Foundations Exam #3
Peak Flow Meter
A peak flow meter is a portable, inexpensive, hand-held device used to measure how air flows from your lungs in one fast blast.
Pneumonia Assessment
Assessment •Auscultate lungs •Observe sputum color, consistency, & amount •Observe for cough •Obtain temperature •Observe for increased RR & breathing difficulty Diagnostic tests •Blood tests •Chest x-ray •+/- sputum culture •Pulse oximetry
Pneumonia Assessment
Assessment •Auscultate lungs •Observe sputum color, consistency, & amount •Observe for cough •Obtain temperature •Observe for increased RR & breathing difficulty Diagnostic tests •Blood tests •Chest x-ray •+/- sputum culture •Pulse oximetry
Respirations
•External •. Alveolar-capillary gas exchange •. Conditions that slow diffusion include: Pleural effusion (fluid around the lungs) Pneumothorax (lung collapse) Asthma (bronchospasms). •Hypoxemia •Internal •. Capillary-tissue gas exchange •. Requires adequate external respirations & adequate peripheral circulation •. Hypoxia
Bowel Incontinence
•External collection devices •. Advantages: prevent skin breakdown, minimize odor, track output accurately, and enhance patient comfort. •. Limitations: Not for ambulatory, agitated, or active clients - dislodged, causing skin breakdown. •Internal drainage devices •. Advantages: Protect perianal skin, protect caregivers from potentially infectious stool, decrease urinary tract infections. •. Disadvantages and Precautions: FDA approved: only 29 consecutive days, and not for pediatric patients. Other contraindications include: Severe hemorrhoids Recent bowel, rectal, or anal surgery or injury Rectal or anal tumors Stricture or stenosis •Bowel training program
Functions of the Kidney *
•Filter wastes, toxins, excess ions & H2O •Help regulate blood volume, BP, electrolytes, acid-base •Secondary functions erythropoietin, secrete renin & activate vitamin D3
Analysis/Nursing Diagnosis
•Fluid balance •Deficient Fluid Volume •Excess Fluid Volume •Risk for Deficient Fluid Volume •Risk for Imbalanced Fluid Volume •Electrolyte/acid-base imbalances •Impaired Gas Exchange •Risk for Electrolyte Imbalance
Managing Constipation
•Increase intake of high-fiber foods. •Increase fluid intake. •Increase activity/exercise. •Provide privacy. •Help client to a position that facilitates defecation. •Allow uninterrupted time. •Offer laxatives when lifestyle changes are ineffective.
Urinary Elimination: Life Span Considerations
•Infants •Children •Toilet training requires •Mature neuromuscular system •Adequate communication skills •Problems include •Enuresis (urinating unintentional) •Nocturnal enuresis ( bed wetting at night) •Older adults •Kidney function decreases •Urgency and frequency common •Loss of bladder elasticity and muscle tone leads to •Nocturia •Incomplete emptying
Pneumonia Plan of Care: Impaired Gas Exchange
•Inflammation of lung parenchyma •Community-acquired pneumonia(CAP) •Health Care-associated pneumonia (HCaP) •Ventilator-Associated pneumonia (VAP) •Characteristics/symptoms •. Cough •. Malaise •. Pleural pain from coughing •. Discolored sputum •. Fever & chills •. Dyspnea Elevated WBC
Pneumonia Plan of Care: Impaired Gas Exchange
•Inflammation of lung parenchyma •Community-acquired pneumonia(CAP) •Health Care-associated pneumonia (HCaP) •Ventilator-Associated pneumonia (VAP) •Characteristics/symptoms •. Cough •. Malaise •. Pleural pain from coughing •. Discolored sputum •. Fever & chills •. Dyspnea •. Elevated WBC
Nursing Interventions
•It is better to prevent imbalances than to treat them •Dietary teaching •To promote fluid and electrolyte balance, most people need to limit their sodium intake and increase their dietary potassium and calcium •Instruct clients to read food labels, particularly when trying to limit sodium intake •Oral electrolyte supplements •Many clients are unable to correct electrolyte disturbances with dietary changes alone •Encourage clients to take potassium supplements with juice to mask the taste •Caution clients that salt substitutes contain potassium; if the client has been advised to use salt substitutes, review the need for potassium supplements •Limiting or facilitating oral fluid intake •Parenteral replacement of fluids and/or electrolytes •Whenever possible, clients should take fluids by mouth •When fluid loss is severe or the client cannot tolerate oral or tube feedings, fluid volume is replaced parenterally •Intravenous (IV) therapy is the administration of fluids, electrolytes, medications, or nutrients by the venous route
Establishing a Bowel Training Program
•Plan program with the client. •Increase fiber in diet gradually. •Increase fluid intake to eight glasses of water per day. •Establish a designated time for defecation. •Privacy should be provided for the client. •The treatment plan should be staged. •The treatment may include a stool softener. •The plan should be modified based on client results.
Optimal Oxygenation: Non invasive Interventions
•Positioning: Maximum lung excursion •Mobilizing secretions •. Deep breathing and coughing •. Hydration •. Chest physiotherapy •Therapeutic self •Incentive spirometry •Intermittent positive pressure breathing •Acapella vibratory PEP therapy device
Cardiovascular Nursing Planning and Interventions 2
•Prevent clot formation •A thrombus is a stationary clot adhering to the wall of a vessel •An embolus is a clot that travels in the bloodstream •Clots can form after injury to vessels, or in response to hypercoagulability •All the strategies to promote venous return also help prevent clot formation •Administer medication(s) per prescribed orders •CV medications are used to prevent atherosclerosis and to enhance cardiac output, thus providing increased blood flow and oxygenation to organs and tissues •CV medications include vasodilators, beta-adrenergic blocking agents, calcium channel blockers, diuretics, positive inotropes, and/or statins (lipid-lowering medications) •Vasodilators cause vessel dilation, which eases the work of the heart; vasodilating agents include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and nitrates •Drugs that dilate arterioles decrease the resistance against which the heart pumps (afterload) •Drugs that dilate veins (afterload) will decrease venous return to the heart (preload) •Vasodilators can cause hypotension, especially when the person rises from a sitting or lying position •Clients at high risk for thrombus formation may be prescribed anticoagulant medications to help prevent abnormal clot formation
Managing Urinary Incontinence
•Prevent skin breakdown. • Encourage/teach lifestyle modifications. • Implement bladder training. • Encourage client to perform Kegel exercises. • Use anti-incontinence devices as needed. •Strategies to promote independent urination •. Pharmacological interventions •. Surgical interventions •Parental teaching for enuresis
Nursing Interventions
•Prevention •Remove catheter ASAP •Teaching •. 8 to 10 8-ounce glasses fluids •. Urinate when feel urge •. Wipe front to back •. Wear cotton underwear •. Urinate after intercourse •. Avoid spermicidal - if history of UTI •. Avoid bubble baths •. Report symptoms promptly
Fluid Intake
•Primarily through drinking fluids •National Academies of Science, Engineering, and Medicine (2004, updated 2018) recommendations •2,700 mL/day women; 3,500 mL/day men •We should obtain 80% of our intake from drinking fluids and the remaining 20% from food and cellular metabolism of foods •Prolonged exercise and heat exposure increase the requirements •Reduced perfusion to the extremities may indicate a need to increase fluid intake •Fluid intake regulated by thirst - changes in plasma osmolality signal the thirst center in the hypothalamus, which leads to the urge to drink
Promoting Regular Defecation
•Privacy •Correct position •. Seated upright •Timing •. Often occurs after meals •. Some clients may need assistance •Fluid intake •Proper diet •. Fresh fruits, vegetables, whole grains, fiber •Exercise •. Three to five times a week • Range of motion for clients on bedrest
bowel elimination
•Process •. Defecation: Process of elimination of waste •. Valsalva •. Feces: Semisolid mass of fiber, undigested food, inorganic material •Structures •. Upper gastrointestinal tract •. Small intestine •. Large intestine •. Rectum and anus •. Bowel pattern
Cardiovascular Nursing Planning and Interventions 1
•Promote circulation (venous and arterial) •Promote Peripheral Arterial Circulation •Peripheral artery disease, usually found in the legs and feet, occurs when tissues do not receive enough blood flow to keep up with the demand for oxygen; it is caused by the buildup of fatty deposits and plaque within the arteries (atherosclerosis) •Symptoms include: •Pain with exercise: when arteries that supply blood to the legs are narrowed, leg pain occurs, especially with walking; this is called intermittent claudication •Pain at rest: as the blood flow becomes more restricted, pain occurs at rest, as well as numbness or a cold feeling to the leg or foot, especially on one side; other symptoms are weak pulse, change in color, hair loss or shiny skin on the legs, sores that won't heal, and erectile dysfunction in men
Promoting Normal Urination
•Provide privacy: Curtains, doors. •Assist with positioning •. Men à standing, women à seated upright. •Facilitate toileting routines • Identify the client's pattern. •Promote adequate fluids and nutrition. •Assist with hygiene.
