for pulmonary edema ∙ Emotional support ∙ Maintain IV access ∙ Restrict fluids prn Goal: Remove fluids without messing up electrolytes or osmolarity Treatment: ∙ Fluid and sodium restriction ∙ Diuretics (IV or PO) ∙ Dialysis ∙ Find cause/treat ∙ Remove fluid ∙ Cardiac monitor ∙ Assess skin/edema

Nursing Implications for Digoxin

∙ Monitor apical pulse for 1 full minute before administering. ∙ Monitor potassium levels. ∙ Monitor therapeutic levels: 0.5-2 ng/mL. ∙ Monitor I & O's, daily weights (fluid retention) ∙ Monitor peripheral edema ∙ Monitor for adventitious lung sounds ∙ Assess for toxicity

Osmosis

∙ Movement of water from an area of low solute concentration to an area of higher solute concentration. ∙ Water moves across the membrane to dilute higher concentration of solutes. ∙ Concentration gradients. ∙ Semipermeable membranes let certain things through. Semipermeable membranes let water pass through but not solutes.

What are some side effects of antihistamines?

∙ N/V/D ∙ Drowsiness/Fatigue ∙ Dizziness ∙ Thickened bronchial secretions ∙ Anticholinergic effects

What are some signs of Digoxin toxicity?

∙ N/V/D ∙ Fatigue ∙ Headache ∙ Yellow/green or halo vision ∙ Arrhythmias, including bradycardia ∙ Irritability/insomnia *** If you see these signs you want to request a STAT DIG LEVEL ***

Passive Transport

∙ Requires NO energy ∙ Movement of molecules from high to low concentration ∙ Moves with the concentration gradient ∙ Osmosis ∙ Diffusion ∙ Filtration

When should you hold warfarin (Coumadin)?

∙ S/Sx of bleeding ∙ Hold for platelets < 150,000mcL ∙ Hold & verify with MD prior to giving dose if INR > 3

Fluid Output (loss)

∙ Sensible vs Insensible Fluids are lost from the body in the following ways: ∙ Urine: 1200-1500 mL/day ∙ Skin: 650-900 mL/day ∙ Lungs: 300-400 mL/day ∙ Feces: 100-200 mL/day

What are some implementation considerations for nystatin (Mycostatin)?

∙ Shake well before administration per Davis' Drug Guide ∙ No POs are to be given after this medication, give this medication last ∙ Patient is to hold suspension in mouth and swish throughout mouth for at least two minutes. It continues to kill the fungal infection the longer it is in the mouth. ∙ No food or drink for at least 30 minutes after dosage.

Antidiuretic Hormone (ADH)

∙ Stimulated by increase ( ) of electrolytes or decreased BP ∙ Produced by hypothalamus, released from pituitary gland into blood to act on kidneys. ∙ Stimulates constriction of blood vessels and water conservation by increasing water reabsorption. Low blood volume(high serum osmolality) ➞ pituitary gland secreted ADH ➞ ADH causes kidneys to retain water ➞Water retention increases & boost s blood volume ➞ (serum osmolality decreases) High blood volume (low serum osmolality) ➞ inhibits release of ADH ➞ No ADH = less water reabsorbed by kidneys = kidneys excrete more urine ➞ water excretion decreases blood volumes ➞ high serum osmolality

ATP (adenosine triphosphate)

∙ Supples energy for solute movement in and out of cell. ∙ Moves Na+ out of the cell, forces K+ back into the cell.

Lung Compliance

∙ The ease of lung inflation ∙ Reduced by increased lung water (edema), loss of surfactant, or conditions that cause elastin fibers in teh lungs to be replaced with scar tissue (collagen).

Osmolarity

∙ The number of particles in a solution by volume (mOsm/L) ∙ Osmotic pressure ∙ Amount of pressure required to stop osmotic flow of water ∙ Pressure needed to stop fluid movement across a cell membrane created by concentration gradients. When molecules can't move across a membrane, fluid will move to equilibrate concentrations.

What are some s/sx of dehydration?

∙ Thirst: First S/S ∙ Dizziness/weakness ∙ Mental status changes ∙ Restlessness ∙ Dry skin/mucous membranes ∙ Poor skin turgor ∙ Decreased urine output ∙ Fatigue ∙ Fever ∙ Seizures ∙ Hypotension ∙ Tachycardia ∙ Weight loss

What is warfarin contraindicated in?

∙ Uncontrolled bleeding ∙ Open wounds ∙ Active ulcer disease ∙ Recent brain, eye, or spinal cord injury or surgery ∙ Severe liver or kidney disease ∙ Uncontrolled hypertension ∙ OB: Crosses placenta and may cause fatal hemorrhage in fetus.

What are some adverse reactions of antihistamines?

∙ Wheezing Hematologic reactions: ∙ Hemolytic anemia ∙ Thrombocytopenia ∙ Agranulocytosis *Use cautiously in asthmatic patients

What are some non-narcotic antitussives?

∙ dextromethorphan (in Robitussin DM) Chemically similar to opioids but less potential for abuse. ***Contraindicated in patients with COPD & asthma ∙ benzonatate (Tessalon Pearls) Desensitizes stretch receptors in lungs, do not chew

The Timeline of HIV

≈ 1969 Arrived in U.S. ≈ 1979 U.S. men seemed to have opportunistic diseases 1981 AIDS 1983 Virus management figured out Name HIV ➨ Acquired Immunodeficiency Syndrome (AIDS) ➨ HIV Disease *It is called HIV disease today because it is a chronic disease

Hypocalcemia: What do nurse's do?

▪ID high-risk patients ***Closely monitor post parathyroid or thyroid surgery patients*** ▪ Assess/monitor serum Ca++ ▪ Monitor VS - Hypotension, bradycardia, tachypnea ▪ Cardiac monitoring ▪ Assess ability to perform ADLs ▪ Assess for Chvostek's and Trousseau's signs ▪Seizure precautions, safe environment - Trach tray at BS in the event of laryngospasm ▪ Maintain IV line ▪ Administer PO supplements as ordered: - Ca++ supplements: calcium carbonate (TUMS) - Vitamin D supplements: calcitriol (Calcijex, Rocaltrol) ▪ Administer IV Ca++ carefully - Calcium gluconate when severe

Nursing Responsibilities: Telemetry 5 Lead

▪️ Electrode change Per facility policy (q24hr & PRN) ▪️ Clean skin with soap and water, ETOH if necessary ▪️ Electrodes Do not get wet. Attach lead wire then press electrode pad firmly to site.

What is measured on a "TELE" strip?

▪️ PR interval ▪️ QRS interval ▪️ QT interval

EKG/ECG

▪️Can be done resting, ambulatory, during exercise ▪️ Gives a view of one point in time. Shows how heart is doing right then electrically ▪️ Show conductive abnormalities, cardiac dysrhythmias, hypertrophic, pericarditis, MI (site & extent), pacemaker performance, and effectiveness of drug therapy.

What do nurses do for patients taking spironlactone?

◆ Assess fluid volume status (Daily weights, I&Os, skin turgor, lung sounds) ◆ Monitor for s/s of hyperkalemia

What should nurses do with a patient suffering from hypernatremia?

◆ Assess: VS, neuro status, I/O and daily weights, edema, lab values (Na+, chloride, osmolarity) ◆ Meds: Are they taking Alka Seltzer??? ◆ Observe high risk patients closely to prevent ◆ Involve patient and family: Set fluid intake goals, provide fluids w/in easy reach, all them to record ◆ Maintain IV patency ◆ Frequent oral hygiene ◆ Safe environment ◆ Educate patient

Diamox (Acetazolamide)

◆ Carbonic Anhydrase Inhibitor ◆ A super powerful diuretic because of where it works in the nephron.

How is chloride regulated in the body?

◆ Chloride follow sodium. So, wherever sodium goes, chloride follows. ◆ It is absorbed in the colon

How should nurses treat a patient with Hypernatremia from decreased Na+ secretion (Na+ gain)?

◆ Dilute sodium concentration with IVF D5@ ◆ Administer diuretics to promote sodium excretion (furosemide)

What should nurses do with a patient who is hypervolemic hyponatremic?

◆ Fluid restriction: Safer than Na+ administration ◆ Osmotic diuretics: water out, not sodium ◆ Severe: hypertonic solution (3% NaCl) (can be paired with osmotic diuretics)

What areas (in terms of patient condition/diagnosis) should be avoided when starting an IV?

◆ Poor vascular return ◆ Phlebitis/infiltration ◆ An arm with a: graft/shunt, CVA, masectomy, amputation, orthopedic/plastic surgery

Spironolactone (Aldactone)

◆ Potassium sparing diuretic ◆ Treats HTN (in combo); reduce edema with kidney or liver disease; slow progression of HF ◆ Promotes Na+ and water excretion adn K+ retention in distal renal tubules ◆ Blocks action of aldosterone b/c aldosterone causes us to retain Na+ and water and excrete potassium

What is the MOA of thiazide diuretics?

◆ Promotes Na+, K+, and water excretion in distal renal tubules ◆ May also cause vasodilation of arterioles

What are fluid volume excess s/sx?

◆ Rapid, bounding pulse ◆ Increased BP With progression: falling BP & CO ◆ Development of S3 ◆ Distended veins ◆ Edema Tissues, lungs ◆ Labs: Hemodilution ∙ BNP: Increased ∙ Hematocrit: decreased due to dilultion ∙ Sodium: decreased in presence of water retention ∙ Urine Specific Gravity: decreased when kidneys are removing excess fluid Also: ∙ Faster, shallow respirations (tachypnea) ∙ SOB ∙ Chest xray: vascular congestion/pulmonary congestion ∙ Pale, cool skin ∙ Lungs (crackles) ∙ Increased urine volume ∙ Increased CVP (central veinous pressure) Could turn into cardiogenic shock Remember patient is HYPOtonic

Hypervolemia

◆ Retention of both fluid and electrolytes (primarily Na+) ◆ Isotonic ◆ Fluid gain is primarily ECF ◆ Causes: Renal failure, heart failure, too much isotonic IVF, others

Overhydration (water intoxication)

◆ Retention of water only ◆ Hypotonic ◆ Fluid from ECF pulled into ICF ◆ Causes: Overzealous water intake, SIADH, too much hypotonic IVF, others

What are some signs and symptoms of infiltration?

◆ Swelling ◆ Pallor ◆ Coolness ◆ Pain at the IV site ◆ Slowed infusion rate

What are some signs and symptoms of extravasation?

◆ Swelling, blanching, bleb formation ◆ Stretched firm and/or cool skin ◆ Can progress to form blisters with subsequent sloughing of tissues (necrosis)

What are some signs and symptoms of thrombophlebitis?

◆ Tender to touch ◆ Redness ◆ Warmth ◆ Cord-like veins

Hypervolemic Hyponatremia

◆ Too much fluid, not enough sodium ◆ Happens with: HF, hepatic cirrhosis, renal failure, overhydration ◆ Edema, HTN, weight gain, rapid, bounding pulse r/t hypervolemia

What should nurses do with a hyponatremic patient?

◆ VS ◆ Neuro status ◆ I&Os ◆ Daily weights ◆ Turgor ◆ Labs (Na+, chloride because of their relationship, & osmolarity) ◆ Fluid restriction ◆ Maintain patent IV line ◆ Cautious rehydration/replacement 10mEq/L in 24 hours ◆ Dietary intake ◆ Keep patients safe

Thiazide Diuretics

◆ hydrochlorothiazide (HCTZ, Microzide) ◆ Usually first line diuretic given for HTN. ◆ Edema from heart, liver, &/or renal failure ◆ Promotes Na+, K+, and water excretion in distal renal tubules ◆ May also cause vasodilation of arterioles ◆ Onset (PO) = 2 hours

Osmotic Diuretics

◆ mannitol (Osmitrol) ◆ Increase osmotic pressure of glomerular filtrate ◆ Inhibit water and electrolyte reabsorption ◆ Used for: Decreases in ICP, oliguria, prevention of RF *FYI for now*

What are the mechanisms of action for ACE Inhibitors?

∙ Affects the RAAS ∙ Inhibit angiotensin-converting enzyme, which is responsible for converting angiotensin I (through the action of renin) to angiotensin II. ∙ Angiotensin II is a potent vasoconstrictor and causes aldosterone secretion from adrenals. ∙ ACE inhibitors lead to a decrease in aldosterone production (sodium and fluid loss & a small increase in K+ levels. ∙ As Angiotensin II is reduced, arterioles dilate and peripheral vascular resistance is reduced ∙ Also prevent the breakdown of the vasodilating substance, bradykinin (therefore you can get vasodilation) ∙ Result: decreased systemic vascular resistance (afterload), vasodilation, and therefore decreased blood pressure.

Acetaminophen (Tylenol)

∙ Analgesic and antipyretic effects ∙ Inhibits prostaglandin synthesis ∙ Little to no anti-inflammatory effects ∙ Fewer side effects than NSAIDs ∙ Available OTC and in combination products with opioids ∙ NO MORE THAN 3G/DAY Contraindicated in Allergy, liver disease Interactions ETOH & other drugs metabolized in the liver can cause an interaction. Precautions ∙ Inadvertent excessive doses may occur when different combination drug products are taken together ∙ Be aware of the acetaminophen content of all the medications taken by the patient (OTC & prescription) ∙ Recommended antidote: acetylcysteine regimen (Mucomyst)

Intranasal Glucocorticoids

∙ Anti-inflammatory properties, decrease symptoms of allergic rhinitis ∙ Use 1-3 weeks for peak effectiveness ∙ May experience burning or epistaxis due to dryness with continued use ∙ May be used in combination with an H1 blocker ∙ Low risk of system side effects when delivered intranasally ∙ Ex. fluticasone (Flovent/Flonase)

What are the contraindications of NSAIDS & ASA?

