Midterm Exam
sexual maturation in girls
- thelarche: appearance of breast buds: 9-13 years - adrenarche: growth of pubic hair on mons pubis: 2-6 months after thelarche - menarche: initial appearance of menstruation, approximately 2 years after the first pubescent changes: average age 12 years 4 months in North America
therapeutic management of ALTE
- theophylline/caffeine - home apnea monitors - family support - CPR training
venous diseases
- thromboembolism - venous insufficiency - varicose veins - phlebitis
toddler personal social behavior
- toddlers develop skills of independence; - skills for independence may result in tyrannical, strong-willed, volatile behaviors; - skills include feeding, playing, and dressing and undressing self - recognize feelings of others, but care about their own feelings more
Coping with Concerns Related to Normal Growth and Development
- toilet training - sibling rivalry - temper tantrums - negativism - regression (regress during periods of stress)
tracheobronchial trauma treatment
- tracheotomy - surgical repair - mechanical ventilation
how to prevent or decrease dysrhythmias for pts with ischemic heart disease
- treat angina promptly with rest and nitro. decreases chance of experience dysrhythmia - if angina not relieved after nitro, seek medical attention - if angina is more severe than normal or you have other symptoms (sweating, nausea, weakness, palpitations) seek medical attention
nurse's role in sex education
- treating sex as normal part of growth and development - questions and answer - differentiation between "sex" and "sexuality" - values, problem-solving skills - open communication with parents
interventions for functional urinary incontinence
- treatment of reversible causes - if incontinence is not reversible, urinary habit training (schedule) - final strategy - containment of urine (absorbent pads, undergarments) and protection of skin - applied device, such as intravaginal pessary - urinary catheterization temporarily
non-modifiable risk factors for heart disease
-Age -Family history -Race: African-Americans have a higher risk -Gender: men have a greater incidence but the incidence increases for women after menopause
venous ulcers: location and appearance
-Ankle area -Brown pigmentation -Ulcer bed pink -Usually superficial, with uneven edges -Granulation tissue present
what does HDL do
-Antioxidative properties -Takes LDL back to liver
beta blockers and DM
-Can mask hypoglycemia symptoms -Prolong hypoglycemia effects of insulin -Not contraindicated, just need to monitor
venous ulcers: history
-Chronic nonhealing ulcer -No claudication or rest pain -Moderate ulcer discomfort -Patient reports of ankle or leg swelling
neobladder and infection
infection is common in pts with neobladder teach s/s of infection and to call immediately
pericarditis
inflammation of pericardium, the sac around the heart NOT infection
phlebitis
inflammation of superficial veins most common is IV therapy s/s redness warmth tenderness management warm, moist soaks complications tissue necrosis, infection, PE
subjective cardiac assessment of child
mother's health - rubella - drugs, ETOH - seizure meds - DM pregnancy, birth history family history - heart problems in family
diabetic ulcers: history
-Diabetes -Peripheral neuropathy -No complaints of claudication
arterial ulcers: location and appearance
-End of toes -Between the toes -Deep -Ulcer bed pale, with even edges -Little granulation tissue
lipid levels chol LDL Trig HDL
chol: <200 LDL: <130, <100, <70 Trig: <150 HDL: >45 men, >55 women
normal lipid profile
cholesterol <200 triglycerides <150 HDL >45 men >55 women LDL <130, <100, <70
why does Na+ increase BP
increases blood volume
PDA is more common in who?
preterm infants genetic disorders (Down Syndrome) babies of mothers who had rubella during pregnancy common in babies who have congenital heart problems such as: - hypoplastic left heart syndrome - transposition of great vessels - pulmonary stenosis
balloon valvuloplasty
procedure that uses a balloon catheter to open narrowed (stenotic) orifices in cardiac valves
severe sepsis:
progression of sepsis with an amplified inflammatory response
teach patients with valve disease the importance of
prophylactic antibiotic therapy before any invasive dental or oral procedure. this includes pts with previous hx of endocarditis and cardiac transplant or valve recipients.
therapeutic management of hypoxemia in kids
prostaglandin E (keep PDA open) respond to TET spells hydration respiratory support
PTT antidote
protamine sulfate
ECG
provides graphic picture of heart's electrical activity
cardiopulmonary bypass during CABG
provides oxygenation, circulation and hypothermia during surgery blood is diverted from heart to bypass machine and back to circulation After procedure: heart is rewarmed and regains rate, rhythm weaned from bypass machine sternum closed
temporary pacing
provides timed electrical stimulus to heart may be delivered to single or dual chambers goal is adequate HR potential pt: decreased HR pt modes: - synchronous (demand) if HR drops below threshold - asynchronous (fixed-rate) all the time
18 months nutrition
rate of growth slows appetite declines, picky eaters, decreased caloric needs and they're too busy to stop and eat spoon, fingers do not force food, meal time should be pleasant 1/4-1/3 adult portion what is eaten is more important than how much is eaten
respiratory alkalosis intervention
rebreathe (paper bag)
what are contraindications for t-PA
recent abdominal surgery (risk of bleeding) recent CVA (hemorrhage)
which temp is most accurate
rectal
types of echocardiography
regular echo Pharmacologic stress echocardiogram Transesophageal echocardiogram (TEE) - through esophagus or stomach - visualizes posterior heart - prep and f/u similar to GI endoscopy (NPO, assess gag reflex)
diastole
relaxation and filling
Extubation
removal of the endotracheal tube
cause of metabolic acidosis
renal failure (most common) DKA hypoxia liver failure
what compensation mechanism is the most powerful?
renal, but they are not triggered unless the imbalance continues for several hours to days
hormonal functions of the kidney
renin angiotensin II prostaglandins bradykinin erythropoeitin vitamin D activation
HTN ACEI nursing implications
report persistent, dry cough (try other med) Monitor BP, orthostatics (vasodilation, decreased BP) hold for systolic <100, check with HCP assess for hyperkalemia (reduced excretion of K+)
puberty is the time period that introduces first signs of what health issues
reproductive health issues
school health in school age child
responsibilities of parents, schools, and health departments routine services - health appraisal - education - communicable disease control - counseling - follow-up care and referral
as the blood pH decreases, the kidneys will
retain HCO3
renal/urinary blood tests
serum creatinine - males 0.6-1.2 - females 0.5-1.1 - increased: kidney failure (can't filter) Blood urea nitrogen (BUN) - 10-20 - increased: renal impairment or dehydration
malignant hypertension, hypertensive crisis definition
severely elevated BP systolic >200 diastolic 130-150
physical growth in adolescence
sexual maturation accompanied by dramatic increases in growth adolescent growth spurt - 20%-25% of total height achieved during puberty - usually occurs within 24-36 months characteristic sequence of changes
side effects of adenosine
significant bradycardia with pauses nausea vomiting have emergency equipment readily available when administering adenosine
many of the manifestations of shock are ______ no matter __________
similar what starts the process
IVGG dose for Kawasaki disease
single dose of 2g/kg over 10 to 12 hours
CAD is
single largest killer of Americans
sinus bradycardia picture
sinus bradycardia picture
sinus tachycardia picture
sinus tachycardia picture
sleep in preschooler
sleep: 12 hours/night - infrequent naps - waking during night: common - night terrors (can't wake, can't interact) - routine!!!
urolithelial cancer interventions
surgery - procedure depends on type and stage - resection of small cancers (cystoscopy with laser or cautery) - complete bladder removal for large, invasive cancers (cystectomy)
coarctation of the aorta: treatment
surgical correction - resection of coarctated area with end-to-end anastomosis - enlargement of area using graft of stent BP stabilization with meds (IV, then oral agent) - pre and post operatively - some may require life-long antihypertensive medication (prevent aneurysms)
statins reduce cholesterol __________ in the ___________ and increase _________ of __________ from the _______.
synthesis liver clearance LDL-C blood
right-sided HF symptoms are
systemic (edema)
behavior in toddlerhood
temper tantrums obstinacy negativism intense period of environmental exploration
when one side of the heart fails, the other
tends to eventuallyf ail
relationships with parents in adolescence
testing relationship with parents - roles change from protection/dependency to mutual affection/equality - process involves turmoil and ambiguity - teenager struggles between privileges and responsibility - emancipation from parents may begin with rejection of parents by teenager
atrial repolarization is hidden in
the QRS complex
cause of hypovolemic shock
total body fluid decreased (in all fluid compartments) hemorrhage trauma GI ulcer surgery inadequate clotting hemophilia liver disease cancer therapy anticoagulation therapy dehydration vomiting diarrhea heavy diaphoresis diuretic therapy nasogastric suction diabetes insipidus
when would kids get PPD testing?
travel outside of country, 6 months after return trade school kids in facilities - psych - juvenile detention - large foster centers
amiodarone adverse effects
tremor, fatigue, peripheral neuropathy, photosensitivity, rarely pulmonary toxicity
T OR F? A patient experiencing severe COPD exacerbation who is at risk for respiratory failure would benefit from BiPAP.
true
true of false? all anti-dysrhythmia drugs are themselves capable of causing dysrhythmias
true
toddler adult height prediction
twice the height at age 2
what drug therapy follows thrombolytic therapy?
typically heparin
cause of mitral valve prolapse
unknown
urolithiasis etiology, what increases risk
unknown although most have metabolic risk factor family history increased risk: - dehydration - urinary stasis - urinary retention - immobility
defibrillation
unsynchronized countershock depolarizes a critical mass of myocardium simultaneously to stop the dysrhythmia and allow SA node to regain control treatment for ventricular fibrillation and pulseless ventricular tachycardia
how much weight is ok for baby to lose after birth
up to 10% of birthweight ok back to birthweight by 2 weeks old
pain management for teething pain
motril/tylenol (6 month old for motrin) NO numbing agents (numbs gag reflex)
s/s of cardiac tamponade
muffled heart sounds edema (JVD) paradoxysmal pulse
Pulmonary artery catheter has and are advanced through
multiple lumens can infuse through some and monitor through others advanced through RA, RV, to pulmonic circulation
MODS
multiple organ dysfunction syndrome
high myoglobin
muscle damage
what is the most serious acute coronary syndrome?
myocardial infarction
elevated troponin indicates
myocardial injury or infarction
MI occurs when
myocardial tissue is severely deprived of oxygen d/t vessel occlusion, usually by a clot
why are children often undermedicated?
myths - infant's don't feel pain - children can tolerate pain better than adults - children cannot tell you where it hurts - children become accustomed to painful procedures - narcotics are more dangerous for children
mitral stenosis
narrowing of the mitral valve
components of the nephron
nephron image
commonly used intravenous vasodilators and inotropes
nitrates - nitroprusside sodium - nitroglycerin - milrinone - fenoldopam sympathomimetics - dopamine - dobutamine
should nurses touch carseats?
no
is edema an accurate sign of HF?
no, daily weights are the most reliable indicator of fluid gain and loss
s/s of mitral valve prolapse
none chest pain palpitations mid-systolic click (dizziness, syncope a/w dysrhythmia)
permanent pacemaker
permanent pacemaker - intended to treat permanent conduction disorders - surgeon implants pulse generator in right or left subclavian area, introduces lead wires through central vein follow up care - monitor HR - assess/care for site - limit activity
knows address + phone numbers
5 years
stays calm when left w/ stranger
5 years
uses pretend play
5 years
pulmonary artery diastolic pressure
5-15 mmHg
pulse 12 years and older
50-90
good grasp of objects with fingers
9 months
rib fracture treatment
- not usually splinted - decrease pain to maintain adequate ventilation
holds 2 objects 1 in each hand
9 months
imitates speech sounds
9 months
reacts to quiet noises
9 months
says mama and dada
9 months
understands a few words
9 months
uses a cup
9 months
by age 3-4 months, nocturnal sleep lasts how long
9-11 hours
vaccine schedule
birth Hep B 6 weeks-2 months Hep B IPV DTaP HiB PCV13 Rotavirus 4 months IPV DTaP HiB PVC13 Rotavirus 6 months IPV DTaP HiB PCV13 Rotavirus Hep B Flu 12 months Hep A Varicella MMR
measuring weight
birth through 36 months, weight naked on platform scale
Buerger's Disease: assessment
- claudication in feet and lower extremities worse at night - causes ischemia and fibrosis of vessels in extremities with increased sensitivity to cold - ulcerations and gangrene on digits - cause unknown but is associated with smoking
tension pneumothorax causes
- complete collapse of affected lung - air collects and compresses blood vessels, limiting venous return (decreased CO, decreased filling of heart) - may be quickly fatal
pulse rates for different ages
birth to 1 week: 100-160 1 week to 3 months: 100-220 3 months to 2 years: 80-120 2 years to 12 years: 70-110 12 years and older: 50-90
UTI symptoms in the older adult
- confusion - frequent, unexplained falls - sudden onset of incontinence or worsening incontinence - fever, tachycardia, tachypnea, hypotension (urosepsis) - loss of appetite - nocturia - dysuria
urolithelial cancer is
bladder cancer
what s/s would be concerning following cardiac cath
bleeding cool extremity dimished pulse etc
aortic valve replacements - be alrt for
bleeding because of higher risk for postoperative hemorrhage
symptoms of alkalosis
↑ CNS twitching seizures numbness of lips, toes, fingers irritability tetany ↑ reflexes ↑ Heart rate increased digitalis toxicity
fears in preschooler
- dark - being left alone - animals (large dogs) - ghosts - objects/people associated with pain - be honest in healthcare setting - fears are often associated with misperception and inability to separate reality from imagined
what direction do children grow
cephalocaudal and proximal distal
obesity in adolescence
- defined as increase in body weight caused by accumulation of excessive body fat in relation to lean body mass - obese: BMI >95th percentile for age, gender, and height - overweight: BMI between 85th and 95th percentile - proportion of obese children and adolescents: 17%
estrogen
- feminizing hormone - low quantities during childhood - boys: gradual production through maturation - girls: increases until about 3 years after menarche - girls: levels then remain at this maximum throughout reproductive life
Subclavian Steal Assessment
- occurs in upper extremities as result of subclavian artery occlusoin or stenosis causing ischemia in the arm and pain - paresthesias and dizziness are also common - BP differences in arms and presence or subclavian bruit on affected side
how to introduce new foods
- one at a time - one every 4-7 days - timing - problems: constipation, vomiting, rash, fussiness - veggies, then meat - breastmilk is still primary source of nutrition
acute arterial occlusion cause/assessment/meds
- onset of symptoms occurs suddenly - embolus: most common cause - assessment: 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cold)) - drug therapy: ???, clot busters, abcixamab - surgery: thrombectomy, embolectomy
flail chest manifestations
dyspnea chest pain anxiety tachycardia paradoxical chest movement
decreasing fatigue in HF nursing interventions
- organize care to provide rest - increase activity gradually and monitor closely teaching: - balance activity and rest - nap to restore energy - recognize energy limitations - conserve energy - adapt lifestyle to energy level - report adequate endurance for activity
acute respiratory failure assessment
dyspnea orthopnea decreased pulse oximetry hypoxemia hypercarbia looks like respiratory acidosis!
s/s of aortic stenosis
dyspnea, syncope with exertion, fatigue, murmur
primary sex characteristics
external and internal organs necessary for reproduction
FTT
failure to thrive
kidney stones and genetics
family history is strong indicator for likelihood of getting a stone
digoxin action for HF
increase force of contractility, reduce HR
PaCO2 in shock
increased anaerobic metabolism
lactic acid (lactate) (arterial) in shock
increased anaerobic metabolism with buildup of metabolites
potassium in shock
increased dehydration acidosis
L-sided HF HR
increased or may alternate in strength: pulsus alternans irregular rhythm
relationship between K+ and HR
increased K+ = decreased HR decreased K+ = increased HR K+ is a cardiac depressant
shock respiratory symptoms
increased RR shallow depth of respirations increased PaCO2 decreased PaO2 cyanosis, especially around lips and nail beds
L-sided HF respiratory assessment
increased RR, decreased SaO2
what lab changes occur with pericarditis?
increased WBC possible ECG changes
R-sided HF abdomen
increased abdominal girth
birthweight and rate of cardiac issues
increased brithweight = increased rate of cardiac issues
ventricular septal defect
- VSD - opening between ventricles - acyanotic - left to right shunt - s/s - crackles - treatment: may close spontaneously. complete surgical repair favored - other treatment: pulmonary artery banding, device closure during cath
Raynaud's Phenomenon/Disease Interventions
- Vasodilating drugs, such as nifedipine - management of ulceration and gangrene - chronic pain management modalities same as Buerger's
Buerger's Disease: Interventions
- Vasodilating drugs, such as nifedipine - management of ulceration and gangrene - chronic pain management modalities same as Raynaud's
urine casts
increased indicates bacteria, protein, or urinary calculi
coarctation of the aorta causes
increased pressure to head and upper extremities decreased pressure to lower extremities
anticipatory guidance: care of families in school age child
- parents adjust to child's increasing independence - parents provide support as unobtrusively as possible - child moves from narrow family relationships to broader world of relationships
ARDS Phase 2 manifestations
- patchy infiltrates form from increasing pulmonary edema
personal-social behavior in preschooler
- ritualism and negativism of toddlerhood diminish - child can dress self - child is willing to please - child has internalized values and standards of family and culture - child may begin to challenge family's code of conduct
diabetic ulcers: treatment
- rule out major arterial disease - control DM - pt education re foot care - prevent infection
play in school age child
- rules and rituals - team play - quiet games and activities - ego mastery
causes of high pressure ventilator alarm
increased secretions anxiety airway is displaced tubing is obstructed biting on ET tube
infective endocarditis key features
- fever w/ chills, night sweats, malaise, fatigue - anorexia and weight loss - cardiac murmur (new or changed) - development of HF - evidence of systemic embolization - petechiae - splinter hemorrhages - Osler's nodes (on palms of hands/soles of feet. painful) - Janeway's lesions (flat, reddened maculae on hands and feet) - positive blood cultures
why is a temp in a child under 12 weeks such a big deal
- few vaccines blood and urine cultures chest x-ray CBC lumbar puncture
inventions of new means through mental combinations
- final sensorimotor stage: 19-24 months - object permanence advances - domestic mimicry - concept of time: still embryonic
attention span and memory in preschool years
increases
symptoms of left sided heart failure
**L for lungs Pulmonary congestion • cough • crackles • wheezes • hemoptysis • tachypnea S3 heart sound Restlessness Confusion Tachycardia Exertional dyspnea Fatigue Cyanosis Paroxysmal nocturnal dyspnea Elevated pulmonary capillary wedge pressure
safety promotion and injury prevention in preschooler
- safety education - increase in pedestrian-MVA - education concerning safety and potential hazards - appropriate protection (helmets, protective equipment)
Thoracic Outlet Syndrome
- Compression of subclavian artery by rib or muscle that is more common in women and those who have to keep arms moving or above their heads (golfers, swimmers) - also present with trauma - causes neck, arm, and shoulder pain with numbness and possible cyanosis
changes in the renal system related to aging
- Decreased GFR, - nocturia, - decreased bladder capacity, - weakened urinary sphincter and shortened urethra and women, - tendency to retain urine
offer what after med administration
juice or snack (opportunity for choice) - food not a great reward
HF Increasing gas exchange actions
- O2 to maintain >90% - if dyspneic, high fowler's with pillows under each arm to maximize chest expansion - reposition and perform coughing and deep-breathing exercised every 2 hours (improve gas exchange and prevent atelectasis)
Thoracic Outlet Syndrome Interventions
- PT for exercise program - avoiding aggravating positions - surgery as last resort for severe pain
Raynaud's Phenomenon/Disease Assessment
- Painful vasospasms of arteries and arterioles in extremities, especially digits - causes red-white-blue skin color changes on exposure to color or stress - cause unknown, occurs more in women, and may be autoimmune b/c a/w many rheumatic diseases such as systemic lupus erythematosus
inferior vena cava filtration
- device inserted into femoral vein - traps emboli before entering heart, lungs
INR normal range
0.8-1.1
how long do you have to correct the progressive stage of shock
1 hour or less continuously monitor and compare with earlier findings to assess therapy effectiveness and determine when therapy changes are needed
height increases in infancy
1 inch per month x 6 months
building tower of two blocks by
1 year
no cow's milk before age
1 year
walking alone by
1 year
why is a calm approach important for pt with MI
keeps pt calm anxiety increases SNS which increases HR and causes vasoconstriction, increases O2 demands, worsens ischemia
grasping objects age
1-2 months (reflex) gone by 3 months
head circumference and chest circumference are equal when?
1-2 years
Troponin I normal range
< 0.03 ng/mL
modes of ventilation
1. AC - Assisted Control - ventilator takes over work of breathing - delivers pre-set # of breaths at a set tidal volume 2. SIMV - synchronized intermittent mandatory ventilation - tidal volume and ventilatory rate are preset - allows spontaneous breathing at the pt's own rate and tidal volume between breaths - used as a ventilatory mode or as weaning mode 3. BiPAP - Bilevel positive airway pressure - provides noninvasive pressure support ventilation - nasal or face-mask is worn - keeps airway open with less pressure than CPAP
drug therapy for PE
1. Anticoagulants - prevents enlargement of clot and development of new clots - when contraindicated??? - Heparin is often initial agent: interferes with clotting cascade (monitored by PTT - normal: 20-30 or 30-40) (therapeutic goal is 1.5-2.5 times control) - others: enoxaparin (Lovenox) (low molecular weight heparin) (given subq, don't push air out of needle, don't massage) 2. Fibrinolytic agents (Activase, tPA) - used if massive PE (obstructing blood flow to a lobe) or hemodynamic instability (BP is not maintained) - bread up clot - contraindications??? heparin therapy follows for a few days Oral anticoagulant is begin: warfarin (Coumadin) - inhibits production of certain clotting factors in the liver - monitored by INR, PT (goals is 2-3) - enoxaparin (Lovenox) given until warfarin gets upt o therapeutic level New agents: apixaban (Eliquis), rivaroxaban (Xarelto) - no antidote - no blood tests
steps to reading ECG
1. rate 2. rhythm (regular/irregular) 3. P waves present? occurring regularly? one for each QRS? smooth, rounded, upright? all look similar? 4. PR interval 0.12-0.20 seconds 5. QRS duration 0.04-0.10 seconds 6. ST segment elevated? depressed? 7. T wave peaking? inversion? 8. QT interval < or = to 1/2 RR interval
Troponin T normal range
< 0.10 ng/mL
D-dimer normal range
<0.5 mcg/mL or <200 ng/mL ??
C-reactive protein normal range
<1.0 mg/dL
LDL normal range
<130, but <100 is better
normal cholesterol
<200 mg/dL
bradydysrhythmia rate
<60
tachydysrhythmia rate
>100
complications of arterial catheter
???
causes of undereliminiation of hydrogen ions what does this cause
kidney failure metabolic acidosis
Risk factors for PE
1. abnormal bloodflow - prolonged immobilization (poling, platelet aggregation) 2. Injury to blood vessel wall - central venous catheters - sugery - smoking 3. Hypercoagulability of blood - advanced cancer - pregnancy
what helps maintain normal pH range in body
1. buffers 2. lungs 3. kidneys
2 groups of cardiovascular dysfunction
1. congenital: anatomic abnormalities present at birth - check which ones 2. acquired: result from - infection - autoimmune response - environmental factors - familial tendencies
examples of kinds of ECG
1. continuous ambulatory (Holter monitor) 2. Exercise ECG (stress test) 3. 30-day event monitor
digoxin action
1. decrease heart rate 2. Increases force of contraction
ECG rhythm analysis steps
1. determine the HR 2. determine the heart rhythm - use calipers to assess P-P intervals and R-R intervals: are they the same? 3. analyze the P waves - are P waves present? - are P waves occurring regularly? - Is there a P wave for every QRS complex? - Do P wave appear normal, look similar? 4. measure the PR interval: impulse from atrial depolarization to ventricular depolarization - 0.12-0.20 seconds? - are all measurements the same? 5. measure the QRS duration - 0.04-0.10 seconds? - are all measurements the same? - do all appear similar? 6. interpret the rhythm
main med classes for BP control
1. diuretics 2. ACEI 3. Ca+ channel blockers
identification of the phlebostatic axis
1. position pt supine 2. palpate the 4th intercostal space at the sternum 3. follow 4th intercostal space to the side of the pt's chest 4. determine the midway point between anterior and posterior 5. find the intersection between the midway point and the line from the 4th intercostal space and mark it with an X in indelible ink. This is the phlebostatic axis
3 ways that inspiration is cycled
1. pressure-cycled: pushes air until a pre-set pressure is reached 2. time-cycled: pushes air for a pre-set period of time 3. volume-cycled: pushes pre-set volume of air (avg 6-8 mL/kg)
3 types of valvular heart disease
1. stenosis (narrowing) 2. regurgitation 3. prolapse
what causes acute respiratory failure?
