Test 4 Perfusion and Gas Exchange

Hypertension Clinical Manifestations

"Silent killer" Symptoms of severe hypertension Fatigue Dizziness Palpitations Angina Dyspnea

Risk Factors for Primary Hypertension

Age Alcohol Tobacco use Diabetes mellitus Elevated serum lipids Excess dietary sodium Gender Family history Obesity Ethnicity Sedentary lifestyle Socioeconomic status Stress

Hypertension facts

As BP increases, so does the risk of MI Heart failure Stroke Renal disease Affects 1 in 3 adults in United States High priority health concern identified in Healthy People 2020 83% of people > age 20 with hypertension are aware they have high BP 76% are being treated 48% of those aware do not currently have their BP well controlled

Resistant Hypertension

Failure to reach goal BP in patients taking full doses of an appropriate 3-drug therapy regimen that includes a diuretic. Reasons include Improper BP measurement Drug-induced Associated conditions Identifiable causes of secondary hypertension

Primary Hypertension Pathophysiology

Genetic links Stress and increased SNS activity Causes increased vasoconstriction ↑ HR ↑ Renin release Altered renin-angiotensin- aldosterone system (RAAS) Increased renin activates RAAS Renin levels do not decrease in response to elevated BP Insulin resistance and hyperinsulinemia High insulin levels stimulate SNS activity and impair nitric oxide- mediated vasodilation

Hypertension Nursing Implementation

Health Promotion Primary prevention via lifestyle modification Individual patient evaluation and education Screening programs Cardiovascular risk factor modification Ambulatory Care Evaluate therapeutic effectiveness Detect and report adverse effects Assess and enhance compliance Patient and caregiver teaching. Home BP monitoring Patient teaching is critical for accuracy Proper equipment Proper procedure Frequency Accurate recording and reporting Target BP Reasons for poor adherence to treatment plan are complex Inadequate teaching Low health literacy Unpleasant side effects of drugs Return to normal BP while on drugs High cost of drugs Lack of insurance Measures to enhance compliance Individualize plan Active patient participation Select affordable drugs Involve caregivers Combination drugs Patient teaching

Hypertensive Crisis Nursing and Interprofessional Mgmt

Hospitalization IV drug therapy: titrated to MAP Monitor cardiac and renal function Neurologic checks Determine cause Education to avoid future crisis

Hypertensive Crisis Clinical Manifestations

Hypertensive encephalopathy Headache, nausea/vomiting, seizures, confusion, coma Renal insufficiency Cardiac decompensation MI, HF, pulmonary edema Aortic dissection

Hypertension in Older Persons

Increasedincidencewithage Isolatedsystolichypertension(ISH): Most common form of hypertension in individuals age >50 Olderadultsaremorelikelytohave "white coat" hypertension Age-relatedphysicalchanges contribute to hypertension Altered drug absorption, metabolism, and excretion Often a wide gap between first Korotkoff sound and subsequent beats is called auscultatory gap ↑ Risk for orthostatic hypotension Also postprandial hypotension BP goal for people > 60 is < 150/90 Preferred antihypertensive drugs Thiazide diuretic Calcium channel blockers ACE inhibitors or ARBs Caution use of NSAIDS

Hypertension Diagnostic Studies

MeasurementofBP Urinalysis BUNandserumcreatinine Creatinineclearance Serumelectrolytes,glucose Serumlipidprofile Uricacidlevels ECG Echocardiogram

Hypertension Nursing Management

Nursing Evaluation Patient will: Achieve and maintain goal BP Understand, accept, and implement treatment plan Report minimal side effects of therapy

Hypertension Interprofessional Care

Overall Goals Control blood pressure Reduce CVD risk factors and target organ disease

Pathophysiology Primary Hypertension

Persistently increased SVR Abnormalities in any mechanisms involved in maintenance of normal BP

Hypertensive Crisis

SBP>180mmHgand/orDBP>110 mmHg Hypertensive urgency Developsoverhourstodays Maynotrequirehospitalization Hypertensive emergency Verysevereproblemscanresultifprompt treatment is not obtained Rateofrisemoreimportantthan absolute value