∙ At risk for bleeding (peptic ulcer disease, anticoagulant therapy) ∙ Conditions or other drug therapy that places client at risk for renal impairment b/c we need the patient to filter it out. ∙ Pregnancy, especially last trimester due to risk of maternal bleeding and possible miscarriage. ∙ Allergy/hypersensitivity (either drug) ∙ ASA products (and all agents containing ASA) contraindicated with children who may have viral infection due to association with Reye's Syndrome.

What is the mechanism of action of Digoxin (Lanoxin)

∙ Boosts intracellular calcium and enhances movement of calcium into myocardial cells. This enables stronger heart contractions. ∙ Acts on the CNS to slow the heart rate ∙ Increases the refractory period when cells cannot conduct an impulse

Structures of the Lower Respiratory Tract

∙ Bronchi, bronchioles, alveolar ducts, alveoli ∙ Surfactant ∙ Blood supply

Atelectasis

∙ Collapsed lung; incomplete expansion of alveoli ∙ Inadequate amount of surfactant present ∙ Lower respiratory disorder

What are the different types of pneumonia?

∙ Community Acquired Pneumonia (CAP) ∙ Medical Care-Associated Pneumonia (MCAP) ∙ Aspiration Pneumonia (can be either CAP or MCAP) ∙ Opportunistic Pneumonia

Tonicity

∙ Comparing two solutions ∙ Term to describe the effect of particles in concentration on osmolality. ∙ Basically another term for osmolality/total concentration of solutes. ∙ In medicine, we are comparing tonicity of different IV fluids to blood. A solutions solute concentration compared to another. ∙ If IV fluids and blood concentration can effect water movement between the plasma and inside of the RBCs.

Osmolality

∙ Concentration of solutes in body fluid ∙ The measure of particles in a solution: shape, size, and charge of particles do not impact osmolality ∙ Number of particles in a solution by mass (mOsm/kg)

Chemoreceptors

∙ Control respiration ∙ Located in the medulla of the brain stem, the carotid arteries, and the aorta ∙ Detect changes in the blood pH, O2, and CO2 levels and send message back to the central respiratory center in the brainstem. ∙ In response, the respiratory center increases or decreases ventilation to maintain normal levels of pH, O2 (PO2), and CO2 (PCO2)

Renin-Angiotensin System

∙ Created by kidneys in response to decreased blood flow ∙ Balances Na+ and water ∙ Renin stimulates the conversion of angiotensinogen to Angiotensin 1 converted to Angiotensin 2 ∙ Causes blood vessel constriction to stimulate aldosterone. ∙ blood volume/blood pressure Blood flow to glomerulus decreases, specialized cells secrete RENIN ➞ Renin (through complex steps*all you need to know) ➞ leads to the production of Angiotensin II, a powerful vasoconstrictor ➞ Angiotensin II causes peripheral vasoconstriction & stimulates Aldosterone, both increase BP

Active Transport

∙ Energy-requiring process that moves material across a cell membrane against a concentration difference. ∙ Solutes move across a cell membrane from an area of low concentration to an area of high concentration. ∙ Requires energy - ATP Think sodium-potassium pump.

What are the side effects and interactions of NSAIDS & Salicylates?

∙ Epigastric distress to GI bleeding, tinnitus, platelet dysfunction Drug Interactions: ∙ ETOH (additive affect) ∙ Anticoagulants (increased bleeding) ∙ Diuretics (reduced diuretic effects)

Varicose Veins

✤ Abnormally swollen, twisted veins with defective valves; most often seen in the legs. ✤ Pooled blood in the veins

Venous Stasis Ulcers

✤ Most commonly found in lower extremities, appear as an erosion of the skin ✤ Poorly healing ulcers that result from inadequate venous flow

Nursing Interventions: Captopril

✤ VS (BP) ✤ Monitor WBC (neutropenia) & electrolytes (⇧K+ & ⬇︎Na+) Teaching ✤ Not for use when pregnant Can cause fetal injury or death ✤ Dizziness may be present during 1st week

Mast Cell

❖ A cell that produces histamine and other molecules that trigger inflammation in response to infection and in allergic reactions. ❖ Most important activator of the inflammatory response? ❖ Degranulation Release powerful inflammatory modulators (histamine, leukotriene, prostaglandin...) ❖ These modulators... ∙ Vasodilate ∙ Increase vessel permeability ∙ Constrict bronchial smooth muscle

Ribonucleic Acid (RNA) Virus

❖ A molecule that plays a major role in the pathway from DNA to proteins. When RNA viruses invade the human organism, they inject their RNA into the cytoplasm of the host cell. Once they are inside the cytoplasm, RNA can be used to synthesize proteins, and, eventually, to form replica viruses. ❖ A retrovirus

Pneumocystis Jiroveci

❖ A pneumonia not seen in healthy people ❖ Can be treated with antibiotics ❖ Seen in HIV/AIDS patients

Asthma Pathophysiology

❖ A restrictive lung disease. Inflammation causing airway narrowing & hyper-responsiveness. ❖ A trigger stimulates mast cells to release chemical mediators leading to bronchoconstriction, bronchial edema, and increased bronchial secretions.

Pseudoephedrine (Sudafed)

❖ A systemic decongestant ❖ Alpha-1 adrenergic agonist ❖ Speeds up the heart, opens up the airways, vasocontricts

Nursing Diagnoses for DVT

❖ Acute pain ❖ Ineffective health maintenance ❖ Risk for impaired skin integrity ❖ Potential complication: bleeding Because they will be on an anticoagulant ❖ Potential complication: PE

Pneumothorax (PTX)

❖ Air in the pleural space ❖ Complete or partial lung collapse ❖ S/S: SOB, chest pain, unequal lung expansion ❖ Diagnose: CXR ❖ Treatment: Chest tube

Beclomethasone (Beconase)

❖ Anti-inflammatory Glucocorticoid (inh) ❖ Inhaled steroid ❖ Decreases inflammation ❖ Therapeutic Effect/Uses ∙ Maintenance prophylactic for asthma ∙ Almost no side effects ❖ Pharmacodynamics/MOA ∙ Prevents release of and synthesis of inflammation mediators (Leukotrienes, prostaglandins, histamine) ∙ Decrease migration of inflammatory cells into the lungs (acts locally) ∙ Decreases edema of airways ❖ Side Effects Throat irritation, hoarseness, dry mouth, coughing ❖ Adverse Reactions Candida albicans infection, possible systemic effects of steroids ❖ Nursing Interventions ∙ When to administer? (1) albuterol (2) ipatropium (3) beclomethasone ∙ NO spacer ∙ Monitor for thrush

Montelukast (Singulair)

❖ Anti-inflammatory leukotriene receptor antagonist ❖ Prevention of chronic/maintenance treatment of asthma ❖ MOA/Pharmacodynamics: ∙ Inhibit release of leukotrienes ∙ Binds with leukotriene receptors to inhibit smooth muscle contractions and bronchoconstriction ❖ Side Effects ∙ Minimal. HA, dizziness, nausea, generalized pain, fever ❖ Nursing Interventions ∙ Monitor VS ∙ Provide adequate hydration ∙ Administer after meals to prevent GI upset ∙ Do not discontinue other asthma medications w/o consulting with MD ∙ NOT for acute asthma attacks

Ipratropium

❖ Anticholinergic bronchodilator Will find receptor sites in PSNS and will not allow acetylcholine on the sites leading to bronchodilation. Without systemic anticholinergic effects. ❖ Prophylactic medication. Take daily. ❖ Maintenance therapy for obstructive disorders Will relieve and prevent bronchospasm. Adjunctive management of bronchospasm in asthma. Off label. ❖ Not for acute attacks. Rinse mouth after use

What are the nursing interventions for albuterol?

❖ Assess lungs sounds, RR, and O₂ levels ❖ Nebulizer & inhaler administration ❖ Teaching ・Self administration of inhaler and correct use ・Contact MD if SOB not relieved by medication ・Use Albuterol 1st if using many inhaled drugs (It is a rescue inhaler!) ・1 minute between doses. Rinse mouth after dose.

Who would take albuterol?

❖ Asthmatics, COPD, flu, pneumonia, respiratory infection ❖ Treatment of bronchospasm.

HIV: Goals of Treatment

❖ CD4 > 900 and reduction in viral load Starting therapy ASAP is much more effective in keeping CD4 levels high ❖ Take the meds

COPD: ACT (Airway Clearance Techniques)

❖ Effective coughing: Huff coughing Pushes the sputum up through the airways ❖ Chest Physiotherapy (CPT) ❖ Postural Drainage Positioning techniques that drain secretions by using gravity. ・Administer bronchodilators and hydration prior ・Position held for 5 minutes ・Percussion and vibration therapy Vibration is only done when the client is about to breathe out.

Crackles (rales)

❖ Fluid in the alveoli or alveoli popping open ❖ Heard on inspiration and may clear with cough ❖ May be high-pitched, popping sounds, or low-pitched, bubbling sounds ❖ Described as rubbing strands of hair together with fingertips

Wheezes

❖ High-pitched, continuous musical sounds, usually heard on expiration. ❖ Caused by narrowing of airways

HAART (ART)

❖ Highly Active Anti-Retroviral Therapy ❖ On a combo of at least 3 meds Viral Entry Blockers ❖ Fusion Inhibitors ❖ CCR5 Coreceptor Antagonists Enzyme Inhibitors ❖ Nucleoside Reverse Transcriptase Inhibitors (NRTI) ❖ Nucleoside Reverses Transcriptase Inhibitors (NNRTI) ❖ Protease Inhibitors (PI) ❖ Integrase Inhibitors 3 Drug Combo ❖ PI + 2 nRTI ❖ NNRTI + 2 NRTI *Consistency is key

What are some possible nursing diagnoses for asthama?

❖ Impaired gas exchange ❖ Ineffective airway clearance B/C they pt. is having trouble clearing whatever is in the bronchioles. Give lots of fluids IV. ❖ Anxiety ❖ Deficient Knowledge

What are some nursing diagnoses for COPD?

❖ Ineffective airway clearance ❖ Impaired gas exchange ❖ Imbalanced nutrition, less than body requirements Malnourished. The pt. cannot eat enough for the energy they need. ❖ Insomnia Can't lay down to sleep ❖ Risk for infection Due to collapsed cilia

Long Term Management of Asthma

❖ Obtain health and medication history ❖ Pneumococcal & flu vaccines ❖ Watch out for allergies to aspirin ❖ Beta Blockers can stimulate B₂ causing bronchoconstriction ❖ Teaching self care Know your triggers, stress management, etc. ❖ Prevention of exacerbations Avoid triggers. Peak flow meter & action plan. Proper medication administration.

What oral manifestation associated with HIV infection presents as a white mucosal plaque that does not rub off, and most often involves the lateral border of the tongue?

❖ Oral Hairy Leukoplakia (OHL) ❖ This is a sign of severe immunosuppression in HIV-infected patients. ❖ No treatment

Theophylline

❖ Pharmacologic class: Xanthine ❖ Therapeutic class: Bronchodilator ❖ Used infrequently ・Unresponsive to asthma ・Narrow safety margin ・Many interactions ❖ Therapeutic range: 10-20 mcg/mL ❖ Oral or IV route

Stridor

❖ Piercing, high-pitched sound that is heard without a stethoscope ❖ Primarily during inspiration ❖ Infants experiencing respiratory distress or if someone has an obstructed airway.

Peak Flow Meter (PFM)

❖ Portable instrument used to measure air flow early in forced exhalation; helps monitor asthma and adjust medication accordingly ❖ Green 80%-100% ❖ Yellow 50%-79%

Systemic Glucocorticoids

❖ Prednisone (Rayos) PO ❖ Methylprednisolone (Medrol) IV (succinate) or PO ❖ Action of Both ∙ Suppresses inflammation and normal immune response ∙ Can be used for autoimmune diseases ∙ Immunosuppressive

PE Long Term Management: What do nurses do?

❖ Prevention Incentive spirometer will keep alveoli open ❖ TCDB/IS Turn, cough, deep breath/Incentive Spirometer ❖ S/S of complications Keep a look out for R. sided heart failure ❖ Self-care Anticoagulation therapy for 6 mos to 1 year. Oxygen therapy.

What are some s/s of asthma?

❖ RAT (Restlessness, anxiety, tachypnea) ❖ Retractions (Ribs concaving in during breathing) ❖ Cough ❖ Increased mucus ❖ SOB ❖ Expiratory wheeze ❖ CO₂ retention (respiratory acidosis) ❖ Prolonged expiration (because the body is trying to get rid of CO₂)

COPD Pathophysiology

❖ Repeated, ongoing tissue injury & repair ・Inflammation & formation of scar tissue (remodeling) = airway narrowing ・Increase in mucous production ・Cilia & macrophage malfunction They are deflated sad. Also leads to lower immunity. ❖ S/S Presence of cough & sputum production ❖ Over-distended alveoli/bronchioles ・Big & floppy ・Alveoli destroyed & capillary bed reduced ❖ S/S ・Lack of recoil (100 mph vs 600 mph) ・Hyperinflation ・Barrel chest B/C the lung tissue has been expanded so much and cannot snap back the way it used to.

What are some contraindications of ipatropium?

❖ Side Effects/Adverse Reactions Minimal d/t low systemic absorption ❖ Drug-Lab-Food Interactions Minimal. Increases with other anticholinergics.

Acute Management of COPD: What do nurse do?

❖ Stay calm ❖ Assess respiratory system ❖ Yes/No questions ❖ Tripod position ❖ PLB (1:3) breathing ❖ Small, frequent meals to increase caloric intake Interprofessional Care: ・IVF (as long as they can have it) ・Administer meds Quick relief, oxygen, ACT (Airway Clearance Techniques) * You don't want to give your COPD pt. too much oxygen b/c their body could think that they've had enough and they the pt. would stop breathing.