1. ventilatory failure 2. oxygenation failure or combination
MI: necrosis development
1. zone of ischemia 2. zone of injury 3. zone of necrosis necrotic tissue will expand without treatment
a serum creatinine of _________ or greater places a patient at risk for AKI from iodinated contrast media and some drugs.
1.5
head circumference increases at a rate of
1.5 cm for the first 6 months and then 0.5 cm for the next 6 months
walks
12 months
anterior fontanel closes by
12-18 months
metformin and kidneys
make sure the pt who takes metformin does not receive the drug after a procedure requiring IV contrast material until adequate kidney function has been determined
ventilated pt: perform mouth care every
2 hours
check ventilated pt for need for tracheal, oral, or nasal suctioning every
2 hours and suction as needed
coos
2 months
follows to midline
2 months
what does aspirin do to platelets?
makes them less sticky
risk factors for SIDS
male preterm low birth weight low apgars viral illness family history of SIDS ethnicity
normal PaCO2
35-45 mmHg
normal HCO3
22-28 mEq/L
toddler height increase rate
3 inches/year
75% speech understood by others
3 years
ask why, what
3 years
attempts to dress self
3 years
balance on one foot
3 years
can identify 2 picture-animals
3 years
•Prioritize the following nursing diagnoses: 1. Fatigue 2. Decreased cardiac output 3. Impaired gas exchange ______,______,_______ •Primary collaborative problem: Potential for pulmonary edema
3,2,1
preschool age range
3-5
plays with hands-touch together
4 months
reaches for object
4 months
recognize parents voice
4 months
adds "s" to make words plural
4 years
draws person w/ at least 3 body parts
4 years
hops on 1 foot
4 years
nearly 100% speech understood
4 years
plays games taking turns/rules
4 years
wash dry hands w/o help
4 years
HF nursing care
Assist to improve cardiac function monitor afterload reduction decrease cardiac demands reduce respiratory distress maintain nutritional status assist to promote fluid loss support child/family
chronic peripheral arterial disease stage I
Asymptomatic no claudication bruit or aneurysm may be present pedal pulses are decreased or absent
s/s of mitral valve regurgitation
Asymptomatic for years. chest pain fatigue DOE orthopnea irregular rhythm murmur
tetralogy of fallot definition
4 defects pulmonary stenosis VSD overriding aorta right ventricular hypertrophy
follows parents-turns head
4 months
gurgles, coos, babbles
4 months
holds head steady
4 months
laugh w/out tickle or touch
4 months
lift chest w/ arm support
4 months
places objects in mouth by
4 months
roll abdomen to back by
4-5 months
roll from back to side by
4-5 months
when can kids learn to swallow pills
4-5 years old fear of choking is the main issue
toddler weight gain
4-6 lbs/year
identify objects by color
5 years
total lipid range
400-1000 mg/dL
national obesity guidelines
5 fruits and vegetables 2 hours of recreational screen time 1 hour of activity 0 sugary beverages 10 hours of sleep
National Obesity Prevention Guidelines
5 fruits and vegetables 2 hours or less of screen time 1 hour or more of physical activity 0 sugar sweetened beverages
answers ?s what want, if cold/tired
5 years
A 21 year old male reports burning with urination. Which question would a nurse consider to be a priority? A "Are you sexually active?" B "Have you had a fever?' C "How long have you had this symptom?" D "Do you have low back pain?"
A "Are you sexually active?"
pulmonary contusion
A bruise of the lung.
/s of inadequate organ perfusion
may be the result of decreased CO - a change in orientation or mental status - urine output < 0.5-1 mL/kg/hr - cool, clammy extremities with decreased or absent pulses - unusual fatigue - recurrent chest pain
is combined metabolic and respiratory acidosis more or less severe than only one?
more severe
acute respiratory failure is based of what lab values?
ABGs: PaO2 SaO2 PaCO2 pH
Lisinopril is
ACE inhibitor
reducing afterload meds
ACE inhibitors (angiotensin converting enzyme inhibitors) - LISINOPRIL, Enalopril, Fosinopril, Ramipril - stops RAA pathway - vasodilator - blocks aldosterone release ARBs (angiotensin receptor blockers) - LOSARTAN, Valsartan, Irbisartan - blocks receptors on artery vessel alls - blocks vasoconstrictor hormones
MI: which arteries affect what?
LAD obstruction causes anterior MI
which kind of cholesterol is worst
LDL
what makes up a normal ECG?
P wave PR interval QRS complex ST segment T wave U wave QT interval
what part of ECG waveform is affected in atrial dysrhythmias?
P-wave
high pressure ventilator alarm means
PIP is too high
therapeutic management of plagiocephaly
PT for 4-8 weeks and then helmet clinic then craniofacial surgeon
how is warfarin therapy monitored?
PT/INR
warfarin lab test
PT/INR
labs to monitor for heparin
PTT Platelet: assess for heparin-induced thrombocytopenia (HIT)
how is heparin monitored?
PTT or aPTT
3 weaning methods
SIMV: synchronous intermittent mandatory ventilation T-Piece Technique PSV: Pressure Support Ventilation
MI: hypoxia leads to _________. What is effect?
SNS activation increased HR vasoconstriction increased contractility MALADAPTIVE
effect of infarction on ECG
ST elevation (STEMI) T wave inversion non-ST elevation (NSTEMI) Abormal Q wave
sodium foods
Salt, canned foods, pickles, cold cuts, and soy sauce
postpubescence definition
period of 1-2 years after puberty; skeletal growth is complete; reproductive functions become well established
nuclear perfusion imaging tests
Technetium scan - dye injected - camera scans heart to identify areas of increased uptake (dye accumulates in damages tissue) thallium may also be used may be performed at rest or during exercise using Dipyridamole (Persantine) can measure ejection fraction
prepubescence definition
period of approximately 2 years before onset of puberty; preliminary physical changes occur
pallor with elevation and dependent rubor occur with what disorder?
peripheral arterial disease
surgical management of dysrhythmias
permanent pacemaker ICD (implantable carioverter/defibrillator)
PT used for what med
warfarin
treatment for a-fib: meds
warfarin beta blockers Ca+ channel blockers Eloquis
comfort measures for cystitis
warm sitz bath or tub bath
a-fib
what is this
asystole
what is this
stemi
what is this
heart block
what rhythm is this
when is coarctation of the aorta noticed?
when the DA closes asymptomatic at first. when DA closes, rapid deterioration 4 BPs to screen on premature babies (2 arms, 2 legs)
when is rib fracture diagnosis worrisome
when there are multiple rib fractures - makes it unstable
when can babies have solid food
when they have: - head control - lost extrusion reflex
Denver Developmental Screening Test
An instrument used to assess the development of children between birth and 6 years of age. lengthy
commonly used drug classifications for patients with systolic heart failure
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) Diuretics - high-ceiling - potassium-sparing Human B-type natriuretic peptides Nitrates Inotropics - Beta-adrenergic agonists - Phosphodiesterase inhibitors - calcium sensitizers - Digoxin (Lanoxin) Beta-adrenergic blockers Angiotensin receptor neprilysin inhibitor (ARNI) - sacubitril/valsartan (Entresto) Aldosterone antagonist HGN channel blocker - Ivabradine (Corlanor)
lidocaine mode of action
Antidysrhythmic slow depolarization, used for ventricular dysrhythmias
•Atropine___________ •Metoprolol___________ •Amiodarone__________ •Epinephrine__________ A Asystole B Ventricular tachycardia C Sinus tachycardia D Complete heart block
Atropine: complete heart block (needs pacemaker) metoprolol: sinus tachycardia amiodarone: ventricular tachycardia (with pulse) epinephrine: asystole
therapeutic management of other substances
acute care rehab long-term management family support prevention
morphine nursing concern
administer IV, usually 1-5 mg doses every 5 to 30 minutes
physical assessment of vascular problems (steps)
BP pulses cap refill bruit circulatory, sensory, motor (CSM) function
options for valvular surgery
Balloon valvuloplasty Commisurotomy Annuloplasty Replacement procedures Biologic valves Prosthetic valves
urinary/renal studies (not blood or urine tests)
Bedside bladder scanner Special diagnostic tests - x-ray of kidney, ureter, bladder (KUB) - IV urography (not common). IV contrast as it progresses through urinary tract - CT scan/MRI (contrast through kidneys) - Renography, renal angiography (renal blood flow) Urodynamic studies - assess voiding and urine flow (bladder pressure as it fills, bladder emptying Cytoscopy (look into bladder w/ a scope) Purpose: - Dx: evaluate mucosa, biopsy - Treatment: remove/treat lesions, stones Preparations: - teaching, informed consent, NPO, bowel prep Procedure: - cytoscope introduced through urethra, advanced into bladder, ureters F/U care: - VS, urine pink tinged expected - hydration - complications: bleeding, infection Renal biopsy Preparation: - teaching: performed percutaneously. Pt is awake, though sedated. Informed consent. - Labs: H&H, platelets, PT/INR Procedure: Post-procedure care: - monitor dressing, VS, I/O, labs (H&H, PT/INR, Plt) - bedrest for 2-6 hours - avoid heaving lifting, exercise for 1-2 weeks - highly vascular - risk of bleeding
metoprolol action
Blocks beta-adrenergic receptor sites in the heart, lungs and blood vessels. The beta 1 blocking action on the heart decreases heart rate, conduction velocity, myocardial contractility and cardiac output. The beta 2 effects may cause bronchoconstriction
Lisinopril action
Blocks the conversion of angiotensin I to the vasoconstrictor angiotensin II which will help cause vasodilation
ETOH and bleeding
ETOH injures platelets, increases risk of bleeding
when do valve disease pts NOT need prophylactic antibiotics?
GI procedures upper GI endoscopy colonoscopy procedures requiring genitourinary instrumentation
elevated cholesterol indicates pt it as risk for
CAD
elevated lipids put pt at risk for
CAD
elevation in triglycerides indicates pt at risk for
CAD
possible causes of dysrhythmia
CAD HF electrolyte imbalance changes in oxygenation drug toxicity
CO equation
CO = HR x SV
why does smoking increase atherosclerosis risk?
CO is an irritant to vessel wall (carbon monoxide) cholesterol sticks to places on vessel that are damaged
what is a product of cellular metabolism?
CO2
v-fib treatment
CPR - trying to achieve CO Immediate defibrillation - causes myocardium to depolarize at once, allows SA node to regain pacemaker role
defibrillation steps
CPR should already be going "CLEAR!" check that everyone is clear deliver shock, start CPR for 5 cycles (2 min) reassess rhythm every 2 minutes and if indicated charge, reshock with same energy level during CPR, give meds/interventions
diagnosis of abdominal aortic aneurysm
CT scan or ultrasound x-ray of abdomen or spine evidences eggshell appearance aortic arteriography
dramatic play
Children's creation of scenes when they play "pretend"
Potassium foods
Citrus fruits, bananas, watermelon, potatoes, nuts, chocolate, salt substitutes, colas, milk, tomatoes and cooked greens
chronic peripheral arterial disease stage II
Claudication Muscle pain, cramping, or burning occurs with exercise and is relieved with rest symptoms are reproducible withe exercise
interventions for metabolic alkalosis
Correct underlying disorder Prevent further losses of hydrogen, potassium ions - antiemetics Restore fluid balance Monitor changes
Interventions for metabolic acidosis
Correct underlying problem Hydration Drugs - insulin to treat DKA - antidiarrheal drugs - bicarbonate if serum bicarbonate levels are low
sepsis =
widespread infection! infection escapes local control
A nurse is caring for a patient with ARDS who was extubated 2 hours ago. The nurse compares the patient's current assessment with the assessment documented in the patient's record 1 hour ago. The nurse's best response is to: Prior findings: RR 16, SaO2 93%, Ventimask set at 25% Current findings: RR 20, SaO2 92%, Ventimask set at 30% A Place the patient in a prone position. B Obtain an arterial blood gas (ABG). C Notify the MD. D Document findings and re-evaluate the patient in 30 min.
D Document findings and re-evaluate the patient in 30 min.
Cholesterol lab values
adult recommended ranges: cholesterol - <200mg/dL; HDL - males >45mg/dL - females >55mg/dL; LDL - >130 triglycerides- - males 40-160mg/dL in males - females 35-135mg/dL in females VLDL - 7-32 ng/dL C-reactive protein - <1.0 mg/dL
indicators of risk factors for metabolic syndrome
HT BP >130/85 or taking antihypertensives Decreased HDL (often with high LDL) HDL <45 men or <55 women or taking antihyperlipidemics Increased triglycerides >or= 160 men or 135 women or taking anticholesterol drugs Increased fasting blood glucose > 100 or taking antidiabetic drugs Large waist size >or= 40" men or >or= 35" women
s/s of aortic regurgitation
DOE Orthopnea Paroxysmal nocturnal dyspnea Palpitations Angina Bounding pulse Widened pulse pressure
where do most PEs originate
DVT in leg or pelvis
valvular heart disease nursing diagnoses
Decreased CO r/t altered SV Impaired gas exchange r/t V/Q imbalance Activity intolerance r/t inability of the heart to meet metabolic demands during activity Acute pain r/t physiological injury agent (hypoxia)
L ventricular failure key features
Decreased cardiac output - fatigue - weakness - oliguria during the day (nocturia at night) - angina - confusion, restlessness - dizziness - tachycardia, palpitations - pallor - weak peripheral pulses - cool extremities Pulmonary congestion - hacking cough, worse at night - dyspnea/breathlessness - crackles or wheezes in lungs - frothy, ping-tinged sputum - tachypnea - S3/S4 summation gallop
biggest concern in Kawasaki Disease
Development of coronary artery aneurysms Potential for MI - d/t thrombotic occlusion of coronary aneurysm
digoxin adverse effects
Digoxin toxicity (visual halos, GI upset, vomiting, lethargy, altered mental status, death); bradycardia hypokalemia potentiates digoxin toxicity elderly at higher risk
B-type natriuretic peptide (BNP)
Heart ventricles secrete BNP hormone in response to volume expansion and pressure overload. Congestive heart failure causes vasodilatin and diuresis through sodium loss
what vaccines are recommended for babies?
Hep A and B Diptheria Tetanus Pertussis Polio Measles, mumps, rubella Pneumococcus Haemophilus influenzae B Varicella (chickenpox) influenze rotavirus
coarctation of aorta assessment
High BP and bounding pulse in UE Weak/absent pulse in LE (including femoral) Murmur, which is harsh-sounding, can be hard from back Other s/s may not occur until child is older
infectious conditions in preschooler
Immunizations - IPV and DTaP - MMR (increased risk of febrile seizure, live) Communicable diseases - incidence has declined with increase of immunizations - complications have decreased with use of antibiotics and antitoxins - handwashing
PE pathophysiologic events
Impaired gas exchange - low O2 Vasoconstriction - ???
interventions for respiratory acidosis
Improve ventilation - HOB up Drug therapy - albuterol - solumedrol - prednisone (check this) Oxygen therapy Ventilation support Prevent complications
who is at higher risk for kidney failure than white americans?
african americans
complications for pt on vent: lung
Lung - damage to lungs by pressure (barotrauma) - damage to lungs by excess volume (volutrauma)
do men and women have similar symptoms of MI?
NO
reduce preload interventions
NUTRITION low sodium DRUG THERAPY (diuretics) Loop Diuretics - FUROSEMIDE, Torsemide - give in morning - watch for hypokalemia Thiazide Diuretics - HCTZ, Metolazone (Zaroxolyn) - more for BP control than HF
chronic peripheral arterial disease stage IV
Necrosis/Gangrene ulcers and blackened tissue occur on the toes, forefoot, and heel distinctive gangrenous odor is present
passive parenting style
Parents are uninvolved, indifferent, and emotionally removed
antidote for heparin
Protamine
teach pt to report s/s of worsening or recurrent heart failure:
Rapid weight gain - 3 lb/week or 1-2 lb overnight Decrease in exercise tolerance for 2-3 days Cold symptoms >3-5 days Nocturia Dyspnea or angina at rest Worsening angina Edema
ROME acronym
Respiratory Opposite Metabolic Equal
stroke volume
The amount of blood ejected from the heart in one contraction.
therapeutic management of Infective Endocarditis
Therapeutic management - PO penicillin before dental procedures - IV antibiotics to treat acute infection
Serum lipids
Total cholesterol < 200 mg/dL Triglyceride < 150 mg/dL HDL > 40 mg/dL LDL < 70 mg/dL for cardiovascular patients
rheumatic fever meds
Treatment of strep infection - Penicillin G, IM x 1 injection - Penicillin V, oral x 10 days - Sulfa, oral x 10 days (if cillin allergy) - Erythromycin (if allergic to above), oral x 10 days Treatment of recurrent RF - same meds as above Prophylaxis - daily oral PCN, monthly I PCN, daily oral sulfa
labs for MI
Troponin CK-MB (creatinine kinase MB) Myoglobin (no specific to heart muscle)
Serum Markers of Myocardial Damage
Troponin T Troponin I Creatine Kinase (CK) Myoglobin
bloodwork for cardiovascular testing
Troponin T and I CK Myoglobin Serum lipids hsCRP (highly-sensitive C-reactive protein) BUN, creatinine Electrolytes: K and Na Coagulation studies: aPTT/PTT, INR/PT ABG analysis CBC
essential (primary) hypertension risk factors
age >60 (vessels thicken and harden) family history overweight physical inactivity excessive ETOH intake hyperlipidemia african american ethnicity high intake of Na+ or caffeine reduced intake of K+, Ca+, Mg+ smoking stress
gay/lesbian family
Two members of the same sex who have children and a legal or common-law tie
MI: assess__________
VS ABGs ECG chest pain
sinus bradycardia
Which rhythm is this?
sinus tachycardia
Which rhythm is this?
solitary play
a child plays alone, unaware of any other children playing nearby
pericardial effusion
a collection of fluid between the pericardial sac and the myocardium
a higher percentage of __________ than ____________ have hypertension until _________ years of age. From ages ____ to ________, the percentages of men and women with hypertension are ______. After age ___, ______ have a higher percentage of the disease. The causes for these differences are ____________.
a higher percentage of __men________ than ___women_________ have hypertension until ___45______ years of age. From ages __45__ to ___64_____, the percentages of men and women with hypertension are ______. After age _64__, __women____ have a higher percentage of the disease. The causes for these differences are ___not known_________.
renin-angiotensin-aldosterone system
a hormone cascade pathway that helps regulate blood pressure and blood volume
contractility
ability of heart muscle cells to contract in response to electrical stimulation
bruit indicates
abnormal, turbulent bloodflow
metoprolol is
beta blocker
Metoprolol mode of action
beta blocker inhibits sympathetic nervous system effects, thys slow heart rate
adolescence is the transition
between childhood and adulthood
what do buffers do for pH
bind hydrogen ions when they are excessive and release hydrogen ions when not enough are present
protective factors for SIDS
back to sleep (SIDS at all time low 0.57/1000 births) breastfeeding pacifier
hypoxemia - base off of what for kids neonate level
base off of baseline and physical exam findings neonate 94% = emergency
drowning risks for infants
bathtub buckets dry drowning toilet (close bathroom doors)
After valvuloplasty, observe the patient closely for
bleeding from the catheter insertion site and institute post-angiogram precautions. bleeding is likely because of the large size of the catheter assess for signs of a regurgitant valve by closely monitoring heart sounds, CO, and heart rhythm observe for systemic emboli (clots could have been dislodged)
puberty definition
development of secondary sex characteristics
pt with sinus tachycardia, what should nurse assess for?
fatigue weakness SOB orthopnea decreased SpO2 increased HR decreased BP restlessness/anxiety (cerebral perfusion) decreased urine output (impaired renal perfusion) anginal pain palpitations T-wave inversion or ST elevation/depression on ECG r/t myocardial ischemia
pain is often associated with
fear, anxiety, and stress
contributing factors to UTI
female poor hygiene dehydration sex incomplete emptying of bladder BPH holding urine
myocardial necrosis evolves over
hours Reverse the cause!
apsirin intended effect
inhibit platelet aggregation
aspirin action
inhibits platelet aggregation and vasoconstriction, decreasing clot formation often recommendation is to chew side effect: bleeding
furosemide action
inhibits reabsorption of sodium and chloride in the loop of Henle and distal renal tubules diuretic
lead and iron
inverse relationship
in oxygenation failure, ventilation is _________ but _______________ is decreased
normal lung perfusion
normal sinus rhythm
normal sinus rhythm
metabolic acidosis pathology
overproduction of hydrogen ions underelimination of hydrogen ions underproduction of bicarbonate overelimination of bicarbonate
HF assessment
physical assessment psychosocial assessment imaging assessment ECG hemodynamic monitoring assessments
prevention of coronary artery disease
smoking quit diet limit fats limit cholesterol limitsodium cholesterol check lipids regularly statins for elevated LDL physical activity moderate 3-4 x/week work up to it DM manage HT check regularly manage Obesity avoid fad diets limit saturated fats, sweets, cholesterol increase physical activity
S1
the first heart sound, heard when the atrioventricular (mitral and tricuspid) valves close
heart failure is
the inability of the heart to work effectively as a pump
MI symptoms in women
-nausea -lightheadedness -epigastric burning -sudden onset of weakness or unexplained tiredness -pain may radiate down right arm instead of left
urine protein
0-0.8 increased: stress, infection, recent strenuous exercise, glomerular disorders
follows visually
0-1 month
good suck
0-1 month
makes vocalizations
0-1 month
moves all extremities well
0-1 month
responds to sounds
0-1 month
nutrition birth - 1 year
0-6 months, breast is best, Fe fortified formula is ok no milk under 1 year (not easily digested, lack of componenets needed for growth) no solids before 4-6 months
ECG each small block is how long
0.04 seconds
normal QRS duration
0.04-0.12 seconds 0.12 is too long
normal PR interval length
0.12-0.20 sec
ECG each large block is how long
0.20 seconds
how long does it take for the lungs to start compensating for changes in pH
1-3 minutes
altered hemodynamics in the heart
1. blood flows from area of high pressure to an area of low pressure 2. blood flow takes path of least resistance
what are the three mechanisms to control pH in body
1. buggers 2. lungs 3. kidneys
factors that change in blood flow before and after birth
1. high pulmonary vascular resistance caused by collapsed fetal lungs - increased pressure on right heart and pulmonary arteries 2. clamping of umbilical cord = expansion of lungs 3. change in pressure due to placental removal = DA + FO close - ducturs arteriosis and foramen ovale
classification of heart defects
1. increased pulmonary blood flow (acyanotic) (blood flow from left to right side of heart) - atrial septal defect - ventricular septal defect - patent ductus arteriosis 2. obstructive (blood flow is obstructed d/t narrowing) - coarctation of aorta 3. decreased pulmonary blood flow (cyanotic) (deoxygenated blood flows from right to left side of heart) - tetralogy of fallot 4. mixed (survival depends on mixing of blood) - transposition of great vessels - hypoplastic left heart
therapeutic PT range for PE
1.5-2.0 times normal
therapeutic goal for PTT on heparin therapy
1.5-2.5 times control (40-75)
PTT therapeutic range for PE
1.5-2.5x normal
move from prone to sitting position by
10 months
pincer grasp by
10 months, cheerios
BUN (blood urea nitrogen)
10-20 mg/dL (older adults: slightly higher) increased: liver or kidney disease, dehydration or decreased perfusion, a high-protein diet, infection, stress, steroid use, GI bleeding, or other situation in which blood is in body tissues decreased: malnutrition, fluid volume excess, severe hepatic damage
pulse birth to 1 week
100-160
pulse 1 week to 3 months
100-220
under 12 weeks, temp cutoff for full septic workup
100.4 very little immune system
removing objects from container by
11 months
walking with assistance by
11 months
PT normal range
11-12.5 seconds
can hold and drink from a cup
12 months
can tell parents from strangers
12 months
cruises
12 months
feeds self
12 months
follows simple commands
12 months
goes from sit to stand w/out help
12 months
looks for hidden objects
12 months
plays pat-a-cake
12 months
says 1-2 words
12 months
stands holding for 30+ seconds
12 months
tries to imitate spoken words
12 months
uses pincer grasp-picks objects
12 months
toddler age
12-36 months
can bend pick up objects-stand
15 months
can say words + mama dada
15 months
climbs stairs or furniture
15 months
indicate wants w/out crying/pointing
15 months
sands alone w/out support
15 months
stacks 2 blocks
15 months
uses a spoon
15 months
walk w/out falling or wobbling
15 months
walks well
15 months
colic experienced by
15%-40% of all infants
follows simple directions - 1 step
18 months
knows at least 2 body parts
18 months
listen to a story
18 months
runs
18 months
says at least 10 words
18 months
scribbles
18 months
shows affection
18 months
stacks 3 blocks
18 months
throwing ball by
18 months
throws a ball
18 months
uses a spoon + fork + cup
18 months
walks backwards
18 months
phases of cardiac rehab
1: acute illness to discharge 2: discharge through recovery at home 3: long-term conditioning
rear facing until
2
•Order: Ticaricillin 750 mg IM every 6 hours Directions for use state: Add 2 mL of 0.9% sodium chloride (Normal Saline). Reconstituted solution contains 1 gram/ 2.6 mL. How many mL will a nurse administer in 1 dose? Document in whole number. ______________ mL
2 mL
grasp objects with hands
2 months
lift head momentarily
2 months
social smile
2 months
therapeutic goal for INR
2-3 for most pts 2.5-3.0 for PE 3.0-4.5 for recurrent PE normal is 0.8-1.1
when does rheumatic fever occur?