Hypertension Nursing Assessment

Subjective Data Past health history Hypertension Cardiovascular, cerebrovascular, renal, thyroid disease Diabetes mellitus, pituitary disorders, obesity, dyslipidemia Menopause or hormone replacement Drugs SubjectiveData Family history Salt and fat intake Weight gain or loss Nocturia Fatigue, dyspnea on exertion, palpitations, pain Dizziness, blurred vision Erectile dysfunction Stressful events Objective Data Blood pressure readings Heart sounds Pulses Edema Body measurements Mental status changes

Hypertension BP Measurement

Take in both arms initially Proper size and placement of cuff Can use forearm if needed Document site Assess for orthostatic hypotension BP and HR supine, sitting, and standing Measure within 1 to 2 minutes of position change Positiveif↓of20mmHgormorein SBP, ↓10 mm Hg or more in DBP, or ↑ 20 beats/minute or more in heart rate Auscultatory measurement Estimate SBP by palpating radial pulse and inflating cuff until pulse disappears Inflate cuff 20-30 mm Hg above this level Deflate cuff at a rate of 2-3 mm Hg/sec

Hypertension Complications

Target organ diseases occur most frequently in Heart Brain Peripheral vascular disease Kidney Eyes

Goals of Drug Therapy

Thefollowingarerecommendationsfor from the JNC 8: Inpatients>60years,startdrugtreatment for BP ≥ 150 mm Hg systolic or ≥ 90 mm Hg diastolic and treat to goal BP less than those thresholds Inpatients<60 years, treatment initiation and goals should be 140/90 mm Hg, same threshold used in patients 18 years or older with either chronic kidney disease or diabetes FindingsfromSystolicBloodPressure Intervention Trial (SPRINT) TreatmentofsystolicBPto<120mmHg (rather than 140 mm Hg) reduced rates of major cardiovascular events by almost 1/3 and risk of death by almost 1/4 Thesedatamayresultinchangesto JNC 8 guidelines

Hypertension Lifestyle Modifications

Weight reduction Weightlossof22lb(10kg)may decrease SBP by approx. 5 to 20 mm Hg Calorie restriction and physical activity DASH eating plan Fruits, vegetables, fat-free or low-fat milk, whole grains, fish, poultry, beans, seeds, and nuts Dietary sodium reduction < 2300 mg/day for healthy adults < 1500 mg/day for AfricanAmericans Middle-aged and older Those with hypertension, diabetes, or chronic kidney disease Moderation of alcohol intake Physicalactivity Moderate-intensity aerobic activity, at least 30 minutes, most days of the week Vigorous-intensity aerobic activity at least 20 minutes, 3 days a week Muscle-strengthening activities at least 2 times a week Flexibility and balance exercises 2 times a week Avoidanceoftobaccoproducts Nicotine causes vasoconstriction and elevated BP Smoking cessation reduces risk factors within 1 year Psychosocialriskfactors Low socioeconomic status, social isolation and lack of support, stress, negative emotions ActivateSNSandstresshormones

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

"Use of an incentive spirometer will help prevent pneumonia."

Hypertension Classification

*Secondary Hypertension: When specific disease states and drugs cause hypertension *Isolated Systolic Hypertension: MAJOR HEALTH THREAT -BP of >140/<90 -Most common form of hypertension in older adults *Malignant Hypertension: -Severe type of Hypertension that rapidly progresses -Symptoms-morning headaches, blurred vision, and dyspnea & symptoms of uremia -Pts are usually in 30s, 40s, & 50s -BP is >200/150 -Pt may experience renal failure, left ventricular failure, or stroke

ACE inhibitors

-pril Angeotincer inhibitors Lisinorpil MOA: antagonize angiotensin

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?

10 seconds

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?

100% oxygen via a tight-fitting, nonrebreather face mask

The nursing student is presenting a clinical conference and discusses the cause of β-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these?

A child of Mediterranean descent

Chronic Venous Insufficiency (CVI)

A condition that develops when leg veins and valves fail to keep blood moving forward Causes S/S Edema Bulging veins Venous ulcers Chronic venous stasis Improved when legs are elevated Think gravity! Treatment: focus on management of edema & promoting venous return Elevate legs, wear elastic or compression stockings, avoid prolonged sitting TEDs apply in am & remove before hs Apply compression over wound dressing Unna boot Profore- wrap

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.

A hyperinflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

PAD DRUG THERAPY

ACE Inhibitors (-pril) Antiplatelet agents Intermittent claudication treatment Pentoxifylline (Trental) Cilostazol (Pletal) Contradicted in patients with heart failure

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?

Administer oxygen, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.

Auscultating lung sounds Obtaining the client's temperature Obtaining information about the client's respirations A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

PAD NUTRITIONAL THERAPY

BMI < 25 kg/m2 Waist circumference <40 inches for men and <35 inches for women Dietary cholesterol <200 mg/day Decreased intake of saturated fat Sodium <2 g/day

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication?

Betamethasone Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if the labor can be inhibited for 48 hours. Nalbuphine is an opioid analgesic. Rho(D) immune globulin is given to Rh-negative clients to prevent sensitization. Dinoprostone vaginal insert is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions.

Factors Influencing BP

Blood pressure = cardiac output x systemic vascular resistance Sympathetic nervous system (SNS) Activation increases HR and cardiac contractility Vasoconstriction and renin release Increases CO and SVR Baroreceptors Sensitive to stretching Send impulses to sympathetic vasomotor center Vascular endothelium Essential to regulation of vasodilating and vasoconstricting substances Renal system Control sodium excretion and ECF volume RAAS system Prostaglandins Endocrine system Epinephrine and norepinephrine from adrenal medulla Aldosterone from adrenal cortex ADH from posterior pituitary

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?

Bronchospasm

When teaching a patient with peripheral arterial disease, the nurse determines that further teaching is needed when the patient says, A. "I should not use heating pads to warm my feet." B. "I will examine my feet every day for any sores or red areas." C. "I should cut back on my walks if they cause pain in my legs." D. "I think I can quit smoking with the use of short- term nicotine replacement and support groups."

C.

You are caring for a 74-yr-old male patient who is recovering from left femoral-popliteal bypass graft surgery. When responding to the patient's call bell, the patient reports severe pain in the operative leg. On assessment, you note that the dorsalis pedis and posterior tibial pulses are no longer palpable and the foot is cold to touch. What are your next actions?

Call HCP

RAYNAUD'S PHENOMENON

Caused by vasospasm of the arterioles and arteries of the upper and lower extremities Characterized by discoloration of fingers, toes, ears, & nose (white, blue, red) Primarily in young women Drug therapy: calcium channel blockers Avoid temperature extremes, tobacco, caffeine Reinforcement of client education Work-up for autoimmune disease

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

Check for an air leak, because the bubbling should be intermittent. Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a health care provider's prescription.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?

Chest pain that occurs suddenly

The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority?

Connect the resuscitation bag to the oxygen outlet. The highest priority on admission to the nursery for a newborn with a low Apgar score is the airway, which would involve preparing respiratory resuscitation equipment and oxygen. The remaining options are also important, although they are of lower priority. The newborn would be placed on an apnea and cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support. The radiant warmer would provide an external heat source, which is necessary to prevent further respiratory distress.

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply.

Cyanosis. Tachypnea Retractions Audible grunts

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?

Decreased wheezing Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dry skin indicates an improvement in the child's condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats/minute. The normal respiratory rate in a 10-year-old is 16 to 20 breaths/minute.

A child with β-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to be prescribed?

Deferoxamine Exjade or deferoxamine may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?

Diminished breath sounds

VARICOSE VEINS

Distended, protruding veins that appear darkened and tortuous Risk Factors: >30 years old, occupations who require long periods of standing, pregnancy, obesity, family history **Prevention is key factor Collaborative management includes: Elastic stockings Elevation of extremities Sclerotherapy Surgical removal of veins Radio frequency energy to heat the veins

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate?

Document the findings. The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/minute. The normal apical heart rate is 90 to 130 beats/minute, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.

Drainage system maintained below the client's chest 50 mL of drainage in the drainage collection chamber Occlusive dressing in place over the chest tube insertion site Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

ACUTE ARTERIAL ISCHEMIC DISORDERS

Embolus: the most common cause of occlusions, although local thrombus may be the cause Assessment: 6 Ps Drug therapy Surgical therapy

PAD EXERCISE THERAPY FOR INTERMITTENT CLAUDICATION

Exercise improves oxygen extraction in the legs and skeletal metabolism. Walking is the most effective exercise for individuals with claudication. 30 to 45 minutes at least 3 days per week

The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction?