Oxygen Therapy
•Provides oxygen concentrations greater than room air (RA) 21% •Oxygen is a medication •Prescription of dosage and route
Mechanical Ventilation
•Provides support until underlying pathophysiology process corrected •Improves ventilation & respiration •Decreases work of breathing
Common Diagnostic Tests
•Radiographic views •. Flat plate of the abdomen •Direct visualization •. Colonoscopy •. Sigmoidoscopy •Laboratory studies •. Stool for occult blood •Nursing responsibilities/patient preparation for tests §Guaac test §KUB test
Ventilation
•Rate and depth •. Hyperventilation - Hypocarbia (hypocapnia) •. Hypoventilation - hypercarbia (hypercapnia) •Lung compliance - ease of lung inflation •. Edema, loss of surfactant or scar tissue •Lung elasticity - elastic recoil •. Overstretched •Airway resistance - airflow within airways •. Loss of diameter by secretions or bronchospasm
Pulmonary Function: Older Adult
•Reduced lung expansion & less alveolar inflation •. Costal cartilage calcify •. Lungs have less recoil ability •. Alveoli lose elasticity •Difficulty expelling mucous or foreign materials •Diminished ability ventilate with increased demand •. Diaphragm strength decrease •. Vital capacity reduced •Declining immune response •Gastroesophageal reflux more common •Chemoreceptors response slows
Impaired Urinary Elimination
•Sexually active women •Use spermicidal contraceptive gel •Older women •Pregnant women •Enlarged prostate •Presence of indwelling catheter •Kidney stones •Diabetes mellitus •Immunocompromised •History of UTI Symptoms: •Bladder spasms •Burning with urination •Chills •Dysuria •Edema •Fever •Flank pain - kidney infection •Foul-smelling urine •Hematuria •Urinary frequency More likely to go along with cystitis or bladder infection = dysuria, frequency , urgency Kidney - chills, fever, flank pain= pyelonephritis
Nonrebreather Mask
•Similar partial rebreather •One-way valve - prevents exhale air from entering bag •One-way valve - sides of mask •Inflate at one-third to one-half •Minimal flow rate 10L/min •Provides 90% O2
Partial Rebreather Mask
•Simple mask plus attached reservoir bag •Keep reservoir bag 1/3 to ½ full on inspiration •Flow rate 8 to 10 L/min •Provides 50% to 75% O2 •Advantage - can deliver high levels of O2
If Mrs H went into cardiac arrest how long do you have before brain damage can occur?
A.1 to 3 minutes B.4 to 6 minutes C.7 to 10 minutes D.11 to 15 minutes A
Which Diagnostic test is used to gallstones or fecal impaction?
A.A&P abdomen X ray
The oxygen saturation of a client admitted with pneumonia decreases despite receiving 2 liters of oxygen via nasal cannula. The on-call MD orders to increase the oxygen flow rate from 2L/min to 4L/min. Based on this order, what is the priority action for the nurse to complete?
A.Add humidification to oxygen
What lab is used to evaluate cardiovascular health?
A.C-reactive protein (CRP) B.Sodium C.Blood glucose D.Cholesterol E.Lipid panel F.Creatinine ADE
Mrs H is brought to the emergency department due to chest pain. What cardiovascular abnormality is of greatest concern?
A.Cardiac ischemia
Which diagnostic test is most important to diagnose pneumonia?
A.Chest X-ray
Which of the following is a diagnostic test was used to diagnose Mrs. H's chronic obstructive pulmonary disease?
A.Chest X-ray
Which of the following is a change in Mrs. H's cardiac function that is related to her age?
A.Decrease myocardial strength
A nurse is caring for a 76 year old man with benign prostatic hyperplasia (BPH). The client has not voided in seven hours and his bladder is distended. Which of the following is the priority response by the nurse to this situation?
A.Use bladder scan to determine urine volume
Possible Nursing Diagnoses: Cardiac Clients
Actual •Activity intolerance •Acute pain •Anxiety •Chronic pain •Decreased CO •Deficient knowledge •Excess fluid volume •Fear •Ineffective peripheral tissue perfusion •Impaired skin integrity •Impaired tissue integrity Potential •Risk for activity intolerance •Risk for adverse reaction to iodinated contrast media •Risk for bleeding •Risk for decreased CO •Risk for decreased cardiac tissue perfusion •Risk for electrolyte imbalance •Risk for imbalance fluid volume •Risk for ineffective cerebral tissue perfusion Potential •Risk for falls •Risk for infection •Risk for shock •Risk for impaired skin integrity •Risk for surgical site infection •Risk for unstable BP •Risk for vascular trauma •Risk for venous thromboembolism
Urinary Retention Symptoms
Acute •Urinary hesitancy, dribbling, or weak urine stream •Urgent need to urinate •Pain, discomfort, bloating in lower abdomen Chronic •Urinary frequency •Trouble beginning a urine stream •Weak or an interrupted stream •Urgency, but with little stream •Feels urination urge, even after voiding •Mild, constant discomfort in lower abdomen
Capnography
Capnography is the monitoring of the concentration or partial pressure of carbon dioxide in the respiratory gases. Its main development has been as a monitoring tool for use during anesthesia and intensive care.
Collaboration
Evaluation •Midstream, clean-catch urine specimen—for culture •Dipstick urine •leukocytes, blood, estrace, and nitrates; •negative dipstick does not rule out UTI. Treatment •Antibiotic treatment •Cystitis (symptomatic) oral •Pyelonephritis IV antibiotics •Phenazopyridine •Liberal fluid intake
Healthy People 2020/2030 Categories - think "SHEEN"
Key Domain Subsets Notes Social and Community Context 1.Civic Participation 2.Discrimination 3.Incarceration 4.Social Cohesion Health Care - Access and Quality 1.Access to Health Care 2.Access to Primary Care 3.Health Literacy Economic Stability 1.Employment 2.Food Insecurity 3.Housing Instability 4.Poverty Education - Access and Quality 1.Early Childhood Education and Development 2.Enrollment in Higher Education 3.High School Graduation 4.Language and Literacy Neighborhood and Built Environment 1.Access to Foods that Support Healthy Eating Patterns 2.Crime and Violence 3.Environmental Conditions 4.Quality of Housing
Intake and Output (I&O)
Measuring •. Record all fluids •. Fluid intake •. Fluid output •. Ensure accuracy •. Total I&O at end of shift •. Practice asepsis Interpreting •Quantity of fluids client drinks •Ability of hear to circulate blood •Kidney function •Amount fluid excreted
Optimal Oxygenation: Health Promotion/Prevention
Out-patient •Influenza vaccination •Pneumococcal vaccine •Smoking cessation In-patient •Aspiration precautions •Prevent healthcare-associated pneumonia
MAP Equation
SBP + ( 2x DBP) / 3
acapella device and incentive spirometer
airway clearance device is used to help remove mucus from the airways. The device may be used after taking a short-acting inhaled bronchodilator medication (as prescribed by your doctor). The medication helps open the airways to make the technique more effective.