2-6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract.
when should birth weight have quadrupled?
2.5 years
normal PTT level
20-30 or 30-40, depending on lab
PTT normal range
20-30, some labs say 30-40
toddler visual acuity
20/40 is acceptable, improves
needle for IM injection
22-25 gauge 1/2 to 1 inch needle
50% speech is understood by others
24 months
can kick a ball forward
24 months
can take clothes off
24 months
can walk step w/o holding next 1
24 months
copies parents actions
24 months
feeds w/spoon/fork w/o spilling
24 months
follows 2 step command
24 months
imitates adults
24 months
jumps
24 months
knows name and age
24 months
points and names body parts
24 months
says 2 word sentences
24 months
stacks small blocks w/o falling
24 months
vocab of at least 50 words
24 months
can pedal a tricycle
3 years
copy drawings - circle, cross, line
3 years
counts to 3
3 years
knows 4 colors
3 years
knows name, age, gender
3 years
plays w/ other kids
3 years
speak 3-5 word sentences
3 years
throws ball 5 ft
3 years
toilet trained
3 years
walks upstairs alternating feet
3 years
normal lactate level arterial
3-7
after a CABG, check the pt's neurologic status every
30 to 60 minutes until pt has awakened from anesthesia then check every 2 to 4 hours or per policy
HDL:LDL ratio
3:1
rolls in 1 direction
4 months
how long to wait between live vaccines?
4 weeks
can copy picture of square
4 years
can dress self w/o help
4 years
can say full name
4 years
can stack 8 blocks w/o falling
4 years
booster seat until
4'9"
balance on foot 6 seconds
5 years
can copy pictures of triangle
5 years
can fasten buttons
5 years
draw person w/ head/body/arms/legs
5 years
dresses self complete w/o help
5 years
enjoys jokes
5 years
follows verbal orders w/o gestures
5 years
hops on foot 2 times
5 years
infant weight gain per week
5-7 oz
thrombolytic drugs must be given within name
6 hours t-PA tissue plasminogen activator
babbles reciprocally
6 months
focuses gaze on small objects
6 months
hold head upright and steady
6 months
laugh
6 months
no head lagging on sitting up
6 months
no mobiles after
6 months
picks up toys within reach
6 months
pulls to a sit
6 months
roll back to abdomen by
6 months
rolls in both directions
6 months
sits briefly w/out support
6 months
sunscreen not until how old
6 months
transfer objects hand to hand
6 months
when prone lift chest off ground
6 months
will hold bottle by
6 months
remember the basics
6 rights of administration 2 pt identifiers - can use parents for verification - always use 2 identifiers from ID band: Name, DOB, hospital ID number double check all high risk and facility regulated meds with second nurse - insulin - heparin check med and food allergies
determining heart rate
6 second strip method - count QRS complexes in 6 seconds - multiply by 10 big block method - count big blocks between 2 R waves - divide into 300 memory method - find QRS complex that falls on a dark line - count backwards to next QRS complex - each dark line is a memorized number
when do first teeth erupt
6-10 months
"school age" age range
6-12 years
BUN/Creatinine Ratio
6-25 increased: fluid volume deficit, obstructive uropathy, catabolic state, high-protein diet decreased: fluid volume excess
crawls by
6-7 months
how many teeth by 12 months
6-8
posterior fontanel closes after
6-8 weeks
can catch a small ball
6-8 years
can complete if/then sentences
6-8 years
can copy a picture of a diamond
6-8 years
can ride a bicycle
6-8 years
draw a person w/ 6 parts
6-8 years
CRAFFT
6-item screen for alcohol or drugs in adolescents, 14-18 (C=car, R=relax, A=alone, F=forget, F= family or friends, T= trouble)
sits by age
7 months
transferring object between hands by
7 months
biologic valve longevity
7-10 years
VLDL normal range
7-32 ng/dL
normal pH of body fluids
7.35-7.45
notify the provider of the aPTT is greater than
70 seconds assess for s/s of bleeding (hematuria, frank or occult blood in stool, ecchymosis, petechiae, altered LOC, pain if bleeding occurs, stop anticoagulant immediately and call HCP or RRT
pulse 3 years to 12 years
70-110
Kawasaki disease incidence and length
75% of cases affect kids under 5 years old - not spread person to person - occurs most often in late winter/early spring self-limiting (6-8 weeks) but if not treated, risk of coronary artery aneurysm increases - give meds to decrease side effects
high dose salicylate dose
80 to 100 mg/kg/day - divided doses every 6 hours - until fever subsides 3 to 5 mg/kg/day - after fever subsides - used as an antiplatelet
normal PaO2
80-100 mmHg
pulse 3 months to 2 years
80-120
can play peek-a-boo
9 months
can sit w/out support
9 months
can stand with support
9 months
crawls, creeps, or scoots
9 months
creeping by
9 months
feeds self cookie or cracker
9 months
stranger fear develops around
9 months
______% of people who experience sudden cardiac arrest die before reaching hospital
95%
normal SaO2
95-100%
metabolic acidosis mostly affects which system?
???
why do fluids move into interstitial tissues in shock?
???
HF lab values
??? check book
While assessing a patient who has been receiving heparin for the past 3 days, a nurse notes that the IV pump is set at twice the required flow rate. What orders does the nurse expect from the health care provider? SATA A Activated partial thromboplastin time (aPTT) B Protamine C Vitamin K D International normalized ratio (INR) E Complete blood cell (CBC) count
A Activated partial thromboplastin time (aPTT) B Protamine E Complete blood cell (CBC) count
•Which meal choices would be optimal for a patient with hyperlipidemia? SATA A Baked chicken, grilled asparagus, baked sweet potato B Macaroni and cheese, roasted broccoli, whole milk C Corn chowder with bacon, tossed salad + oil/vinegar D Steak with French fries, tossed salad + Ranch E Whole wheat wrap with turkey, lettuce, tomato and low-fat mayonaise F Grilled salmon with butternut squash, baked potato G Cheese and tomato omelet with whole wheat toast
A Baked chicken, grilled asparagus, baked sweet potato E Whole wheat wrap with turkey, lettuce, tomato and low-fat mayonaise F Grilled salmon with butternut squash, baked potato
Which of the following agents are recognized by a nurse as high-alert drugs? SATA A Heparin B Enoxaparin (Lovenox) C Alteplase (tPA) D Rivaroxaban (Xarelto) E Aspirin
A Heparin C Alteplase D rivaroxaban (Xarelto) maybe
Which of the following would a nurse assessing a patient with pulmonary embolus expect? SATA A RR 32 B HR 56 C Sudden onset dyspnea D Diaphoresis E Temperature 100.3 F
A RR 32 C Sudden onset dyspnea D Diaphoresis E Temperature 100.3 F
•When removing the mask following an aseptic procedure, a nurse should: A Remove gloves first. B Untie bottom strings last. C Untie top strings and let mask hang. D Untie top strings first.
A Remove gloves first.
metabolic syndrome
A cluster of conditions that increase the risk of heart disease, stroke, and diabetes.
sepsis/septic shock
A complex type of distributive shock that usually begins as a bacterial or fungal infection & progresses to a dangerous condition over a period of days.
What is atherosclerosis? Build-up of fatty plaque: A in coronary arterial wall B in myocardium C on heart valve surfaces D in coronary veins
A in coronary arterial wall
c-reactive protein
A nonspecific protein, produced in the liver, that becomes elevated during episodes of acute inflammation or infection. normal is <1.0 mg/dL
•Nursing interventions for a patient receiving enoxaparin (Lovenox) may include: SATA A teaching the patient or family to give SQ injections at home B monitoring INR C teaching to observe for bleeding D Monitoring for development of deep vein thrombosis (DVT) E Teaching to leave air bubble in syringe when giving Lovenox
A teaching the patient or family to give SQ injections at home C teaching to observe for bleeding E Teaching to leave air bubble in syringe when giving Lovenox
A nurse is caring for a patient receiving mechanical ventilation when the high-pressure alarm sounds. Which of the following conditions can cause this to occur? SATA A) Bronchospasm B) Tube becomes disconnected C) Occluded endotracheal tube D) Kinked tubing E) Coughing
A) Bronchospasm C) Occluded endotracheal tube D) Kinked tubing E) Coughing
Acute coronary syndromes describes either
A) unstable angina or B) acute myocardial infarction
respiratory acidosis cause
ALWAYS DUE TO RESPIRATORY PROBLEMS causing inadequate excretion of CO2 - respiratory depression - inadequate chest expansion - airway obstruction - reduced alveolar-capillary diffusion
surgical management of abdominal aortic aneurysm
Abdominal aortic aneurysm resection preop: autologous transfusion procedure: aneurysm is exposed, clamps applied, aneurysm is excised, graft is sutured in place postop: - monitor VS, - assess for complications: MI, graft occlusion/rupture, hypovolemia, renal failure (deprived of O2), respiratory distress, paralytic ileus Endovascular repair of AAA Entails stent graft placement - inserted through femoral artery - advanced to diseased area and released Benefits: - shorter recover - fewer complications Complications - bleeding aneurysm rupture - peripheral embolization - misplacement of stent graft monitor urinary output after surgery
Kawasaki disease course
Acute phase: fever - abrupt high fever (>5 days) - unresponsive to antipyretics or antibiotics - very irritable (miserable) - physical symptoms Subacute Phase: after fever until s/s are gone - resolution of fever until all clinical signs are gone - skin peels (around nails, on palms/soles) - greatest risk for coronary artery aneurysms - irritability persists Convalescent Phase: s/s gone, labs still off - all clinical signs are gone, but lab values have not returned to normal
tetralogy of fallot nursing care
After PDA closes, give prostaglandin Acute hypoxic episodes (TET spells) - knees to chest to help oxygenation Preventing/observing for physiologic effects of chronic hypoxia Caring for child at risk for/with CHF Post-op following repair - temporary shunt placement - complete repair: close VSD, remove thick muscle, repair PA
nonmodifiable risk factors for CAD
Age Gender Ethnicity Family history Genetic predisposition
Intrapulmonary causes of ventilatory failure
Airway Disease - COPD - asthma Ventilation-perfusion (V/Q) mismatch - PE - Pneumothorax - ARDS - Amyloidosis - PE - Interstitial fibrosis
fibrinolytic drugs
Alteplase
chronic stable angina pectoris
"strangling of the chest" caused by temporary imbalance between coronary artery's ability to supply oxygen and cardiac muscle's demand for oxygen ischemia: doesn't always cause permanent damage frequency, duration, and intensity of symptoms remain the same predictable pattern, doesn't worsen
atrial septal defect definition s/s treatment
- ASD - opening between atria - increased pulmonary blood flow - acyanotic - left to right shunt - s/s? - treatment: closure with occluding device in catheterization lab or surgical patch closure
tPA contraindications
- Acute ICH - History of ICH - BP above 185/110 - Unknown time of onset - Stroke/Trauma in past 3 months - Thrombocytopenia/Coagulopathy - Anticoagulation if INR>1.7
L-sided heart failure - what happens physiologically
- CO decreases: decreased perfusion, decreased oxygenation, decreased BP, increased HR - pulmonary congestion develops
s/s of heart transplant rejection
- SOB - fatigue - fluid gain (edema, increased weight) - abdominal bloating - new bradycardia - hypotension - a-fib or a-flutter - decreased activity tolerance - decreased ejection fraction (late sign)
infant colic symptoms
- abdominal pain, cramping, drawing legs up - crying for greater than 3 hours per day, 3 days per week for at least 3 weeks - late afternoon - usually younger than 3 months - no known cause
health teaching postop aneurysm surgery
- activity restriction - incision care - pain management - F/U
potential problems after PCI
- acute closure of the vessel (chest pain, ST elevation) - bleeding from insertion site - reaction to contrast medium - hypotension - hypokalemia - dysrhythmias
preoperational phase
- age 2-4 - is the transition between self-satisfying behavior and socialized relationships - ego-centric
renal/urinary assessment: history
- age, gender, race/ethnicity - health hisotry: urinary/renal, DM, HTN, surgery - current s/s - tobacco, ETOH, recreational drug use - medications - work history, especially for exposure to toxic chemicals - family hisotry - nutrition
communicating with children
- allow children time to feel comfortable - body language - talk to parent if child is shy - communicate transitions thoroughly - assume a position that is at eye level with pt - speak in a quiet, unhurried and confident voice - offer a choice only when one exists - state directions in a positive manner - be honest - allow children to express their fears and concerns
pelvic muscle exercises
- alternate contacting and releasing pelvic floor muscles (feels like stopping flow of urine) - to identify: sit on toilet, feet flat/12 inches apart, begin to urinate and try to stop. don't use accessory muscles - kegels: contract slow count of 10, relax slow count of ten, 15 times lying, sitting, standing. repeat, this time rapidly. - do 3 sets/day - may take months to see improvement
female circumcision and urinary health
- alters appearance - increases risk for UTI - make urethral inspection or catheterization difficult
venous ulcers: other assessment findings
- ankle discoloration and edema - full veins when leg slightly dependent - no neurologic deficit - pulses present - may have scarring from previous ulcers
when is surgery considered for infective endocarditis
- antibiotics ineffective (large vegetations) - refractory HF - multiple embolic events
bleeding precautions
- antidotes available - protect from situations that could lead to bleeding - ensure correct drug therapy - assess lab values - monitor the amount of bleeding that occurs
transdermal nitroglycerin administration
- apply to clean, dry, hairless area - rotate application sites to prevent skin irritation - remove the patch before defibrillation to prevent burns - remove after 12-14 hours each to to prevent drug tolerance
habit training
- assess 24 hr pattern - base interval off voiding pattern (eg 2 hrs) - assist to toilet/bedpan q 2hr - if incontinent, reduce interval - don't sit longer than 5 minutes on toilet - attempt to lengthen interval if possible - praise, socialize - incontinent? clean up, don't socialize - discuss with staff, get on board
emergency care of the pt with chest discomfort
- assess airway, breathing, and circulation (ABCs). Defibrillate as needed - provide continuous EGC monitoring - obtain the pt's description of pain or discomfort - obtain pt's vs (BP, HR, RR) - assess/provide vascular access - consult chest pain protocol or notify the HCP or RRT for specific intervention - obtain a 12-lead ECG within 10 minutes of report of chest pain - provide pain relief meds and aspirin (non-enteric coated) as prescribed - administer oxygen therapy to maintain oxygen saturation >or= to 90 - remain calm. stay with the pt if possible - assess the pt's vs and intensity of pain 5 minutes after administration of medication - remedicate with prescribed drugs (if vs remain stable) and check the pt every 5 minutes - notify the provider if vs deteriorate
bladder training
- assess awareness and ability - assess 24 hr pattern for 2-3 days - base interval on voiding pattern (eg. 45min) - day 1: void every 45 minutes, no sooner. (assist, privacy, run water) - if unable, decrease interval - continue until pt is comfortable with interval - increase by 15 minute increments until 3-4 hr window is comfortable - praise successes
care of pt with pericarditis
- assess chest discomfort (typically substernal, worse on inspiration, less when leaning forward) - assess for pericardial friction rub - assist pt to position of comfort - anti-inflammatories - NO aspirin/anticoagulants (increase risk for tamponade) - assess paradoxical BP (pulsus paradoxus)(sign of tamponade) - assess other s/s of tamponade (JVD w/ clear lungs, muffled heart sounds, decreased CO) - notify HCP if tamponade suspected
nursing assessment of arterial catheter pt
- assess collateral circulation by dopplar - purge system of air - assist MD with insertion - maintain continual saline flush solution - monitor site and color, pulse, temp distal to site
nursing care for varicose veins
- assess for bleeding - keep legs elevated - encourage ROM exercises, wearing compression stockings
preventing/managing pulmonary edema
- assess for early signs: crackles in bases, dyspnea at rest, disorentation, confusion - high-fowler's position - high-flow O2: 5-6 L/min via face mask or 10-15L/min via non-rebreather with reservior - meds: nitroglycerine, diuretics (loop IV), morphine - continual assessment - Acute failure: dobutamine/milrinone IV
alteplase nursing implications
- assess hourly for internal and external bleeding while pt is receiving drug and for 8 hours after. hemorrhage is most common complication - to administer, reconstitute with sterile water that contains no preservatives immediately before use to ensure drug stability - administer with caution to pts who have been receiving aspirin, dipyridamole, heparin, or other anticoagulatns because these drugs also increase the risk for bleeding
care of Pt with dysrhythmias
- assess vs at least every 4 hours and as needed - monitor pt for cardiac dysrhythmias - evaluate and document the pts response to dysrhythmias - encourage the pt to notivy the nurse when chest pain occurs - assess chest pain (PQRST) - assess peripheral circulation - provide antidysrhythmic therapy according to unit policy as appropriate (meds, cardioversion, defibrillation) - monitor and document pt's response to antidysrhythmic meds or interventions - monitor appropriate lab values (cardiac enzymes, electrolytes, etc) - monitor the pt's activity tolerance and schedule exercise/rest periods to avoid fatigue - observe for respiratory difficulties - promote stress reduction - offer spiritual support to the pt and/or family as appropriate
play in preschooler
- associative play (group play w/out rules) - imitative play - imaginative play (imaginary playmates) - dramatic play - mutual play
septal defects
- atrial septal defect (ASD) - ventricular septal defect (VSD)
sleep and rest in school age child
- average 9-11 hours/night - may resist going to bed ages 8-11 - >12: usually less resistant to bedtimes
nutrition in school age child
- balanced diet to promote growth - quality of diet r/t family's pattern of eating - developing a taste for a variety of foods - "fast food" concerns - MyPlate - National obesity Prevention Guidelines
language development in preschooler
- becomes more sophisticated - is the major mode of communication and social interaction - vocab increases dramatically between ages 2 and 5 years - complexity of language use increases between ages 2 and 5
activity for pt with CAD
- begin by walking the same distance at home as in the hospital (usually 400 ft) 3 times a day - carry nitro with you - check pulse before, during, and after exercise - stop the activity for a pulse increase of >20 bpm, SOB, angina, dizziness. Make gradual increases in distance - exercise outdoors when weather is good - after an exercise tolerance test and with your HCP's approval, walk at least 3x/week, increasing the distance every other week, until the total distance is 1 mile - avoid straining (lifting, push-ups, pull-ups, and straining at bowel movements)
maturation of systems in school age child
- bladder capacity increases - heart is smaller in relation to rest of body - immune system is increasingly effective - bones continue to ossify - physical maturity doesn't necessarily correlate with emotional and social maturity
DVT (deep vein thrombosis)
- blood clot occurring most commonly in LE - results from venous stasis, endothelial wall injury, hypercoagulability (Virchow's triad) Potential causes - surgery - immobility - birth control - smoking - pregnancy
nutrition in preschooler
- calories: 1400-1600 - need half the calories adults do - fluids: 100mL/kg - fads, strong tastes: common - 5 yo = willing to try new things - amount eaten varies greatly from day to day - obesity has increased dramatically - healthy balance between drawing attention to health problems and criticizing weight
non-pharmacological pain management for children
- can help pt require less medication - distraction, massage, dog, music, clown - containment (swaddling), non nutrient sucking, kangaroo care
sustained tachycardias and bradydysrhytmias key features
- chest discomfort, or pain, may radiate to the jaw, the back, or the arm - restlessness, anxiety, nervousness, confusion - dizziness, syncope - palpitations (in tachy) - change in pulse strength, rate, and rhythm - pulse deficit - shortness of breath, dyspnea - tachypnea - pulmonary crackles - orthopnea - S3 or S4 sounds - jugular venous distention - weakness, fatigue - pale, cool skin; diaphoresis - nausea, vomiting - decreased urine output - delayed capillary refill - hypotension
hemothorax treatment
- chest tube insertion - IV hydration - blood transfusion - surgery
pneumothorax management
- chest tube to remove air/blood
anticipatory guidance: care of families in preschooler
- child care focus shifts from protection to education (verbal explanations of how to avoid danger) - children begin questioning previous teachings of parents - children begin to prefer companionship of peers - children enter school
developing a self-concept in school age child
- children develop conscious awareness of a variety of self-perceptions (abilities, values, appearance) - significant adults can help children experience success - positive self-concept leads to feelings of self-respect, self-confidence, and happiness
spiritual development of school age child
- children think in very concrete terms - children are avid learners with a desire to know their God - children expect punishment for misbehavior - children may view illness or injury as punishment for a real or imagined misdeed
arterial diseases
- chronic: peripheral arterial disease - acute: acute peripheral arterial occlusion - aneurysm - aortic dissection - Buerger's disease - Raynaud's disease/phenomenon
complications for pt on vent: nutrition
- decreased peristalsis - poor absorption - short-term parenteral nutritional support - malnutrition affects ability to be weaned from ventilator
s/s of coarctation of the aorta
- degree of s/s depends on how much blood can flow through the artery - 1/2 of newborns with this will have s/s in first few days of life (depends on when DA closes) - mild? - maybe no s/s until adolescence - chest pain - cold feet or legs - dizziness or fainting - decreased ability to exercise - FTT - leg cramps with exercise (decreased blood flow) - epistaxis (increased blood flow) - poor growth - pounding headache (increased pressure) - SOB - bounding arm pulses - weak/thready lower extremity pulses
suicide in adolescence
- deliberate act of self-injury that causes death - suicidal ideation is a preoccupation with suicidal thoughts - suicide attempt is intended to cause death or serious injury - "parasuicide" describes behaviors ranging from gestures to serious attempts - reasons - methods - motivation - diagnostic evaluation/therapeutic management - case management - nurse alert (no threat of suicide should be dismissed)
ALTE diagnostic evaluation
- detailed history of event - 72 hr admission - car seat - GI problems, resp problems, metabolic disorders, seizures are noted to increase risk of ALTE
FTT diagnostic evaluation
- diet recall - admission (does baby gain if someone else feeds?) - blood work - PE - meal time behaviors
aterial catheter uses
- direct, continuous measurement of BP - obtaining samples for ABG analysis
potential causes of dysrhythmias
- disturbance of impulse formation - disturbance of ability to respond to impulse - disturbance of impulse conduction - disturbance between electrical activity and mechanical response of myocardium
thrombolytic therapy: observe for signs of bleeding by
- documenting pt's neurologic status (in case of intracranial bleeding) - observing all IV sites for bleeding and patency - monitoring clotting studies - observing for signs of internal bleeding (H&H, BP) - testing stools, urine, and emesis for occult blood
preventing UTI
- drink fluids liberally (2-3 L/day) - sleep, rest, nutrition (immune system) - spermicides? try something else - wipe front to back - no douches, scented lube, bubble bath, tight panties - pee after sex - wash before sex (men and women) - don't delay urinating (colonizes) - call HCP for burning, difficulty, urgency, frequency, especially if you have a chronic medical condition - cranberry juice - topical estrogen if postmenopausal (normalizes vaginal flora, oral not effective)
ARDS phase 1 manifestations
- dyspnea - tachypnea
therapeutic management of obesity in adolescence
- early recognition and prevention - treatment: difficult - diet modifications and nutritional counseling - behavior modification - pharmacologic therapy - bariatric surgery for severely overweight adolescents - family and group involvement
anorexia nervosa
- eating disorder: refusal to maintain normal body weight - severe weight loss in the absence of obvious physical causes - primarily in adolescent girls and young women - meant age at onset: 13 years, ranging from 10 to 25 years or more - life-threatening
Bleeding precautions education
- electric shaver - soft-bristle toothbrush - dental work (consult MD) - no aspirin - no contact sports - bumped? ice for 1 hour - no hard, scratchy foods - no hot food - check skin daily - no anal intercourse - stool softener - no enemas/rectal suppositories - no tight/rubbing clothes - blow nose gently - no wind instruments - get lab tests - call MD for injury w/ persistent bleeding, excessive menstrual bleeding, blood in urine or stool
improving gas exchange in HF
- elevate HOB - administer O2 - close monitoring
care of pt in hypovolemic shock
- ensure patent airway - insert an IV catheter or maintain an established catheter - administer O2 - elevate the pt's feet, keeping his or her head flat or elevated to no more than a 30-degree angle - examine the pt for over bleeding - if overt bleeding is present: apply direct pressure to the site - administer drugs as prescribed - increase the rate of IV fluid delivery - do not leave the pt
dental health in preschooler
- eruption of deciduous teeth: complete - professional care and prophylaxis - fluoride supplements - assistance and supervision of brushing (flossing by parents) - trauma - prompt dental intervention
spiritual development in toddler
- evolution of spirituality often parallels cognitive development (most understand basis of spirituality before being able to engage in it) - family and environment influence a child's perception of the world - spiritual routines can be comforting - spirituality is often fantasy-like
spiritual development of preschooler
- faith/religion learned from significant others and religious practices - development of conscience is strongly linked to spiritual development - may misinterpret illness as punishment from God - too concrete to fully understand God
causes and pathophysiology of adolescent obesity
- familial influence - environmental conditions - perinatal factors - community factors - institutional factors - physical inactivity - appetite regulation - psychological factors
industry vs. Inferiority (inferiority)
- feelings may derive from self or social environment - feelings may occur if child is unable or unprepared to assume the responsibilities associated with developing a sense of accomplishment - all children feel some degree of inferiority regarding skill(s) they cannot master
development of self-concept and body image in adolescence
- feelings of confusion are common in early adolescence - teenagers are acutely aware of appearance, compare appearance with those of others - teenagers may try to hide their bodies or advertise them - blemishes/defects are magnified out of proportion - the right clothes and hairstyle are very important
urinary calculi patient education
- finish antibiotic - may resume usual daily activities - balance exercise with sleep and rest - return to work 2 days to 6 weeks after surgery, depending on type of intervention, tolerance, and HCP directives - might need to take meds or adjust diet - drink at least 3L of fluid a day - monitor urine pH as directed - expect bruising after lithotripsy - urine may be bloody for several days after surgery - pain may indicate infection. call HCP with fever, chills, difficulty urinating - keep f/u appointments, have repeat cultures
sexual maturation in boys
- first pubescent changes: testicular enlargement, thinning, redenning, and increased losseness of scrotum: ages 9.5-14 years - penile enlargement, pubic hair growth, voice changes, facial hair growth - temporary gynecomastia in 1/3 of boys; disappears within 2 years (marijuana increases risk)
development of sexuality in preschoolers
- forms strong attachment to opposite-sex parent while identifying with same-sex parent - modesty becomes a concern (around 5yo) - sexual exploration is more pronounced - questions arise about sexual reproduction
social development in adolescence
- goal: to define identity independently from parental authority - intense sociability; intense loneliness - acceptance by peers - parent/child relationship allow more independence - best friend relationships become stronger and help create skills to form an intimate relationship - peers create transition between parents and "real world"