Fluid overload Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency; these include vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis. Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1½ to 2 times the daily requirement to prevent dehydration.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?

Flushing Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.

While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action?

Grasp the retention sutures to spread the opening.

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?

Hyperventilation Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?

Perform the Valsalva maneuver When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take?

Place the tube in a bottle of sterile water. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection.

VTE PREVENTION

Prevention of VTE: Exercise Early ambulation Weight control Quit Smoking Drink plenty of H2O Leg exercises

Etiology of Primary Hypertension

Primary hypertension Also called essential or idiopathic hypertension Elevated BP without an identified cause 90% to 95% of all cases Exact cause unknown but several contributing factors

PERIPHERAL ARTERIAL DISEASE

Progressive narrowing of the arteries of the upper and lower extremities Atherosclerosis is the leading cause of majority of cases

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?

Promote carbon dioxide elimination

Drug Therapy for hypertension

RAAS suppressants Calcium channel blockers Sympatholytics Direct-acting vasodilators Pt teaching Follow-up care Identify, report, and minimize side effects Orthostatic hypotension Sexual dysfunction Dry mouth Frequent urination Time of day to take drug

Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?

Respiratory distress

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

Rhythmic respirations with periods of apnea Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition?

Right pneumothorax

Etiology of Secondary Hypertension

Secondary hypertension Elevated BP with a specific cause 5% to 10% of adult cases Clinical findings relate to underlying cause Treatment aimed at removing or treating cause

The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

Shortness of breath

PAD MANAGEMENT

Smoking cessation DM management Glycosylated hemoglobin (A1C) <7.0% for diabetics Optimal near 6.0% Aggressive treatment of hyperlipidemia Hypertension management Exercise DASH diet No heating pads Trim nails straight across Float heels (place pillow under calves)

Diurectis

Spirlactone K sparing check K levels Loop diuretics Furosemide Lasix MOA:inhibitor sodium reabsorption which ups fluid excretion, HF, PE, Ascites, RE, edema, cirrhosis Lab:Fluid and electrolyte pannel (k, Na, Mg) Bun, creatinine ,ASt, Lst Side effects:dehydration, hypotension, k imbalances,Na imbalances Food interactions: salt substitutes, cross allergy if allergic to sulfide Druh int:digoxin an lithium toxicity, lovanox Weight loss if meds working if 3lbs in a day or 5lbs in a week gained call HCP

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate?

Stop the procedure and reoxygenate the client.

Altoplase (IV only) If you want to breakup a clot you've came to the right plASE

Streptokinase MOA: Thrombolytic, Lysis of clots, MI,PE, Ischemic, CVA or stroke Adverse reactions: Intracranial hemorrhage, GI bleeding, Nursing INt: BP if greater than 180 cannot have venipuncture or IM injections, volley Cath before med Food int: garlic, ginger, licaits

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client?

Stridor Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the HCP.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?

The child is leaning forward, with the chin thrust out. Epiglottitis is a bacterial form of croup. A primary concern is that it can progress to acute respiratory distress. Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, the use of accessory muscles for breathing, and the presence of stridor. Option 4 is an incorrect position. Options 1 and 3 are incorrect because epiglottitis causes tachycardia and a high fever.

Venous Thromboembolism (VTE)

Thrombus: a blood clot Results from Virchow's Triad (endothelial injury, venous stasis, hypercoagulability) Deep vein thrombosis (DVT, more common) Pulmonary embolism (High rate of death) Assessment: Calf or groin tenderness or pain Sudden onset of unilateral swelling of the leg Localized edema Venous flow studies/venous Doppler D-dimer Risk Factors: Immobility, estrogen therapy, pregnancy, long periods of sitting, dehydration, surgery, obesity

VTE (venous thromboembolism)