Acid-Base Balance
•Acid: compound that contains hydrogen (H+) ions •Base: compound that accepts hydrogen ions •Amounts in solution reflected by pH •Acceptable range for serum pH: 7.35 to 7.45 •Measured by arterial blood gases (ABGs)
Acid-Base Imbalances
•Acidosis •Serum pH below 7.35 •Respiratory cause: Retention of CO2 •Metabolic cause: Loss of bicarbonate •Alkalosis •Serum pH above 7.45 •Respiratory cause: Blowing off CO2 •Metabolic cause: Increase in bicarbonate
Nursing Interventions (continued)
•Administer prescribed IV fluids based on the client's condition •Osmolality (or tonicity) refers to the concentration of solutes creating pressure in body fluid •Isotonic •An isotonic solution is of the same osmolality as blood; thus, no osmosis (movement of water) will occur •Remain inside the blood vessels •As a result, they are useful for clients with hypotension or hypovolemia •Hypotonic •A hypotonic solution is of lower osmolality than blood •When a hypotonic solution is infused, water moves by osmosis from the vascular system into the cells •These solutions pull body water from the intravascular compartment into the interstitial fluid compartment •Hypotonic fluid is used to correct cellular dehydration •Hypertonic •When a hypertonic solution is given to a client, water moves by osmosis from the cells into the ECF •These solutions pull fluids and electrolytes from the intracellular and interstitial compartments into the intravascular compartment
Nonmodifiable Risk Factors
•Age •Gender •Note: As with men, women's most common heart attack symptom is chest pain or discomfort •But women are somewhat more likely than men to experience some other symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain •Family history •Ethnic background (some will report it as "race"). Dr. Cox's soapbox: •The medical literature on HTN is rife with genetic explanations of the disease's higher prevalence among US blacks than whites, although HTN prevalence is higher in Spaniards, Finns, and Germans than in US blacks •If either are used to frame a client scenario then it should be in relation to health disparities and the role of racism and bias in health care •Race should not be used as a tool for classification •Need to see a client as an individual rather than as a stereotyped member of a group ... it's supposed to be client/patient-centered care
High-Flow Nasal Cannula (HFNC)
•Air-oxygen blender •Active humidifier •Deliver heated & humidified gas up to 60L/min •Reduce anatomical dead space •Positive end-expiratory pressure (PEEP) •Constant FIO2 & humidification •Soft flexible prongs
Pulmonary System
•Airways and lungs •Ventilation •. Movement of air into/out of the lungs •Respiration •. Exchange of oxygen/carbon dioxide •. Alveolar capillary/capillary cell membrane •Respiratory centers •. Chemoreceptors •. Lung receptors
Hormonal Regulation
•Antidiuretic hormone (ADH) •Renin-angiotensin system •Aldosterone •Thyroid hormone •Atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and C-type natriuretic peptide (CNP)
Collaborative/Provider Interventions
•Antipyretics •Expectorants •Anti-infective agents (oral or intravenous) •Chest physiotherapy •Oxygen therapy •Respiratory inhalations •. Nebulizers •. Short acting beta 2 agonist - Albuterol (Ventalin) •. Inhaled steroids - Fluticasone (Flovent)
Vascular Access
•Approaches •Peripheral •Central •Intraosseous •Subcutaneous infusions Peripheral vascular access devices: Intravenous therapy requires placement of a vascular access device. You will choose the type of device based on the client's condition, type of fluid that will be infused, and the anticipated length of treatment. Types of devices •Over-the-needle catheters are also called an angiocatheters (angiocaths). A polyurethane or Teflon catheter is threaded over a metal stylet (needle). You pierce the skin and vein with the needle, advance the catheter into the vein, and remove (or retract) the metal needle. In most cases, the plastic catheter is less than 7.5 cm (3 in.) in length. This type of access device is ideal for brief therapy. You cannot give highly irritating or hyperosmolar solutions through this type of catheter because it may cause severe damage to the vein. •Inside-the-needle catheters are similar to over-the-needle catheters; however, the polyurethane or Teflon catheter lies inside the metal needle. After you advance the catheter into the vein, you withdraw the needle. •Butterfly needles are also called scalp vein needles or wing-tipped catheters. It is a short, beveled metal needle with flexible plastic flaps attached to the shaft. You can pinch the flaps and hold them tightly together to facilitate insertion. After insertion, flatten them out and tape them against the skin to prevent dislodgement during the infusion process. INS (2016) recommend using these needles for single-dose medications and drawing blood. Because the inflexible metal needle remains in the vein, a butterfly needle is more likely than a plastic catheter to infiltrate (damage the vein and allow fluid to leak into the interstitial spaces). •Midline peripheral catheters (midline VADs) are flexible IV catheters, typically inserted into the antecubital fossa and then advanced into the larger vessels of the upper arm for greater hemodilution. It can be used for a longer period of time than a shorter, over-the-needle catheter—typically 1 to 4 weeks. A midline catheter is still considered a peripheral line, so you cannot administer highly osmolar and irritating solutions through it. •Peripheral intravenous locks (e.g., saline lock, prn adapter, heparin lock) establish a venous route for clients whose condition may change rapidly or who may require intermittent infusion therapy. A peripheral IV catheter or butterfly wing-tipped catheter is inserted into a vein, and the hub is capped with a lock port. Patency of the lock is maintained by injecting normal saline or a dilute heparin. Central venous access devices (CVADs) are intravenous lines inserted into a major vein. Typically, the subclavian or internal jugular vein is used. Types of devices •Peripherally inserted central catheters (PICC lines) are long, soft, flexible catheters inserted at the antecubital fossa through the basilic or cephalic vein of the arm. The catheter is then advanced into the superior vena cava. A qualified provider performs the insertion. PICC lines are most commonly used for prolonged IV antibiotic therapy, parenteral nutrition, and chemotherapy. •Nontunneled central venous catheters are inserted by a qualified provider through the skin into the jugular, subclavian, and, occasionally, femoral veins. They are sutured in place. These are often referred to as single-, double-, triple-, or quadruple-lumen catheters, depending on the number of ports in the line. •Tunneled central venous catheters are inserted by a surgeon through a 7.5- to 15-cm (3- to 6-in.) subcutaneous tunnel in the chest wall and then into the jugular or subclavian vein. One end of the catheter comes out through the skin and is sutured in place, with the sutures removed when fibrosis has developed around the catheter, or it can be secured with an IV-securing device. CVCs are tunneled through the skin rather than through a vein and, therefore, have a lower the risk of infection. •Implanted ports are devices made of a radiopaque silicone catheter and a plastic or stainless steel injection port with a self-sealing silicone-rubber septum. The catheter enters the internal jugular vein in the neck, and it may be tunneled or untunneled to a completely implanted subcutaneous reservoir (port) in the upper chest. Intraosseous (IO) devices are designed for immediate access (within seconds) and short-term use (less than 24 hours). IO access devices are used to administer fluids when a peripheral catheter cannot be inserted or when a central line insertion is not advisable—especially in emergency situations. IOs are placed into the matrix of a bone. The venous sinusoids in the matrix can quickly absorb fluids to send to the central circulation. The most common access site is the proximal tibia in both children and adults. The sternum and the head of the humerus can also be used in adults. Subcutaneous infusions are an alternate method to administer medications, continuous fluids, or nutrition. They have been widely used in home-based therapy with palliative care clients. Advantages of subcutaneous infusions are low cost, ease of use, and low infection and complication rates
5 A's Treating Tobacco Dependence
•Ask •. About tobacco use and document tobacco use status •Advise •. To quit. Use a clear, strong, personalized approach •Assess •. Willingness to make a quit attempt at this time •Assist •. In quit attempt, if client willing refer for counseling & medication •. If not willing provide interventions to increase future quit attempts •Arrange •. Begin follow-up beginning first week
Cardiovascular Assessment: Physical Exam
•Assess fatigue •Subjective experience •Client feels tired and lacks endurance •Fatigue is a common symptom of various oxygenation problems, including anemia and HF •Ask client to rate his/her or her fatigue on a 0 to 10 scale, as you would for pain •Assess dyspnea •Any signs of hypoxia? This can be associated with CV diseases and anemia as well as with respiratory problems •As with pain, dyspnea provokes anxiety •Assess peripheral circulation •Palpate the peripheral pulses, assess skin color and temperature, and note the distribution of hair on the extremities •Weak pulses, cool feet, lack of hair, and shiny skin on lower legs and feet usually accompany peripheral vascular disease •Look for skin ulcers (which differ from pressure ulcers) that often accompany severe venous or arterial disease •Check for edema of the feet and ankles; this is one symptom of HF
Cardiovascular Assessment - DVT