biologic development of the preschooler
- growth slows and stabilizes - weight = 5lb/year - height = 2.5-3"/year - body systems mature/stabilize: can adjust to moderate stress and change - body changes from wide stance and protruding abdomen to graceful and postural erect
Thoracic Outlet Syndrome nursing implications
- health teaching about avoiding activities and positions that aggravate pain - monitor for new s/s - neurovascular assessments - post-op care if needed
removal of the ET tube
- hyperoxygenate the pt - suction ET and oral cavity - rapidly deflate cuff of ET - remove tube at peak inspiration - instruct pt to cough monitoring after extubation is essential
ARDS assessment
- hypoxia decreased pulmonary compliance (inflammation, infiltrates, edema) - dyspnea - noncardiac-associated bilateral pulmonary edema - dense pulmonary infiltrates seen on x-ray
nursing care of the maltreated child
- identification of abusive situations as early as possible - documentation of history pertaining to incident - thorough physical examination - observation of caregiver-child interactions - protection of the child from further abuse
developing a body image in school age child
- in general, children like their physical selves less as they grow older - the head is the most important part of the body (hair and eye color) - body image in influenced by significant others - increased awareness of "differences" may influence feelings of inferiority (e.g. hearing or visual defects)
FTT definition
- inappropriate growth due to an inability to obtain or use calories - less than 5th percentile - many causes
pathology of metabolic alkalosis
- increase of base components - decrease of acid components
compensatory mechanisms for heart failure
- increased HR because of decreased CO - activated when cardiac output is insufficient to meet tissue demands - initially improve CO but eventually have damaging effects EVENTS SNS stimulation: - vasoconstriction - increased heart rate - increased contractility Renin-angiotensin-aldosterone system activation - b/c of decreased renal perfusion - effects: holds Na+, water --> increased BP, worsens L-sided HF B-type natriuretic peptide (BNP) released - causes vasodilation and diuresis through Na+ loss ADH (antidiuretic hormone) is released - causes vasoconstriction, fluid retention - DOESN'T HELP, WORSENS HF
positional plagiocephaly
- increased since "back to sleep" in 1992 - front to play: tummy time - torticolis (same side as plagiocephaly)
development of body image in preschooler
- increasing comprehension of "desirable" appearances - aware of racial identity, differences in appearances, and biases - comparing begins - poorly defined body boundaries (children fear if skin is "broken" all blood and "insides" can leak out) (intrusive experiences are frightening)
complications of PA catheter
- infection/sepsis - embolism (thromboembolism, air embolism) - pneumothorax - dysrhythmias
disorders related to the male reproductive system in adolescence
- infections (e.g. urethritis) - hematuria - penile problems - scrotal varicocele (feels like bag of worm) - testicular torsion (emergency) - gynecomastia
child maltreatment
- intentional physical abuse or neglect (17%) - emotional abuse or neglect (8%) - sexual abuse of children (9%) usually by adult - children younger than 1 year have the highest rate of abuse < 1yo w/ femur rx = red flag for abuse most likely to abuse: mom's boyfriend
ARDS interventions
- intubation and mechanical ventilation with PEEP or CPAP to keep alveoli open - drug and fluid therapy - nutrition therapy - Management depends on phase of ARDS
interventions for stress urinary incontinence
- keep a diary - modify diet (irritants, lose weight, hydrate) - pelvic floor (Kegel) exercises - biofeedback (helps evaluate effectiveness of Kegels) - drug therapy (local estrogen cream) - corrective surgery
teach patients who have permanent pacemakers to
- keep cell phones at least 6" away from generator, with handset on the ear opposite the side of the generator - avoid sources of strong electromagnetic fields, such as magnets and telecommunications transmitters (could cause interference and change settings) - avoid MRI, depending on machine's technology - carry pacemaker ID card and wear medical alert bracelet at all times
foot care for the patient with peripheral vascular disease
- keep feet clean by washing with mild soap in room-temp water - keep feet dry, especially the ankles and in between the toes - avoid injury to your feet and ankles. Wear comfortable, well-fitting shoes. Never go without shoes - Keep your toenails clean and filed. Have someone cut them if you cannot see them clearly. Cut your toenails straight across. - to prevent dry, cracked skin, apply lubricating lotion to your feet. - prevent exposure toe extreme heat or cold. Never use a heating pad on your feet. - avoid constricting garments - if a problems develops, see a podiatrist or health care provider - avoid extended pressure on your feet or ankles, such as occurs when you lean against something
management of chest pain at home
- keep fresh NTG available for immediate use - stop activity and sit or lie down - 1 dose of NTG - wait 5 minutes - if no relief, call 911 - repeat NTG and wait 5 minutes - if there is no relief, repeat NTG and wait 5 more minutes - carry medical id card or wear a bracelet or necklace that identifies a history of heart problems
causes of underproduction of bicarbonate what does this cause
- kidney failure - pancreatitis - liver failure - dehydration metabolic acidosis
how to prevent or decrease dysrhythmias for pts at risk for potassium imbalance
- know s/s of decreased K+ levels (muscles weakness, cardiac irregularity) - eat foods high in K+ (tomatoes, beans, prunes, avocados, bananas, strawberries, lettuce) - take K+ if prescribed
interest and activities in adolescence
- leisure activities revolve around peers - activities allow teenagers to set priorities and structure their time - teenagers make use of social media (facebook, twitter, blogs, chat room, social networking, cyberbullying)
toddler language
- level of comprehension increases - ability to understand increases - comprehension is much greater than the number of words a toddler can say - at age 1 year: child can use one-word sentences - at age 2 years, child uses multiword sentences
important points for hospitalized patient
- limit admissions - parental reactions: helplessness, fear, question nursing skills, seek reassurance - impact on siblings - family centered: if separation can be avoided, children are able to withstand many other stressors - limit duration of hospital stay: hospital stays are longer and disease management is more complex nowadays because the kids that are admitted are sicker - reduce pain (FLACC pain scale) - prepare child for procedures - primary nursing - use of play - safe areas (bed) - don't do procedures in pt's bed - increase control (a child has already lost control over their body, basic decisions, school, socialization, and routine)
urinary incontinence history
- lose urine with cough, sneeze? on way to bathroom? - wear protective pads? - chart 66-2 - chart 66-1
hypovolemic shock pathophysiology
- loss of blood volume from vascular space, decreasing MAP (avg BP) - blood flow is slowed, tissue perfusion decreases - cells are deprived of oxygen - blood is shunted to vital organs - anaerobic metabolism, increased lactic acid release - causes electrolyte imbalances - causes metabolic acidosis (anaerobin -> lactic acid) - if not corrected within 1-2 hours, cell damage is extensive and irreversible
toddler play
- magnifies physical and psychosocial development - interaction with others: becomes more important - solitary play to parallel play - imitation (coping household tasks) - tactile play (sensory) - selection of appropriate toys
ARDS Phase 3 interventions
- maintaining adequate O2 transport - preventing complications - supporting the failing lung until it has time to heal
urolithelial cancer patho
- malignancy in bladder - greatest risk factor is smoking - exposure to toxins in hair dressing, paint, textile, rubber industries, from developing film or furniture refinishing
androgens
- masculinizing hormones - secreted in small and gradually increasing amounts for up to 7-9 years - then rapid increase in both sexes; in boys, rapid increase continues until age 15 years - responsible for rapid growth in early teen years - testosterone: secreted by testes: in boys, level reach maximum at maturity
ARDS Phase 2 interventions
- mechanical ventilation - prevention of complications
adhering to treatment for BP management teaching
- meds, lifestyle changes - goals, administration specifics, potential side effects, what to report - regular F/U - monitoring BP at home - consequences of non-adherence (dangerous BP, sudden d/c can cause sudden HT crisis)
Subclavian Steal Nursing implications
- monitor pt closely for new s/s - post-op: check pulses and observe for ischemic changes, including severe pain or color changes
injury prevention in school age child
- most common cause of severe injury and death in school-age children is MVA: pedestrian and passenger - bicycle injuries: benefits of bike helmets - appropriate safety equipment for sports - concussion awareness (impact screening) - water safety - cooking and fire safety - booster seat and back seat (until 9yo or 4'8") - start drug and alcohol education mouthguard helps absorb shock of impact
speech problems in preschooler
- most critical period is between 2 and 4 years of age - hearing (ear infections - can be determined as early as 12-14 months - failure to master sensorimotor integration may result in stuttering and stammering - prevention and early detection are crucial
toddler safety
- motor vehicle (car seat, rear facing until 2) - drowning - burns - accidental poisoning - falls - aspiration and suffocation - bodily injury
safety promotion and injury prevention in adolescence
- motor vehicle-related injuries - other vehicle-related injuries - firearms - sports injuries - injury prevention (anticipatory guidance)
proportional changes in school age child
- movements more graceful - skeletal lengthening/fat diminution - increased muscle tissue - decrease in head circumference related to height - change in facial proportions - the age of "loose teeth"
physical exam guidelines for children
- non threatening environment - place frightening equipment out of sight - provide privacy - observe for behaviors - begin with least intrusive exam
urinary incontinence patient education
- normal body weight, less pressure on bladder - don't restrict fluid intake - catheter? maintain sterile drainage system - suprapubic catheter - inspect, clean, dress, daily - nothing in vagina until 6 week post-surgery checkup - no lifting over 5 lbs until 6 week checkup, up to 3 months - avoid exercises other than walking or swimming after drains removed and healed - do your kegels if recommended
social development of school age child
- peer group extremely important - identification with peers is a strong influence in achieving independence from parents - sex roles are strongly influenced by peer relationships - school - conformity - confidence = establishing positive self concept and contributing to community in positive way - opposite sex becomes intriguing by the end of this school-age period
promoting optimal health during adolescence
- personal care - vision, hearing: greatly impact learning - posture: scoliosis (becomes apparent during period of growth) - body are: sanitary! - tanning - stress reduction
child neglect
- physical (food, clothing, shelter, supervision, medical care, education) - emotional (lack of affection, attention, and emotional nurturance) emotional abuse or psychological maltreatment = destruction or impairment of child's self-esteem
what causes ventilatory failure in acute respiratory failure
- physical problem of lungs or chest wall - defect in respiratory control center in brain (brain injury) - poor function of respiratory muscles, especially diaphragm - too little oxygen reaches alveoli! - extrapulmonary causes (table 32-2) - intrapulmonary causes
prepubescence in school age child
- preadolescence is the period of 2 years before age 13 - prepubescence typically occurs during preadolescence - age at prepubescence varies from 9-12 for girls and 11-13 for boys - puberty begins at approximately age 10 in girls and age 12 in boys puberty <8 in girls or <9 in boys = problem
latency period
- precedes heterosexual fascination that occurs in puberty - a time of tranquility - relationships revolve around same-sex peers - this time is the "latency" period of psychosocial development Freud
urolithiasis patho
- presence of calculi (stones) in urinary tract - most are composed of calcium - involves: slow urine flow causing supersaturation and crystal formation; damage to urinary tract lining; decreased stone inhibitor substances
ARDS Phase 4 interventions
- preventing sepsis, pneumonia, and MODS - ventilator care (dependent for weeks to months - transfer to facility for LTC and eventual weaning from ventilator - if cannot be weaned may remain in LTC or be dishcarged home
assessing the patient about to undergo a kidney test or procedure using contrast media
- previous reaction? - hx of asthma? hay fever, food or drug allergies, especially seafod, eggs, milk, chocolate? - hx of renal impairment or chronic illness? - metformin? - hydration status - when last ate/drank anything
ARDS Phase 3 manifestations
- progressive hypoxemia that resonds poorly to high levels of oxygen
Child Life and Play
- provides diversion, brings about relaxation - helps child feel more secure in a strange environment - helps lessen separation stress - means for release of tension and fear - means for accomplishing therapeutic goals - allows decision making and control
SIMV weanng
- pt breathes between machine's preset breaths/min rate - the machine is initially set on an SIMV rate of 12, meaning that the pt receives a minimum of 12 breaths/min by the ventilator - the pt's respiratory rate will be a combination of ventilator breaths and spontaneous breaths - as the weaning process ensues, the pulmonary health care provider prescribes gradual decreases in the SIMV rate, usually at a decrease of 1 to 2 breaths/min
T-Piece Technique for weaning
- pt is taken off the ventilator for short periods (initially 5 to 10 minutes) and allowed to breathe spontaneously - the ventilator is replaced with a T-piece or CPAP, which delivers humidified oxygen - the prescribed FiO2 may be higher for the pt on the T-piece than on the ventilator - weaning progresses as the pt can tolerate progressively longer periods off the ventilator - nighttime waning is not usually attempted until the pt can maintain spontaneous respirations most of the day
chest traumas include
- pulmonary contusion - rib fracture - flail chest - pneumothorax - tension pneumothorax - hemothorax - tracheobronchial trauma
ARDS Phase 4 manifestations
- pulmonary fibrosis with progression occurs after day 10 - if pt survives, there will be permanent lung damage
diabetic ulcers: other assessment findings
- pulses usually present - cool or warm foot - painless
feeding retraining for FTT
- quiet unstimulated environment - primary person feeding - be persistent - give direction to the child - develop a structured routine
cognitive development in preschooler
- readiness for school/scholastic learning (typically 5-6 yo) - ego-centric to self aware and intuitive - may judge based on visual appearances - magical thinking (poor ability to understand cause and effect)(ie Johnny got cancer b/c he didn't listen to mommy. If I don't listen to mommy I'll get cancer) - animism - time
toddler dental health
- regular dental examinations (1-3 yo) - removal of plaque - fluoride for anyone over the age of 6 who does not have fluorinated drinking water - dietary factors - early childhood caries
discipline
- reinforcement - consistency! - praise - don't withhold love - consequences - parents often need help developing strategies that are age appropriate and reasonable (limit setting, consistency, consequences that should be told in advance and truthful explanation of why behavior is desired or not) - physical punishment is least effective
causes of secondary HT
- renal disease - primary aldosteronism (increased blood volume, increased BP) - pheochromocytoma - Cushing's syndrome - medications (steroids mimic Cushings syndrome)
pts with endocarditis: after discharge
- report s/s of recurrence - record temp daily for up to 6 weeks - report fever, chills, malaise, weight loss, increased fatigue, sudden weight gain, dyspnea
effects of childhood obesity
- risk for adult obesity - increase in type 2 diabetes - HT, hyperlipidemia, cardiovascular disease - respiratory and orthopedic contitions - social isolation, low self-esteem, depression
nutrition in second 6 months of life
- selection and preparation of solid foods - introduction of solid foods - weaning from breast or bottle
the hospitalized child experiences
- separation anxiety - loss of control - bodily injury and pain (seen as punishment. explain!) kids can deal with most things int he hospital if separation anxiety is managed. encourage parents to stay prepare child so they don't see procedures as punishment
social development in preschooler
- separation-individuation process is complete - stranger anxiety and fear of separation from parents are overcome - parental security and guidance are still needed - security is derived from familiar objects - play therapy is beneficial for working through fears, anxieties, and fantasies
coping with the school experience
- sharp break in the structure of child's world - school is second only to the family as socializing agent - values of the society are transmitted in school - peer relationships become increasingly important - "Latchkey" children - limit setting and discipline - dishonest behavior is normal - stress and fear
Common causes of acute lung injury
- shock - trauma - serious nervous system injury - pancreatitis - fat and amniotic fluid emboli - pulmonary infections - sepsis - inhalation of toxic gases (smoke, oxygen) - pulmonary aspiration (especially of stomach contents - drug ingestion (eg, heroin, opioids, aspirin) - hemolytic disorders - multiple blood transfusions - cardiopulmonary bypass - submersion in water (especially fresh water)
common causes of acute lung injury
- shock - trauma - serious nervous system injury - pancreatitis - fat and amniotic fluid emboli - pulmonary infections - sepsis - inhalation of toxic gases (smoke, oxygen) - pulmonary aspiration (especially of stomach contents) - drug ingestion (heroin, opioids, aspirin, etc) - hemolytic disorders - multiple blood transfusions - cardiopulmonary bypass - submersion in water with water aspiration (especially in fresh water)
physiological changes in adolescence
- size and strength of heart, blood volume, and systolic blood pressure increase - pulse rate and basal heat production decrease - adult value are reached for all formed elements of blood - respiratory volume and vital capacity increase - performance capabilities increase
sex differences in general growth patterns
- skeletal growth, muscle mass, adipose tissue, and skin - appear to be result of hormonal effects at puberty - obesity is associated with early onset of menarche in girls - obesity effects are less predictable in boys - voice changes in both sexes
spiritual development in adolescence
- some adolescents may question values and beliefs of family; defy or strengthen - adolescents are capable of understanding abstract concepts and of interpreting analogies and symbols - greater levels of spirituality are associated with fewer high-risk behaviors
Industry vs. Inferiority (industry)
- stage of accomplishment - eagerness to develop skills and participate in meaningful and socially useful work - acquisition of sense of personal and interpersonal competence - growing sense of independence - peer approval: strong motivator
tanner stages of sexual maturity
- stages of development of secondary sex characteristics and genital development - defined as guide for estimating sexual maturity - occur in an orderly sequence - does tanner staging correlate with growth? It should
PE prevention
- stop smoking - reduce weight if overweight - increase exercise - if traveling or sitting for long periods, take a break every 2 hours, walk - avoid massaging legs: could dislodge clot
pericarditis assessment
- substernal precordial pain radiating to left side of neck, shoulder, or back - grating, oppressive pain, aggravated by position changes (CHECK) - pain worsened by lying position, relieved when sitting - pericardial friction rub: scratchy, high-pitched sound reflecting roughened surfaces rubbing together
Respiratory manifestations of PE ON EXAM
- sudden onset of dyspnea, - anxiety, - tachypnea, - tachycardia, - pleuritic chest (worse with breathing), - pain, - dry cough, - hemoptysis If severe: cardiac manifestations - distended nech veins, - syncope - cyanosis - hypotension (decreased CO) - abnormal heart sounds - abnormal ECG
cardaic cath f/u care
- supine, leg straight 4-6 hrs - pressure dressing to insertion site - frequent assessment: VS, insertion site, perfusion/pulse/color/temp in affected extremity - hydration to flush contrast - teaching (activity, site care)
obtaining readings from PA catheter
- supine, or HOB elevated 15-30 degrees - place transducer at 4th ICS at mid-axillary line (corresponds to right atrium) - zero system to atmospheric presure - note waveforms and quantitative values - inflate balloon for a few seconds to obtain wedge pressure - compare findings to monitor trends
ARDS Phase 1 interventions
- supporting the pt - providing O2
Subclavian Steal Interventions
- surgical interventions for cyanosis or unrelenting pain (endarterectomy, bypass, or dilation of subclavian artery)
s/s of cardiogenic shock
- tachycardia - hypotension - BP <90 or 30 less than baseline - urine output < 0.5-1 mL/kg/hr - cold, clammy skin with poor peripheral pulses - agitation, restlessness, or confusion - pulmonary congestion - tachypnea - continuing chest discomfort
beta blocker/Digoxin teaching
- take at same time each day - don't stop - don't take with antacids or cathartics (laxatives) - take pulse. call for change - call for fatigue, muscle weakness, confusion, loss of appetite (s/s of toxicity) - if you forget a dose, it may be delayed a few hours - don't double a dose to makeup for forgetting - lab tests (digoxin, potassium) - take potassium if prescribed
how to prevent or decrease dysrhythmias for pts with premature beats and ectopic rhythms
- take meds, report adverse effects - stop smoking, avoid caffeine, moderate alcohol intake - learn ways to manage stress - avoid getting too tired
Raynaud's Phenomenon/Disease Nursing implications
- teach smoking cessation - avoid cold by wearing gloves and warm clothes - manage stress - avoid caffeine - nifedipine - avoid grapefruit - vasodilators - side effects (facial flushing, hypotension, headaches) same as Buerger's
Buerger's Disease Nursing implications
- teach smoking cessation - avoid cold by wearing gloves and warm clothes - manage stress - avoid caffeine - nifedipine - avoid grapefruit - vasodilators - side effects (facial flushing, hypotension, headaches) same as Raynaud's
toddler and body image
- understand "fat" "skinny" "chubby" - child refers to body parts by name - child recognizes words used to describe appearance by age 3 (don't use negative labels about appearance) - child recognizes gender differences by age 2 years
causes of metabolic alkalosis
- vomiting - gastric suctioning (most common) - medications, especially long-term diuretic use - hypokalemia
PE—> hypoxemia—> respiratory rate↑—> what results
-CO2 is blown off -O2 can't get in respiratory alkalosis
venous ulcers: treatment
-Long-term wound care (Unna boot, damp-to-dry dressings) -Elevate extremity -Patient education -Prevent infection *never apply direct heat to the limb such as with the use of heating pads or extremely hot water. Sensitivity is decreased in the affected limb. Burns may result.*
arterial ulcers: history
-Patient reports claudication after walking about 1-2 blocks -Rest pain usually present -Pain at ulcer site -Two or three risk factors present
diabetic ulcers: location and appearance
-Plantar area on foot -Metatarsal heads -Pressure points on feet -Deep -Pale, with even edges -Little granulation tissue
arterial ulcers: treatment
-Treat underlying cause (surgical, revascularization) -Prevent trauma and infection -Patient education, stressing foot care
FTT prognosis
-Variable, depends on cause -If in first year of life, may lead to developmental and behavioral deficits due to brain growth - slow growth for life - parental education greatly impacts prognosis
ARDS clinical manifestations
Increased work of breathing - noisy respirations - pallor - intercostal or substernal retractions - hyperpnea - cyanosis Lower PaO2 value (ABGs) Refractory hypoxemia - doesn't respond to O2 administration "Whited out" appearance to chest x-ray No cardiac involvement on ECG
complications for pt on vent: other
Infection - VAP - ventilator-associated pneumonia Muscle deconditioning Vetilator dependence
patho of infective endocarditis clinical manifestations
Infection of lining of heart - d/t exposure to bacteria - staph or strep - bacteria grow on endocardial surfaces Clinical manifestations - fever, malaise - weight loss - petechiae
what does warfarin do
Inhibits clotting factors which are made in the liver
stages of shock
Initial Compensatory (nonprogressive) Progressive (intermediate) Irreversible (refractory)
etiology of secondary hypertension
Kidney disease Primary aldosteronism Pheochromocytoma Cushing's disease Coarctation of the aorta Brain tumors Encephalitis Pregnancy Drugs: - Estrogen (e.g., oral contraceptives) - Glucocorticoids - Mineralocorticoids - Sympathomimetics
Right-sided heart failure typical causes
L ventricular failure Right ventricular MI Pulmonary hypertension
Causes of mitral regurgitation
LHF, infective endocarditis, acute rheumatic fever
what is sometimes substituted for heparin
LMWH = enoxaparin (Lovenox)
•As a charge nurse on a unit in a long-term care facility, the RN develops a plan for the onging assessment of patients with heart failure (HF). Which activity included in the plan is most appropriate to delegate to the LPN? To NA? A Updating activity plans for patients with HF every 3 months B Assessing lung sounds and checking for dependent edema each week C Reviewing all HF medication with patients each month D Weighing all patients with HF each morning
LPN: B Assessing lung sounds and checking for dependent edema each week NA: D Weighing all patients with HF each morning
HLHS consequence
LV and aorta are poorly developed (hypoplastic). In most cases, LV and aorta are much smaller than normal Left side of heart is unable to send enough blood to body. Right side must maintain circulation for both lungs and body extra workload eventually causes the right side of the heart to fail. Right HF
testing for Kawasaki Disease
Labs - increased platelets (risk for occlusion, thrombosis) - inflammatory markers (CRP, ESR) chest x-ray, ECG, echocardiogram (coronary arteries)
medications for cystitis
Antibiotics tremethoprim/sulfamethoxazole (Bactrim) - BID 3 days Nitrofurantoin (Macrodantin, Macrobid) - prevents new bacteria (7 days) Ciprofloxacin (Cipro) - lots of resistant bacteria Analgesics phenazopyridine (Pyridium) - decreases s/s - can turn urine red/orange - available OTC
emergency care of pt with hypertensive urgency or crisis
Assess Severe headache Extremely high BP Dizziness Blurred Vision SOB Epistaxis Severe anxiety Intervene - semi-Fowler's - O2 - IV w/ NS slowly (avoid fluid overload) - IV beta blocker or nicardipine, switch to oral when stable - monitor BP every 5 to 15 minutes until diastolic <90 and not <75. Then monitor every 30 minutes to ensure it doesn't drop too quickly - observe for neurologic or cardiovascular complications such as seizures; numbness;, weakness, or tingling of extremities; dysrhythmias; or chest pain (possible indicators of target organ damage)
endotracheal tubes: nursing care
Assess tube placement, minimal cuff leak, breath sounds, chest wall movement Prevent movement of tube by patient Check cuff pressure address anxiety - sedation (lorazepam, propofol)
Which diagnostic study is identified by a nurse as providing an image of renal arteries? A Cystoscopy B Angiography C Urography D Biopsy
B Angiography
•A nurse is caring for a newly admitted patient with a diagnosis of HF and chest pain. At 1850 the nurse assesses the patient (See next slide). At 1900 the pharmacy enters the ordered meds into the EMR and asks the nurse to check the meds to be administered beginning at 0800 tomorrow (See next slide). The nurse's next action would be to: •Patient Assessment: C/O SOB Crackles in both lungs •Medication orders: -Digoxin 0.25 mg orally daily -Furosemide (Lasix) 80 mg IV twice daily A Acknowledge the meds per pharmacy request. B Call the MD because the patient's assessment warrants administering the furosemide today. C Administer the ordered meds according to the schedule in EMR so the patient will not have to get up to void during the night. D Verify that pharmacy entered the meds correctly per MD order.