VALVES DESTROYED, LOWER EXTREMITIES A DARK COLOR, USUALLY ULCERS AROUND ANKLES. COMPLICATIONS - PE. INTERVENTION -ANTICOAGULANTS OR VENA CAVA FILTER. Patho:localized platelet aggregation Risk factor: Dehyrdation, cancer, 60 year old, clotting disorders protein C and S factors bleeding factor 5's, Obesity, critical care admission, hip and knee surgery=embolization prolonged Expected Findings: edema, pain, dilated superficial veins, palpably warm, chest pain Lungs SOB life threatening, oral contraceptives Nursing interventions: bed rest, med- anticoagulant, don't cross legs, no massages, heating pad PT Edu: no massages, no leg crossing for long periods of time, heating pad on 20 min off 20 min, Diagnostics: ultra sounds, PTT 40-70 , Pt, INR2-30 therapeutic Drugs/meds: warren (cumaden) PO, IV heparin or lovenox Sub Q Complications:PE, Stroke=CVA, edema, MI, congestive heart failure Pt Edu discharging: Signs and symptoms VTE lungs, bleeding precautions, electric razors, soft tooth brush, Iv sticks minimization, protect from injury (FALLS)

peripheral vascular disease (PVD)

Valves not working, Pooling and swelling patho: inability to return fluid risk factors: immobility, obesity, pregnancy, thrombophlebitis labs:doppler flow- rolling out VTE, D Dimer test Nursing interventions:no crossing legs, compression stockings, legs elevated above heart 20 minutes 4 times per day Expected findings: leg pain, DVT, varicose veins, lower peritibuial (brown) around ankle Meds:diuretics, medication evaluation to see if its medicine related Complications- ulcers, pulmonary embolism, edema Pt edu: foods without Na, less than 2.3g per day, take meds and food care

VENOUS VS. ARTERIAL ULCERS

Venous Location Between knee and ankle Cause Venous stasis Characteristics Large with irregular borders Beefy red Granular tissue Moderate to heavy exudate Hyperpigmented surrounding skin Pain is decreased by elevating legs Arterial Location On feet/ankles Cause Arterial insufficiency Characteristics Wound margins even and sharply demarcated Pale, gray, or yellow No evidence of new tissue Necrosis Dry, necrotic eschar Painful while exercising, while resting with feet elevated, and at night

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client?

Venturi mask

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Wheezes

PAD (peripheral arterial disease)

blockage of arteries carrying blood to the legs, arms, kidneys and other organs Patho: artheosclerosis, tissue damage, blockage inflow distale aorta, plaques Risk Factors: hypertension, smoking, diabetes, HPL(hyperlipidemia) Treatment:bypass graft around occlusion, ballon stint(PTA stent) Physical exam: pulse low or absence, loss of hair on feet and toes, ulcers on toes lateral materoles (ankle), enter mitten claudication, cold extremities , red dependent rubor pain relived when foot hung off bed( gravity) Gangrene black and shriveled Complications: graft occlusion decreased or absent pedal pulses, graft infection, compartment syndrome= emergency Diagnostic arteriography doppler Meds:antiplatlets (clopedigral) Caspirn(plavics) Alboerstatin(Lipitor) Heparin Mod:stop smoking, DASH diet glucose control

The nurse determines that the patient has stage 2 hypertension when the patient's average blood pressure is (select all that apply) a. 150/96 mm Hg. b. 155/88 mm Hg. c. 172/92 mm Hg. d. 160/110 mm Hg. e. 182/106 mm Hg.

c. 172/92 mm Hg. d. 160/110 mm Hg. e. 182/106 mm Hg.

Hypertrophy

increase in muscle size

Hypertension

increased BP at 140/90 twice systolic or diastolic Patho: weight increase SVR, alter RAAS system, abnormalities normal BP Primary no known cause Secondary has a cause, Higher sodium, smoking, kidney disease, pregnancy, illicit drugs, medications ex birth control oral, steroids, Cushing's syndrome Risk factors: family history, obesity, age greater that 60, ethnicity, African American, hypolibiedmeia, HPL, smoking Findings: no symptoms, secondary symptoms: target organ damage, headache in am, dizziness, facial flushing (red face), fainting, vision changes Labs: BUN 10-20, Creatinine , potassium(electrolytes) Diagnostics- lipid panel, blood glucose, cholesterol studies, chest x ray, CKR, ECG Nursing interventions:Monitor BP, orthostatic pressure less than 20 mm hg, verbal or written BP log, health assessment, diet history of NA Lifestyle Mod: low Na, reduce alcohol less than 2 men and less than 1 women, exercise mod activity 5 days week, smoking cessation, Doctor follow up 3-6 months Treatment:meds antihypertensives, loop dieuretics k+ sparing, K+ wasting ace inhibitors end in PRil, Calcium channel blockers, DASH diet, beta blockers Hypertensive emergency greater than or equal to 180/90 every 5 min BP checked, Nitroproside Iv for BP light sensitive only IV, metabolizes into cyanid High alert and deadly, Nipride given on own pump and line submolents= drowsy, sleepy goal of therapy is to prevent target organ damage