•Assess for a clot in the veins (deep vein thrombosis/DVT), deep under the muscles of the leg •This condition is serious because blood clots can loosen and lodge in the lungs •Signs of DVT may be leg pain, warmth, redness, and swelling of the leg, but there may be no symptoms •Homan's sign (pulling toes forward) and Pratt's sign (squeezing calf to trigger pain) are not reliable in diagnosing DVT; however, these signs may help confirm DVT when also considering the clinical signs of DVT •Treatment includes medications and use of compression stockings; measures to prevent DVT include avoid sitting still, not smoking, exercising, and managing weight
Urinary Elimination: Pathological Problems
•Bladder/kidney infections •Kidney stones - aka renal calculi •Hypertrophy of the prostate (male) •. Benign prostatic hyperplasia •Mobility problems •Cardiovascular & metabolic disorders •. Decreased blood flow through glomeruli •Neurological conditions •Communication problems •Alteration in cognition
Analysis/Nursing Diagnosis
•Bowel Incontinence •Constipation •Risk for Constipation •Chronic functional constipation •Risk for chronic functional constipation •Diarrhea •Dysfunctional gastrointestinal motility •Risk for dysfunctional gastrointestinal motility •Toileting Self-Care
Acid-Base Regulation
•Buffer systems prevent wide swings in pH •Chemical buffers •The first line of defense to restore normal pH •The main chemical buffers are bicarbonate, phosphate, and protein •Respiratory mechanisms •The lungs are the second line of defense to restore normal pH •They control the body's carbonic acid supply via carbon dioxide retention or removal •When the serum pH is too acidic (pH is low), the lungs remove carbon dioxide through rapid, deep breathing •If the serum pH is too alkaline (pH is high), the lungs try to conserve carbon dioxide through shallow respirations •Renal mechanisms •The last line of defense to restore normal pH are the kidneys, which regulate the concentration of plasma bicarbonate •They can neutralize more acid or base than either the chemical buffers or the respiratory system •If the serum pH is too acidic, the kidneys conserve additional bicarbonate to neutralize the acid •If the serum pH is too alkaline, the kidneys excrete additional bicarbonate to lower the amount of base and thereby decrease the pH •Although the renal system is very effective at altering pH, it is slow; it may take up to 3 days to return the pH to normal limits; this process is known as compensation (e.g., to regain acid-base balance, the lungs may respond to a metabolic disorder and the kidneys may respond to a respiratory disorder)
Factors That Influence Cardiac Function (continued)
•CV abnormalities •Coronary artery disease (CAD) •Condition in which plaque builds up inside the coronary arteries •Plaque narrows the arteries, reducing blood flow to the heart muscle and making it more likely that clots will form and block the arteries •Dysrhythmias (alterations in heart rate or rhythm) •Can lower cardiac output, decrease tissue oxygenation, and increase the risk of stroke •Heart valve abnormalities •They create turbulent flow, leading to a decrease in cardiac output and compromised tissue oxygenation •Often there is an audible murmur •Valves most commonly affected are the mitral and aortic valves
Factors That Influence Cardiac Function (continued 3
•CV abnormalities interfere with the flow of oxygenated blood to organs and tissues and continue to be the number one cause of death for adults in the US •Heart failure •Heart becomes an inefficient pump and is unable to meet the body's demands •Blood is oxygenated when it passes through the lungs, but it is not well circulated to the organs and tissues •Impaired circulation leads to systemic and pulmonary edema, which further impairs gas exchange •Left-sided heart failure occurs when the left ventricle does not pump sufficient amounts of blood to body organs and tissues; fluid may back up in the lungs, causing shortness of breath, tachypnea, and/or rales (crackles) •Right-sided heart failure occurs when the right ventricle does not pump sufficient amounts of blood to the lungs for oxygenation, and blood backs up into the peripheral veins; when the right side loses pumping power, blood backs up in the body's veins; this usually causes swelling or congestion in the legs, ankles, and swelling within the abdomen such as the GI tract and liver (causing ascites); clients will also have left-sided heart failure symptoms •Because the left and right ventricles are part of one circuit, failure of one side of the heart eventually leads to failure of the other side •Both left-sided and right-sided heart failure reduce the amount of oxygenated blood available to organs and tissues, resulting in fatigue and organ dysfunction •Excess Fluid Volume is an appropriate nursing diagnosis for someone demonstrating increased fluid retention •Heart failure causes blood to back up into the lungs and can result in pulmonary edema; therefore, clear breath sounds with no shortness of breath would be an effective outcome
Factors That Influence Cardiac Function (continued)
•Environment •Stress •The stress response stimulates release of catecholamines from the SNS •This results in increased heart rate and contractility, vasoconstriction, and increased tendency of blood to clot •In other words, when the body is under stress, it releases a chemical that increases the heart rate and the tendency of the blood to clot •Allergic reactions and air quality - inflammatory substances released during an allergic response (e.g., histamine, protease) cause can cause CV events (e.g., blood vessels dilate in areas affected, which increases blood flow to the areas; local tissues are damaged by protease; capillaries become more permeable, resulting in fluid leak into tissues; and/or smooth muscle cells contract) •Altitude - oxygen pressure falls proportionally with increased altitude; hence, people who live at high altitudes undergo physiological changes that facilitate oxygenation •Heat and cold •Heat generally causes vasodilation, which increases cardiac output and oxygenation •Heat also increases metabolism •Cold causes vasoconstriction and slows the heart rate; prolonged exposure to cold causes frostbite, loss of hypothalamic temperature regulation, and death
Factors That Influence Cardiac Function
•CV function is influenced by developmental stage, environment, lifestyle, substance abuse, medications, and pathophysiological conditions •Developmental Stage •Infants - transition to life outside the uterus; may be born with a congenital heart defect •Preschool/school-age •Have body systems mature enough to adapt to moderate stress and change, including the heart and circulatory systems •However, children as young as school age sometimes begin habits that can have long-term adverse effects on the CV system (e.g., a diet high in fats and sugars contributes to hyperlipidemia and the beginning of plaque lining the walls of blood vessels and processed foods contain a great deal of salt and fat, which can contribute to high BP and high cholesterol) •Adolescents •Developmentally at little risk for heart or circulatory disorders, although some athletes can be at risk for collapse and sudden cardiac dysrhythmia that is familial/hereditary •Some adolescents adopt behaviors and habits that can create risk throughout life •87% of the adults who use tobacco were regular smokers by their 18th birthdays •The overall incidence of childhood obesity has risen to epidemic levels in the US •Developmental Stage •Young and middle adults •Sedentary lifestyle, lack of aerobic exercise, and tobacco use also contribute to CV disorders in this group •Crack cocaine and methamphetamine abuse can lead to sudden cardiac failure •Family history of CV disease is yet another risk factor for this age group •Older adults - cardiac efficiency gradually declines •Thicker and more rigid valves •Decreased myocardial strength •Lower exercise tolerance; need more rest after exercise •Are more prone to orthostatic/postural hypotension •Occurs when the BP drops when the client goes from lying down to sitting up, or from sitting to standing •Inactivates the baroreceptors involved with vasoconstriction and dilation; hence, the client is less able to regulate blood pressure (BP) •When the BP drops, less blood goes to organs and muscles; this can make the client more likely to fall; dizziness and light-headedness occur •
Factors That Influence Cardiac Function (continued 4
•Cardiomyopathy •This is a heart muscle disorder that results in heart enlargement and impaired cardiac contractility •Cardiac ischemia •Oxygen requirements of the heart are unmet •Prolonged ischemia leads to myocardial infarction (MI) as parts of the heart necrose (die) from inadequate oxygen •Hypertension (HTN) is major risk factor for atherosclerotic cardiovascular disease, heart failure (HF), stroke, and kidney failure and is a common and manageable chronic condition •Risk factors include age, gender, race, and socioeconomic status •Considered a "silent" disease because it rarely produces symptoms until it's extreme •Clinical manifestations •Evident only after long-term increased BP has resulted in target organ damage (TOD) •Symptoms of chronic uncontrolled HTN are headaches, chest pain, vision changes, shortness of breath, renal dysfunction, dizziness, fatigue, or nosebleeds •75% are using antihypertensive medication
Chest Tubes
•Chest thoracotomy tube •Three chamber water-seal system
Factors Impacting Oximetry Accuracy
•Client movement •Ear probe, nasal sensor •Acrylic nails/nail polish? •Dirt & skin oils •Poor perfusion •. Position, cool extremities & disease process •Lighting •Anemia, carbon dioxide •Equipment function •Rely on clinical judgement/assessment
Cardiovascular system
•Coronary arteries •The heart has its own blood supply via the coronary arteries •The coronary arteries are the only arteries in the body that fill during diastole
Patient Teaching
•Crede's maneuver.- pressing the bladder to get urine to come out •Pelvic floor muscle exercises •Intermittent self-catheterization •Contact healthcare professional if: •. Complete inability to urinate. •. Fever, vomiting, pain, chills. •. Blood in the urine.