B Call the MD because the patient's assessment warrants administering the furosemide today.
•A nurse is caring for a newly admitted patient with a diagnosis of HF and chest pain. At 1850 the nurse assesses the patient (See next slide). At 1900 the pharmacy enters the ordered meds into the EMR and asks the nurse to check the meds to be administered beginning at 0800 tomorrow (See next slide). The nurse's next action would be to: •Patient Assessment: C/O SOB Crackles in both lungs •Medication orders: -Digoxin 0.25 mg orally daily -Furosemide (Lasix) 80 mg IV twice daily A Acknowledge the meds per pharmacy request. B Call the MD because the patient's assessment warrants administering the furosemide today. C Administer the ordered meds according to the schedule in EMR so the patient will not have to get up to void during the night. D Verify that pharmacy entered the meds correctly per MD order.
B Call the MD because the patient's assessment warrants administering the furosemide today.
•Which property of heart muscle cells allows them to transmit an electrical impulse to adjacent heart muscle cells? A Automaticity B Conductivity C Contractility D Excitability
B Conductivity
•Which lab result in a patient with atherosclerosis and diabetes is of greatest concern to the nurse? A Cholesterol 139 mg/dl B LDL 98 mg/dl C HDL 55 mg/dl D Triglycerides 125 mg/dl
B LDL 98 mg/dl if person has DM or CAD, you want LDL to be <70 usually have to use meds to get this low
An RN is caring for a patient sent to the ER with s/s of MI. Which of the following should the nurse administer? A Acetaminophen B Nitroglycerin C Oxygen D Naloxone E Aspirin F Morphine G t-PA
B Nitroglycerin C Oxygen E Aspirin F Morphine G t-PA
A patient is admitted with a diagnosis of right renal calculus. Which assessment finding would a nurse report immediately? A Patient reports feeling "sweaty." B No urine output in 2 hours C Flank pain that radiates to lower abdomen D Nausea
B No urine output in 2 hours
•A nurse is assessing a patient who has just undergone AAA repair. Which findings are of greatest concern? SATA A Absent bowel sounds B Severe abdominal pain C Urine output 30 mL hourly D BP 104/72 HR 96
B Severe abdominal pain maybe, borderline C Urine output 30 mL hourly
mitral regurgitation pathophysiology
Blood backflows from L ventricle into L atrium L atrium and ventricle working hard to deal with all the blood, gets overworked and eventually fails
metoprolol adverse effects
Bronchospasm, bradycardia, edema, and drowsiness.
•A patient diagnosed with atherosclerosis has been prescribed atovastatin (Lipitor). Which statement by the patient indicates a need for further teaching? A "I shouldn't drink grapefruit juice." B "I need to quit smoking as soon as possible." C "I won't need to change my diet now." D "I'll see my NP regularly."
C "I won't need to change my diet now."
For which patient in a long-term care facility is habit training the best choice for incontinence management? A 86 year old with severe osteoarthritis B 56 year old diabetic who is blind C 75 year old with Alzheimer's disease D 79 year old with a cystocele
C 75 year old with Alzheimer's disease
•After receiving change-of-shift report, which patient should a nurse assess first? A 58-year-old admitted 2 days ago with heart failure, whose BP is 126/76 and RR 21 B 62-year-old admitted yesterday with pulmonary embolus who is receiving IV heparin C 76-year-old admitted 1 hour ago with suspected endocarditis whose blood cultures were just drawn D 88-year-old with end-stage heart failure, BP 78/50, and a do-not-resuscitate (DNR) order
C 76-year-old admitted 1 hour ago with suspected endocarditis whose blood cultures were just drawn
•What assessment finding would a nurse expect in a patient whose mean arterial pressure (MAP) is 40 mmHg? A Hypertension B Hyperkalemia C Chest pain D Bradycardia
C Chest pain (decreased perfusion) possibly B Hyperkalemia - could be with acidosis
•After receiving change-of-shift report, which patient should a nurse see first? The pt. with: A ulcerative colitis who reports episodes of bloody diarrhea B pneumonia whose O2 saturation is 91% C DVT who reports chest discomfort D Newly diagnosed with hypertension whose BP is 155/75
C DVT who reports chest discomfort
•Which patient should the RN assign to the LPN working on a cardiac care unit? A patient with: A Pericarditis who is manifesting JVD B Mitral valve disease whose systolic murmur is more pronounced C Dilated cardiomyopathy who uses O2 for DOE D Aortic valve disease who is receiving IV furosemide for acute heart failure
C Dilated cardiomyopathy who uses O2 for DOE
•A patient is prescribed lisinopril. Nursing interventions during initial therapy should include monitoring: A electrocardiogram (ECG) B intake and output C blood pressure D serum drug levels
C blood pressure
coarctation of the aorta: prognosis
Can be cured with surgery: symptoms quickly decrease! High risk for heart problems among those who have had their aorta repaired Without treatment, most people die before 40 - recommendation is to repair prior to age 10 (if mild) - most commonly, repair occurs during infancy Conditions can return after surgery: More likely in patients having had surgery as a newborn
complications for vent pt: cardiac
Cardiac - hypotension - fluid retention
shock physical assessment/clinical manifestations
Cardiovascular changes Pulse Blood pressure Oxygen saturation Skin changes Respiratory changes Renal and urinary changes Central nervous system changes Musculoskeletal changes Psychosocial assessments - changes in mental status and behavior may be early signs - monitor those at risk - alert/oriented? calm? able to concentrate? NO Laboratory tests (chart 37-2) see chart 37-1
causes/patho of eating disorders
Causes unclear Distinct psychologic component Common initiator: dieting Relentless pursuit of thinness Distorted body image Media impact Triggered by an adolescent crisis
TET spells: nursing care
Child may squat: observe response to position change Acute hypercyanotic (TET spell) - knee-chest position - calm, comforting approach (crying increases O2 demand) - 100% oxygen - morphine SQ or through existing IV line - initiate IV fluid replacement and volume expansion, if needed - repeat morphine if needed (decreases O2 demand and vasodilates --> increased perfusion)
24 hour urine collection labs
Creatinine - men: 1-2 g - women: 0.6-1.8 g decreased: impaired function r/t kidney disease increased: infection, exercise, DM, meat meals Urea nitrogen - 12-20 decreased: kidney damage, liver disease increased: high-protein diet, dehydration, trauma, sepsis Sodium 40-250 decreased: hemorrhage, shock, hyperadolsteronism, prerenal AKI increased: diuretic therapy, excessive salt intake, hypokalemia, acute tubular necrosis Chloride 110-250 decreased: kidney disease, malnutrition, puloric obstruction, prolonged nasogastric tube drainage, diarrhea, diaphoresis, HF, emphysema increased: hypokalemia, adrenal insufficiency, massive diuresis Calcium 100-400 decreased: hypocalcemia, hypoparathyroidism, nephrosis, nephritis increased: calcium kidney stones, hyperparathyroidism, sarcoidosis, certain cancers, immobilization, hypercalcemia Total catecholamines <100 increased: pheochromocytoma, neuroblastomas, stress, heavy exercise Protein <80 increased: glomerular disease, nephrotic syndrome, diabetic nephropathy, urinary tract malignancies, irritations
tetralogy of fallot s/s
Cyanosis at birth (mild to severe) characteristic systolic murmur acute episodes of cyanosis and hypoxia - TET spells: oxygen requirements exceed supply physiologic impact - systemic effects of chronic hypoxia (dev delay, R HF, stroke risk) - HF (R HF, JVD, circulation overload
A patient is scheduled for a urodynamic study. Which nursing action would be important several hours before? A Maintaining NPO B Administering antibiotic C Administering bowel prep D Encouraging fluids
D Encouraging fluids
•Which clinical finding would a nurse identify as indicative of DVT? A Positive Homan's sign B Sudden pallor and cyanosis affecting one leg C Intermittent claudication D Unilateral leg swelling
D Unilateral leg swelling
•A nurse reviews a patient's lab values throughout warfarin (Coumadin) drug therapy. What is the expected therapeutic level? A activated partial thromboplastin time (aPTT) 25-40 seconds B aPTT 1-2 times the patient's baseline C platelet count 100,000/mm D international normalized ratio (INR) 2-3
D international normalized ratio (INR) 2-3
drug therapy for valvular heart disease
Diuretics Beta blockers (decrease SNS, HR, BP) Digoxin (slows HR, increases contractility) O2 Sometimes nitrates
Meds for HTN
Diuretics Potassium-sparing: spironolactone (Aldactone) Loop: furosemide (Lasix); bumetanide (Bumex) Thiazide: HCTZ (Microzide); chlorothiazide (Diuril) Beta Blockers atenolol (Tenormin) metoprolol (Lopressor, Toprol) Calcium Channel Blockers verapamil (Calan, Isoptin) amlodipine (Norvasc) Diltiazem (Cardizem) Angiotensin-Converting Enzyme (ACE) inhibitors lisinopril (Prinivil, Zestril) enalapril (Vasotec) Captopril (Capoten) Angiotensin II Receptor Blockers (ARBs) valsartan (Diovan) losartan (Cozaar)
drug therapy for cardiomyopathy
Diuretics (HCTZ) Vasodilators (lisinopril) Glycosides (digoxin) antidysrhythmic agents beta blockers
medications for HT
Diuretics: thiazide, loop, K+ sparing Furosemide (lasix), spironolactone (Aldactone) Action: increased urine output Nursing concerns: hypotension, K+ levels Calcium channel blockers amlodipine (Norvasc), diltiazem (Cardizem) Action: antihypertensive, vasodilator, decreased HR Nursing concerns: decreased contractility, decreased cardiac output. Ankle edema Angiotensin converting enzyme (ACE) lisinopril (Vasotec) Action: vessel dilator Nursing concerns: cough, angioedema, increased K+ Angiotensin II receptor antagonists (ARBs) losartan (Cozaar) Beta blockers metoprolol (Toprol) not first line of defese for BP Others aldosterone receptor antagonists (Inspra) Renin inhibitors: Aliskiren (Tekturna) Alpha blothers: Doxazosin (Cardura) Central alpha antagonists: clonidine (Catapres)
diagnostic assessment for peripheral arterial disease
Doppler probe for pedal pulses ankle/brachial index (ABI): ankel presure compared to brachial pressure - abnormal if <0.9 - normal = 1.0 exercise tolerance test plethysmography imaging: arteriogram (looking without contrast dye) - determines exact lcoation, extent of disease - usually performed prior to surgery
minimizing bleeding with PE
Drug antidotes - heparin: protamine sulfate - warfarin: Vitamin K/phytonadione - clotting factors, fresh frozen plasma (FFP), aminocaprioc acid (Amicar) Assessment Monitoring lab values - PT/INR, PTT, H&H, Plt
interventions for cardiomyopathy
Drug therapy OCD Toxin exposure avoidance Alcohol avoidance Surgery
Nonsurgical management of valvular heart disease
Drug therapy Prophylactic antibiotics prior to invasive procedures Management of a-fib Rest with limited activity O2
interventions for urge urinary incontinence
Drugs - anticholinergics/antispasmodics including: - tolterodine (Detrol) - solifenacin (Vesicare) - oxybutynin (Ditropan) - side effects: dry mouth, blurred vision, constipation, increased HR Diet therapy - avoid caffeine and alcohol - space fluids and avoid after dinner behavioral interventions - kegel exercises - bladder training (gradually increasing voiding intervals) - habit training (maintaining voiding schedule)
continuous ECG monitoring
ECG cables attached to: - wall mounted monitor - battery-operated monitor allowing freedom of movement (telemetry system)
lead systems for ECG
ECG provides 12 leads or views of heart's electrical activity made up of a positive and negative pole 6 are limb leads 6 are chest leads
foods and drugs that interfere with warfarin (coumadin)
Eat only small amount of foods rich in vit K each day, including: - broccoli - cauliflower - spinach - kale - other green leafy veggies - brussel sprouts - cabbage - liver If possible, avoid: - alopurinal - NSAIDS - acetaminophen - vitamin E - histamine blockers - cholesterol-reducing drugs - antibiotics - oral contraceptives - antidepressants - thyroid drugs - antifungal agents - other anticoagulants - corticosteroids - herbs, such as St. John's wort, garlic, ginseng, Ginkgo biloba
furosemide adverse effects
Electrolyte imbalance (cardiac depression), ototoxicity, alteration in glucose levels
surgical management of PE
Embolectomy Inferior vena cava filtration
Causes of aortic regurgitation
Endocarditis Congenital condition Hypertension Marfan's syndrome
rheumatic fever treatment
Eradicate hemolytic streptococcus with meds Prevent permanent cardiac damage Support other symptoms Prevent recurrence of RF
developing a sense of autonomy
Erikson - autonomy v shame and doubt - only if need for trust has been satisfied can a child engage in autonomy - netagivism - ritualization, which provides sense of comfort
Causes of overproduction of hydrogen ions What does this cause?
Excessive oxidation of fatty acids - DKA - starvation Hypermetabolism - heavy exercise - seizure activity - fever - hypoxia - ischemia Excessive ingestion of acids - ethanol or methanol intoxication - salicylate intoxiation Metabolic acidosis
pediatric pain scales
FACES - Wong-Baker FLACC (for anyone who is nonverbal) pain is whatever the child says it is
NSAIDS and heart attack or stroke
FDA has strengthened warning associated with NSAIDS and cardiovascular risk nonaspirin NSAIDS can increase risk of heart attackand stroke
not back to birthweight by 2 weeks, increased risk for
FTT
Etiology of Essential or Primary Hypertension
Family history of hypertension African-American ethnicity Hyperlipidemia Smoking Older than 60 years or postmenopausal Excessive sodium and caffeine intake Overweight/obesity Physical inactivity Excessive alcohol intake Low potassium, calcium, or magnesium intake Excessive and continuous stress
nursing concerns with ACE inhibitors
Lisinopril - Hyperkalemia
classification of dysrhythmias
Location - Atrial or ventricular Type - Flutter, fibrillation, block Atrial fibrillation most common
risk factors for atherosclerosis (book)
Low HDL-C High LDL-C Increased triglycerides Genetic predisposition DM Obesity Sedentary lifestyle Smoking Stress African-American or Hispanic ethnicity Older adult
Common causes of oxygenation failure
Low atmospheric oxygen concentration: - high altitudes, - closed spaces, - smoke inhalation, - carbon monoxide poisoning - Pneumonia, - CHF with pulmonary edema, - pulmonary embolism, - acute respiratory distress syndrome, - interstitial pneumonitis- fibrosis, - abnormal hemoglobin, - hypovolemic shock, - hypoventilation, Complications of nitroprusside therapy: - thiocyanate toxicity, - methemoglobinemia
progressive (intermediate) stage of shock
MAP decreases >20 mmHg from baseline vital organs develop hypoxia rapid, weak HR; low BP; anuria; cool, moist skin must be corrected within 1 hour or less; an emergency
nonprogressive stage of shock (compensatory)
MAP decreases by 10-15 mmHg Renin, aldosterone, ADH, epi and norepi (adrenal glands) are released, lactic acidosis and increasing K+ tissue hypoxia affects nonvital organs increased blood glucose, decreased pH thirst, anxiety, increased HR, RR, decreased urine output, narrowed pulse pressure, cool extremities
initial stage of shock (early shock)
MAP decreases by <10 mmHg adequate bloodflow is maintained overall cell metabolism is still aerobic increased RR, HR, increase in diastolic BP (slight)
Health teaching for HF
MAWDS Medications - take, know side effects, no NSAIDS (to prevent Na+ retention) Activity - conserve, gradually increase Weight - daily 1kg=1L call for 2 lbs overnight, 3/week Diet - Na 2-3 g, 2L fluid restriction Symptoms - when to report, weight gain, edema, SOB, nocturia
pulmonary artery line is inserted by ______ through________
MD, right neck vein
HF remains a major cause of disability and death after
MI
cardiogenic shock
MI affecting >40% of myocardium
which vaccines are live?
MMR Varicella (chickenpox) rotavirus
traditional MI treatment pneumonic
MONA Morphine Oxygen (AHA says not necessary anymore) Nitrates Aspirin
what is the leading cause of accidental death in babies
MVA
serum creatinine
Males: 0.6-1.2 Females: 0.5-1.1 increased: kidney impairment decreased: decreased muscle mass
health teaching for cystitis
Medication Prevention - after urinating, women should wipe front to back - increase daily fluid intake - don't delay urination (bacteria colonize!) - cranberry juice - after sex, women should urinate
MCHAT
Modified Checklist for Autism in Toddlers
assessment for infective endocarditis
Fever Murmur (new or changed) (changes shape of valves) Petechiae, splinter hemorrhage in nails, Studies: + blood cultures low hgb/hct echo revealing abnormal valve
plagiocephaly
Flattening or asymmetry of the head
Managing hypotension with PE
Fluids Drug therapy
renal/urinary physical assessment
General appearance - skin (pallor, edema) - LOC (decreased alertness) - VS, weight Insepction - asymmetry, swelling, distention Auscultation - renal artery bruit Palpation - bladder distention Percussion - costovertebral (CVA) tenderness Urethra - discharge, redness, lesions, ulceration
nonsurgical management of DVT
Goals: prevent PE, increase in clot size, further clot formation rest drug therapy - heparin therapy followed by warfarin (monitor PT/INR) - low molecular weight heparin: enoxaparin (lovenox), then warfarin warfarin takes 3-5 days to reach therapeutic level thrombolytic therapy: may be injected into clot
PAD surgery post-op comlications
Graft occlusion - monitor: pulse, pain, coolness, color, etc. - promote patency: stabilize BP, restrict activity - Treatment: thrombectomy, antiplatelets Compartment Syndrome - edema, pain, pulseless Infection
what is the metabolic acid-base parameter?