Acute Asthma: What do nurses do?

❖ Stay calm ❖ Sit them up as high as they need to be so the lungs can expand. ❖ PLB (1:3) "We are going to smell some roses and then blow out 100 candles." ❖ Assess respiratory system ❖ Yes/No questions No long winded answers ❖ IVF Isotonic. 5,000-4,000 mL/day ❖ Small, frequent meals ❖ Interprofessional care Oxygen, administer meds, quick relief, long term control

PE Acute Management: What do nurses do?

❖ Stay calm and stay with patient ❖ Sit them up ❖ Assess VS, respiratory assessment. Breath sounds will be normal until the alveoli collapse and then the sounds will be diminished. ❖ Oxygen Depends on the patient ❖ IV access: IVF ❖ Anxiety treatment Morphine is good for anxiety & will pull blood down into the extremities ❖ Anticoagulation meds ❖ Interprofessional care

Anaphylaxis: Priority Nursing Actions!

❖ Stop the offending agent or antibiotic causing it!!! ❖ Call RRT or Code ❖ Epinephrine Reverses the symptoms (↑ HR, ↑BP, bronchodilation) ❖ Assess respiratory status Maintain patent airway, elevate HOB, administer O₂ as necessary ❖ Establish IV access ❖ Nubulized Albuterol ❖ Diphenhydramine (Benadryl) ❖ Corticosteroids ❖ Document

Nursing Interventions: CT of Chest

❖ Test renal function b/c of IV dye ❖ Patient must be well hydrated to urinate the dye out ❖ Shellfish or iodine allergies? ❖ Warn pt. that when dye is injected they will feel a warm sensation, and they must lie very still on a hard surface. The warmth can extend to the groin and they may feel like they've wet themselves. ❖ Get correct weight for pt. since machines have a weight limit.

Why would a patient have a D-Dimer lab test performed?

❖ Used to rule out active blood clot formation ❖ Negative outcome = Ruled out blood clot formation in the body

Venous Thromboembolism (VTE)

❖ VTE = DVT + PE ❖ S/S of acute VTE Mild to moderate calf pain and tenderness, unilateral edema, warmth, and tenderness of affected extremity, elevated temp, erythema, edema.

Hypokalemia

・ < 3.5 mEq/L ・ Can be life threatening ・Cardiac dysrhythmias are most dangerous with this balance ・ The consequences of a patient having hypokalemia are often worsened by alkalosis, or on digoxin therapy, or they also have hypocalcemia.

Hyponatremia

・ <135 mEq/L ・S/Sx are not apparent until the sodium level is less than 120 mEq/L ・Body fluids are diluted and cells swell from decreased extracellular osmolality ・Severe symptoms (110 mEq/L or less) include seizures, coma, and permanent neurologic damage.

Heart Failure: What Medications May Be Used?

・ ACE Inhibitors & Angiotensin Receptor Blockers Inhibition of RAAS ・ Beta Blockers Decrease heart rate Allow more filling time ・ Vasodilators Decreases blood pressure ・ Diuretics Removes excess fluid ・ Cardiac Glycosides Decreases heart rate Increases contraction

What medications may be used for hypertension?

・ ACE Inhibitors and Angiotensin Receptor Blockers Inhibition of the RAAS ・ Beta Blockers Decrease heart rate Allow more filling time ・ Vasodilators Decreases blood pressure ・ Diuretics Removes excess fluid ・ Calcium Channel-Blockers Reduce afterload Vasodilation

Potassium Regulation & the Kidneys

・ Absorbed in intestines and excreted from kidneys ・ Kidneys eliminate about 90% of potassium ・ Kidneys have no effective mechanism to combat loss of K+, may excrete K+ even when levels are low ・If kidney function is significantly impaired, retained potassium can lead to toxic levels.

Aspirin: MOA, Use, & Considerations

・ Acetylsalicyclic Acid, ASA ・Antiplatelet MOA ・Blockage of COX-1 Prevents platelets from forming a clot ・Prevents ADP from binding with platelet receptors Prevents fibrinogen binding to platelet receptors Use ・Mainly used for prophylaxis ・Prevent MI or PAD/CVA ・Prevent repeat MI or PAD/CVA ・Prevent arterial clot formation Considerations ・Platelet aggregation inhibition caused by ASA is irreversible (cannot be on a week before surgery) ・DC for one week prior to elective surgery ・Available in enteric coated form ECASA dissolves in small intestine and not the stomach. If not EC it could burn a hole in the stomach and cause bleeding.

Nursing Interventions for Heart Failure Drug Interactions

・ Assess fluid status Monitor weight, I&O's, lung sounds, skin turgor, mucous membranes, edema ・ Monitor BP before and during administration ・ Monitor electrolytes (baseline and ongoing) ・ Monitor kidney function (BUN, Creatinine) ・ Give in the AM

Stimulation of the RAAS System

・ Automatic response ・ Activated by decreased perfusion and/or oxygenation of kidneys ・ Involves multi-organ response ・ Leads to fluid retention and vasoconstriction ・ Ultimately harmful in patients with heart failure ・ Further increases workload on the heart *** CONCEPT MAP ***

When would you hold Digoxin (Lanoxin)?

・ Check apical pulse for one full minute; Hold if < 60BPM or EKG changes ・ Hold if K⁺ is low (<3.5mEq/L) ・ Hold if Digoxin level is > 2 ng/mL

Nursing Management of Heart Failure

・ Decrease intravascular volume Give patient a diuretic. This will get the fluid to flow into the kidneys and help the kidneys to get rid of excess fluids (as long as kidneys have function) ・ Decrease venous return Helps to decrease workload on heart so there is not as much fluid going into it. (If needed) ・ Decrease afterload Vasodilate or lower BP ・ Increase gas exchange Help get fluid out of the lungs. Maybe a diuretic could help. Diuretics help pull fluids from where they aren't supposed to be back into the kidneys so the kidneys can pump it out. ・ Reduce anxiety

Teaching Points for Heart Failure Drug Interactions

・ Do not double dose if missed ・ Change positions slowly ・ Diabetic patients- monitor BS, may increase levels ・ Teach S/Sx of hypokalemia ・ Safety precautions Frequent urination, dizziness

Heart Failure: Diagnostic Studies

・ Echocardiography ・ Electrocardiogram (ECG) ・ CXR ・ Heart Catheterization ・ Elevated Brain Natriuretic Peptide (BNP) - Draw blood and look for this BNP

Examples of Alpha- and Beta-Adrenergic Agonists

・ Epinephrine ・Norepinephrine ・Dopamine ・Dobutamine ・Ephedrine ・Metaraminol

Factors affecting SV are:

・ Preload How much blood is in the ventricle right before systole. (volume of blood in the ventricles at the end of diastole and before the next contraction) ・ Contractility The ability for the muscle to contract. Increasing raises the SV by increasing vascular emptying ・ Afterload The peripheral resistance against which the left ventricle must pump. Resistance left ventricle must overcome to circulate blood. ・ Increasing preload and/or afterload increases the workload of the myocardium, resulting in increased O₂ demand

Heart Failure is...

・ Progressive condition generally speaking ・ Over time... Increased workload on the heart muscle causes decreased function leading to: Decreased elasticity of ventricles Decreased filling capacity Decreased force of contractions Decreased cardia output Leading to decreased perfusion and oxygenation to organs and tissues. Also leading to... ・ Decreased CO causes a "backup" in the blood flow ・ Right sided heart failure means the right side cannot pump enough blood to the lungs and the blood will back up into the body. ・ Left sided heart failure means the left side cannot get the blood out into the body and it is going to back up into the lungs (shortness of breath, crackles in lungs, activity intolerance, issues with organs and perfusion)

What is blood pressure affected by?

・ Systemic Vascular Resistance (SVR) Force opposing the movement of blood ・ CO (without adequate CO the organs do not get enough perfusion and will in turn tell the body they need more blood and the body will produce more blood, leading to higher blood pressure)

Functions of Potassium

・ Transmission and conduction of nerve impulses ・ Muscle contractions ・ Maintenance of cardiac rhythms/maintains cell's electrical neutrality and osmolality ・ Cellular growth ・ Acid-base balance

Signs and Symptoms of Hypertension

・ When severe a patient may experience: fatigue, dizziness, palpitations, angina, dyspnea. ・ Generally asymptomatic if not severe.

Magnesium

・1.5-2.5 mEq/L ・The second most abundant cation in the body located in the ICF ・50%-60% of Mg is stored in bone, 1% in blood, rest inside cell. ・Mg++ and K+ levels rise and fall together ・Must replace Mg++ before K+ (or at least at the same time)

Sinus Tachycardia (Intervals, EKG, why is it an issue? What could cause it? Medications?)

・100-160 bpm ・Each complex is complete. Note: P waves may be buried in the previous T wave. All intervals except the rate are WNL Why is ST an issue? Decreased filling time (preload) ⟹ Decreased SV ⟹ Decreased CO What could cause ST? ・Identify and treat underlying cause. ・Usually caused by SNS stimulation. ・Fear, anxiety, exercise, pain, fever, bleeding, dehydration, HF, hyperthyroid Medications ・Beta Blockers, CCB, ablation

If a client has Stage 1 HTN, what is the treatment and follow-up?

・130-139/80-89 ASCVD risk less than 10% Recommend healthy lifestyle changes, re-evaluate in 3-6 mos ASCVD risk greater than 10% (high risk) or if client has history of CVD, DM, or CKD Recommend healthy lifestyle changes, initiate pharmacologic treatment and re-evaluate monthly until target BP met

Phosphate

・2.5-4.5 mg/dL ・Exists in ECF as phosphorus ・Major anion in the ICF (bound with oxygen = phosphate) ・Phosphate is the primary anion in the ICF and the 2nd most abundant mineral in the body after calcium ・Most phosphate is in the bones and teeth as calcium phosphate ・The remaining phosphate is metabolically active and essential to the function of muscle, RBCs, and the nervous system.

HIV Facts

・70% of HIV cases are not under control ・% of people with HIV virus under control increases with age ・When used correctly, antiretroviral medications can keep HIV controlled. Reduce sexual transmission by 96%

Calcium

・8.5-10.5 mg/dL ・Most abundant electrolyte in the body ・Total serum calcium level looks at the total amount of calcium in the blood. Includes both ionized and protein bound calcium. This includes all three forms.

Chloride

・95-105 mEq/L ・Most abundant anion in the extracellular fluid

Hypophosphatemia & S/Sx

・< 2.5 mg/dL ・Mild to moderate levels do not usually cause symptoms ・Affect musculoskeletal, CNS, cardiac, and hematological system ・Phosphorus is required to make high energy ATP, many of the signs and symptoms relate to low energy stores ・Hypotension, irritability, confusion, low CO

What is hypochloremia and what are the s/sx?

・<95 mEq/L ・Could be due to acid base imbalances: Hyponatremia Hypokalemia Metabolic alkalosis ・Respirations slow and shallow (compensation) ・Nerves excited = tetany, hyperactive deep tendon refluxes ・Muscle cramps, twitching, weakness, irritability ・***life threatening*** arrhythmias, seizures, coma, respiratory arrest

What are some signs and symptoms of hyperkalemia?

・> 5 mEq/L ・Muscle cramps, weakness, flaccid paralysis ・Drowsiness ・EKG changes Tented T wave, flattened p wave, widened QRS, heart block, ventricular arrhythmias, asystole ・Abdominal cramping, diarrhea ・Oliguria

Hyperchloremia

・>105 mEq/L ・Rarely produces symptoms on its own but are present due to metabolic acidosis, hypernatremia, or hyperkalemia. Signs & Symptoms: ・Tachypnea ・Lethargy ・Thirst/dehydration ・Weakness ・Hypotension ・LOC ・Arrhythmia, decreased CO ・Coma

Hypernatremia

・>145 mEq/L ・Severe: can lead to seizures, coma, permanent neurological damage ・Fluids have moved from ICF into ECF ・Cells are shrinking

Basophils

・A circulating leukocyte that produces histamine. ・Mast cells

Western Blot

・A final test to confirm HIV status ・Detects the presence of circulating antibodies against HIV and Viral Proteins

What is an autoimmune disease/disorder?

・A group of disorders caused by the breakdown of the ability of the immune system to differentiate between self and non-self antigens ・Destroys host tissues ・Can affect almost any cell or tissue in the body

What are the MOA, uses, and assessment considerations for enoxaparin (Lovenox)?

・A low molecular weight heparin (LMWH) MOA ・Works similar to the way heparin works (not as easily manipulated though) ・More predictable anticoagulant response ・Used to "bridge" to warfarin (Coumadin) ・Inhibit thrombus and clot formation by blocking Xa Uses ・Prevention of DVT/VTE Surgery/immobility ・Prevention of ischemic complications USA (Unstable Angina) = much bigger dose, MI Assess for bleeding ・PTT/aPTT not necessary ・H&H Discontinue if platelets < 100,000

Superinfection

・A secondary infection that results from the destruction of normal microflora and often follows the use of broad-spectrum antibiotics. ・A second infection that has occurred on top of an earlier infection, especially following treatment with antibiotics.

Hydralazine

・A vasodilator ・Directly relax arteriolar and/or venous smooth muscle Result: Decreased systemic vascular response, decreased afterload, and peripheral vasodilation Adverse Effects: ・Dizziness ・Headaches ・Anxiety ・Tachycardia ・N/V/D ・Anemia ・Dyspnea ・Edema ・Nasal congestion

What are the side effects/adverse effects of atropine?