Perfusion

•Definition: The promotion of optimum flow of blood or other fluids through blood vessels with the purpose of supplying nutrients and oxygen to organs or tissues, removing cellular waste, and inclusion of implementation of therapeutic measures used to enhance flow, volume, or removal of waste. •Exemplars: Hypertension Peripheral vascular disease Deep vein thrombosis

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

Increased respiratory rate

Warferin (Coumadin)

Indications: prevents blood clots, used for pt atrial Fib, treatment VTE and PE MOA: Antagonizes vitamin L antidote vitamin K Qquamephytion Pt inr 2-3.0 if more than 3 contact HCP before next scheduled dose Side effects: cramps, nausea, hepatitis food interaction:green leaf vegetables, vitamin K, ginger, ginkgo, garlic

Heparin Iv meds

Indications:VTE profilaxies MOA: prevents new formation of clots and growth of clots, VTE, PE, Afib, Stroke Side effects:Drug induced hepatitis, anemia Adverse reactions: heparin induced thrommbocytopemia Food inter:pork, corn Ancdote: protamine sulfate

PHLEBITIS

Inflammation of the superficial veins of arms and legs, predisposes patient to thrombus Redness, warmth, pain, inflammation Management: warm, moist soaks to dilate vein and promote circulation Usually subsides after a few days Complications: tissue necrosis, infection, or pulmonary embolus

PERIPHERAL ARTERIAL DISEASE Symptoms

Intermittent Claudication - Classic symptom of PAD 6 Ps Pain, pulse, Pallor, Paresthesia, paralysis Thin, shiny, and taut skin Loss of hair on the lower legs

The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route?

Intratracheal

An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron deficiency anemia The normal hemoglobin level for an adult female client is 12-16 g/dL (120-160 mmol/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacit

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?

Maintain a patent airway. Myxedema coma is a rare but serious disorder that results from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics. In myxedema coma, the initial nursing action is to maintain a patent airway. Oxygen should be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route.

VTE MANAGEMENT

Maintain bedrest as ordered Drug therapy includes: Vitamin K antagonists Thrombin inhibitors Indirect thrombin inhibitors: unfractionated heparin Direct thrombin inhibitors: LMWHs Facto Xa inhibitors (ENOXAPARIN-LOVENOX) Low-molecular weight heparin (LMWH) Examples Enoxaparin (lovenox), dalteparin (fragmin), antidote protamine sulfate, monitor platelets periodically Antidote Protamine Sulfate Monitoring Platelets periodically H/H What about a Bubble? air lock Venous Thrombectomy - removal Vena cava interruption Greenfield filter, Vena tech

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily accessible should respiratory depression occur?

Naloxone

BUERGER'S DISEASE (THROMBOANGIITIS OBLITERANS)

Nonatherosclerotic, segmental, recurrent inflammatory vaso-occlusive disorder of small- and medium-sized arteries and veins Often identified with tobacco smoking & predominately in men Nursing interventions to prevent progression of disease No tobacco of any form, avoid vasoconstriction, promote vasodilation, relieve pain Medications Surgical intervention

A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position?

On the left side, with the head lower than the feet Air embolism occurs when air enters the catheter system, such as when the system is opened for intravenous (IV) tubing changes or when the IV tubing disconnects. Air embolism is a critical situation; if it is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the remaining options are inappropriate if an air embolism is suspected.

PAD MANAGEMENT surgical

PTA (percutaneous transluminal angioplasty) Stents Arthrectomy Cryoplasty Peripheral artery bypass Endarterectomy Patch graft angioplasty Amputation

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

Pain, especially with inspiration

VENOUS LEG ULCER

Painful, debilitating, costly Brownish skin discoloration Eczema, "stasis dermatitis" Higher skin temperature in ankle Typically located above the medial maleolus

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

Paradoxical chest movement

Hypertension Nursing Planning

Patient will Achieve and maintain goal BP Follow the therapeutic plan Including HCP appointments Experience minimal side effects of therapy Manage and cope with this condition

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?

Percussion and vibration