HCO3-
clinical consequences of CHD
HF chronic hypoxemia
complications of infective endocarditis
HF Arterial embolization (traveling clots) Infarction (splenic, renal, pulmonary, neurologic)
Commonly used drugs for lowering LDL-C levels (book)
HMG-CoA Reductase Inhibitors (statins) lovastatin atorvastatin simvastatin fluvastatin rosuvastatin pravastatin pitavastatin combo drugs ezetimibe and simvastatin (Vytorin) amlodipine and atorvastatin (Caduet) niacin and lovastatin (Advicor)
MI priority actions IV access, HOB, O2
HOB O2 IV access
hold metoprolol for
HR < 50-60 BP < 90-100
typical causes of left-sided heart failure
Hypertension (increased afterload = hypertrophy) Coronary artery disease Valve disease
causes of excessive loss of CO2
Hyperventilation, fear, anxiety Mechanical ventilation Salicylate toxicity High altitudes Shock Early-stage acute pulmonary problems
Killip Classification of HF
I absent crackels and S2 II crackles in the lower half of the lung fields and possible S2 III crackles more than halfway up the lung fields and frequent pulmonary edema IV cardiogenic shock
how to monitor fluid balance in ventilated pt
I & O
enhancing contractility meds
INOTROPIC DRUGS DIGOXIN (Lanoxin) cardiac glycoside - monitor HR and rhythm - Digitalis toxicity (hypokalemia makes it worse) dobutamine (Dobutrex), Milrinone (Primacore) - for acute HF or chronic w/ acute exacerbation BETA BLOCKERS METOPROLOL (Lopressor, Toprol) Carvedilol (Corec), bisoprolol (Zebeta), atenolol (Tenormin) - blocks stress response - decreases HR - watch for bradycardia, hypotension - check HR before giving (>55)
IVGG
IV Gamma Globulin used for Kawasaki disease
what increases risk of endocarditis?
IV drug abuse valve replacement systemic infection structural heart defects
CABG postop care
IV hyration, urinary catheter mechanical vent for 3-6 hours usually hemodynamic monitoring
how are antibiotics for infective endocarditis given?
IV through PICC at home after inpatient initiation
fetal blood flow
IVC via ductus venosus --> RA --> foramen ovale (shunts bood from RA to LA) --> LA --> LV --> body via aorta OR SVC --> RA --> RV --> pulmonary artery --> ductus arteriousis --> aorta
interventions for urolithiasis
Pain management - narcotic analgesia Lithotripsy (extracorporeal shock wave lithotripsy or ESWL) - use of sound waves or laser to break stone into fragments - involves conscious sedation and EKG monitor Surgery - minimally invasive, usually entails placement of stent into ureter to dilate passage - open procedure (into ureter or kidney) to remove larger stone
pericarditis interventions
Pain management NSAIDS Corticosteroids Treating cause: infection Pericardiectomy: surgical excision of pericardium in chronic constrictive pericarditis
Assessment of Abdominal Aortic Aneurysm (AAA)
Pain related to AAA is usually steady with a gnawing quality, unaffected by movement, may last for hours or days Pain in abdomen, flank, back Abdominal mass is pulsatile Rupture is most frequent complication and is life threatening
sensorimotor phase
Piaget - birth to 1 month: use of reflexes and eventually behavior is transitioned from reflexive (sucking, rooting, crying) to simple, purposeful - separation: infants learn to separate themselves from other objects in the environment - object permanence: realize that when objects leave the visual field, they still exist (9 months) (peek-a-boo)
sonsorimotor and preoperational stage
Piaget cognitive processes develop rapidly between ages 12 and 24 months tertiary circular reactions - active experimentation - applying knowledge to new situations - learning spatial relationships
nursing concerns for valve replacement surgery
Preop teaching stop anticoagulant dental exam Postop similar to CABG monitoring for decreased CO, bleeding (aortic valve surgery)
PSV weaning
Pressure support weaning - PSV allows the pt's respiratory effort to be augmented by a predetermined pressure assist from the ventilator - as the weaning process ensues, the amount of pressure applied to inspiration is gradually decreased - another method of weaning with PSV is to maintain the pressure but gradually decrease the ventilator's preset breaths/min rate
antismoking campaigns
Prevention is most effective way to reduce incidence Programs that focus on long-term effects have been ineffective Peer-led programs more successful Media are used in smoking prevention School-based programs focus on prevention
causes of decrease of acid components what does this cause?
Prolonged vomiting Nasogastric suctioning Hypercortisolism Hyperaldosteronism Thaizide diuretics metabolic alkalosis
assessment of pt with HT
Pt history Physical exam - take BP in both arms - orthostatic BP Psychosocial Diagnostics: labs, ECG
HLHS causes, incidence
Rare CHD More common in males No known cause About 10% of pts with HLHS also have other birth defects
CAD health promotion and maintenance
Reducing elevated serum lipids - LDL increases risk for MI - good lipid levels LIfestyle changes, medications Eliminate tobacco use Increase physical activity
enoxaparin contraindications
Renal and hepatic impairment Pregnancy or lactation Patients using anticoagualants Uncontrolled HTN Recent surgery Renal insufficiency
Pt after PE assessment (home)
Respiratory - rate/depth - nail beds/mucous membranes for cyanosis - pulse oximetry - chest pain or SOB? - presence of sputum/color/character Cardiovascular - VS, apical pulse, pulse pressure, orthostatic hypotension, quality/rhythm of peripheral pulses - peripheral edema - hand vein filling in dependent position - neck vein filling in recumbent and sitting positions Lower Extremities for DVT - edema - calf swelling - surface temp - red streaks or cordlike, palpable structure - calf cirumference Evidence of Bleeding - mouth/gums for oozing or frank bleeding - all skin for bleeding, bruising, petechiae - voids? test for occult blood Cognition/Mental Status - LOC - Orientation - Read seven-work sentence Understanding of Illness and Adherence to Treatment - symptoms to report - drug therapy plan (timing/dose) - bleeding precautions - DVT prevention
causes of underelimination of hydrogen ions (respiratory) what does this cause?
Respiratory depression - anesthetics - drugs (especially opioids) - electrolyte imbalance Inadequate chest expansion - muscle weakness - airway obstruction - alveolar-capillary block
chronic peripheral arterial disease stage III
Rest Pain pain while resting commonly awakens pt at night Pain is described as numbness, burning, toothache-type pain Pain usually occurs in the distal part of the extremity (toes, arch, forefoot, or heel), rarely in the calf or the ankle) Pain is relieved by placing the extremity in a dependent position
age-related cardiovascular changes
Results in loss of cardiac reserve. Not usually evident when the older adult is resting Hardening of vessel walls (arteriosclerosis), O2 and nutrients don't make it to tissues as well as before so there is a build up of waste products in the tissues, hardening of peripheral vessels, loss of elasticity in the peripheral vessels
why can we give aspirin to kids with Kawasaki disease
Reye's syndrome is a risk when you give aspirin to a kid with a virus Kawasaki disease is not viral
causes of valvular heart disease
Rheumatic fever Endocarditis IV drug abuse Family history
cardiac cath procedure
Right side of heart: cath through femoral vein, vena cava, and into right heart Left side of heart: cath through femoral artery, aorta, and into left ventricle Pressures, valve function are assessed Coronary arteriography (same as for left-sided): iject contrast into coronary arteries - provides into re site(s), severity of blockage(s)
sequence of conduction pathway
SA node atrial muscle av node bundle of his right and left bundle branches purkinje fibers ventricular muscle
sinus bradycardia
SA node generates <50-60 impulses/minute caused by excessive vagal stimulation occurs with athletic training, valsalva maneuver, drug therapy (beta blockers, CCC, digitalis)
sinus tachycardia
SA node generates >95-100 beats/minute due to increased sympathetic stimulation anxiety may cause it increases myocardial demand decreases filling time and coronary artery perfusion
cardiac conduction system
SA node, AV node, AV bundle, bundle branches, Purkinje fibers
method fors weaning
SIMV - patient breathes between preset breahts/minute rate, which is gradually reduces T-piece technique: pt is taken off ventilator for short periods. Vent is replaced with T-piece, which delivers humidified O2 Pressure support ventilation: pt's respiratory effort is augmented by pressure assistance from ventilator - amount of pressure applied to inspiration is gradually decreased
contractility is increased by
SNS, some medications
s/s of MI in women
SOB jaw pain fatigue GI upset
blood flow through the heart
SVC --> Rt atria --> Tricuspid --> Rt ventricle --> Pulmonic valve --> Lungs --> Lt atria --> Mitral valve --> Lt ventricle --> aortic valve --> aorta --> Body
manifestations of respiratory acidosis
Neuro - anxiety, irritability, confusion Cardiac - tachycardia - dysrhythmia Respiratory - tachypnea (trying to blow of CO2)
symptoms of metabolic acidosis
Neuro - drowsiness, lethargy, confusion Cardiac - delayed electrical conduction of heart (r/t increased K+) - decreased heart rate - decreased BP - decreased cardiac output Muscle weakness Respiratory - increased respiratory rate (trying to compensate) (Kussmaul)
manifestations of metabolic alkalosis
Neuro - numbness, tingling (paresthesia) - muscle weakness/cramps - agitation, confusion - seizure (in extreme) Cardiac - tachycardia - CO ??? - BP ???
Extrapulmonary causes of ventilatory failure
Neuromuscular Disorders - Myasthenia gravis - Guillain_Barre syndrome - Poliomyelitis - Spinal cord injuries affecting nerves to intercostal muscles Central Nervous System Dysfunction - stroke - increased intracranial pressure - meningitis Chemical Deppression - Opioid analgesics, sedatives, anesthetics - Kyphoscoliosis - Massive obesity - Sleep apnea - External obstruction/constriction
acute coronary syndrome drug therapy
Nitrate monitor BP, headache assess for pain relief don't give with sexual dysfunction drugs! - nitroglycerin (tabs, spray, patch) - isosorbide dinitrate - isosorbide mononitrate Beta Blockers assess HR and BP first hold for HR <50-60 hold for BP <90-100 observe for s/s of HF (decreased CO) assess for wheezing/SOB - carvedilol (Coreg) - metoprolol (Lopressor, Toprol) (cardioselective) Antiplatelets inform pt to report bleeding/bruising avoid OTC meds with aspirin take aspirin with food aspirin - assess ringing in ears (toxicity) platelet inhibitors - take with food platelet inhibitors - DO NOT CONFUSE PLAVIX WITH PAXIL - aspirin - P2Y12 inhibitors \\\ clopidogrel (Plavix) \\\prasugrel (Effient) \\\ ticagrelor (Brilinta) \\\ cangrelor (Kangreal) - PAR-1 inhibitor \\\ vorapaxar sulfate (Zontivity)
drug therapies for CAD
Nitrates - nitroglycerin Beta blockers - metoprolol Antiplatelet agents - aspirin - clopidogrel (Plavix)
medication management for MI
Nitroglycerine Morphine, ASA Oxygen
ventricular asystole treatment
No defibrillation (won't help) CPR Goal is to restore electrical activity Oxygen Medication - epinephrine - can help generate electrical activity - atropine
s/s of mitral stenosis
None initially DOE Orthopnea Paroxysmal nocturnal apnea Irregular rhythm Murmur Right-sided HF
flail chest treatment
O2 - humidified Pain management deep breathing, positioning secretion cleaance close monitoring
Vent settings: FiO2
O2 delivered to the pt. 21-100%
what is happening in oxygenation failure?
O2 is reaching alveoli but there is a gas exchange problem
Hypoplastic Left Heart Syndrome
Occurs when parts of left side of heart (mitral valve, left ventricle, aortic valve, and aorta) do not develop completely. The conditions i present at birth
Possible ports of entry for Infective Endocarditis
Oral cavity Skin rash Lesion/abscess Infection Surgery or invasive procedure
causes of increase of base components what does this cause?
Oral ingestion of bases - antacids Parenteral base administration - blood transfusion - sodium bicarbonate - total parenteral nutrition metabolic alkalosis
drug therapy for atherosclerosis
Statins (HMG-CoA reductase inhibitors) simvastatin (Zocor) atorvastatin (Lipitor) Action: reduce chol synthesis in liver, increase LDL clearance) Nursing concerns: myalgia, weakness, no grapefruit, LFTs (AST, ALT) Ezetimide (Zetia) added on to other drugs Action: inhibit chol absorption in small intestine Nursing concerns: GI issues, gas, diarrhea simvastatin/ezetimide (Vytorin) Action: combo Nursing concerns: combo
what can sulfamethoxazole/trimethoprim (Bactrim, DS, Septra DS) cause?
Stevens-Johnson syndrome - aching joints and muscles - bilateral blistering of skin) toxic epidermal necrolysis - redness - blistering - peeling skin and mucous membranes d/c at first sign of rash
ICD teaching
Similar teaching as pacemaker Family should learn CPR Patients often anxious about device working - suggest support group Driving may be restricted If ICD fires, call HCP immediately If ICD fires more than once, patient looses consciousness or feels bad, call EMS
post op care for heart transplant
Similar to CABG Tamponade is risk Heart is disconnected to ANS (not innervated) Immunosuppresant emds Monitor for infection Monitor for coronary artery vasculopathy (vascular endothelial injury)
modifiable risk factors for CAD
Smoking, HTN, DM, obesity, diet, activity level, hyperlipidemia, stress
medications for HF
Oxygen Digoxin - increase force of contractility, reduce HR Lisinopril - vasodilation Furosemide - decrease fluid retention Metoprolol - decrease HR, cardiac contractility
Which interventions would be therapeutic? Oxygen Trendelenberg position Energy-conserving measures, such as assisting with ADLs Antibiotics if cause is viral pneumonia Decreasing anxiety
Oxygen Energy-conserving measures, such as assisting with ADLs Decreasing anxiety
PVC picture
PVC picture
what is the respiratory acid-base parameter?
PaCO2
PDA symptoms and Dx
Tachypnea Poor feeding habits Tachycardia SOB Sweating while feeding Tiring very easily Poor growth - work so hard to eat, using more calories than taking in heart murmur (not always in premature infants) Changes may be seen on chest x-ray Dx confirmed with echocardiogram A small PDA may not be dx until later in childhood
labs for cystitis
UA Bacteria, WBCs, RBCs Leukocyte esterase, nitrites highly sensitive Mid-stream clean catch technique Urine Culture and Sensitivity identifies pathogen and antibiotic needed
what illnesses are common in toddlers
URI otitis media tonsillitis
renal/urinary urine tests
Urine specimen collection Urinalysis (abnormals are bold) - color, odor, and turbidity - specific gravity (1.005-1.30 - check) - pH (average 6) - glucose - ketone bodies - protein - leukocyte esterase, nitrites - RBCs, WBCs, casts, crystals, and bacteria Culture and Sensitivity - identifies UTI - requires midstream clean catch Composite urine collections - analysis of substances - creatinine clearance: best indication of overall kidney function. Requires 24 hour urine collection Urine electrolytes Urine osmolarity
ECG lead placement
V1 - R 4th intercostal space sternal border V2 - L 4th intercostal space sternal border V3 - placed halfway between V2 & V4 V4 - L 5th intercostal space midclavicular line V5 - L 5th intercostal space anterior axillary line V6 - L 5th intercostal space mid axillary line
pathophysiology of mitral stenosis
Valve leaflets fuse, stiffen Caused by rheumatic heart disease Opening narrows L atrium must work even hard
drug therapy for shock
Vasocontrictors: drugs increase CO and MAP - used in septic shock - Dopamine (Intropin) - Norepinephrine (Levophed) Inotropic drugs: enhance cardiac contractility. given IV - dobutamine (Dobutrex) - milrinone (Primacor)
antidote for warfarin
Vitamin K
antidote for warfarin
Vitamin K (AquaMEPHYTON)
warfarin drug class
Vitamin K antagonist decrease synthesis of vit K in intestinal tract, reduces K-dependent clotting factors
on looker play
Watching everyone play, but having no interaction.
PE - managing hypoxemia, nonsurgical
What is critical to consider??? 1. elevate HOB 2. administer O2 3. notify Rapid Response close monitoring drug therapy
Care for ET or tracheostomy tube
Suction as needed (secretions, increased PIP, wheezes, decreased breath sounds) Assess tube position at least every 2 hours - mark where tube touches patient's nose or teeth Provide frequent mouth care
assess for, document, and report s/s of cardiac tamponade
Sudden cessation of previously heavy mediastinal drainage Beck's Triad - JVD but clear lung sounds - distant, muffled heart sounds - hypotension Pulsus paradoxus (BP 10 higher on expiration) An equalizing of PAWP and right atrial pressure Cardiovascular collapse
•Only definitive treatment for aortic stenosis
Surgical intervention - aortic valve replacement
epinephrine mode of action
Sympathomimetic, adrenergic agonist mimics sympathetic nervous system, capable of generating automaticity
R ventricular failure key features
Systemic congestion - jugular (neck vein) distention - enlarged liver and spleen - anorexia and nausea - dependent edema (legs and sacrum) - swollen hands and fingers - polyuria at night - weight gain - increase blood pressure (from excess volume_ or decreased blood pressure (from failure)
symptoms of right sided heart failure
Systemic vascular congestion Distended neck veins Tender/non-tender hepatic congestion Decreased appetite/nausea Depended pitting edema Hepatomegaly
affect of ischemia on ECG
T wave inversion ST depression or both
nutrition 6-12 months
solids can be introduced strawberries, eggs, peanuts are controversial new foods in AM/early PM and one per 4-7 days by 8-9 months, finger foods are great by 12 months, table food is appropriate if well cooked and appropriately cut
echocardiography uses
ultrasound to evaluate heart structure and mobility, particularly of valves - noninvasive
otic medication administration
under 3: pull pinna downward and straight back over 3: pull pinna upward and back ("grown UP") warm drops to room temp engage the child
respiratory acidosis patholoty
underelimination of hydrogen ions
cause of SIDS
unknown maybe brainstem abnormality maybe genetics suspected causes - maternal smoking during pregnancy - co-sleeping, bed sharing with older sibling - prone sleeping - prolonged QT intervals
2nd degree AV block
some impulses are blocked
when to go to dentist
some say 1 year, some say 3 years old
rates and patterns of growth are
specific to parts of body
exercise and activity in school age child
sports - controversy regarding early participating in competitive sports - concerns with physical and emotional maturity in competitive environment acquisition of skills - children generally like competition
teaching older children to take pills
sprinkle, tic-tac, m&m, pill
growth happens in
spurts rather than gradual pattern
restrictive cardiomyopathy definition s/s causes
stiff ventricles that resist filling CO is diminished s/s disease is fatal in a few years cause ?
what foods are controversial in first year
strawberries, peanuts, eggs
types of urinary incontinence
stress involuntary urine loss with cough, sneeze d/t weakened pelvic floor muscles urge perception of urgent need to urinate d/t bladder contractions overflow (or reflex) involuntary loss of urin a/w bladder overfilling cause: prostate enlargement, neurogenic bladder functional involuntary urine loss a/w factors outside of urinary system (e.g. dementia) mixed secondary to another problem
exercise ECG
stress test assesses cardiac response to gradually increasing workload
complications for pt on vent: GI
stress ulcer --pharmacological prophylaxis ---antacids (Carafate - protects mucosa) ---histamine receptor blockers (ranitidine/Zantac - decreased HCl) ---Proton-pump inhibitors (esomeprazole/Nexium - most potent acid reducers) - test for occult blood in stool H&H
tracheobronchial trauma often occurs from
striking neck against dashboard or steering wheel during MVA
why is hypertension worrisome?
stroke, MI
echocardiogram evaluates
structure of the heart
enoxaparin administration
subcut don't massage site keep air bubble in syringe give in 2" circle around umbilicus rotate injection sites
enoxaparin administration
subq don't push air out don't massage
one DVT puts you at risk for
subsequent DVTs
angina key features
substernal chest discomfort - radiating to the left arm - precipitated by exertion or stress (or rest in variant angina) - relieved by nitroglycerin or rest - lasting less than 15 minutes few, if any, associated symptoms
pericarditis assessment
sudden sharp, stabbing, moderate to severe substernal; usually spreads to the left side or the back intermittent; relieved with sitting upright, analgesia, or administration of anti-inflammatory agents
SIDS definition
sudden death of a baby under 1 that remains unexplained even after autopsy, investigation of scene and history of recent events
aortic dissection
sudden tear in wall of aorta allowing blood to accumulate within wall potentially lethal s/s - pain (tearing, ripping, stabbing) - elevated BP - N/V, diaphoresis, presyncopy Treatment: - medical: reduce BP, pain control - surgical: remove tear, suture synthetic graft in place
angina assessment
sudden, usually in response to exertion, emotion or extremes in temp squeezing, viselike - usually the left side of chest without radiation - substernal, may spread across the chest and the back and/or down the arms usually lasts less than 15 min; relieved with rest, nitrate administration, or oxygen therapy
myocardial infarction assessment
sudden, without precipiating factors, often in early morning intense, stabbing, viselike pain or pressure, severe substernal; may spread throughout the anterior chest and to the arms jaw, back, or neck continuous or no chest discomfort, relieved with morphine, cardiac drugs, and oxygen therapy
optic medication for kids (administration)
supine or sitting extend head and look up pull lower eye lid down and apply medication in pocket allow child to close eye, drop in inner canthus, when child opes eyes, drop will roll in ointments best applied before naps or bed chill (if med stings, chilling helps)
what do beta blockers do for CAD?
suppresses SNS, decreases HR/BP
Sepsis with Systemic Inflammatory Response Syndrome (SIRS) Criteria
suspected or identified infection with some of the following: - temp above 101 (38.3) or less than 96.8 (36) - HR above 90 - RR above 20 - abnormal WBC - normal WBC w/ >10% bands - plasma C-reactive protein >2 standard deviations above normal - plasma prolactin >2 standard deviations above normal - arterial hypotension (BP <90; MAP <70) - arterial hypoxemia - urine output <5mL/kg/hr for 2 hrs - creatinine increase >0.5 - INR >1.5 or aPTT >60 - absent bowel sounds - platelet <100 - total bilirubin >4 - elevated lactic acid - decreased cap refill - mottling - hyperglycemia >140 w/out DM - unexplained change in mental status - significant edema or positive fluid balance
teach pts taking the extended-release forms of anticholinergic drugs to
swallow the tablet or capsule whole without chewing or crushing it. chewing or crushing ruins the extended-release feature, allowing entire dose to be absorbed quickly, increases adverse drug side effects
cardioversion
synchronized countershock delivered only during QRS complex via 2 chest electrodes performed in emergencies for unstable dysrhythmias or electively for stable dysrhythmias resistant to medical therapies goal: depolarize most myocardium to allow SA node to regain role of pacemaker syncronized to avoid t-wave
what is the trigger for ARDS?
systemic inflammatory response
HT definition
systolic BP >or= 140 diastolic BP >or=90
what is orthostatic hypotension
systolic decrease of 20 and/or diastolic decrease of 10 HR: 10-20% increase
two types of left-sided heart failure
systolic failure: ventricles cannot contract well diastolic failure: ventricles cannot fill well
teach pts receiving HTN treatment about importance of _____________. teach to report these s/s promplty:
taking prescribed drugs abdominal fullness or pain or back pain chest or back pain SOB difficulty swallowing or hoarseness
atorvastatin nursing concern
teach that liver function tests are needed periodically
nitroglycerine sublingual (Nitrostat) nursing concerns
teach that side effects are headache, flushing, low BP
nitroglycerine transdermal nursing concerns
teach to avoid alcohol, sildenafil (Viagra), take patch off after 12 hours and replace next day
apsirin nursing concerns
teach to take with food, as drug may cause GI irritation
cardiac cath pt prep
teaching: explain purpose, procedure and associated sensations, aftercare informed consent Labs, ECG, chest x-ray, VS any allergy to contrast agent (shellfish, iodine, etc)
cardiac output
the amount of blood pumped by the heart per minute
why can rheumatic fever cause mitral valve problems?