Fluid Imbalances
•Deficit fluid volume •Hypovolemia occurs when there is a proportional loss of fluid and electrolytes from the ECF •Dehydration describes a state of negative fluid balance in which there is a loss of water from the intracellular, extracellular, or intravascular spaces •Weight loss of a sudden 5% loss of body weight is considered clinically significant; when loss approaches 8%, fluid loss is severe; a sudden loss of 15% of body weight due to fluid loss is usually fatal •Causes •Insufficient fluid intake •Excessive fluid loss (e.g., bleeding, vomiting, diarrhea) Fluid shifts (e.g., intravascular fluid may leak into body tissues, burns)
Transtracheal Oxygen Therapy (TTOT)
•Delivers directly into trachea •Small plastic catheter •Cannot humidify, rarely used
Factors That Influence Cardiac Function: DevelopmentalStage (continued)
•Developmental Stage •Young and middle adults •Sedentary lifestyle, lack of aerobic exercise, and tobacco use also contribute to CV disorders in this group •Crack cocaine and methamphetamine abuse can lead to sudden cardiac failure •Family history of CV disease is yet another risk factor for this age group •Older adults - cardiac efficiency gradually declines •Thicker and more rigid valves •Decreased myocardial strength •Lower exercise tolerance; need more rest after exercise •Are more prone to orthostatic/postural hypotension •Occurs when the BP drops when the client goes from lying down to sitting up, or from sitting to standing •Inactivates the baroreceptors involved with vasoconstriction and dilation; hence, the client is less able to regulate blood pressure (BP) •When the BP drops, less blood goes to organs and muscles; this can make the client more likely to fall; dizziness and light-headedness occur
Factors Affecting Bowel Elimination
•Developmental stage • Personal and sociocultural factors • Nutrition/hydration/activity • Medications • Surgery and procedures • Pregnancy • Pathological conditions •. Neurological disorders • Cognitive conditions •. Pain or immobility
Assessing Oxygenation Status
•Diagnostic testing •Sputum samples •Skin testing •Pulse oximetry •Capnography •Spirometry •Arterial blood gases (A B G's) •PO2, PCO2 •Peak flow monitoring
Common Alterations in Defecation
•Diarrhea •Constipation •Fecal impaction •Bowel diversions
Nursing Interventions: Long-Term
•Eat well-balanced meals. •Get adequate rest. •Exercise •Avoid smoking •Avoid others with upper respiratory infections (URI) •Drink large amounts of fluids •Void spread by washing hands •Prompt treatment
Modifiable Risk Factors
•Elevated serum cholesterol •Tobacco/nicotine use •Hypertension •Impaired glucose tolerance/DM •Obesity •Excessive alcohol •Limited physical activity •Stress
Enemas
•Enemas •.Cleansing •Retention •Return flow •Manual/digital removal: Disimpacting •Establish bowel program to prevent recurrence.
Assessment: Breathing Patterns
•Eupnea •Tachypnea •Bradypnea •Kussmaul's respirations •Biot's respirations •Cheyne-Stokes respirations •Apnea
Fluid Imbalances (continued)
•Fluid volume excess •Hypervolemia •Involves excessive retention of sodium and water in the ECF •Fluid volume excess can result from excessive salt intake, diseases affecting kidney or liver function, or poor pumping action of the heart •The retained sodium increases osmotic pressure in the ECF •This pressure pulls fluid from the cells into the ECF •Signs of fluid overload •Elevated blood pressure, bounding pulse, increased and/or shallow respirations •Neck veins may become distended •Pale, cool skin •Edema - excess ECF may accumulate in the tissues, especially in dependent areas; will see a weight gain (hence, daily weights on same scale and same time of day are necessary) •In severe fluid overload, the client develops moist crackles in the lungs, dyspnea, and ascites (excess peritoneal fluid)
Nephron *
•Formation of urine •Ureters transport urine •Bladder stores urine •Urethra transports urine
Common Urinary Studies
•Freshly voided specimen •Clean catch •Sterile specimen •24-hr urine Urinalysis Dipstick testing Specific gravity Serum Creatinine Blood urea nitrogen (BUN) Glomerular filtration rate (GFR)
Nursing Assessment: Fluid, Electrolyte, Acid-Base Imbalances
•Head-to-toe physical assessment •Vital signs: Temperature, pulse, respirations, blood pressure •Daily weights •Fluid intake/output •Laboratory studies •Complete Blood Count •Serum Electrolytes •Others
Structures of cardiovascualr system
•Heart •Cardiac cycle: simultaneous contraction of the two atria, followed a fraction of a second later by the simultaneous contraction of the ventricles •Electrical conduction: electrical activity that initiates contraction of the myocardium •Cardiac cycle •Sinoatrial (SA) node: acts as the pacemaker of the heart because it initiates an impulse that triggers each heartbeat; rate will be 60 to 100 beats/min, depending on the body's oxygen needs; cardiac output will decrease as a result of the decrease in heart rate; damage to the SA node interferes with the electrical activity of the heart but does NOT directly affect the pumping action of the heart •Atrioventricular (AV) node: electrical activity passes through the AV node into the left and right bundles of HIS and into Purkinje fibers to the ventricles; if the SA node fails, the AV node can take over as the pacemaker, but it generally triggers a slower heart rate
Cardiac Output
•Heart rate (HR) •Can be affected by many variables •Stroke volume (SV) •Contractility (think "force") •Preload (think "volume") •Afterload (think "resistance") •CO is calculated by the formula HR x SV •Normal CO is 4-7 L/min •Decreased CO is the appropriate diagnosis when the heart is unable to pump adequate amounts of blood to meet the metabolic demands of the body Heart rate (HR) is simply the number of cardiac contractions per minute. Normal CO in an adult is 4 to 7 L/min. This value does not remain constant but is increased by exercise or activity, decreased at times of rest. Cardiac output is calculated by the formula HR × stroke volume (the amount of blood ejected with each ventricular contraction). Preload is the amount of blood in the ventricles at the end of diastole. It also refers to the amount of stretch of the muscle tissue at the end of filling. Afterload refers to the resistance to flow the ventricle must overcome to open the semilunar valves and eject its contents. Contractility refers to the force of the mechanical contraction. Contractile force can be increased with sympathetic stimulation or calcium release.
High-Flow Delivery Devices: Venturi Mask
•High flow device •Humidified •Use different adapters •24% to 60% •O2 flow 2 to 15 L/min
Nursing Interventions: Short-Term
•Hydration, to thin secretions •Rest, to conserve energy •Perform deep breathing & coughing exercises •Position for ease of breathing •Assist with frequent position changes
Nursing Interventions (continued)
•IVFs can replace fluid volume, but they do not restore oxygen-carrying capacity or replace clotting factors •Blood products are infused when the client has (a) experienced significant blood loss, (b) diminished oxygen-carrying capacity, or (c) a deficiency in one of the blood components •Replacement of blood and blood products •Update: Client must give consent for blood products •Obtain a set of vital signs •Ensure client has good IV access •To help prevent transfusion reactions, be extremely careful in identifying the client and the blood, start the transfusion slowly, remain with the client for the first 5 min of the transfusion, and assess again at 15 min •You must assess your client throughout the transfusion •Monitor for transfusion reactions (allergic, bacterial, febrile, hemolytic, and circulatory overload) •STOP THE BLOOD TRANSFUSION Assess client and notify the provider
Analysis/Nursing Diagnosis
•Impaired Urinary Elimination •Urinary Incontinence (functional, reflex, stress, urge, risk for urge) •Urinary Retention •Risk for urinary tract injury
Analysis/Nursing Diagnosis
•Impaired gas exchange - Domain 3 Elimination & exchange •Ineffective breathing pattern - Domain 4 Activity/rest •Impaired spontaneous ventilation - Domain 4 •Dysfunctional ventilatory weaning response - Domain 4 •Ineffective airway clearance - Domain 11 Safety/protection •Risk for aspiration - Domain 11
Analysis/Diagnosis and Goals
•Impaired gas exchange r/t ventilation perfusion mismatch AEB hypoxemia (SaO2 90 without supplemental O2) • •By the end of this shift, patient's SaO2 will remain at 94% or better while receiving supplemental oxygen (2L/min via NC) • • •By the time of discharge, patient will identify/demonstrate at least three strategies to optimize oxygenation
Analysis/Diagnosis and Goals
•Impaired gas exchange r/t ventilation perfusion mismatch AEB hypoxemia (SaO2 90 without supplemental O2) • •By the end of this shift, patient's SaO2 will remain at 94% or better while receiving supplemental oxygen (2L/min via NC) • • •By the time of discharge, patient will identify/demonstrate at least three strategies to optimize oxygenation Short term= physiological Long term- 3 strategies to optimize oxygenation
Impaired Urinary Elimination
•Impaired urinary elimination r/t urinary tract infection AEB dysuria & frequency • •Infection in urinary system •. Urethra •. Bladder •. Ureters •. Kidney •Types of UTI •. Urethritis •. Cystitis - infection of bladder •. Pyelonephritis- infection into ureters •. Catheter-associated Urinary Tract Infections (CAUTI)
Planning Outcomes/Evaluation
•Kidney function •Urinary continence •Urinary elimination •Tissue integrity, skin, and mucous membranes Planning Outcomes/Evaluation The general goal for urinary elimination is that patients will comfortably void approximately 1,500 mL of light yellow urine in 24 hr. Because normal urine elimination patterns vary, you must consider the individual's pattern, food and fluid intake, medications, and other factors when setting target amounts. NOC standardized outcomes for urinary problems, regardless of the specific problem, are: •Kidney function •Urinary continence •Urinary elimination •Tissue integrity, skin and mucous membranes (because urinary elimination problems often place the patient at risk for impaired skin integrity).