・ADRENERGIC ACTIONS! ・Dry mouth ・Constipation ・Urinary retention ・Increased HR (tachycardia) ・Pupillary dilation/blurred vision/photophobia ・CNS excitement (delirium) Also: ・Palpitations ・Bradycardia ・Altered taste perception ・Decreased sweating

What do anticholinergics do?

・Act by competing with acetylcholine for the muscarinic acetylcholine receptor sites. ・Block the effects of acetylcholine ・Decrease parasympathetic activities to allow the sympathetic system to become more dominant ・Induce the fight or flight response

Respiratory Mechanisms

・Act within minutes to compensate for acidosis or alkalosis ・Respiratory center in medulla controls breathing

What are the functions of magnesium?

・Activates enzymes that break down carbohydrates and proteins ・Helps maintain calcium and potassium balances ・Necessary for sodium-potassium pump ・Involved in electrical activity in nerves and muscles ・Helps maintain heart rhythm ・Acts synergistically with calcium in hundreds of reactions in the body ・Is required for calcium and B12 absorption ・Has a sedative effect on the neuromuscular junction, which causes smooth muscle relaxation.

Pulmonary Edema

・Acute heart failure in which there is severe fluid congestion in the alveoli of the lungs; life threatening. ・Most common cause is left-sided heart failure secondary to CAD.

What are some drug interactions of Beta Blockers?

・Antacids delay absorption ・NSAIDS decrease hypotensive effects ・Diuretics Increases hypotensive effects

What is atropine? What are it's therapeutic effects/uses?

・Anticholinergic ・Treats bradycardia/PEA/Asystole by increasing the HR ・Pupil dilation (mydriatic) ・Decreases respiratory secretions. Used prior to anesthesia/surgery and in hospice.

What is the therapeutic class and effect of doxazosin?

・Antihypertensive ・Decreases BP ・Benign Prostatic Hypertrophy (BPH)

What are some nursing interventions for hypercalcemia?

・Assess/monitor serum Ca++ & other electrolytes ・Neuro, CV assessments ・Low Ca++ diet ・Maintain IV access (hydrate with isotonic saline solutions) ・Promote excretion of Ca++ Encourage 3-4L fluid intake/day, monitor I/O, loop diuretics, Calcitonin (synthetic) IM/SQ ・Strain urine for calculi ・Mobilize patient to prevent bone loss of Ca++

What are some food sources that are high in potassium?

・Bananas, oranges ・Chocolate ・Dried fruits, nuts, and seeds ・Beans, potatoes, mushrooms, broccolis, tomatoes, and celery ・Meats ・Salt substitutes Contain high potassium. We need to make sure to educate patients with a high potassium level not to use salt substitutes at that time due to the risk of toxicity.

What are the nursing implications for enoxaparin (Lovenox)?

・Be sure to inject the air bubble to help with absorption (keep the air bubble in the syringe and it should be injected last... so pay attention to positioning of your syringe) ・Be sure plunger pushes all the way in to avoid injury ・Rotate injection sites

Active DVT: What do nurses do?

・Bed rest We don't want it to break off and travel ・Palpate site gently for warmth/edema Do not massage extremity. May break off and travel. ・Measure/record leg circumferences ・Monitor for SOB/chest pain ・Elevate affected extremity Avoid pillow under knee ・Intermittent warm compresses ・Administer diuretics, analgesics, and anticoagulants as prescribed. ・ Prepare for Vena Cava filter

What are the side effects/adverse reactions of Beta Blockers?

・Bradycardia and other dysrhythmias ・Fainting ・Fluid retention ・Peripheral edema ・Rare: liver injury ・ Respiratory problems- more common with non-selective medications ・Can cause or worsen HF- use with caution ・***Discontinuing suddenly may trigger angina, HTN, and acute MI***

Home BP Monitoring: Educaton

・Bring monitor to office for verification ・Teach BP steps ・New HTN Dx or medication adjustments: LOG First thing in AM and last thing before bed (for 1 week or until normoretensive) ・Stable HTN clients AM or PM for 1 week every 3 months ・While taking BP No talking, don't cross legs, no smoking, no drinking, no caffeine, cuff size & placement, same time every day.

What do adrenergics that stimulate Beta₂ receptors do?

・Bronchial dilation ・GI relaxation ・Uterine relaxation ・Increased blood sugar ・Increased blood flow to muscles

Regulatory Mechanisms for Acid-Base Balance

・Buffer System Immediate ・Respiratory Mechanisms Minutes to hours ・Renal Mechanisms Hours to days

Describe the parameters needed to be diagnosed with the final stage of the HIV disease, AIDS.

・CD4 counts of less than 200 ・Severe immunosuppression ・The presence of some opportunistic diseases and cancer

What are some clinical manifestations of respiratory acidosis?

・CNS depression ・Low BP ・Warm, flushed skin ・Headache ・Hypoventilation with hypoxia ・Dysrhythmias

What are some treatments for severe hyperkalemia?

・Calcium gluconate IV (for EKG changes) ・IV insulin & glucose ・Sodium bicarbonate IV (if acidotic) ・Dialysis

Respiratory Acidosis

・Carbonic acid excess (CO2 retention) ・Can be acute or chronic

T-lymphocytes are responsible for __________. What are the two types and how do they work?

・Cell-mediated immunity T-Cytotoxic Attracted to bad antigens of foreign pathogens. Memory t-cells. Attack foreign antigens, recognize them and destroy them. Think of them as the body's surveillance. T-Helper Make different cytokines that help with phagocytosis. Help get the immune system to work together.

What are some nursing interventions when administering epinephrine?

・Check VS q 5 min ・Asses lung sounds ・Watch UO ・Monitor IV site (it is a vesicant-can destroy tissue) ・Client teaching (self-administration/parent-administration)

Cholinergic Agonists

・Chemicals that act at the same time as the neurotransmitter acetylcholine (ACh). ・Parasympathetic(PSNS) agonists, parasympathomimetics

What are the functions of phosphate?

・Combines with calcium to form mineral salts of teeth and bones ・Essential function of muscle, red blood cells, and nervous system ・Component of ATP ・Acid-Base balance ・Helps with deregulation of Ca+ levels

Angiotensin II Receptor Blockers (ARBs)

・End in -sartan (-sartan = satan and therefore angiotensin) ・Blocks angiotensin II in arteriolar smooth muscle and in adrenal gland ・Prevent release of aldosterone ・Dilates arterioles and increases sodium excretion by kidneys ・Few side effects except s/s of low blood pressure First dose phenomenon ・Ex. losartan (Cozaar), valsartan (Diovan)

ELISA

・Enzyme-Linked Immunosorbent Assay ・Test to detect presence of circulating anti-HIV antibodies & 1 viral protein ・Negative: Could mean no HIV, or the pt. is in a window period. ・Positive: Another ELISA positive ➞ Western Blot

Cardiac Catheterization/PCI

・Examines blood flow in the coronary arteries to heart muscle and heart function ・Catheter inserted into the appropriate coronary artery ・Blockage located → catheter passed through blockage → balloon inflated → stent placed ・Can enter through femoral or radial artery

What is the function of chloride?

・Follows sodium and potassium ・Essential for production of HCL for gastric secretions ・Acid-base balance (chloride vs bicarbonate)

What are the functions of calcium?

・Formation of teeth and bone ・Facilitates blood clotting ・Promotes transmission of nerve impulses ・Myocardial contractions ・Muscle contractions ・Hormone release

Warfarin (Coumadin)

・Given orally ・Monitored by prothrombin time (PT) and INR (PT-INR) ・May be started while the patient is still on heparin until PT-INR levels indicate adequate anticoagulaton. ・Full therapeutic effect takes several days ・Monitor PT-INR regularly--keep follow-up appointments ・Vitamin K (phytonadione) can be given if toxicity occurs ・Must watch their diet, no drastic changes to a diet either already high or already low in leafy greens. Must speak with physician first.

What are some food sources of magnesium?

・Green leafy vegetables ・Chocolate ・Dried beans ・Nuts ・Seafood ・Legumes ・Whole grains

Describe two ways a bacteria can cause disease within a human body.

・Grow inside a cell ・Secrete toxins

Describe how HIV replicates

・HIV reverse replicates. When HIV infects a cell, it first attaches to and fuses with the host cell. Then the viral RNA is converted into DNA and the virus uses the host cell's machinery to replicate itself during a process called reverse transcription. ・Target CD4 cells by destroying Helper T-cells and infecting CD4 cells. So when they replicate, the HIV replicates also.

HIV: Nursing Assessment

・HIV risk factors ・HIV test result, date of HIV infections, CD4 count, viral load ・Client's knowledge base Etiology, s/s, mode of transmission, disease progression, treatment regimen ・Adherence to medication regimen If pt misses even a few doses it will render the meds useless ・Immunizations

What do nurses do for clients with CAD?

・Health promotion ・Flu/Pneumonia vaccines Infections are inflammatory and lead to a potential heart attack ・Medication BP, cholesterol lowering drugs, antiplatelet therapy

Diastolic Failure

・Heart Failure with Preserved Ejection Fraction (HFpEF) ・Hypertension is the most important cause

Systolic Failure

・Heart Failure with Reduced Ejection Fraction (HFrEF) ・Results from the inability of the heart to pump blood effectively ・Hallmark is reduced EF (Normal is 55% to 60%)

B-lymphocytes are responsible for ___________. Once activated what do they become?

・Humoral immunity Once activated they become memory cells or plasma cells. Plasma Cells Antibody factories. Start releasing tons of antibodies against foreign invader antibodies (immunoglobulins)

What are the uses for ACE Inhibitors?

・Hypertension ・Heart failure (either alone or in combination with diuretics or other drugs) ・To slow progress of left ventricular hypertrophy after an MI (cardioprotective) ・Renal protective effects in patients with diabetes

What are some clinical manifestations of respiratory alkalosis?

・Hyperventilation ・Dysrhythmias, tachycardia ・Lightheadedness, lethargy, confusion ・N/V ・N/T extremities ・Seizures

Clinical Manifestations of Metabolic Alkalosis

・Hypoventilation ・Dysrhythmias, tachycardia ・Neuromuscular excitability ・N/T ・Confusion ・N/V, anorexia ・Seizures

What do nurses do with a patient suffering from hypokalemia?

・ID high risk patients (diuretics, anorexia, NG suctioning, dialysis) ・Assess/monitor serum K+ level ・Assess for skeletal muscle weakness (cramps?) ・Assess for cardiovascular changes ・Assess respiratory system ・Assess bowel sounds ・Monitor I&O ・Safe environment ・Implement HCP orders

Respiratory Alkalosis Interventions

・If caused by anxiety, encourage the patient to relax & breathe slowly ・For other causes, identify and treat the underlying disorder ・Decrease settings if patient on ventilator

If sodium is low, what does ADH do? If it is high?

・If sodium is low, Na+ thirst and ADH secretion are suppressed, kidneys excrete more water. ・If sodium is high, NA+ causes a person to feel thirsty and release ADH, which reabsorbs water.

What do the kidneys do if the body has too much sodium? Too little?

・If the body has too little sodium, the kidneys hold it. ・If the body has too much sodium, the kidneys excrete it.

What are some general patient education points regarding anticoagulants?

・Importance of regular lab testing ・Signs of abnormal bleeding ・Measures to prevent bruising, bleeding, or tissue injury ・Wearing a medical alert bracelet ・Avoiding drastic changes in foods high in Vitamin K (tomatoes, dark leafy greens) ・Consulting physician before taking other meds or OTC products, including herbals

Effects of Blocking the PSNS

・Increase in HR ・Decrease in GI activity/secretions ・Decreased respiratory secretions ・Decrease in urinary bladder tone and function ・Pupil dilation (Mydriasis) ・Cycloplegia (Accommodating) ・Decreased sweating

What do adrenergics that stimulate Beta₁ receptors do?

・Increased HR ・Increased myocardial contraction ・Increased renin secretion (increased BP)

What do adrenergics that stimulate Alpha₁ receptors do?

・Increases force of heart contraction ・Vasoconstriction (Increased BP) ・Mydriasis (pupil dilation) ・Decreased salivation ・Bladder relaxation ・Urinary sphincter contraction

What are some nursing diagnoses for HTN? Client goals? Education of lifestyle modifications?

・Ineffective health maintenance ・Deficient knowledge ・Anxiety ・Sexual dysfunction ・Ineffective therapeutic regimen management ・Noncompliance ・Disturbed body image ・ Ineffective tissue perfusion Client goals: Understanding of HTN, understanding of treatment, participation in self-care program, Absence of complications Education on lifestyle modifications: BP measurement/monitoring, weight reduction/nutritional therapy (DASH and alcohol consumption), physical activity, stress reduction

What are the pharmacodynamics/MOA of atropine?

・Inhibition of ACh by occupying the receptor sites ・Increased HR by blocking vagus stimulation ・Promote dilation of the pupils by blocking the iris sphincter muscle

Renal Mechanisms of Acid-Base Balance

・Last line of defense ・Regulate concentration of plasma HCO3- ・If serum pH is too acidic, kidneys conserve bicarb (and excrete h+) ・If serum pH is to alkaline, kidneys dump bicarb (and increase absorption of H+)

What are some food sources of phosphate?

・Meat ・Fish ・Poultry ・Dairy Products ・Legumes ・Whole Grains

What are the nursing precautions of atropine?

・Monitor VS ・Monitor I&Os ・Auscultate bowel sounds ・Provide mouth care ・Client education (avoid hot environments)

What nursing precautions would you take with bethanechol?

・Monitor VS ・Monitor I&Os ・Monitor for side effects: Auscultate bowel sounds & breathsounds, monitor for bradycardia and hypotension

Nursing Interventions: Sublingual Nitroglycerine (Nitro-Dur, Nitrostat)

・Monitor VS Q5 min ・Sit down ・How to self administer ・Feels bubbly, fizzy, burning under tongue ・Store away from light, heat, moisture, do not change containers

What are the nursing implications of warfarin (Coumadin)?