the antibodies for strep attack the mitral valve
use caution when giving positive inotropes because of
the potential risk for increasing myocardial oxygen consumption and further decreasing CO monitor the pt frequently, paying particular attention to the development of chest pain
if the HCO3 and pH are moving in _________ __________, then the problem is primarily metabolic
the same direction
carbon monoxide and oxygen bind to
the same receptors. when you're smoking, you're delivering carbon monoxide through the body instead of oxygen
S2
the second heart sound, heard when the semilunar (aortic and pulmonic) valves close
hemodynamic monitoring
the use of pressure monitoring devices to directly measure cardiovascular function invasive system used in critical care areas to provide quantitative info about vascular capacity, blood volume, pump effectiveness, and tissue perfusion Pulmonary artery (PA) catheter (also known as Swan Ganz catheter) - most commonly used Invasive arterial catheter - less common
sexual abuse of child
the use, persuasion, or coercion of any child to engage in sexually explicit conduct; the simulation of such conduct for producing visual depiction of such conduct the rape, molestation, prostitution, or incest with children
why is combined metabolic and respiratory acidosis so bad?
there are no backup compensatory mechanisms to use
growth charts and premature infants
they catch up by age 3
aerteriosclerosis definition
thickening or hardening of the arterial wall often associated with agin
report the presence of glucose or protein in the urine because
this is an abnormal finding and requires further evaluation
surgical management of DVT
thrombectomy: removal of clot, (uncommon) inferior vena cava interruption (IVC filter) - device inserted via femoral vein, traps emboli before entering pulmonary circulation - candidate: pt unable to take warfarin - post-op care: monitor groin site for bleeding, infection
Buerger's Disease
thromboangitis obliterans: uncommon occlusive disease limited to medium and small arteries, veins of hands, feet (fingers, toes most often affected) s/s - pain, particularly at night - increased sensitivity to cold - diminished distal pulses - ulceration, gangrene (fingers/feet) most often a/w smoking nursing concerns: similar to PAD
venous thromboembolism
thrombus: formed clot embolus: dislodged clot or clot fragment
what is the amount of air inhaled and exhaled with each breath
tidal volume
PR interval
time required for atrial depolarization and spread of impulse to Purkinje fibers
QT interval
time requires for ventricular depolarization and repolarization
sign of aspirin toxicity
tinnitus (ringing in the ears)
elevations in C-reactive protein indicate
tissue death/damage
C-reactive elevation indicates
tissue infarction or damage not specific to cardiac
indications for cardiac catheterization
to confirm suspected disease
what is the goal for mechanical ventilation nursing interventions
to maintain patient/ventilator synchrony
The priority for nursing care following a percutaneous intervention or atherectomy is
to observe for bleeding at the arterial puncture site, which is sealed with a special collagen plug monitor for s/s of impending hypovolemic shock, including a decrease in BP, increased HR, decreased urinary output perform frequent checks of distal pulses in both legs to assess perfusion
physiologic anorexia
toddlers simply do not require as much food intake for their size as they did in infancy also too busy to stop and eat
what is happening in ventilatory failure
too little O2 is reaching alveoli
hypovolemic shock
too little circulating volume potential causes: hemorrhage very common
refractory (irreversible) stage of shock
too much cell death and tissue damage body cannot respond to interventions
milk and iron
too much milk = not enough iron consumption
tissue perfusion and mean arterial pressure depends on
total blood volume cardiac output size of vascular bed
antidepressants for urinary retention
tricyclics imipramine (Tofranil, Novo-Pramine) amitriptyline (Elavil, Levate) SNRI duloxetine (Cymbalta) increase norepinephrine and serotonin levels, which are thought to strengthen the urinary sphincters; also have anticholinergic effects - don't combine with other antidepressants (interactions can cause HTN crisis) - tell HCP if you take drugs to manage HTN - change positions slowly (orthostatic hypotension) - same interventions as for anticholinergic meds
tobacco use in adolescence
use has declined slowly since its peak in 1999 the use of available tobacco products did not change from 2006 to 2009 although the rate of smoking has declined over the past decade, smoking is still the chief avoidable cause of death reasons for tobacco use - imitation of adult behavior - peer pressure - a desire to control weight less likelihood of smoking pr parents/family do not smoke less likelihood of smoking with high-performance sports activities
aerosolized medication administration
use mask for younger children use distraction to complete treatment spacer maximizes med administration
supraventricular tachycardia
Which rhythm is this?
giving infants oral medication
use proper measuring device - oral med syringe - nipple on special med cup position infant in a semi-reclined manner - administer med into side of mouth in small amounts to allow for swallowing - don't rush! smile and engage the infant - rub under chin for swallow reflex
immunization schedule
use sheet from lab
DM and thiazide diuretics
use with caution can interfere with serum glucose control
secondary sex characteristics
used as visual cues to identify stage of puberty result of hormonal changes: voice changes, hair growth, breast enlargement, fat deposits play no direct role in reproduction but visually suggest puberty
24 hour urine collection
used to collect the total volume of urine excreted in 24 hours for diagnostic examination
ECG at rest provides
valuable info re dysrhythmias, MI, set/extent of MI, etc
Complications of infective endocarditis
valve disease CHD dental procedures are risky. prophylactic antibiotics
what does infectice endocartitis lead to
valve disease even when vegetations heal, it leaves scarring in heart and valves
aortic regurgitation pathophysiology
valve leaflets do not close blood regurgitates into ventricle
mitral valve prolapse pathophysiology
valve leaflets enlarge, prolapse into left atrium during systole
pleuropulmonary assessment
variable moderate ache, worse on inspiration lung fields continuous util the underlying condition is treated or the pt has rested
isolated systolic hypertension
a condition most commonly seen in the older adult in which the systolic pressure is greater than 140 mm Hg and the diastolic pressure is within normal limits (less than 90 mm Hg)
what might indicate an arterial occlusion in a pt with atherosclerosis
a decrease in intensity or a complete loss of a pulse immediately report pulselessness to HCP and document for ER management
anxiety
variable, may be in response to stress or fatigue dull ache to sharp stabbing; may be associated with numbness in fingers not well located and usually does not radiate to other parts o the body as pain usually lasts a few minutes
single parent family
a family in which only one parent is present to care for the children
traditional family
a married opposite-sex couple and their own or adopted children living at home
permissive parenting style
a parenting style that allows freedom, lax parenting that doesn't set limits or enforce rules constantly
what do you need to survive with HLHS
a patent ductus arteriosus and ASD
who is at greatest risk for v-fib
a patient who is experiencing an MI (dead cells misbehave electrically)
aneurysm of central arteries types most common site
a permanent localized dilation of an artery, enlarging the arterial lumen to twice its normal diameter types fusiform, saccular, dissecting abdominal is most common
esophageal-gastric
variable; squeezing, burning, heartburn, variable severity; substernal; may spread to the shoulders or the abdomen; variable relief: antacids, food intake, or sitting position
which are the live vaccines
varicella MMR rotavirus
PE causes vasoconstriction or vasodilation?
vasoconstriction
SNS stimulation in HF causes
vasoconstriction increased heart rate increased contractility
atherosclerosis definition
a type of arteriosclerosis involving formation of plaque within the arterial wall
is a-fib or a-flutter worse?
a-fib
a-fib picture
a-fib picture
a-flutter picture
a-flutter picture
drugs for hypovolemic shock
vasoconstrictors improve MAP by increasing peripheral resistance, increasing venous return, and increasing myocardial activity - dopamine - norepinephrine - phenylephrine inotropic agents directly stimulate beta-adrenergic receptors on the heart muscle, improving contractility - dobutamine - milrinone agents enhancing myocardial perfusion improve myocardial perfusion by dilating coronary arteries rapidly for a short time - sodium nitroprusside
lisinopril action for HF
vasodilation
IM sites
vastus lateralis deltoid choose site based on age
where to give babies immunizations
vastus lateralis (IM in leg) Subcut for MMR and Varicella PO rotavirus
infective endocarditis results in
vegetation, which is destructive to valve, may cause embolization (changed architecture of valve, changes blood flow)
what is v/q
ventilation-perfusion matching
automaticity
ability of heart muscle cells to generate electrical impulses
excitability
ability of heart muscle cells to responds to electrical impulses (then depolarize)
conductivity
ability of heart muscle cells to transmit electrical impulses
contractility
ability to shorten forcibly when stimulated
refinement and coordination 2-3 years old
able to undress
fine motor development toddler
able to use crayon
combined ventilatory and oxygenation failure often occurs in pts who have
abnormal lungs ie chronic bronchitis or emphysema or during asthma attacks
What is a dysrhythmia?
abnormal rhythms of heart's electrical system
dilated cardiomyopathy definition s/s causes
ventricles are dilated and CO is decreased S/S DOE fatigue palpitations causes genetics ETOH chemo infection
hypertrophic cardiomyopathy definition s/s causes
ventricles enlarged, impaired filling and CO, s/s sudden death DOE syncope causes some genetic causes
which rate is the HR?
ventricular
systole
ventricular contraction left side works harder
QRS complex
ventricular depolarization
contraindications for thrombolytic therapy
absolute - any prior intracranial hemorrhage - known structural cerebral vascular lesion - known malignant intracranial neoplasm (primary or metastatic) - ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours - suspected aortic dissection - active bleeding or bleeding diathesis (excluding menses) - significant closed-head or facial trauma within 3 months relative - hx of chronic, severe, poorly controlled HT - severe uncontrolled HT on presentation (>180/110) - hx of prior ischemic stroke within 3 months, dementia, or known intracranial pathology not covered in contraindications - traumatic or prolonged (<or= 10 minutes) CPR or major surgery (within 3 weeks) - recent (within 2-3 weeks) internal bleeding - noncompressible vascular punctures - for streptokinase/anistreplase: prior exposure (>5 days ago) or prior allergic reaction to these agents - pregnancy - active peptic ulcer - current use of anticoagulants; the higher the INR, the higher risk for bleeding
T wave
ventricular repolarization
ventricular asystole also called
ventricular standstill
ventricular tachycardia picture
ventricular tachycardia picture
surgery for cardiomyopathy
ventriculomymectomy creates outflow tract in hypertrophic disease heart transplant in end stage HF, severe DCM
hemothorax
accumulation of blood in the pleural cavity
low HCO3
acidosis
rheumatic fever is what kind of cardiac disorder?
acquired cardiac disorder
preventing DVT: counter virchow's triad (check)
activity hydration SCDs stop smoking avoid birth control if smoker
parallel play
activity in which children play side by side without interacting
after angioplasty (PTCA) nursing concerns
vessel closure bleeding at site reaction to contrast hypotension dysrhythmia
why does excessive ETOH intake increase risk for HT?
vessels dilate when drinking, then stress response is activated, causes vasoconstriction
intradermal injection
administer on the inside surface of the forearm TB syringe 26-30 gauge needle with intradermal bevel insert at 15 degree angle do not aspirate
t-PA nursing concerns
adminster IV, monitor carefully for internal and external bleeding
who is at higher risk for HF
african americans likely because of their higher risk for hypertension
who is at higher risk for CAD
african americans hispanic women american indians alaskan natives
assessment after nitroglycerin
after 5 minutes, recheck the pt's pain intensity and vs if BP is < 100 or 25 less than previous reading, lower the HOB and notify the HCP
what is the most important risk factor for developing CAD in women
age
what increases risk of a-fib
age heart disease lung disease meds alcohol
who does rheumatic fever usually affect
age 5-15
stages and ages trick
age X cubes = how many block tower a child should be able to build 1: walk, single word 2: climb 2 steps, two word sentences, parallel play (50% understood by others) 3: tricycle, three word sentence, repeats three digits (75% understood by others) 4: copies a square (100% understood by others) a child will speak sentences in number of words equal to their age
what are doses based on for kids
age and weight body surface area (not on exam)
v-tach treatment
airway, breathing circulation oxygen if stable: cardioversion, drugs if unstable: treat as cardiac arrest
High HCO3
alkalosis
A nurse is concerned about risk for blood clot formation in which patients? A patient who: SATA A underwent knee replacement surgery this morning B has colon cancer that has spread to the liver C is an IV drug abuser D has a history of 2 episodes of deep vein thrombosis (DVT)
all
3rd degree AV block (complete heart block)
all impulses are blocked
shock affects how much of the body
all of it
interventions for reflex urinary incontinence
also called overflow incontinence - surgery to relieve obstruction, such as prostatectomy - drug therapy for short-term: Bethanecol (Urecholine) stimulates bladder contractions - bladder compression techniques, such as Crede method (press over bladder area to manually assist with emptying) - double voiding - intermittent self-catheterization
disorders related to the female reproductive system in adolescence
amenorrhea dysmenorrhea
breastfed babies need what
vitamin D and Iron supplements
who should assess vs of a person suspected of being in shock
an RN not an LPN or UAP the rapid progression associated with shock requires the interpretation of vs, which is in the RN scope of practice
Kawasaki disease definition cause
an acute systemic vasculitis cause unknown must have had a fever for 5 days
foster family
an adult or couple cares for children whose biological parents are unable to care for them
rheumatic fever
an inflammatory disease that may develop after group A beta-hemolytic Streptococcus infection (GABHS) (such as strep pharyngitis) disease can affect heart, joints, skin, and brain
in kidney, Na+ and K+ have _________________
an inverse relationship if ridding Na+, then retaining K+
atraumatic care for injections
anesthetize site - EMLA or vapocollant - doesn't make muscle less sore, though distraction - pressure at site - concentrating on something else - parental soothing lidocaine v. sterile water as diluent - especially for ceftriaxone - if <6months, need to use sterile water perform injection quickly but safely
what is the difference between angina and MI
angina - a symptom of an MI that should go away when the pt rests. MI - death of heart tissue
who is a candidate for a CABG
angina with >50% occlusion of LCA unstable angina with multiple vessel disease acute MI with cardiogenic shock ischemia after PTCA
amlodipine adverse effects
ankle edema, bradycardia, hypotension, heart failure
Annyloplasty
annulus: junction of valve leaflets and heart muscle performed for mitral insufficiency entails suturing leaflets to an annuloplasty ring or taking tucks in patient's annulus
Blended Family (Reconstituted Family)
another term for stepfamily; a family that may consist of stepparents, stepsiblings, or half-siblings
what meds are most often given in error to people with a known allergy to them?
antibiotics
atropine mode of action
anticholinergic has anticholinergic properties, used to increase heart rate
vasopressin name
antidiuretic hormone (ADH)
interventions for infective endocartitis
antimicrobial meds - given 4-6 weeks, initiated in inpatient setting Rest Monitor for: - HF - emboli Surgery
diagnosing rheumatic fever
antistreptolysin-O (ASO) titer - blood test for streptococcal antibodies (increased in 80% wirth RF) - reveals recent strep infection ESR, C-reactive protein (CRP) - inflammatory markers CBC, ECG AHA guidelines for diagnosis (Jones Criteria): 2 Major or 1 Major + 2 Minor Major - chorea - carditis - erythema marginatum - polyarthritis Minor (and later findings) - fever - hx of recent sore throat - SQ nodules - abdominal pain
HF psychosocial assessment
anxiety depression
epinephrine adverse effects
anxiety, tachycardia, palpitations, restlessness
for pts taking warfarin, assess for
any bleeding, such as hematuria or blood in stool ensure vitami K antidote is available teach pt to avoid foods high in vitamin K - dark green leafy veggies - interfere with the action of warfarin
ALTE
apparent life-threatening event - aborted or near-miss SIDS - pale, cyanotic, apnea, changes in muscle tone, choking, gagging, coughing, CPR - correlate to an increased risk of SIDS
PVD is usually
arterial Peripheral Vascular Disease
peripheral arterial disease affects
arteries in legs patho: atherosclerosis, obstruction
CAD affects
arteries supplying heart muscle
teens are most likely to die _____________
as a passenger in a car with a driver who is drunk/high
high dose salicylate therapy
aspirin for Kawasaki disease
HTN beta blockers nursing implications
assess HR and BP before administration (cause a decrease in HR, CO, suppress renin activity) - hold for HR <50-60 - hold for systolic <90-100, contact HCP - monitor for orthostatic hypotension (common adverse effect -- falls/confusion) use w/ caution in DM (glucose production affected) Teach pt it can cause fatigue, depression, sexual dysfunction. Report to HCP
MI assessment
assess VS, ECG, lung sounds, skin - increased HR, cool clammy skin
promoting effective coping for pt with CAD
assess anxiety and encourage its expression give straightforward explanations of treatment and what to expect. Use a calm, reassuring approach identify oping mechanisms. appreciate that denial may have therapeutic value provide opportunities for decision-making and control
HTN diuretics nursing implications
assess for weakness, dizziness, or a new onset of confusion (hypovolemia, dehydration) teach older adults to rise slowly (orthostatic hypotension) potassium-sparing decrease intake of foods high in K+ f/u labs for K+ report weakness and irregular pulse (hyperkalemia) loop and thiazide eat foods high in K+ f/u labs for K+ and other electrolytes use w/ caution in DM (affects glucose control) use w/ caution in gout (uric acid retention)
cardiac cath post procedure
assess pulses below site - may be weak at first and then improve assess temp - cool lower extremity = obstruction assess bleeding - insertion site - monitor VS - decreased BP or increased HR = hemorrahge - apply pressure above the site of bleeding assess blood sugar - hypoglycemia (increased risk if mother is big or has DM) stay in bed 4-6 hours after procedure - decreased risk of bleeding
CVP is used to
assess right ventricular function and systemic fluid satus normal is 1-8 mmHg
detecting cyanosis in dark skinned peopled
assess the skin and nail beds for a dull, lifeless color. The soles of the feet and the toenails are less pigmented and allow detection of cyanosis or duskiness in the lower extremities.
anterior wall MI is
associated with highest mortality
pulmonary contusion: patient can be
asymptomatic at first and can later develop respiratory failure
teach the patient to carry NTG
at all times
extended family
at least one parent, one child, and others that may be related or not
what is the primary factor in development of CAD
atherosclerosis
cause of aortic stenosis
atherosclerosis, RF, congenital condition
P wave
atrial depolarization
AV block is short for
atrioventricular block
atrioventricular junctional area
atrioventricular node bundle of His
many women of any age experience
atypical angina
heart rate is controlled by
autonomic nervous system (via baroreceptors)
how to prevent or decrease dysrhythmias for pts at risk for vasovagal attacks causing bradydysrhythmias
avoid doing things that stimulate the vagus nerve: - raising arms above head - pressure on carotid artery - pressure on eyes - bearing down during BM - stimulating gag reflex
HTN ARBs nursing implications
avoid foods high in K+ (can cause hyperkalemia) monitor BP carefully, orthostatics (vasodilation, decreased BP) hold for systolic <100, check with HCP
management of cardiac arrest
basic cardiac life support advanced cardiac life support - special training is required - entails: oropharangeal airway, ventilating with manual resuscitation bag, defribillation, initiating IV access CPR continues
what does HT do over time to the body
beats against vessel wall injures walls over time damages kidneys, eyes, coronary arteries
why is HCO3 low in metabolic acidosis?
because body has run out of HCO3 as a buffer
why is LDL the worst?
because it carries cholesterol to vessel wall
preschool gross motor skills
walking, running, climbing, and jumping well established - 3 yo: rides a bike, jumps off bottom step - 4 yo: skips and hops on one foot, overhead ball throwing - 5 yo: jumps rope, walks backward
communicating with school aged child
want to know why, concerned about body integrity
measuring BP in children
begin after 3 years old under 3 in critical care situations width of cuff should be between 1/2 and 2/3 the length of the upper arm
adolescence beginning and end physiologically
beginning: appearance of secondary sex characteristics ending: cessation of body growth at 18-20 years
what pH ranges are usually fatal?
below 6.9 above 7.8
when fibrinolytics are given, assess for signs of
bleeding, bruising, or hematoma.
preload is affected by
blood volume
pulmonary contusion presentation
bloody sputum decreased breath sounds crackles wheezes
toddler body temperature
body temperature is maintained
metoprolol adverse effects
bradycardia, fatigue, brochospasm in asthmatic
which babies wake more to eat at night
breastfed babies breastmilk is digested faster
vent settings: rate
breaths/min usually 10-14
HCO3 is a
buffer, weak base
what are the body's first defense against pH changes
buffers
right and left bundle branches extend from
bundle of his impulse is rapidly conducted along interventricular septum
when do children realize that they are distinct from parents
by end of first year
how is shock classified?
by the functional impairment it causes
surgical management of peripheral arterial disease
bypasses areas of obstruction aortoiliac, aortofemoral bypass: graft from aorta to groin axillofemoral bypass graft: graft from chest to groin femoral-popliteal bypass graft femoral-posterior tibial bypass graft arterial revascularization - entails creating bypass of diseased vessels via graft placement graft is saphenous vein or synthetic material
a-flutter
what is this
degree to which plaque is disrupted determines
which disease process is occurring
renin-angiotensin-aldosterone system in HF
why? - decreased renal perfusion effects - - holds Na+ - holds water - increases BP, worsens L-sided HF - causes more hypertrophy
shock is
widespread abnormal cellular metabolism that occurs when need for oxygenation and tissue perfusion is NOT met to the level needed to maintain cell function
when does "school age" physiologically begin/end
with shedding of first deciduous teeth; ends at puberty with acquisition of final permanent teeth
amiodarone mode of action
calcium channel blocker prolong repolarization, used for ventricular dysrythmias
amlodipine mode of action
calcium channel blocker slow impulse conduction through heart, slow calcium influx into muscle, slow heart rate
adolescent nutrition
caloric and protein requirements are higher than almost any point in life eating habits are greatly influenced by peers fad diets, high caloric foods low in nutritional value
what to teach men taking thiazide diuretics
can cause decreased libido and decreased sexual performance
why is DVT worrisome?
can fragment and travel to lung, heart, brain
dementia habit training
can keep pt continent for a long time
stress in preschooler
can lead to regression! minimum amount of stress: can be beneficial parental awareness of signs of stress in child's life stressors and structure - birth of sibling - divorce or separation - relocation - illness
gout and thiazide diuretics
can worsen gout
Hx of significant hypotension and thiazide diuretics
can worsen hypotension
motor vehicle safety
car seats in back seat careful re: hyperthermia
HLHS treatment
cardiac and respiratory support - O2 - IV fluids - g-tube to ease feeding meds to maintain PDA: - prostaglandin E1 surgical repair (done in stages): Norwood procedure (don't memorize procedure) heart transplant. problems with this option: - rejection - availability of neonatal hearts - decreased immunity r/t antirejection meds
v-tach may progress to
cardiac arrest
surgical interventions for MI
cardiac cath first PCTA, possibly with stent placement CABG
what is the most definitive cardiac test
cardiac catheterization
premature complexes
cardiac cells fire an early impulse (ectopic focus) SA node fails to discharge Serve as secondary pacemaker
obstructive shock cause
cardiac function decreased by noncardiac factor (indirect pump failure). total body fluid is not affected, although central volume is decreased cardiac tamponade arterial stenosis pulmonary embolus pulmonary hypertension constrictive pericarditis thoracic tumors tension pneumothorax
digoxin is
cardiac glycoside
CO
cardiac output 4-6 L/min
some degree ofdecrased ________________ is common after MI, particularly with damage to _____________
cardiac output left ventricle
what influences MAP
cardiac output systemic vascular resistance
increasing activity tolerance for pt with CAD
cardiac rehab assists pt to have productive life while remaining within heart's ability to respond
pericardial effusion increases the risk for
cardiac tamponade - excessive fluid in pericardial cavity - an emergency - the heart can't fill, decreased CO)
most severe form of heart failure
cardiogenic shock involves necrosis of >40% of left ventricle
what do you assess first in a pat at risk for acidosis
cardiovascular system because acidosis can lead to cardiac arrest from the accompanying hyperkalemia. If cardaic changes are present, respond by reporting these changes immediately to the health care provider
other treatment for a-fib
cardioversion: under sedation, electrical current is delivered to heart to depolarize most of myocardium avoiding T wave (defibrillator is synchronized to deliver shock during QRS)
what does HDL do
carries LDL out of aterial wall and to liver to be metabolized
cardiac catheterization
catheter inserted into heart, contrast medium injected, images of, pressure in heart and blood vessels are taken purpose: - diagnostic, - interventional (eg. dilate vessel), - electrophysiology study (record impulses of heart. info regarding how the heart is functioning) usually through femoral vein
ADH and heart failure
causes vasoconstriction and fluid retention maladaptive - worsens HF
infarction
cell death that occurs when ischemia is prolonged and causes irreversible tissue damage
CVP
central venous pressure 1-8 mmHg
tips for success with injections
change needle if used to pierce rubber stopper - rubber dulls needle have all supplies ready enlist help secure the infant or child appropriately for age have stickers, special Band-Aids, or toy to hand child after injection
initial stage of shock: what indicators to use
changes in pulse rate and quality changes in BP are not always present at first
self-care for pacemaker
chart 34-7
self-care for ICD
chart 34-8
valvular heart disease physical exam
chart 35-6
malignant hypertension/hypertensive crisis intervention
chart 36-2 give IV meds place pt supine when giving meds so they don't bottom out
stages of peripheral arterial disease
chart 36-3 1. asymptomatic 2. claudication: pain in legs when walking 3. rest pain: pain at rest 4. necrosis/gangrene
DVT teaching
chart 36-7 - bleeding precautions - self-injection technique for LMWH - avoid vitamin K-rich foods (chart 36-8), prolonged sitting, ETOH - lab monitoring
growth charts
charts that show average values of height, weight, and other measures of growth, based on large samples of normally developing infants; the charts are used to evaluate an infant's development
ventilated patient assessment
check book
pediatric administration of digoxin
check dose - ordered by weight - check calculation with another RN - caution converting milligrams to micrograms (can easily kill a baby) check AP (apical pulse) - hold and report - infants and young children <90 to 110 (100 is cut off in many pedi textbooks) - older children <70 - adolescents/adult size <60 don't mix with essential foods or in large amount of liquid
What are the 2 kinds of buffers in the blood?