Influence Pulmonary Function
•Life span and development •. Respiratory distress syndrome, upper respiratory infections [U R I's], adolescent smoking, cardiac insufficiency •Environment •. Stress, allergies •Lifestyle Nutrition, exercise, substance abuse •Smoking •Medications
Factors That Influence Cardiac Function (continued)
•Lifestyle •Pregnancy - during pregnancy, oxygen demand increases dramatically; to compensate, the mother's blood volume increases by 30%; the woman requires additional iron to produce this blood as well as to meet fetal requirements; failure to meet these iron demands can result in maternal anemia, reducing tissue oxygenation of the mother •Nutrition - a low-fat, low-cholesterol, low-sodium diet is considered "heart healthy" •Obesity •Body mass index (BMI) above 30 •Causes multiple health problems, many of which affect the heart and circulation •Increases the risk of developing atherosclerosis and hypertension (HTN) •Excess fat stores in and around the heart reduce the pumping action of the heart •Workload of the heart is increased in an attempt to perfuse excess body tissue; however, tissue perfusion is NOT diminished until the heart is damaged and can no longer adequately perfuse the tissues •Exercise - improves blood circulation and delivery of oxygen to tissues and cells •Tobacco use - major risk factor in several chronic CV conditions; also causes vasoconstriction •Substance abuse •Large amounts of alcohol depress respiratory, cardiac, and vasomotor centers of the brain •Illicit drugs also have adverse effects on the CV system •Smoking has been shown to cause atherosclerosis (fatty buildups in the arteries), hypertension, and decreased high-density lipoproteins (HDL) (good) cholesterol—all of which lead to coronary heart disease and heart attack.
Cardiovascular Nursing Planning and Interventions
•Manage anxiety •Anxiety activates the SNS and triggers the stress response •Hormone changes occur, including the release of aldosterone, which promotes fluid retention and increases blood pressure •The heart rate and contraction force increase, peripheral and visceral vessels constrict, and the blood clots more readily •All of these make a cardiac or vascular condition more serious •Provide clear factual information and keep the client and family informed about treatments being given •Many clients are reassured by the presence of a family member
Factors That Influence Cardiac Function: Hypertension
•Management •Diagnosis, treatment, and medications •Note: we never treat HTN based on one value •Lifestyle o. Weight o. Diet o. Alcohol o. Exercise •Complications •Stroke, aneurysm, and hypertensive crisis •The client with HTN who is not taking medications as prescribed can risk damage to the tiny arterioles in the kidneys, resulting in poor renal tissue perfusion; Nursing diagnosis: Risk for Ineffective Renal Tissue Perfusion •
Mean Arterial Pressure (MAP)
•Mean Arterial Pressure (MAP) is a calculation that checks whether there's enough blood flow, resistance, and pressure to supply blood to the major/vital organs (e.g., heart, brain, and kidneys) •Think of MAP as the average pressure in the arteries throughout one cardiac cycle, which includes the series of events that happen every time the heart beats •Most people need a MAP of at least 60 mmHg or greater to ensure enough blood flow to vital organs •A high MAP is anything over 100 mmHg, which indicates that there's a lot of pressure in the arteries •Anything under 60 mmHg indicates that the blood may not be reaching vital organs; without blood and nutrients, the tissue of these organs begins to die, leading to permanent organ damage
Factors That Influence Cardiac Function -continued 2
•Medications •Various types of medication are used to improve cardiac output and tissue oxygenation; they act to: •Slow the heart rate or reduce the force of myocardial contraction •Ease the workload of the heart •Dilate blood vessels and reduce blood pressure in the pulmonary circulation and systemically •Rid the body of excess fluid accumulation •Block abnormal heart rhythms •Also, an aspirin regimen may help prevent CV problems; it blocks the production of prostaglandin, a hormone-like substance that activates the formation of blood clots •CV depressants are used therapeutically to slow the heart rate or reduce the force of myocardial contraction; this may reduce cardiac output and impair tissue oxygenation; the following are the most commonly used CV depressants •Beta-adrenergic blocking agents (beta blockers) are used therapeutically to reduce the workload of the heart, to control abnormal heart rhythms (dysrhythmias), and to control hypertension; drugs that block beta-1 receptors slow the heart rate and decrease the strength of myocardial contraction •Calcium channel blocking agents (calcium channel blockers) block the flow of calcium into cells of the heart and blood vessels; they decrease blood pressure and the strength of myocardial contraction, slow the heart rate, and dilate the arteries and arterioles
Managing Urinary Retention
•Monitor for distention. •Measure post-voiding residual (PVR). •Drain the bladder. •Straight catheter •Indwelling catheter: Foley •Suprapubic catheter
Managing Diarrhea
•Monitor stools to quantify diarrhea. •Assess and monitor for fluid imbalance. •Monitor for alterations in perineal skin integrity. •Proper dietary teaching •. Clear liquid •. Bananas, rice, applesauce, toast (B R A T) •. Foods to avoid •Antidiarrheal medications •. Not recommended for acute diarrhea •. Lomotil, imodium •. Teach clients about over-the-counter aids
Major Electrolytes (continued)
•Phosphate (phosphorus) •Bound with calcium in teeth and bones •Has an inverse/reciprocal/opposite relationship with calcium •Magnesium •Affects the bone •Has many cellular functions •Although magnesium deficiency is rare, you may find low levels in individuals who have a high alcohol intake • Chloride •It is usually bound with other ions, especially sodium or potassium (e.g., as sodium chloride, or salt) •Bicarbonate •Acid-base balance; produced by body to act as buffer •Regulated by kidneys to maintain an acid-base balance; when serum levels rise, the kidneys excrete excess bicarbonate; if serum levels are low, the kidneys conserve bicarbonate
Body Fluid Compartments
•Most body fluid is contained within two compartments 1.Intracellular - within the cells 2.Extracellular •Interstitial fluid lies in the spaces between the body cells; excess fluid within the interstitial space is called edema (40% of body weight) •Intravascular fluid is the plasma within the blood; its main function is to transport blood cells (20% of body weight) •Transcellular fluid includes specialized fluids, such as cerebrospinal, pleural, peritoneal, and synovial fluid as well as digestive juices •Third spacing: certain conditions cause fluid to move into an area that makes it physiologically unavailable, such as into the peritoneal space (in ascites); this type of fluid movement is known as third spacing because fluid is literally trapped in a third compartment, not within interstitial (cells) or the intravascular spaces (blood vessels)
Nasal Cannula (Low Flow)
•Most commonly used •Two soft nasal prongs •Low levels of oxygen •24% (1L/min) to 44% (6L/min) •Can be humidified •Must humidify 4L/min or >
Cardiovascular Assessment
•Nursing care for clients with CV problems is directed at assessing for and maximizing the effectiveness of the heart and circulatory system •Physical exam •Assess pain •If a client has chest pain, evaluate it immediately because chest pain is the most common heart attack symptom •Ask the client to rate the pain on a scale of 0 to 10, with 0 representing no pain and 10 representing the worst possible pain •Ask the client to describe the pain: location, duration, frequency, and radiation - "Does the pain radiate to your arm, jaw, or shoulder?" •You can differentiate cardiac pain because it is usually in the center or on the left side of the chest and radiates to the left arm, at least in men •Some women have milder chest pain, sometimes none at all; they are thought to be more likely than men are to experience other symptoms, such as jaw or back pain, nausea, fatigue, and shortness of breath •The pain typically lasts several minutes; it may go away and come back •Chest pain may also be caused by musculoskeletal or respiratory conditions; for example, a fractured rib or pleuritis (inflammation in the pleural space)
Assessment
•Nursing history •Physical examination •Diagnostic procedures •Urine output
Urinary Retention
•Obstruction in urinary tract • •Neurological problems • •Medications and anesthesia • •Musculoskeletal • •Psychological Bladder dropping- cystocele Rectocele- rectal dropping
Orthostatic Hypotension