・Monitor the patient closely for bleeding Bleeding gums, tarry stools, bruises ・Monitor H/H (hemoglobin/hematocrit to watch for internal bleeding), platelet count (look out for thrombocytopenia), PT/INR ・Therapeutic INR is 2.0-3.0 (2.5-4.5 in patients with mechanical heart valves). Consider this level if patient is having invasive testing. ・Assess urine, stool, and emesis (will look like used coffee grounds) for blood

Potassium

・Most common cation in intracellular fluid ・ Important role in neuromuscular and cardiac funciton ・ Must be ingested daily b/c body can not conserve it ・ 98% in intracellular fluid, 2% in extracellular. ・When we draw a potassium level it is drawn from extracellular fluid. ・THINK CARDIAC

What are the side effects/adverse effects of epinephrine?

・Nervousness ・Tremors ・Agitation ・Tachycardia/Palpitations ・HTN Also: ・Fear/anxiety ・Restlessness ・Headache ・Nausea ・Decreased renal formation ・Pallor ・Local burning & stinging ・Rebound congestion with inhalation Can't see, spit, pee, or shit!

What s/s could meant that HIV Disease is progressing in a pt. or that they could be experiencing side effects?

・New cough ・SOB or DOE ・Increase in fatigue or malaise Change in LOC ・Depression/anxiety ・Headache or stiff neck ・Fever/rash ・Night sweats ・Visual changes ・N/V/D Blood, dehydration ・Sudden weight loss ・Skin lesions Oral lesions, yellow discoloration of the skin ・Pain Flank, chest, vaginal

Epinephrine

・Non-selective adrenergic agonist

What are the nursing implications for CCB?

・Obtain baseline BP, APICAL pulse rate and rhythm ・Hold if SBP < 90 or P < 60 BPM ・Assist with ambulation at the start of therapy as dizziness may occur ・Fluid and sodium may need to be restricted to minimize edema ・Monitor LFTs as indicated

What are the nursing implications for Beta Blockers?

・Obtain baseline BP, pulse rate & rhythm *** Hold dose if SBP < 90 or APICAL pulse < 60 ・Don't crush SR tablets (Then they will release too much at one time and won't be sustained which could lead to too low a HR or too law a BP) ・Dose is adjusted to patient's BP and tolerance ・Teach patient about orthostatic hypotension (b/c they are a fall risk) ・Monitor LFTs as indicated (b/c it could cause liver injury)

What are the adverse effects of doxazosin? Nursing precautions?

・Orthostatic hypotension ・Dizziness ・Lightheadedness ・Reflex tachycardia Also: headache, fatigue, vertigo, edema, nausea, dyspepsia, diarrhea, sexual dysfunction Get up slowly, change positions slowly, fall precautions.

What are the side effects/adverse effects of bethanechol?

・PARASYMPATHETIC ACTIONS ・Pupillary constriction (miosis) ・Increased SLUD ・Decreased HR ・Decreased cardiac contractility ・Hypotension ・Cardiac arrest ・Bronchoconstriciton

Examples of Alpha-Specific Adrenergic Agonists

・Phenylephrine ・Midodrine ・Clonidine (Alpha2-specific)

Hyperphosphatemia and S/Sx

・Phosphorus and calcium have an inverse relationship ・If one is high, the other is low ・S/Sx are usually the same s/sx caused by the effects of hypocalcemia.

Clopidogrel (Plavix): Uses, Considerations, Labs, Adverse Effects

・Platelet aggregation inhibitor ・Antiplatelet drug Uses ・Acute coronary syndrome (ACS) ・Hx: MI, ischemic stroke, PAD Considerations Given PO with or without aspirin Give with food! Labs to watch AST, ALT, CBC, Hct/Hgb, PT Adverse Effects: - Prolonged bleeding time; bleeding; bruising - Diarrhea Monitor for signs of bleeding Monitor for rash as can cause Stevens Johnson syndrome

Anticoagulants: How They Work and Uses

・Prevent formation of clots by inhibiting clotting factors ・Prophylactic only Have no direct effect on a blood clot already formed ・Decrease blood coagulability Prevent thrombosis Uses ・DVT prophylaxis and treatment postoperatively ・PE treatment ・CVA treatment ・Heart A-fib, unstable angina, MI, indwelling devices such as mechanical heart valves ・Coagulopathies FYI: disseminated intravascular coagulation

HIV/AIDS: Interprofessional Care

・Preventing HIV transmission ・Monitoring HIV disease progression and immune function ・Assessment Preventing/detecting/treating opportunistic diseases ・HAART (ART) Regimen ・Preventing/managing treatment complications

What are some signs and symptoms of hyponatremia?

・Primarily: Neurological ・Vary from patient to patient ・Depends on rapidity of development ・Headache, irritability, disorientation, lethargy, confusion. ・If sodium falls to 110 mEq/L, further deterioration: Stupor, delirium, ataxia, seizures, coma, even death.

Sodium Bicarbonate

・Quickly neutralized acids in blood and body fluid ・PO & IV ・Careful assessment during administration Watch for overcorrection (→alkalosis) Can cause hypernatremia & hypokalemia

IV K+ Replacement

・Rate max 10 mEq/hr ・Should not exceed 40 mEq/L ・Never give IV push -- Can cause cardiac arrest ・Monitor EKG ・Watch for signs of infiltration

Buffers

・React immediately ・Primary regulators of acid-base balance ・Present in blood and tissues ・Take up extra H+ ions or release H+ ・Act chemically to neutralize acids or change strong acids to weak acids ***Can't work without proper functioning of respiratory and renal systems***

What are the pharmacodynamics of Beta Blockers?

・Reduce CO → decreased vascular resistance → decreased BP ・ Reduce BP by reducing HR and contractility through β₁ blockade

What are the functions of sodium?

・Regulation of fluid volume (serum Na+ tells you about water balance) ・Maintaining electrolyte balance ・Generation/transmission of nerve impulses ・Muscle contractility ・Acid-base balance (by combining with chloride or bicarbonate) ・Main contributor to osmolality in blood

Rapid HIV-Antibody Testing

・Screen for antibodies in blood and saliva ・Takes 20 minutes to receive results ・Negative or positive **Note: if it is negative the pt. may be in a window period so a further assessment may be necessary if the pt. has some risk factors (sexually active, drug use, etc)

How do viruses replicate?

・Simple parasites that take over the metabolic machinery of a host cell and use that for replication. ・During attachment and penetration, the virus attaches itself to a host cell and injects its genetic material into it. During uncoating, replication, and assembly, the viral DNA or RNA incorporates itself into the host cell's genetic material and induces it to replicate the viral genome.

What are some other ways we can lose sodium?

・Sweat ・Feces

What are some food sources that are high in sodium?

・Table salt ・Cheese ・Canned foods ・Butter ・Ketchup/Mustard ・Lunch Meat ・Fish, shellfish, poultry ・Soy Sauce ・Pickled Foods ・Snack Foods ***We don't tell them to just avoid sodium products we need to identify specifically which ones. We won't tell the patient to limit sodium necessarily but to identify foods that are high in sodium.

Monocytes

・The clean-up crew ・Better at cleaning but take longer to get there Roughly 3-7 days. ・High monocytes means the infection has been there for a while.

Lymphocytes

・The second highest percentage of WBCs Two Types B lymphocytes Form in the bone marrow and release antibodies that fight bacterial infections T lymphocytes Form in the thymus and other lymphatic tissue and attack cancer cells, viruses, and foreign substances.

Scopolamine

・Transderm Scop ・PSNS antagonist (blocks PSNS) ・Muscarinic antagonist ・Used for motion sickness

Metabolic Acidosis Interventions

・Treat the underlying cause ・Sodium Bicarbonate ・Evaluate and correct electrolyte imbalances ・IVFs ・Insulin for DKA

What are some indications for epinephrine (Adrenalin, Adrenaclick)?

・Treatment of allergic reaction, anaphylaxis, cardiac arrest ・ Treatment of shock when increased BP and heart contractility are essential ・ To prolong the effects of regional anesthetic ・Primary treatment for bronchospasm ・To produce a local vasoconstriction that prolongs the effects of local anesthetics Also used in: ・Ophthalmic & Dental agents vIncrease local anesthetic effects

What are the mechanisms of action of nitrates?

・Vasodilation of coronary arteries Decreases afterload ・Vasodilation of venous vessels Decrease preload ・Reduces myocardial O₂ consumption

No Compensation

・pH abnormal ・EITHER CO2 or HCO3- abnormal

Full Compensation

・pH normal ・CO2 & HCO3- BOTH abnormal

If a client has Stage 2 HTN, what is the treatment and follow-up?

・≥ 140/90 ◆ Recommend healthy lifestyle changes, initiate pharmacologic therapy (2 agents, but might start with 1) and re-evaluate monthly until target BP met

What is the osmolality of a hypotonic solution?

<250 mOsm/kg

What is a normal CD4+ count? Lifespan? Lifespan of an HIV infected CD4+ cell?

800-1200 cells per microliter; 100 days; 2 days

Central Pontine Myelinolysis (CPM)

FYI ◆ What happens if Na+ is brought up too quickly

What is the therapeutic classification of nitroglycerin? Pharmacologic?

Antianginal; Vasodilator, Nitrates

What is the therapeutic classification of digoxin (Lanoxin)? Pharmacologic?

Antiarrhythmics, inotropics; Digitalis glycosides, cardiac glycosides

T/F: All fungi are pathogenic

False

What are some side effects of furosemide (Lasix)?

Frequent urination, dizziness, blurred vision, headache, vertigo.

If a patient's lab values are normal, what kind of fluids do you give them?

Isotonic solutions.

Why is the median antebrachial vein a poor choice for veinipuncture?

It can be painful because it is close to the nerves.

How is D5W different from other isotonic solutions?

It is isotonic in the bag, but becomes hypotonic once it is in the patient.

When sodium levels are low, what does the adrenal cortex do?

It secretes aldosterone which stimulates renal tubules to conserve water and sodium, thus helping to normalize ECF Na+ levels.

How is respiratory alkalosis compensated?

Kidneys conserve hydrogen ions and excrete bicarbonate ions.

How is respiratory acidosis compensated?

Kidneys excrete hydrogen ions and reabsorb bicarbonate ions.

Eosinophils (granulocyte)

Large brick-red cytoplasmic granules Found in response to allergies and parasitic worms

What are the side effects/adverse reactions of systemic glucocorticoids (prednisone, methylprednisolone)?

N/V/D Increased blood sugar Increased appetite Mood changes Ecchymosis HTN Osteoporosis Muscle wasting Infection Abnormal fat deposits Sodium/water retention Euphoria/psychosis Thinned skin with purpura Increased IOP Peptic ulcers Tachycardia Thrombophlebitis Embolism

What are some side effects of nystatin (Mycostatin)?

N/V/D, stomach pain (large doses)

Name some medications used to treat SLE and the reasons for each

NSAIDs Joint pain and swelling Antimalarial Meds Fatigue, skin and joint problems Corticosteroids Severe exacerbations (topical for rashes) Immunosuppressive Medications Reduce the need for corticosteroids Anticoagulants Treatment of blood clots Anticonvulsants Treatment of seizures, phenytoin (Dilantin)

Atrial Fibrillation (atrial flutter)

Irregularly irregular. The atria are being stimulated at a very fast rate. This results in a quivering of the atrial heart muscle. The ECG shows several small P waves before each QRS complex.

What can we give someone who has taken too much morphine/opioids?

Narcan

Why is it important to think of our patients in terms of albumin and calcium?

Nearly half of Ca is bound to protein albumin, serum protein abnormalities. So if the patient is low in albumin, they may be low in calcium. So, we need to draw an ionized level of Ca level to see what level our calcium is truly that is performing those functions.

What information do you need to include when labeling your IV insertion site?

Needle gauge, date, time, initials

How can we best assess for cellular swelling when giving hypotonic IV fluids?

Neuro assessment. The fluids will be moving towards the cells.

What are some signs/symptoms of hypernatremia?

Neuromuscular Twitching, hyperreflexia, ataxia, tremors Early Signs Restlessness/agitation, thirst, anorexia, n/v Later Signs Weakness, lethargy, confusion, stupor, seizures, coma➡️death Low Grade Fever Flushed Skin Intense Thirst If sodium gain: Hypervolemia, increased BP, bounding pulse, dyspnea If water loss: Hypovolemia, dry mucous membranes, oliguria, orthostatic hypotension

How are the boxes in an ECG broken down by seconds?

One small box = 0.04s 5 small boxes = 0.2s (equal one large box) 5 large boxes = 1s

What is the onset, peak, and duration of IV furosemide?

Onset: 5 min (Great for emergencies) Peak: 20-30 min Duration: 2 h *Push slowly for IV due to risk of ototoxicity

What is the onset, peak, and duration of PO furosemide?

Onset: < 60 min Peak: 1-4 h Duration: 6-8 h

What fluids should a patient suffering from Hypernatremia with Hypovolemia (water loss) receive?

Oral or IV D5W

Calcium Regulation

Our bones stores approximately 99% of Ca+. ・The small intestines absorb Ca+ but we need vitamin D for this to take place. ・Vitamin D promotes absorption through the intestines and then Ca+ reabsorption from bone thereby increasing Calcium levels.

Fluid Volume Excess

Overhydration Retention of water only Hypervolemia (ECF volume excess) Retention of water and electrolytes Results from: ∙ Excess intake of fluids (IV or PO) ∙ Abnormal retention of fluids ∙ Decreased renal function ∙ Interstitial-to-plasma fluid shift

How can you diagnose COPD?