•Obtaining orthostatic vital signs: •Take the pulse and BP with client supine, sitting, and standing •Take each reading 1 to 3 minutes after each change of position •Notify the provider of change in measurements •When documenting orthostatic VS, record the client's position in addition to the pulse and BP; for example: •Supine P = 80, BP = 150/90 •Sitting P = 84, BP = 130/84 •Standing P = 90, BP = 84/58 •If the client's blood pressure drops at least 20 systolic or 10 diastolic after going from lying down to standing, that indicates orthostatic hypotension •There are multiple causes, including low fluid volume
Optimal Oxygenation: Artificial airways
•Oropharyngeal •Nasopharyngeal •Endotracheal tubes •Tracheostomy tubes •Artificial airway patency •Pharyngeal suctioning Deep tracheal suctioning
Movement of Fluids and Electrolytes
•Osmosis involves movement of water (or other pure solute) across a membrane from an area of a less concentrated solution to an area of more concentrated solution •Diffusion is a passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration •Filtration is the movement of both water and smaller particles from an area of high pressure to one of low pressure •Active transport occurs when molecules (e.g., electrolytes) move across cell membranes from an area of low concentration to an area of high concentration; active transport requires energy versus passive transport (which requires no energy)
Optimal Oxygenation: Supplemental Oxygen
•Oxygen therapy •Cannula •Mask •Transtracheal catheter •Use of high flow oxygen •Use of a mechanical ventilator •Use of chest tube drainage systems
Oxygen Therapy: Complications
•Oxygen toxicity •Support combustion •Oxygen tanks high pressure •Skin break down •Complication prevention •Assess face, ear & neck skin Q 4-8 hours •Mouth care •Pad elastic band/tubing •Cleanse equipment •Cleanse & moisturize skin
Cardiovascular Nursing Planning and Interventions 3
•Perform CPR •You must be prepared to perform cardiopulmonary resuscitation (CPR) in the event your client experiences a respiratory, cardiac, or cardiopulmonary arrest •Cardiac arrest is the cessation of heart function •Signs of cardiac arrest are pale, cool, grayish skin; absence of femoral or carotid pulses; apnea; and pupil dilation •In the event of cardiac arrest, you have only 4 to 6 min before the brain is damaged by lack of oxygen •Respiratory (pulmonary) arrest is cessation of breathing •Caused by a blocked airway or occurs after a cardiac arrest •May be sudden or preceded by increasingly labored breathing •Begin CPR immediately after activating the alert •Use an automatic external defibrillator (AED) or manual defibrillator as soon as one is available •Before beginning CPR, you are responsible for knowing whether your client has an advance directive stating whether or not she/he would want CPR
Factors That Influence Cardiac Function (continued) 2
•Peripheral vascular abnormalities •Impair blood flow to and from organs and tissues •Arterial abnormalities disrupt flow of oxygenated blood to tissues. •Pallor, pain, weak or absent pulses, poor capillary refill, cool skin, and tissue dysfunction •Venous abnormalities disrupt blood return to the heart. •Edema, brown skin discoloration, and tissue dysfunction (e.g., stasis ulcers) •Oxygen transport abnormalities •Even if the heart is functioning well and arterial blood flow is intact, tissues can become hypoxic if the blood is unable to carry adequate amounts of oxygen •Anemia is an abnormally low level of red blood cells, hemoglobin, or both •Carbon monoxide poisoning •Is a colorless, odorless gas produced by the combustion of flammable materials and fuels •When inhaled, carbon monoxide binds tightly to hemoglobin at the oxygen receptor sites, making it impossible for hemoglobin to carry oxygen
Factors Affecting Urinary Elimination
•Personal •Sociocultural •Environmental •Nutrition •Hydration •Activity level •Medications •Diuretics example: furosemide (Lasix) •Anticholinergic •Nephrotoxic •Surgery and anesthesia
Electrolyte Imbalances
•Sodium •. Hyponatremia •. Hypernatremia •Potassium •. Hypokalemia •. Hyperkalemia •Calcium •. Hypocalcemia •Hypercalcemia •Phosphorous •. Hypophosphatemia •. Hyperphosphatemia •Magnesium •. Hypomagnesemia •. Hypermagnesemia First step: look to see if the client's lab value(s) falls within the normal range to determine if there is even a problem. Hyponatremia is caused by: •Diuretics •GI fluid loss •Adrenal insufficiency •Excessive intake of hypotonic solutions, such as water or D5W IV fluids •Syndrome of inappropriate ADH Hypernatremia is caused by: •Excessive sodium intake •Water deprivation •Increased water loss through profuse sweating, heat stroke, or diabetes insipidus •Administration of hypertonic tube feeding Hypokalemia is caused by: •Diuretics •GI fluid loss through vomiting, gastric suction, or diarrhea •Steroid administration •Hyperaldosteronism •Anorexia or bulimia Hyperkalemia is caused by: •Renal failure •Potassium-sparing diuretics •Hypoaldosteronism •High potassium intake coupled with renal insufficiency •Acidosis •Major trauma •Hemolyzed serum sample produces pseudohyperkalemia Hypocalcemia is caused by: •Hypoparathyroidism •Malabsorption •Pancreatitis •Alkalosis •Vitamin D deficiency Hypercalcemia is caused by: •Hyperparathyroidism •Malignant bone disease •Prolonged immobilization •Excess calcium supplementation •Thiazide diuretics Hypophosphatemia is caused by: •Refeeding after starvation •Alcohol withdrawal •Diabetic ketoacidosis •Respiratory acidosis Hyperphosphatemia is caused by: •Renal failure •Hyperthyroidism •Chemotherapy •Excess use of phosphate-based laxative Hypomagnesemia is caused by: •Chronic alcoholism •Malabsorption •Diabetic ketoacidosis •Prolonged gastric suction Hypermagnesemia is caused by: •Renal failure •Adrenal insufficiency Excess replacement
Interpreting Arterial Blood Gases
•Step 1: Examine the pH; is it acidotic, alkalotic, or normal? •If the pH is low (<7.35), the blood is acidic •If the pH is high (>7.45), the blood is alkalotic •If the pH is between 7.35 and 7.45, the blood is normal •"Neutral" pH is 7.40 •Step 2: Examine the amount of carbon dioxide in the blood (pCO2); is there too little or too much?; this signals a respiratory/acid cause •If pCO2 is <35 mm Hg, there is too little acid in the blood (respiratory alkalosis) •If pCO2 is >45 mm Hg, there is too much acid in the blood (respiratory acidosis) •If pCO2 is 35 to 45 mm Hg, the cause for the abnormal pH is NOT respiratory •Step 3: Examine the bicarbonate level (HCO3); is there too little or too much?; this signals a metabolic/base cause •If HCO3- is < 22 mEq/L, there is too little base in the blood (metabolic acidosis) •If HCO3- is > 26 mEq/L, there is too much base in the blood (metabolic alkalosis) •If HCO3- is 22 to 26 mEq/L, the cause for the abnormal pH is NOT metabolic •Step 4: Is there compensation? •If so, is it partially or fully? •The body will naturally try to correct the unhealthy situation by using the lungs and kidneys to buffer the abnormality and return the pH into a normal range •If breathing is the reason for the abnormal pH, then the kidneys will pick up the slack and try to improve the situation •If the problem is metabolic, then breathing (either faster and deeper or slower and more shallow) is the answer •Another option to interpret ABGs (uncompensated): ROME method (see link below); "draw arrows" •Respiratory = Opposite ↑↓ OR ↓↑ (arrows go in the opposite direction) Metabolic = Equal ↑↑ OR ↓↓ (arrows go in the same/equal direction
Managing a Bowel Diversion
•Stoma assessment and care •. Pay strict attention to skin care/peristomal skin assessment. •. Monitor the amount and type of effluent. •. Be attentive to client's psychosocial needs •. Be professional; show acceptance. •. Attend to odor control. •. Address client participation in ostomy care. •Client teaching for home care
Cardiovascular Assessment (continued)
•Tests of blood oxygenation - results from these tests are pertinent to cardiac conditions because the heart and lungs work together to provide oxygenation; a problem in one creates a problem in the other 1.Pulse oximetry (pulse ox) is a noninvasive and painless test that measures oxygen saturation level 2.Capnography is non-invasive and provides breath-to-breath ventilation data 3.Arterial blood gases (ABGs) are invasive; they measure the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery •Labs - cholesterol, lipid panel, C-reactive protein (CRP), and glucose testing are a valuable part of CV risk assessment •An elevated CRP level indicates the presence of inflammation in the body; this may, but does not necessarily, include arterial inflammation or a myocardial infarction •Cardiac monitoring - the purposes of cardiac monitoring are to: 1.Identify the client's baseline rhythm and rate 2.Recognize significant changes in the baseline rhythm and rate 3.Recognize lethal dysrhythmias that require immediate intervention •Electrocardiogram (ECG/EKG) is a rendering of the electrical activity of the heart; electrodes placed on the skin of the chest display a waveform on a monitor screen or printout