PFT, FEV, CXR, O₂ sat, ABG, sputum samples/cultures

What is a normal interval value for a PR? QRS? QT?

PR interval: 0.12-0.2 seconds QRS interval: 0.06-0.1 seconds QT interval: 0.34-0.43 seconds

Pleurisy

Painful inflammation of the pleura

Cycloplegia

Paralysis of the ciliary body (accommodation)

PCI (Percutaneous Coronary Intervention)

Prep ・NPO ・Consent ・Check allergies Shellfish, iodine ・Assess distal pulses ・Appropriate pt. education Post ・Check site Advise pt. if it is femoral that you will have to continually look under their gown at the groin area. Also, look at foot to see circulation has returned if it was a femoral entry. ・Maintain BR, avoid leg flexion Lay almost flat ・Encourage fluids, IV fluids To flush out the dye ・Think about food to feed them

Losartan (Cozaar)

Therapeutic Effect/Use HTN, HF, Type II Diabetic Nephropathy ✤ No cough ✤ Much less risk of angioedema ✤ ACE first b/c it is stronger

Long-term Management COPD: What do nurses do?

❖ Education ・Vaccines ・Long term control: medication ・Oxygen ・ Activity tolerance: Balance activity & rest! ・Self-care Vaccines, take meds, stop smoking ・Smoking cessation

Hypomagnesemia and S/Sx

< 1.5 mEq/L ・Hyperactive deep tendon reflexes ・Weakness ・Muscle cramping ・Restless legs ・Rapid heartbeat ・Tremor ・Vertigo ・Anxiety, agitation, depress At it's worst it can lead to: ・Respiratory muscle paralysis ・Complete heart block ・Altered mental status ・Coma

What is the target BP for a pt. with HTN?

< 130/< 80

What is the order of blood draw?

1. Sterile blood culture tubes or vials 2. Blue stopper (sodium citrate) tubes 3. Serum tubes (red/black, red/yellow top) 4. Green stopper (lithium heparin, plasma) tubes 5. Lavender stopper (EDTA) tubes 6. Gray-top (glycolytic inhibitor) tubes ***Will not be tested on-- Check facility policy***

QT Interval

0.34-0.43 seconds Ventricles contract and relax. Beginning of the QRS complex to the end of the T wave.

What are some hypotonic IV solutions?

0.45% NaCl (1/2 NS) [154 mOsm] 0.33% NaCl 2.5 % Dextrose in Water

Intake/Output Formula

0.5mL/kg/hr

What are some isotonic IV solutions?

0.9% NS (sodium chloride; normal saline) [308 mOsm] Lactated Ringers (LR) [275 mOsm] *** D5W*** [260 mOsm]

HIV Pathophysiology

1. After HIV binds to the CD4+ T helper cell, it gains entry and is transcribed into single-strand DNA with assistance of REVERSE TRANSCRIPTASE (enzyme made by retroviruses) 2) Single-strand DNA replicates and makes double-strand DNA 3) HIV DS-DNA enters cell nucleus and splices itself into the genome with the assistance of INTEGRASE, and becomes a permanent part of the genetic structure causing two effects: all daughter cells become HIV infected AND viral DNA in cell directs cell to create more HIV (long strands of HIV RNA are created) 4) With the help of PROTEASE, long strands of HIV RNA are "cut to size," which allows RNA to leave the cell in a budding process (this process eventually leads to cellular destruction)

What are some hypertonic solutions?

3% NS [1026 mOsm] *D5 0.45% NaCl [406 mOsm] D5 0.9% NaCl [560 mOsm] D5LR [575 mOsm] D10W [556 mOsm] Colloids: Albumin Plasma protein fraction Dextran Hetastarch

Which end of PaCO2 is alkaline? Acidic?

35 is alkaline 45 is acidic

Arterial Occlusion

4 P's Pain, pulselessness, pallor, paresthesia

Allergic Reaction/Anaphylaxis: Assessment & Diagnostic Tests

Assessment ❖ History & Physical So imortant! Family hx of allergies, hx of allergen exposure, reaction... Diagnostic Tests ❖ CBC with differential Eosinophil count & basophils both ⬆︎ with reaction ❖ Serum IgE ❖ Skin Testing

What are the respiratory disorders of the lower airway?

Atelectasis, Pneumonia, TB, Valley Fever

What is the therapeutic classification of warfarin (Coumadin)? Pharmacologic?

Anticoagulant; Coumarins

What is the therapeutic classification of nystatin (Mycostatin)?

Antifungal

Calcium Channel Blockers: Names, MOA, & Results

Are Very Nice Drugs Amlodapine Verapamil Nifedipine Diltiazem Calcium channels found in the myocardium and arterial smooth muscle. Ca++ increases contractility, peripheral resistance, and BP. These drugs block these effects. MOA Causes smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction. Results Causes decreased peripheral smooth muscle tone & decreased systemic vascular resistance leading to decreased contractility, decreased conductivity of the heart, decreased demand for oxygen, and decreased blood pressure.

All lymphocytes originate in the ___________________-. T-lymphocytes mature in the __________________. B-lymphocytes mature in the _____________________.

Bone marrow; Thymus; Bone marrow.

What are the three forms of calcium?

Bound: Calcium is bound to protein albumin Ionized(free): Carries out most of the Ca+ functions; the most physiologically important form. Complexed: With phosphate, citrate, carbonate

Name 3 late clinical manifestations of inadequate oxygenation

Bradycardia Extreme restlessness Dyspnea at rest

Glycogenolysis

Breakdown of stored glucose to increase the blood glucose levels.

If serum pH is too alkaline, lungs try to...

Breathing slower and less deeply

Hyperlipidemia (HLD): Causes and Treatment Guidelines

Causes ・Excessive dietary intake of fats ・Genetic alterations in fat metabolism leading to a variety of elevated fats in the blood Treatment Guidelines ・Lipid lowering agents are used as an adjunct to diet therapy All reasonable non-drug means of controlling cholesterol levels should be tried for up to 6 mos and found to fail before drug therapy is considered ・Drug choice based on specific lipid profile of client

Atenolol (Tenormin): MOA, Therapeutic Effects/Uses, Side Effects/Adverse Reactions

Cardioselective beta₁ adrenergic blocker MOA Blocks NE from stimulating B₁ which leads to decreased HR and BP. *It might also block B₂ a little bit, leading to bronchoconstriction. Therapeutic Effects/Uses HTN, angina, HF, prevent MI (decrease mortality in pts with MI), dysrhythmia/arrhythmia, migraines, anxiety Side Effects/Adverse Reactions ・Inhibit Fight/Flight Response Fatigue, weakness, hypotension, bradycardia ・Bronchospasm (rare with atenolol) ・Caution diabetics May not feel symptoms of hypoglycemia ・Impotence

What are the Cations and Anions that make up ICF?

Cations ∙ Potassium ∙ Magnesium ∙ Calcium (found in fairly equal concentrations in ICF & ECF) Anions ∙ Phosphate ∙ Sulfate

What are the cations and anions that make up ECF?

Cations ∙ Sodium ∙ Calcium Anions ∙ Chloride ∙ Bicarbonate ∙ Sulfate

Left Sided Systolic Heart Failure

Caused by: ・ Impaired contractile function (MI) ・ Increased afterload (HTN) ・ Cardiomyopathy ・ Mechanical abnormalities (i.e. valvular heart disease) ・ Hallmark is decreased ejection fraction (<45%) ・ Left ventricle loses ability to generate enough pressure to eject blood forward through the aorta

What are some examples of narcotic antitussives?

Codeine & Hydrocodone (low doses)

If you patient has a productive cough, what are 4 assessments you should always perform on the expectorated sputum?

Color, viscosity, amount, presence of blood

What are the two upper airway respiratory disorders?

Common cold & influenza

QRS Complex

Component of the electrocardiogram that represents the depolarization of the ventricles and includes, as a component, the repolarization of the atria. Referred to as a unit. Hopefully contracting and pushing blood out (0.06-0.1 seconds).

Hypertension

Defined as a persistent systolic BP (SBP) of 140 mm Hg or more, diastolic BP (DBP) of 90 mm Hg or more, or current use of antihypertensive medication.

Buerger's Disease: Definition, At Risk, S/S

Definition A condition in which the blood vessels, especially those supplying the legs, are constricted whenever nicotine enters the bloodstream, the ultimate result being gangrene and amputation. At Risk Population Young male smokers S/S Pain and tenderness of hands and feet

Rheumatoid Arthritis (RA): What it is, what it targets, assessment/diagnostic findings, treatment goals

Definition Chronic, progressive autoimmune disease that causes inflammation, thickening and deformation of the joints. Joints are affected bilaterally and symmetrically. Characterized by periods of exacerbations and remissions. More pain after inactivity. Targets Connective tissue in the diarthrodial joints. Assessment/Diagnostics ・Positive Rheumatoid Factor (RF) Antibody 80% of people with RA ・Positive Antinuclear Antibody (ANA) titer 20%-30% of people with RA ・C-Reactive Protein (CRP) Increased = active inflammation ・Erythrocyte Sedimentation Rate (ESR) Increased = active inflammation ・Synovial Fluid Analyzed for MMP-3 enzyme, WBC count, and tissue biopsy ・X-rays To confirm disease activity and monitor treatment Treatment Goals ・Reduce inflammation ・Management of pain ・Maintain joint function ・Prevent/minimize joint deformity

DVT (Deep Vein Thrombosis)

Definition Inflammatory response S/S Swelling, tenderness, redness Treatment Elevate extremity, Heparin

Systemic Lupus Erythematosus (SLE): What it is, how is it diagnosed?

Definition Multisystem inflammatory autoimmune disease. Immune bodies attack "self". Diagnosis **NEED 4*** Can be difficult to diagnose. SLE is diagnosed primarily on criteria relating to pt. hx, physical exam, and lab findings ・Positive Anti-Nuclear Antibody (ANA) ・ELISA for SLE-specific antibodies ・Malar (butterfly) rash ・Discoid lesion rash ・Photo sensitivity ・Oral ulcers ・Arthritis ・Pleuritis or pericarditis ・Renal disorder ・Neurologic disorder ・Hematologic disorder

Superior Vena Cava Syndrome

Definition Occlusion of superior vena cava leading to venous distention in upper extremities & head S/S Edema, venous distention in upper extremities, face & eyes, HA Treatment Radiotherapy, diuretics, steroids, anticoagulants, surgery

Cluster Breathing: Description

Description Clusters of breaths follow each other with irregular pauses in between Location of lesion in a coma pt Medulla or lower pons

Cheyne-Stokes Respiration: Description

Description Cycles of hyperventilation and apnea Location of lesion in a coma pt Bilateral hemispheric disease or metabolic brain dysfunction

Apneustic Breathing: Description

Description Prolonged inspiratory phase or pauses alternating with expiratory pauses Location of lesion in a coma pt Mid or lower pons

Central Neurogenic Hyperventilation: Description

Description Sustained, regular & rapid deep breathing Location of lesion in a coma pt Brainstem between lower midbrain and upper pons

Ataxic (Biot's) Breathing: Description

Description ✷ Completely irregular with some breaths deep and some shallow ✷ Random, irregular pauses ✷ Slow rate. Location of lesion in a coma pt Reticular formation of the medulla

Normal Sinus Rhythm

Description: 60-100 BPM. Each complex complete and all intervals WNL Next step: Monitor patient's condition

What are some nursing interventions for patients with RA?

Diagnoses ・Chronic/Acute Pain ・Self-care deficit ・Distrubed body image Assessment Physical, labs, psychosocial needs, functional status, environment concerns, s/s of depression

What patients might benefit from receiving hypotonic IV fluids?

Dialysis patient on diuretic therapy.

Long Acting Nitrates: Differences, Types, Interventions, Teaching

Differences ・Slower onset ・Taken before CP causing situations ・NOT for acute attacks Types ・Isosorbide dinitrate (Isordil) 2x/day ・Isosorbide mononitrate (ISMO, Imdur) 1x/day ・Nitroglycerin Transdermal Patch NTG paste Interventions ・Do not use fingers for ointment ・Transdermal patch placed anywhere above the liver ・On 12 hours/Off 12 hours Teaching ・Self administration of transdermal patch ・Orthostatic hypotension

What is the reversal agent for Digoxin (Lanoxin)?

Digibind

What are the pharmacodynamics/MOA of bethanechol?

Direct stimulation of the cholinergic (muscarinic) receptor promoting contraction of the bladder and relaxation of the bladder sphincters.

Mucolytics

Directly loosen thick, viscous bronchial secretions by breaking down the chemical structure of mucus molecules.

What is an infiltration?

Discharge or escape of non-vesicant solution or medication into the surrounding tissues as a result of cannula dislodgment which causes: ◆ Delay of fluid & drug absorption ◆ Limits veins available ◆ Predisposes patient to infection

What does DMARD stand for?

Disease Modifying Anti-Rheumatic Drugs

How often should a PIV site be assessed?

Every 4 hours (Mayo Clinic Handout)

How often should IV tubing be changed?

Every 96 hours.

Allows the action potential to move from the interatrial septum to the interventricular septum, connecting the AV node to the Bundle Branches.

Explain the significance of the fact that the AV bundle is the only electrical connection between the atria and the ventricles.

What is Pyrazinamide (PZA)? Side effects?

First line TB drug; hepatotoxic, GI symptoms, polyarthralgias, skin rash, hyperuricemia.

What is Ethambutol? Side effects?

First line TB drug; retrobulbar neuritis, skin rash.

Pleural Effusion

Fluid in the pleural space related to inflammation or third spacing

What should we closely watch for when our patient is receiving hypertonic IV fluids?

Fluid volume excess. This fluid is rich with solutes and the cells will shrink.