CV System continued
•The CV system circulates oxygenated blood to organs and tissues and returns deoxygenated blood to the heart •Deoxygenated blood from organs and tissues flows through the venous system into the right side of the heart and then into the pulmonary circulation •External gas exchange occurs at the alveolar-capillary membrane •The newly oxygenated blood then flows from the lungs into the left side of the heart and out into the arterial circulation •97% of blood oxygen is bound to hemoglobin (red blood cells)
Regulating Cardiovascular Function
•The autonomic nervous system (ANS) regulates CV function through its influence on the: 1.Heart - cardiac heart rate and cardiac muscle contractility 2.Vascular system - maintains vascular tone •Sympathetic control maintains the blood vessels in a constant baseline state of partial contraction (tone) •Vascular tone maintains blood pressure and blood flow even when a person is resting or asleep •Brainstem centers: regulate cardiac function and blood pressure •Baroreceptors •Located in the walls of heart and blood vessels •Sensitive to pressure changes •When baroreceptors sense even a small drop in pressure, they send messages to the brainstem centers to stimulate the sympathetic nervous system (SNS) to increase heart rate and induce vasoconstriction •Vascular system •Chemoreceptors located in the aortic arch and the carotid arteries are sensitive to changes in blood pH, oxygen levels, and CO2 •Their main function is to regulate ventilation, but they also send information to the vasomotor center in response to a lack of oxygen
Fluids/electrolytes and acid base balacne
•The concepts of fluid balance and electrolyte balance are intricately related •Usually, when one electrolyte changes, so does another, and often with fluids shifts that can lead to dysfunction •Likewise, disruption of acid-base (pH) balance can impact overall body functioning •Because an alteration in fluids, electrolytes, and acid-base balance encompasses such a wide variety of disease processes, nurses must possess keen assessment skills •Constant observation of a person's weight, laboratory values, eating habits and food choices, and bowel and bladder habits is essential to proper care and management
Circulation/Perfusion
•The pulmonary, cardiovascular (CV), musculoskeletal, and neurological systems work together to achieve oxygenation •Changes in one system create changes in the other •The lungs oxygenate the blood •The heart circulates the blood throughout the body and back to the lungs •The circulatory system transports oxygenated blood throughout the body to meet the needs •Circulation refers to flow of blood throughout the heart and blood vessels •Perfusion describes blood flow to a capillary bed to provide nutrients and oxygen to tissues and organs •Although the distinction between these two concepts is subtle, they go hand in hand in explaining how a healthy circulatory system contributes to healthy functioning of every organ in the body
Ejection Fraction (EF)
•The types of heart failure are based on a measurement called the ejection fraction (EF) •The EF measures how much blood inside the ventricle is pumped out with each contraction •The left ventricle squeezes and pumps some (but not all) of the blood in the ventricle out to the body •A normal EF is more than 55%. This means that 55% of the total blood in the left ventricle is pumped out with each heartbeat •Heart failure with reduced EF happens when the muscle of the left ventricle is not pumping as well as normal; the EF will be 40% or less
Structures of the Cardiovascular System
•The vascular system is composed of three types of vessels 1.Arteries 2.Veins 3.Capillaries •All vessels are lined with a smooth endothelial layer that promotes nonturbulent blood flow and prevents platelets from sticking to the sides of the walls and beginning clot formation (which can cause an obstruction) •Systemic and pulmonary blood vessels •Arteries •Arterioles •Capillaries •Veins and venules •Arteries have thick, elastic walls that allow them to stretch during cardiac contraction (systole) and to recoil when the heart relaxes (diastole). •Arterioles are smaller branches of arteries. •They are primarily smooth muscle and are thinner than arteries. •Under control by the sympathetic nervous system, the arterioles constrict or dilate to vary the amount of blood flowing into capillaries and help maintain blood pressure. •Capillaries are microscopic vessels, created as arterioles branch into smaller and smaller vessels. •They are one cell thick. •They facilitate the exchange of gases, nutrients, and wastes between the tissue cells and the blood. •Veins and venules are thin, muscular, but inelastic walls that collapse easily. •Walls contract or relax in response to feedback from the sympathetic nervous system. •When blood volume is low, the veins contract to provide a smaller space for smaller volume of blood. •When blood volume is high, the veins relax and enlarge to accommodate increased volume of blood. •Think of the venous system as a holding tank for fluctuations in blood volume.
Major Electrolytes
•To maintain health, the body must balance electrolyte losses and intake •For example, potassium lost through diarrhea and vomiting must be replaced by dietary potassium or potassium supplements •Sodium •The major cation in extracellular fluid (ECF) •Regulates fluid volume •Kidneys reabsorb •Potassium •The major cation in intracellular fluid (ICF) •Affects muscle contraction and cardiac conduction •Kidneys eliminate •Calcium •Affects bone health, neuromuscular function, and cardiac function •If dietary intake is not sufficient to replace it, bone loss occurs; prolonged deficiencies lead to osteoporosis
Influence Pulmonary Function (continued)
•Upper respiratory infections •Cold •Rhinosinusitis •Pharyngitis •Influenza •Lower respiratory infections •Respiratory syncytial virus (R SV) •Acute bronchitis •Tuberculosis •Pulmonary system abnormalities •Pulmonary circulation abnormalities •Central nervous system abnormalities •Neuromuscular abnormalities
Alterations in Urinary Elimination
•Urinary tract infections •Urinary retention •Urinary incontinence •Urinary diversion/urostomy
Fluid Output
•Urine output is the best indicator of hydration •Urine output varies according to intake and activity but should remain at least 30 to 50 mL per hour •When using hydration for the client at risk for thrombus formation, a urine output greater than 1,500 mL/day (24 hours) is ideal •Skin: perspiration •Lungs: exhalation •Feces/stool: 100 to 200 mL/day
Therapeutic Response to Hypoxemia
•Use a calm and confident approach • Provide emotional support and comfort •Sit down and make eye contact. •Speak calmly •Keep the patient informed of what you are doing •Hold the person's hand •Practice therapeutic touch •Sit while providing interventions Oxygenation Experiencing inadequate oxygenation is very frightening. Anxiety, fear, and panic can set in very quickly. ■Use a calm and confident approach when performing interventions to promote optimal respiratory function. ■ Provide emotional support and comfort during episodes of deoxygenation to help alleviate fear. ■ Sit down and make eye contact. Speak calmly and keep the patient informed of what you are doing—for example, Mr. Brown, I realize you are having trouble breathing right now, but you have had a nebulizer treatment. I am here with you. Let's take some deep breaths together and relax. I will recheck your respiratory status and oxygenation level in a few minutes. ■ Hold the person's hand, practice therapeutic touch, and sit with him while providing interventions.
Urinary Elimination
•Voiding, micturition •Process •Filling of bladder à 200 to 450 mL of urine ( 50-60ml per hour! In a healthy person//30 ml acceptable in hospital) •Activation of stretch receptors in bladder wall •Signaling to the voiding reflex center •Contraction of detrusor muscle •Conscious relaxation of external urethral sphincter •Urinary patterns •50 to 50 mL of urine/hour •Five to six times per day Normal specific gravity 1.002 to 1.030
Body Fluid
•Water is the primary body fluid •Total body water content varies with the number of fat cells, age, and sex •Women have less body fluid than do men because they have proportionately more body fat •Likewise, obese people have less body fluid proportionately than do those of lean build •Water contains solutes •Electrolytes - substances (e.g., sodium, potassium) that develop an electrical charge when dissolved in water •Nonelectrolytes - substances (e.g., glucose, urea) that do not conduct electricity
Assessment: Sputum Color
•White or clear - viral infections •Yellow or green - neutrophil response •Black - coal dust, smoke, or soot inhalation •Rust colored - pneumococcal pneumonia, tuberculosis •Hemoptysis - blood or bloody sputum. •Pink and frothy - pulmonary edema •Foul-smelling sputum - bacterial infection (e.g., pneumonia, lung abscess)