Fluid Intake (gain)

Fluids are added to the body in the following ways: ∙ Metabolism ∙ Beverage/drinking fluids ∙ Food/eating foods Fluid intake regulated by thirst ∙ Change in plasma osmolality ∙ Hypothalamus

What food sources are high in chloride?

Food sources that are also high in sodium.

Thrombosis

Formation of fibrin along the wall of the vein

What are the nursing implications for Heparin (monitor, interactions, antidote, administration)?

HIT (Heparin Induced Thrombocytopenia) Happens ≈ 10 days into drug therapy. An autoimmune reaction that occurs in 30% of patients. Monitor platelet counts. Monitor for Bleeding ・VS: ⇧HR, ⬇︎BP ・Mouth, urine, stool ・Decreased LOC Drug-Drug Interactions Potentiated effects of oral anticoagulants & NSAIDs (aspirin, Ibuprofen) Antidote Protamine Sulfate Administration SubQ ・Ensure that SC doses are given SC, not IM ・SC doses should be given in areas of deep subcutaneous fat, and sites rotated. ・Do not give SC doses w/in 2 inches of: The umbilicus, abdominal incisions, or open wounds, scars, drainage tubes, stomas ・Do not aspirate SC injections or massage injection site IV ・Intravenous doses are double checked with another nurse (Safety, high alert med, need four eyes on it) ・IV doses may be given by bolus (quickly) or IV infusions (slowly) or both ways would be called a loading dose. ・Must use an infusion pump

Atorvastatin (Lipitor): MOA, Effect/Uses, Contraindications, Side/Adverse Effects

HMG-CoA Reductase Inhibitors (Statins) Pharmacodyanmaics/MOA Inhibit HMG-CoA reductase Therapeutic Effect/Uses ・Decrease cholesterol levels LDL, VLDL/Triglycerides ・Increase HDL ・Reduce risk of MI & CVA Contraindications ・Active liver disease ・Pregnancy: Category X Will harm or kill fetus Side/Adverse Effects ・HA ・GI disturbances Give with food ・Hepatotoxicity Monitor liver function with blood tests. ALT & AST. Can cause liver failure. ・Muscle breakdown Rhabdomyolysis (can cause renal failure!). Monitor for myalgia. Urine could look like deep red wine. Muscle tissue ends up in the urine. Increased risk of rhabdo with GF juice

What should you do to hear a COPD patient's heart?

Have them lie on their left side and lean forward. q

What is the rationale behind placing a patient on their left side in Trendelenburg position if they experience an air embolism?

Head is lower than the feet and keeps air in the right atrium to prevent pulmonary embolism.

HIV: Prevention & Early Assessment

Health Promotion ・Emphasis on risk reductions ・Education Sexual activity, drug use, work risks ・Detect HIV infection early Antibody testing with counseling ・FYI Prevention PrEP: Pre-Exposure Prophylaxis Certain at-risk groups are on the meds to prevent transmission

What is a healthy adult sodium intake? What should people with HTN, DM, or CKD restrict sodium too?

Healthy adult: 2300 mg/day Sodium restriction: 1500 mg/day More salt ⟹ more water retained ⟹ higher BP

What is Isoniazid (INH)? Side effects?

Isoniazid is an antibiotic used a first line agent for the prevention and treatment of both waiting and active tuberculosis. Side effects include hepatitis & peripheral neurotoxicity. Supplement with vitamin B6 to prevent peripheral neuropathy.

If you were stranded in a desert without any water the amount of ADH secreted would...

Increase (ANTI-diuretic hormone, no diuresing)

When a patient has fluid volume deficit, what is their pulse like? BP?

Increased pulse; decreased BP

How is metabolic acidosis compensated?

Increased respiratory rate

What does epinephrine do when it stimulates Beta₁?

Increases HR (tachycardia), myocardial contraction, and BP

Why is asking a patient to pump their fist after a tourniquet application not best practice?

Increases K+ levels and ionized Ca+ levels leading to inaccurate results.

What does epinephrine do when it stimulates Alpha₁?

Increases force of heart contraction and BP

What is the mechanism of action of nystatin (Mycostatin)?

Inhibits fungal wall synthesis leading to cell leakage and death.

What are the drug-lab-food interactions of Nifedipine (Procardia)? Nursing interventions?

Interactions ・Increased hypotension with other anti-hypertensives ・Increased bradycardia with beta-blockers or digoxin ・Increased medication effects with grapefruit juice Effects the enzymes in the liver Interventions ・VS ・Do not crush SR tablets ・No grapefruit juice

U Wave

May follow T wave Repolarization of Purkinje fibers Sign of hypokalemia

What venous site is the most common site used to obtain blood?

Median cubital

Where do you hear the mitral valve? Which sound is louder?

Mid-Clavicular Line, 5th intercostal space (PMI); S1 > S2

What circumstances warrant a 20 gauge IV?

Minor trauma or surgery, blood administration

What should you be monitoring in a patient taking furosemide (Lasix)?

Monitor I&O, daily weight, peripheral edema, adventitious lung sounds, turgor, labs (K⁺, BUN, Creatinine)

What are some signs/symptoms of hypocalcemia?

Most Common: Nerve transmission, muscle and heart function changes Neuro Anxiety, confusion, irritability, seizures CV V-fib, heart block, EKG changes Neuromuscular Paresthesia (toes, fingers, face), twitching, muscle cramps, laryngo- and bronchospasm, tetany, positive, Trousseau's and Chvostek's sign GI Diarrhea

Filtration

Movement of both water and small particles from an area of high pressure to an area of low pressure.

What circumstances warrant a 14-16 gauge IV?

Multiple trauma, heart surgery, transplantation

List 3 possible causes of a hematoma related to IV therapy

Nicking the vein, inadequate pressure, applying the tourniquet too tightly, not pulling the tourniquet

Propanolol (Inderal): Uses & Cautions

Non-selective β₁ & β₂ antagonists Uses HTN, angina, cardiac dysrhthmia/arrhythmia Caution May cause BRONCHOSPASM, b/c of β₂ blocking effect

If your pt. has a normal BP what treatment/follow-up should they have? Elevated BP?

Normal BP Encourage healthy lifestyle to maintain normal BP, re-evaluate yearly Elevated BP Recommend healthy lifestyle changes, re-evaluate in 3-6 mos

Vesicular Breath Sounds

Normal breath sounds. Soft, low-pitched, gentle.

First Spacing

Normal distribution between ECF and ICF

Structures of the Upper Respiratory Tract

Nose, mouth, pharynx, epiglottis, larynx, and trachea

Coronary Artery Disease (CAD) & Angina: Nursing Diagnoses

Nursing Diagnoses ・Ineffective therapeutic regimen management (prevention) ・Ineffective Tissue Perfusion (cardiac) ・Acute pain ・Anxiety ・Activity intolerance

Nursing Interventions: Antiplatelets

Observe for signs of bleeding Education ・Do not mix with alcohol or other anticoagulants w/o MD consultation ・Notify all MDs about use ・D/C one week before surgery ・GI distress Take with food/fluids, notify immediately ・Report side effects Bleeding, tinnitus, HA, dizziness, GI symptoms, visual changes, seizures

Hypertensive Crisis

Occurs at SBP > 180mm Hg and/or DBP > 110mm Hg. Hypertensive Urgency develops over hours to days and does not have clinical evidence of target organ disease. It may not require hospitalization to correct. Hypertensive Emergencies have target organ diseases and most often require hospitalization for prompt, controlled reduction of BP.

What information do you need to include when labeling your bag of IV fluids?

Patient name, date, time, initials

What is Rifampin contraindicated in?

Patients with HIV; substitute Rifabutin (Mycobutin).

Systolic Blood Pressure (SBP)

Peak pressure exerted when heart contracts

What circumstances warrant a 22 gauge IV?

Pediatric, small veins

Heparin: MOA, Lab Values, & Teaching

Pharmacodynamics/MOA 1. Heparin binds with antithrombin III 2. Inactivates thrombin 3. Inhibits conversion of fibrinogen & decreases fibrin 4. Clot prevented Lab Values ・H&H If their H&H is low, the pt. is already depleted of that and they could be bleeding internally ・PTT Normal is 60-70 seconds. Therapeutic is 90-175 seconds. The bigger the number, the thinner the blood. ・aPTT Normal is 20-35 seconds. Therapeutics is 30-87.5 seconds Teaching ・Medical ID bracelet ・Notify all MD or DDS ・Prevent bleeding ・External hemorrhage

What is the antidote that can be used if a patient experiences extravasation from an IV adrenergic agonist?

Phentolamine Mesylate

P Wave

Represents depolarization of the atria and the firing of the SA node. Na+ and K+ moving in and out of cells.

T Wave

Represents the repolarization of ventricles. Ventricles are resting and being filled.

Dystolic Blood Pressure (DBP)

Residual pressure in the arterial system during ventricular relaxaton, or filling.

RIPE

Rifampin (Rifadin) Isoniazid (INH) Pyrazinamide (PZA) Ethambutol (Myambutol)

Rhythm of the Conduction System

SA node(Pacemaker) fires spontaneously 60-100 times per minute. AV node fires at 40-60 times per minute. If both nodes are suppressed fibers in ventricles by themselves they will fire only 20-40 times per minute.

What range is hypertension stage 1?

SBP of 130-139 or DBP of 80-89

What range is hypertension stage 2?

SBP of 140 or more or DBP of 90 or more

What is the range for elevated BP?

SBP: 120-129 and DBP: Less than 80

What range is hypertensive crisis?

SBP: Higher than 180 and/or DBP Higher than 120

Hypokalemia EKG Changes

ST depression T inversion U wave

What does the parietal pleura line? What does the visceral pleura line?

The parietal pleura lines the chest wall. The visceral pleura lies the lungs.

Oncotic Pressure

The pressure of water to move, typically into the capillary, as the result of the presence of plasma proteins. *The pulling power of albumin to reabsorb water*

What parts of the primary IV tubing administration set must be kept sterile?

The spike and the catheter adapter.

Preload

The stretch on the ventricles prior to contraction. Initial stretching of cardiac myocytes prior to contraction. Another way of expressing EDV. Therefore, the greater the EDV is, the greater the preload is.

Facilitated Diffusion

The transport of substances through a cell membrane along a concentration gradient with the aid of carrier proteins.

Respirator Acidosis Interventions

Treat underlying cause and improve lung function ・Bronchodilators ・Supplemental oxygen ・CPT ・ABX ・Maintaining hydration ・Mechanical ventilation

Define empiric therapy/treatment

Treatment by which experience has already proved to be beneficial. A certain antibiotic proved to work in the past may be prescribed.

How often should peripheral saline locks be flushed? Flushed with?

Twice a day or after each use, whichever is more frequent; Normal saline.

Stable A-fib: What is stable A-fib? What medications would control rate and rhythm? What medications would prevent thrombi/emboli?

What is stable A-fib? Controlled HR of less than 100 BPM (resting). Patient will be hypotensive and dizzy. What medications would control rate & rhythm? Digoxin, beta blockers, CCB What medications would prevent thrombi/emboli? Warfarin, heparin. Educate on importance of these meds

Chronic Stable Angina: Definition, D/T, Defining Characteristics, & Diagnostic Studies

What it is Chest pain (pressure, ache, heavy, suffocating sensations) D/T CAD Characteristics ・Intermittent: 5-10 min ・Predictable Some pattern of onset, duration, and intensity. Provoked by exertion and relieved by rest/meds. ・Controlled with medications Diagnostic Studies for CAD/Angina ・ECG ・Cardiac enzyme and troponin levels ・Exercise stress test ・Cardiac catheterization ・Percutaneous Coronary Intervention (PCI) Percutaneous Transluminal Coronary Angioplasty (PTCA)

Exercise Stress Test: Is, Does, Types,

What it is Study of the heart during activity What it does Detects and evaluates CAD. Under stress parts of the heart may be ischemic and not getting enough blood flow. Treadmill Stress Test ・Noninvasive ・ECG & BP Pharmacological Stress Test ・Vasodilators injected: dipyridamole, adenosine, dobutamine Radionuclide Injection

Echocardiography (Echo): Is, Does, & Interventions

What it is Ultrasounds of the heart What it does Evaluates structural and functional changes of the heart Nursing Interventions Educate pt. to lie still, left side and breathe normally (may need to hold breath occasionally)

Define an infection.

When a pathogen invades the body and begins to multiply and produces disease. The immune and inflammatory response cannot control the pathogen.

When can lower extremity sites be used for IV insertion?

When upper extremity sites have been exhausted. *An order must be obtained for use of lower extremity sites in adults (Mayo Clinic Handout)

It initiates the sinus rhythm.

Why is the SA Node known as the pacemaker of the heart?

Opioid Analgesics

∙ Natural & synthetic compounds that bind to opiate receptors and activate the endogenous analgesia system ∙ Mu receptors are the most effective in relieving pain ∙ Most share the same side effects (SEs): N/V, constipation, drowsiness ∙ Large doses may cause respiratory depression & ↓BP ∙ Other SEs: urinary retention, dry mouth, sweating ∙ ALWAYS ASSESS LEVEL OF ALERTNESS & RESPIRATORY STATUS BEFORE GIVING MED Central nervous system ∙ CNS depression Sedation........leads to........... Respiratory depression - Strongly related to the degree of sedation - More common in those with preexisting condition Reversal First: Try to stimulate the patient Second: Ventilatory assistance Third: Naloxone (Narcan) Interactions ∙ Potential drug interactions with MAOIs which could lead to respiratory depression/seizures/hypotension ∙ Co-administration ∙ Any CNS depressant ∙ ETOH ∙ Antihistamines ∙ Benzodiazepines Cautions & Contraindications ∙ Allergy ∙ Severe asthma ∙ Severe head injury ∙ Sleep apnea ∙ Paralytic ileus (bowel paralysis) ∙ Pregnancy Adverse Effects Unwanted effects usually on other parts of the body other than the CNS. - Psychologic dependence - Physical dependence - Opioid tolerance - Cardiovascular - Gastrointestinal (constipation) - Genitourinary (can cause urinary retentions) - Integumentary - Respiratory

Partial Agonists

∙ Opioid analgesics ∙ AKA agonist-antagonist or a mixed agonist ∙ Binds to pain receptor but causes a weaker neurologic response than an agonist ∙ Stimulate some receptors but block others ∙ Not as strong as the "agonists" ∙ Appropriate for acute moderate to severe pain ∙ Must be administered parentally ∙ Not 1st line drugs ∙ Do not give with the "agonists" as they may block the mu receptor site and reduce/reverse analgesia Examples: ∙ Stadol, Nubain, Talwin

What dietary teaching does a nurse conduct regarding electrolytes?

∙ Oral electrolyte supplements ∙ Limiting or facilitating oral fluid intake ∙ Parenteral replacement of fluids and/or electrolytes ∙ Prevention

Osmotic Pressure

∙ Pressure that must be applied to prevent osmotic movement across a selectively permeable membrane ∙ Power of solution to draw water ∙ Pressure needed to stop fluid movement across a membrane created by concentration gradients.

Causes of Hypovolemia

◆ Hemorrhage ◆ GI loss ◆ Burns ◆ 3rd space fluid shift ◆ Others

Causes of Dehydration

◆ Inadequate fluid intake ◆ Severe or prolonged isotonic fluid loss ◆ Watery diarrhea ◆ DI ◆ Others

Hypovolemic Hyponatremia

◆ Loss of Na+ and H2O ◆ Happens with: Diuretics, diabetic glycosuria, vomiting, diarrhea, excessive diaphoresis, burns, fever, aldosteron deficiency ◆ Poor skin turgor, dry cracked mucous membranes, weak, rapid pulse, low BP or orthostatic hypotension

Dehydration

◆ Loss of water ◆ Hypertonic ◆ Fluid loss in both ECF and ICF ◆ Causes: inadequate fluid intake, severe or prolonged isotonic fluid loss, watery diarrhea, DI, others

Hypovolemia

◆ Low blood volume ◆ Loss of both fluids and electrolytes ◆ Fluid loss is primarily ECF ◆ Causes: hemorrhage, GI loss, burns, 3rd space fluid shift, others

What should we as nurses do for patients with fluid volume deficit?

◆ Monitor symptoms ◆ Daily weights ◆ Accurate I&Os ◆ Oral rehydration ◆ Maintain IV access ◆ IVF replacement as order: Isotonic then hypotonic. Get pressure up with ISO and then hydrate the cell with HYPO. ◆ Watch for s/sx of cerebral edema when replacing fluids ◆ Monitor serum Na+, urine osmolality, and specific gravity ◆Provide safe environment Dizzy, low BP, seizure precautions, etc. ◆Skin and oral care ◆ Documentation

How is hydrochlorothiazide different from furosemide?

◆ No ototoxicity ◆ Less diuresis (Assess BP, weight, lung sounds instead) ◆ Less loss of electrolytes ◆ Can cause hypercalcemia (Bones, groans, moans, and stones) ◆ Can cause hyperglycemia ◆ Furosemide is used for more severe HTN

PE

❖ Clot in the pulmonary vasculature/pulmonary artery ❖ Thrombus which comes from venous circulation or R. side of heart and lodges in the pulmonary arteries. May also be amniotic fluid (air, fat, bone marrow). ❖ S/S Restlessness Anxiety Tachycardia Tachypnea Also, low grade fever & blood tinged sputum ❖ Nursing Diagnoses ∙ Impaired gas exchange Adequate ventilation, but poor perfusion ∙ Anxiety

What patient eduction would you give regarding systemic glucocorticoids (prednisone, methylprednisolone)?

❖ Daily dosing in the a.m. Because it mimics the release of cortisol in the body which is released in the morning ❖ PO: Administer with meals ❖ Do not stop taking abruptly As they taper the adrenals, by tapering it off they will wake up a little bit each day. If you stop suddenly you could go into cardiac arrest. ❖ Inform all doctors ❖ MedicAlert card/bracelet

DVT

❖ Deep Vein Thrombosis ❖ Can by asymptomatic ❖ DVT prevention ∙ Early ambulation ∙ apply graduated compression stockings as prescribed ∙ Apply intermittent pneumatic compression devices (SCDs) as prescribed ∙ AROM/PROM (active/passive) ∙ No crossing legs ∙ Proper leg positioning with pillows ∙ Encourage 3L/day PO/IV Because we don't want the blood to be thick or dehydrated ∙ Monitor IV lines ∙ Prophylactic anticoagulants: LMWH ∙ Encourage lifestyle changes

Nursing Responsibilities: Thoracentesis

❖ Done bedside, sitting upright, elbows over bed table and feet supported on floor ❖ Emotional support, VS, s/s of resp. distress. ❖ Continue to monitor after procedure ❖ Watch puncture site, watch for crepitus, pulmonary edema, encourage coughing and deep breathing ❖ Observe for signs of hypoxia and pneumothorax

Paradoxical Respiration

❖ Early s/s of respiratory distress. How a nurse can tell a COPD pt. is going downhill. ❖ Diaphragm goes in on inspiration. ❖ Will happen 1-2 hours before a change in the ABGs. ❖ Respiratory failure ❖ Have an SBAR with the HCP ASAP

HIV Disease & HAART Regimen Metabolic Complications

❖ Lipodystrophy Fat redistributed ❖ Endocrine Increase in blood sugar ➠ Diabetes. May need insulin or antidiabetic meds ❖ Bone disease/fractures Five fold increase ❖ Cardiovascular disease High risk for atherosclerosis/hyperlipidemia. Increased triglycerides, high LDL, low HDL. May need to be on a statin. ❖ Interventions Assess risk and treat per guidelines. Change in HAART regimen if possible.

Rhonchi

❖ Low-pitched, continuous gurgling sounds caused by secretions in the large airways. ❖ Heard on inspiration and expiration, but predominantly expiration. ❖ Clear with coughing

Mast Cell

❖ Mediator of Injury ❖ Most important activator of inflammatory response/ ❖ Degranulation Release powerful inflammatory modulators. Histamine, leukotriene, prostaglanding... These modulators... ❖ Vasodilate ➜ hypotension ❖ Increase vessel permeability ❖ Constrict bronchial smooth muscle ❖ Increase secretion of mucous ❖ Itching

Nursing Responsibilities: Bronchoscopy

❖ NPO for 6-12 hours ❖ Administer sedative ❖ Post procedure keep NPO until gag reflex returns ❖ Blood tinged mucous is normal (Frank red is not) ❖ Biopsy: Watch for hemorrhage and pneumothorax ❖ If you see bronchospasm report it immediately!

Nursing Responsibilities: MRI of Chest

❖ No iodine dye ❖ No radiation used ❖ Metal screening ❖ Claustrophobia

What are some side effects and adverse reactions of flurosemide?

・ Fluid volume deficit We never want to over correct to where it becomes a problem. We don't want to go from having too much to not having enough. ・ Hypokalemia When we think potassium, we think heart. ・ Hyponatremia ・ Hypomagnesemia ・ Hypochloremia ・ Metabolic alkalosis Part of what keeps our ph normal is hydrogen ions and this has to do with the swap of potassium and hydrogen ions (More for Block 2) ・ Hypotension Overcorrected fluid intake ・ Increased BUN Blood, urine, nitrogen. It would not be therapeutic if these went up because we wouldn't expect the increased BUN b/c they are promoting the excretion of sodium, water, and chloride and what you're peeing out is diluted and you could wind up losing so much water that the concentration of urea in your blood looks like you have too much. ・ Orthostatic Hypotension This is a potent diuresis and when you lose a lot of fluid you are prone to get that with orthostatic hypotension

When is afterload increased?

・ Hypertension ・ Vasoconstriction

When is preload going to be increased?

・ Hypervolemia ・ Regurgitation of the cardiac valves

Diastolic Heart Failure

・ Inability of ventricle to relax and fill during diastole ・ Decreased filling of ventricles results in decreased SV and CO ・ Most common reason - HTN

Treatment Goals of Heart Failure

・ Maximize CO ・ Reduce symptoms ・ Improve ventricular function ・ Improve quality of life ・ Preserve organ function ・ Improve mortality and morbidity risks *This is how you think through your nursing process without an assessment. Your assessment is your expected findings*

Regulation of Low Blood Pressure

・ Nervous/Cardiovascular/Renal/Endocrine Systems ・ Short Term Mechanisms Sympathetic Nervous System & vascular responses ・ Long Term Mechanisms Renal and hormonal processes

What are the drug interactions of furosemide?

・ Oral antihyperglycemics Decreases effectiveness of antidiabetic drugs because it prevents high blood sugar. ・ Anticoagulants Decreases effectiveness of anticoagulants ・ digoxin (Lanoxin) Increases potential for DIG toxicity due to hyperkalemia

Compensatory Mechanisms of Heart Failure

・ Our body tries to "help" ・ SNS activation: 1st, not effective, ultimately harmful ・ Neurohormonal Response Kidney: Renin Brain: ADH ・ Dilation of heart tissues Helps for a little bit but eventually it hurts b/c it makes the heart weaker ・ Hypertrophy

Ejection Fraction

・ Percentage of end-diastolic blood volume that is ejected during systole ・ Normal is 55-70% ・ Heart failure if < 40%

Complications of Heart Failure

・ Pleural effusion ・ Dysrhythmias ・ Hepatomegaly ・ Renal Failure ・ Ventricular Thrombus

Nursing Implications/Education of HTN Drugs

・Conduct a thorough head-to-toe assessment before beginning therapy ・Assess for contraindications to specific antihypertensives ・Assess for conditions that require cautious use of these drugs ・Monitor BP during therapy; instruct client to keep a journal of regular BP checks AM & PM for 1 week or until normotensive with new meds and med adjustments. AM & PM for a week q3months. ・Educate pt about the importance of not missing a dose and taking meds exactly as prescribed ・Clients should never double up on doses if a dose is missed; check with HCP on what to do about a missed dose ・Drugs should not be stopped abruptly b/c this may cause a rebound hypertensive crisis and perhaps lead to stroke ・Oral forms should be given with meals so that absorption is more gradual and effective ・Medication is only part of therapy. Encourage lifestyle modifications. ・Change positions slowly to avoid syncope from orthostatic hypotension ・Men taking these drugs may not be aware that impotence is an expected effect. This may influence compliance. ・Hot tubs, shower, or baths; hot weather; prolonged sitting or standing; physical exercise; and alcohol ingestion may aggravate low BP, leading to fainting and injury. Client should sit or lie down until symptoms subside. ・Monitor for adverse effects such as: dizziness, orthostatic hypotension, fatigue, and toxic effects ・Clients should report unusual SOB, difficulty breathing, swelling of the feet, ankles, face, or around the eyes; weigh gain or loss, chest pain, palpitations, or excessive fatigue ・Clients should contact HCP immediately if they are experiencing serious adverse effects, or they believe that their medication should be changed. ・Monitor for therapeutic effects: BP should be maintained per HCP directions, once antihypertensive therapy is started, clients should return for follow-up adjustments of meds in monthly intervals until BP is reached. Then 3-6 month follow-ups.

Magnesium and the Kidneys

・Conserve magnesium in times of need ・Excretes when there is excessive amounts

Metabolic Alkalosis Interventions

・Correct underlying problem ・Administer NaCl-rich fluids ・Replace potassium ・Dialysis in renal impaired patients

What are some calcium food sources?

・Dairy (milk, cheese, yogurt, ice cream) ・Dark leafy greens(broccolli, spinach, collard greens) ・Salmon

Hypermagnesemia and S/Sx

・Decreased muscle and nerve activity ・Hypotension, bradycardia, and respiratory paralysis ・Hypoactive deep tendon reflexes ・Facial paresthesia ・N/V ・Drowsy and lethargic---altered LOC (coma) ・Weak pulse--heart blocks ・Vasodilation = hypotension

What do cholinergics that stimulate muscarinic receptors do?

・Decreases HR ・Bronchoconstriction ・Increased bronchial secretions ・Vasodilation (decrease BP) ・Miosis (pupil constriction) ・Increase GI motility ・Increase GI secretions ・Increase bladder contractions ・Relaxation of bladder sphincter ・Stimulates urination ・Increased salivation ・Increased perspiration ・Increased tears ・SLUD (salivation, lacrimation, urination, defecation)

Clinical Manifestations of Metabolic Acidosis

・Deep, rapid respirations (Kussmaul respirations) ・CNS depression ・Decreased BP ・Dysrhythmias ・Warm, flushed skin ・N/V/D; abdominal pain

What do anticholinergics do for the eye?

・Dilate the pupil ・Cycloplegia ・Paralyzes accommodation

What is Bethanechol? What are it's therapeutic effects/uses?

・Direct acting cholinergic agonist Treatment of urinary retention ・Non-obstructive post-op and postpartum urinary retention ・Neurogenic atony of the bladder with retention

What are some nursing interventions for Atorvastatin (Lipitor)?

・Do not take if pregnant ・Monitor lipid panel ・Monitor LFTs ・Monitor urine and for muscle tenderness (rhabdo) ・Monitor for GI upset ・Administer with food ・Administer after dinner Rest and digest. The liver is most active at night. ・Teaching Continue with lifestyle modifications, no Gf juice, report any muscle tenderness/weakness immediately

What are some clinical manifestation of HIV?

・Dyspnea ・Cough ・Lymphadenopathy ・Fever ・Weight Loss ・GI symptoms ・Neuro symptoms ・Rash ・Night sweats ・Flu-like symptoms