chemical - bicarbonate - phosphate protein - albumin - globulin - hemoglobin
about 25% of traumatic deaths result from
chest trauma
what is pneumothorax caused by
chest trauma, medical procedure
how to diagnose pneumothorax
chest x-ray
HLHS diagnostic tests
chest x-ray ECG echocardiogram cardiac catheterization
coarctation of aorta diagnostic testing
chest x-ray echocardiogram cardiac catheterization and aortography in older children: heart CT scan, MRI/MRA
Imaging assessment for PE
chest x-ray CT scan Others: - TEE - Doppler ultrasound
HF imaging assessment
chest x-ray (fluid on lungs) echocardiogram nuclear imaging (ejection fraction)
Acute Cardiac Tamponade: Emergency Care
chest x-ray, echocardiogram fluids hemodynamic monitoring pericardiocentesis - withdrawing fluid from pericardial space - monitor pt, pressures, for recurrence
hemothorax diagnosed by
chest xray thoracentesis
associative play
children engage in separate activities but exchange toys and comment on one another's behavior
children and medication metabolism
children metabolize meds quicker and may need more mg/kg than an adult
2 kinds o fCAD
chronic stable angina acute coronary syndrome
modifiable risk factors for heart disease
cigarette smoking sedentary lifestyle overweight/obesity psychological factors
what to assess with v-tach
circulation and airway breathing LOC oxygenation can cause cardiac arrest if stable: administer O2 confirm rhythm with 12-lead ECG may give amiodarone, lidocaine, or magnesium sulfate
medications for dysrhythmias: classes
class I: slow depolarization by blocking Na+ channels - procainamide (Pronestyl) - lidocaine (Xylocaine) for ventricular issues, not atrial - propafenone (Rhythmol) class II: beta blockers, block SNS stimulation, slow down SA and AV nodes - propranolol (Inerall) no selective, can cause airway constriction - esmolol (Brevibloc) - metoprolol - cardiac selective class III: prolong repolarization by blocking K+ channels slows HR, prolongs rest period - amiodarone (Cordarone) used more often than lidocaine now - ibutilide (Corvert) - dofetilide (Tikosyn) class IV: calcium channel blockers, inhibit influx of Ca+ ions, which slows SA, AV nodes good antihypertensive, decreases strength of myocardial contraction - verapamil (Calan, Isoptin) - diltiazem (Cardizem) other drugs: digoxin: decreases HR, increases myocardial contractility atropine: blocks PNS, increasing HR adenosine (Adenocard): slows conduction through AV node
urolithiasis assessment
clinical manifestations - severe flank pain (renal colic) - n/v, pallor, diaphoresis - blood in urine - increased HR, increased BP UA - RBC present - WBC, bacteria indicate urinary stasis CBC elevated WBC if infection present imaging x-ray (KUB) CT scan has highest sensitivity
treatment of Kawasaki Disease
close monitoring meds - gamma-globulin (decrease immune response, decrease vasculitis, decrease coronary aneurysm) - apsirin (antiplatelet) hydration rest, calm environment once resolves: no live vaccines for 11 months - decreased immunity r/t gamma glabulin
why are we concerned with ruptured plaque?
clot formation platelets aggregate at rupture --> thrombus (clot) The thrombus grows to fill entire diameter of vessel --> occlusion
AF pts are at high risk for
clots pooling of blood r/t loss of coordinated atrial contractions
urine turbidity
cloudy urine indicates infection, sediment, or high levels of urine protein
social relationships and cooperation in school age child
clubs and peer groups - formation of formalized groups - bullying relationships with families - parents are primary influence in shaping child's personality, behavior, and value system - increasing independence from parents is primary goal of middle childhood - parents need to be adults, not friends
what categories are considered when considering the overall growth and development of a child?
cognitive: how are they learning fine motor: pincer grasp gross motor: head control sensory: hearing psychosocial: developmental stages spiritual: what God means
urolithelial cancer post-op care
collaboration with enterostomal therapist - drainage mechanism - pouch application - skin, stoma care teaching psychological support
PE definition
collection of particulate matter - solids, liquids, or air -- enters venous circulation and lodges in a branch of pulmonary artery
Urinalysis tests
color - yellow odor - specific aroma, similar to ammonia turbidity - clear specific gravity - 1.005-1.030 pH - 4.6-8, average 6 glucose - fresh: negative - 24 hr: 50-300 mg/day ketones - none protein - fresh: 0-0.8 - 24 hr: 50-80 at rest, <250 with exercise bilirubin (urobilinogen) - none red blood cells (RBCs) - 0-2 per high-power field white blood cells (WBCs) - 0-4 per low-power field casts - none crystals - none bacteria - <1000 parasites - none leukocyte esterase - none nitrites - none
cardiac arrest could lead to what kind of acid-base imbalance?
combined metabolic and respiratory acidosis
Commisurotomy
commissure: site where valve leaflets meat Entails incising fused valve leaflets, widening valve orifice Requires cardiopulmonary bypass
minimizing anxiety in PE
communication - reassure - calm - explain Drug therapy - ie lorazepam (Ativan)
ventricular asystole
complete absence of ventricular rhythm poor prognosis
after heart transplant surgery, perform
comprehensive cardiovascular and respiratory assessments frequently according to agency or heart transplant surgical protocol report s/s of rejection to surgeon immediately surgeon performs regular biopsies to detect rejection
cognitive development of school age child
concrete operations - uses thought processes to experience events and actions - develops understanding of relationships between things and ideas - is able to make judgments on the basis of reason ("conceptual thinking") - problems solvers - time - masters the concept of conservation - develops classification skills
shock is a ______ rather than _________
condition disease
patent ductus arteriosus definition and consequence
condition in which the ductus arteriosus does not close consequence: - aorta to PA then back to circulation of heart instead of to body - pulmonary congestion (SOB, crackles, L heart overload)
bundle branch block
conduction delay or block within one of the two main bundle of His branches typically seen in cardiovascular disease may be temporary or permanent Treatment: - none or - pacemaker NOT ON EXAM
with acute MI, PVCs may be
considered as a warning, possibly triggering life-threatening ventricular tachycardia (VT) or ventricular fibrillation (VF)
long-term complications of coarctation of the aorta after surgery
continued or repeated narrowing of the aorta endocarditis high BP
high dose salicylate therapy given to dose
control fever and symptoms of inflammation 80 to 100 mg/kd/day in divided doses every 6 hours until fever subsides (anti-inflammatory dosing) after fever subsides, med is continued as an antiplatelet dose (3 to 5 mg/kg/day) - 6-8 weeks if no CA abnormalities - indefinitely if CA abnormalities
controlled vs. uncontrolled HT
controlled won't kill you uncontrolled will kill you
arterial ulcers: other assessment findings
cool or cold foot decreased or absent pulses atrophy of skin hair loss pallor with elevation dependent rubor possible gangrene when acute, neurologic deficits noted
shock integumentary symptoms
cool to cold pale to mottled to cyanotic moist, clammy mouth dry; pastelike coating present
CAD
coronary artery disease
cocaine can cause severe __________________ leading to _________
coronary artery spasm MI
pulmonary edema key features
crackles, dyspnea at rest, acute confusion, tachycardia, HTN or HoTN, reduced urinary output, cough with frothy pink-stinted sputum, PVCs, anxiety, lethargy
L-sided HF lung sounds
crackles, wheezes (increased pulmonary pressure)
nutrition for cystitis
cranberry juice - pulls bacteria off bladder wall - takes many weeks to start working avoiding bladder irritants - caffeine - tomatoes - ETOH - check these in book
if a pt had contrast, monitor both baseline and trend ____________ to recognize risk for ____________.
creatinine AKI
adolescent sexuality
critical time in development of sexuality - hormonal, physical, cognitive, and social changes occur - sexual activity is common by late teens - teenagers begin to identify sexual identity (hetero, gay, lesbian, bisexual) - relationship between love and sexual expression developes HPV vaccine
instruct all pts with PAD to avoid
crossing their legs and avoid wearing restrictive clothing, which interferes with blood flow. Teach them the importance of inspecting their feet daily for color or other changes
Ferber
cry it out
treatment for a-fib: goals
decrease HR increase CO decrease atrial irritability
metoprolol action for HF
decrease HR, cardiac contractility
furosemide action for HF
decrease fluid retention
v-fib and CO
decreased
PaO2 in shock
decreased anaerobic metabolism
pH in shock
decreased insufficient tissue oxygenation causing anaerobic metabolism and acidosis
L-sided HF urinary output
decreased (decreased renal perfusion)
bleeding effect on BP and HR
decreased BP increased HR
no matter what causes shock, what is the outcome?
decreased BP decreased perfusion (tissue perfusion)
shock cardiovascular symptoms
decreased CO increased HR thready pulse decreased BP narrowed pulse pressure postural hypotension low central venous pressure flat neck and hand veins in dependent position slow capillary refill in nail beds diminished peripheral pulses
MI --> damaged cardiac tissue -->
decreased CO --> HF
morphine action for MI
decreased RR, vasodilation
why do we give morphine for MI?
decreased RR, vasodilation decreased pain = decreased stress = decreased demand on the heart
shock GI symptoms
decreased motility diminished or absent bowel sounds nausea and vomiting constipation
ASA action for MI
decreased platelet aggregation
elevations in HDL:LDL ration indicate
decreased risk for CAD
elevation in HDL indicate
decreased risk for HDL
shock kidney symptoms
decreased urine output increased specific gravity sugar and acetone present in urine
affect of hypovolemia on preload
decreased. decreases ability of heart tocontract
during cardiac rehab, what indicates intolerance of activity
decreases >20 in BP changes of 20 beats/min in HR reports of dyspnea or chest pain notify HCP and do not advance to next level of cardiac rehab
atorvastatin intended effect
decreases cholesterol synthesis in the liver
metoprolol for MI
decreases heart rate and force of contractility decreases O2 demands of heart which decreases size of infarct
morphine intended effect
decreases pain associated with MI
pulseless v-tach
defibrillate!
how to verify endotracheal tube placement
definitive: x-ray end-tidal CO2 levels Assess bilateral breath sounds
preload
degree of stretch of the cardiac muscle fibers at the end of diastole
nursing concerns with diuretics
dehydration electrolyte imbalances, especially K+
toddler dehydration
dehydration is less common in toddlerhood than infancy
physical abuse of child
deliberate infliction of physical injury on child shaken baby syndrome - abusive head trauma - violent shaking of infant or young child - period of PURPLE Crying Munchausen syndrome by proxy - factitious disorder by proxy or medical child abuse
MI interventions should decrease oxygen ___________ and increase oxygen ___________
demand supply
a common reaction to MI is
denial
R-sided HF skin assessment
dependent edema
electrical sequence in heart
depolarization: electrical current is created - sodium rushed into cell, K+ moves out - causes atrial contraction, impulse goes to AV node, bundle of His.... repolarization: cell returns to resting state - sodium leaves, K+ moves back in
K+ is a cardiac _________
depressant
K+ is a cardiac__________
depressant
unstable angina pectoris
describes a changing (unstable) pattern an increase in attacks and in intensity of pain that occurs something is worsening
what is a cardiac catheterization for with MI
determines extent, location of coronary artery obstruction
psychosocial development of preschooler
developing sense of initiative - feeling of guilt, anxiety, fear: may result from thoughts that differ from expected behavior and this may be either inability to complete a task or misbehaving - learning right from wrong/moral development - energetic learners
moral development of school age child
development of conscience and moral standards - ages 6-7: reward and punishment guide choices - older school age: child is able to judge an act by the intentions that prompted it - rules and judgments become more founded on needs and desires of others
ICD
device senses severe dysrhythmias and delivers a shock to the heart indicated for pt who has experience VT or VF not caused by MI leads are introduced through skin, power source is implanted in left pectoral area
therapeutic management of eating disorders
diagnostic evaluation and screening three major goals of treatment - reinstitution of normal nutrition and reversal of malnutrition - resolution of the disturbed pattern of family interactions - individual psychotherapy to correct deficits and distortions in psychologic functions nutrition therapy - refeeding syndrome pharmacotherapy care management - outpatient care or hospitalization - physical effects of eating disorders - behavioral contract - family therapy
causes of overelimination of bicarbonate what does this cause?
diarrhea metabolic acidosis
how to decrease LDL
diet, exercise, drugs
lifestyle modifications for HT
diet: low fat, low sodium exercise lose weight decreased alcohol no smoking
PTCA may be used to
dilate coronary artery (MI)
cardiomyopathy types
dilated cardiomyopathy hypertrophic cardiomyopathy - nonobstructed - obstructed
types of cardiomyopathy
dilated, hypertrophic, restrictive, arrhythmogenic
nitroglycerine sublingual (Nitrostat) intended effect
dilates arteries/veins. Used as a rescue treatment following onset of angina symptoms
nitroglycerine transdermal intended effect
dilates arteries/veins. Used to prevent angina
nitroglycerine action
dilates coronary arteries increases CA blood flow decreases venous return relieves anginal pain given sublingually in tablet, spray, also administered IV
compartment syndrome s/s and interventions
diminished motor, sensory function pain swelling loose dressing. prepare for fasciotomy (surgical opening into tissue to relieve pressure)
cardiogenic shock cause
direct pump failure (fluid volume not affected) MI cardiac arrest ventricular dysrhythmias cardiac amyloidosis cardiomyopathis myocardial degenreation
MI: continued ______ despite medication therapy warrants _________
discomfort surgical intervention
cardiomyopathy
disease of the heart muscle
why do abnormal lungs cause combined ventilatory and oxygenation failure?
diseased lungs cause oxygenation failure, the work of breathing increases until respiratory muscles are unable to function effectively
peripheral vascular disease definition
diseases that alter blood flow through arteries and veins of peripheral circulation
dysrhythmia is any
disorder of hearbeat
L-sided HF neuro assessment
disoriented, confused (decreased perfusion to brain)
L-sided HF apical impulse
displaced
thrombolytic drugs do what?
dissolve clots in coronary arteries and increase/restore myocardial blood flow
R-sided HF neck veins
distended (JVD)
varicose veins
distended, protruding leg veins that appear darkened and tortuous pathological events - vein wall weakens and dilates - valves become incompetent - further venous dilation occurs management - elastic stockings - elevation of extremities - sclerotherapy: sclerosing agent injected into veins, which then atrophy - surgical removal
ventricular asystole - what to do?
don't defibrillate
measuring devices
don't use home teaspoons always use syringe medicine cup sometimes ok, but syringe is better. can empty into medicine cup if kid prefers to take it that way
infant birth weight in first year
double birthweight by 6 months triple birthweight by 1 year
baby weight changes in first year
double weight by 6 months tripe weight by 1 year
good lung up or down
down
lidocaine adverse effects
drowsiness, lightheadedness, dizziness
substance abuse in adolescence
drug abuse, misuse, and addiction - voluntary behaviors - culturally defined drug tolerance and physical dependence - involuntary physical responses motivation - usually begins with experimentation types of drugs abused - nicotine - alcohol - cocaine - narcotics - CNS depressants - CNS stimulants - mind-altering drugs
improving cardiopulmonary tissue perfusion in MI interventions
drug therapy - aspirin - thrombolytic agents restoration of perfusion to the injured area often limits the amount of damage and improves left ventricular function complete sustained reperfusion of coronary arteries in the first few hours after an MI is a/w decreased mortality
factors contributing to urinary incontinence
drugs - CNS depressants (opioids) - diuretics - multiple drugs can contribute to changes in mental status or mobility, can also irritate bladder - anticholingergic drugs affect both cognition and the ability to void. disease - stroke, Parkinsons, dementia (decreased mobility, sensation, cognition) - arthritis decreases mobility and causes pain depression - decreases energy necessary to maintain continence - decreased self-esteem/self-worth decrease the important to the pt of maintaining continence inadequate resources - assistive devices out of reach or no person to assist - incontinence products are often costly - no one may be available to help
vessel dilators: monitor the pt closely because
drugs that dilate coronary blood vessels, such as nitroprusside, can cause systemic vasodilation and increase shock if the pt is volume depleted
inotropic drugs: monitor the pt because
drugs that increase heart muscle contraction increase heart oxygen consumption and can cause angina or infarction
atropine adverse effects
dry mouth, urinary retention, tachycardia
what kind of antiplatelet therapy is suggested for pts with ACS
dual antiplatelet therapy aspirin + clopidogrel (Plavix) or ticagrelor (Brillinta) major side effects: bleeding
CABG specific concerns
dysrhythmia fluid/electrolytes: edema, hypokalemia hypotension/hypertension hypothermia: gradual rewarming is called for bleeding: chest tube drainage is closely monitored cardiac tamponade: - fluid accumulates around the pericardium causing decreased CO neurologic changes - LOC, orientation, memory s/s of stroke pain Later: pulmonary exercise early ambulation
_____________ are the leading cause of death in most pts with MI who die before they can be hospitalized
dysrhythmias
developmental assessments are done at
each well visit, at every age but are more informal during birth-6months. evaluates milestone meeting at each age. simple and time efficient.
shock neuromuscular symptoms
early anxiety restlessness increased thirst late decreased CNS activity (lethargy to coma) generalized muscle weakness diminished or absent deep tendon reflexes sluggish papillary response to light
interventions for shock
early identification of causative problem! oxygen therapy drug therapy - IV antibiotics (multiple agents): if septic shock fluids, possibly blood replacement therapy
ST segment
early ventricular repolarization
warfarin teaching
eat consistent vit K check before taking other meds - interacts with many other drugs
communicating with early childhood child
ego centric, literal understanding, eye level, quiet and calm voice, be specific and honest, clear rules
ECG evaluates
electrical activity of heart
ventricular fibrillation is a result of
electrical chaos in the ventricles
chest leads for ECG
electrodes are placed on chest (6) (V1-V6)
limb leads for ECG
electrodes are placed on limbs (4) bipolar leads (I, II, III) measure electrical activity between two points unipolar leads (aVR, aVL, aVF) consist of positive electrode only
EPS
electrophysiology study
metabolic syndrome list
elevated BP increased waist circumference increased cholesterol fasting bs >100 pg 772
chorea
emotional instability muscle weakness sudden, uncoordinated, involuntary jerky movements affecting face, feet, and hands will eventually disappear
who is a candidate for heart transplant?
end stage HF pt
Three layers of the heart
endocardium, myocardium, epicardium
myocardial hypertrophy
enlargement of myocardium walls of heart thicken (can't fill enough) eventual problem is insufficient coronary artery supply
what is given until warfarin gets up to therapeutic level?
enoxaparin
what to check before giving NTG
ensure that the pt has not taken any phosphodiesterase inhibitors for erectile dysfunction such as sildenafil (Viagra, Revatio), tadalafil (Cialis), or vardenafil (Levitra) within the past 24 to 48 hours can cause profound hypotension
nursing role in injury prevention
ensuring safety in the home teaching infant CPR
drugs used during cardiac arrest
epinephrine: stimulates SNS, increasing automaticity of myocardium. causes vasoconstriction to maintain BP amiodarone dopamine, dobutamine: increase myocardial contractility
hormones (therapy) for urinary incontinence
estrogen cream enhances nerve conduction to urinary tract, improves blood flow, reduces tissue deterioration of the urinary tract teach to use thin application take 4-6 weeks to achieve continence benefits
EMLA
eutectic mixture of local anesthetics causes vasoconstriction, so can make IV insertion difficult
pathology of respiratory alkalosis
excessive loss of CO2
as the blood pH rises, kidneys will do what
excrete HCO3 through the urine
what do kidneys do to control pH?
excrete or retain bicarbonate (HCO3-)
nonsurgical management of peripheral arterial disease
exercise positioning (dependent) vasodilation drug therapy - pentoxifylline (Trental): increases flexibility of RBCs, inhibits platelet aggregation - antiplatelets: aspirin, clopidogrel (Plavix) - control HTN procedures - percutaneous transluminal angioplasty (PTCA), with/without stent placement - laser-assisted angioplasty - atherectomy
bleeding after CABG
expected to a limited extent with all pts
injection medication administration
explain procedure to child determine site for administration based on: - med amount, viscosity, diluent, and type - muscle mass, condition, access of site, and potential for contamination - age and size of child
toddler development of gender identity
exploration of genitalia is common - genital fondling can occur - parental reaction should be accepting gender roles are understood by toddler - playing house gender identity is formed by age 3 years
HDL normal range
female: >55 male: >45
triglycerides normal range
females: 35-135 males: 40-160
UTI rare symptoms
fever chills n/v malaise flank pain
what criteria is most diagnostic of infective endocarditis
fever, murmur, + blood cultures
purkinje fibers
fibers in the ventricles that transmit impulses to the right and left ventricles, causing them to contract
sex education in preschooler
find out what child knows and thinks - this info helps ascertain what the child wants to know - use correct anatomic words - be honest masturbation is common at approximately 4 years of age - private act
when caring for a ventilated patient, the nurse should be concerned with the pt
first and the ventilator second
ECG negative deflection
flow of current is away from positive electrode
ECG: positive deflection
flow of current is toward positive electrode
decreased lactate indicates
fluid overload
distributive shock cause
fluid shifted from central vascular space (total body fluid volume normal or increased) neural-induced pain anesthesia stress spinal cord injury head trauma chemical-induced anaphylaxis sepsis capillary leak burns extensive trauma liver impairment hypoproteinemia
CVP is decreased by
fluid volume deficit
CVP is elevated by
fluid volume excess right heart failure PA stenosis
what happens in atrial dysrhythmias?
focus of impulse generation shifts from SA node to atrial tissue
cognitive development in adoelscence
formal operations period (Piaget) abstract thinking - formal operations - longer attention span - thinking beyond present, debatable - mental manipulation of multiple variables - concern about others' thoughts and needs
urine odor
foul smell indicates possible infection, dehydration, or ingestion of certain foods or drugs
flail chest
fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment
UTI common symptoms
frequency urgency dysuria hesitancy or difficulty initiating urine stream low back pain nocturia incontinence hematuria pyuria becteriuria retention suprapubic tenderness or fullness feeling of incomplete bladder emptying
exercise ECG helps determine
functional capacity of heart, identify coronary artery disease
L-sided HF heart sounds
gallop sounds: S3 (early diastolic filling)
assess intubated pts to recognize indications of decreased _____________. When these indications are present, respond by checking for ___________
gas exchange DOPE - displaced tube - obstructed tube (often secretions) - pneumothorax - equipment problems
CK-MB indicates________________
general muscle damage
Sinoatrial node
generates electrical impulses at rate of 60 to 100 beats/minute known as heart's pacemaker impulses travel through atrial muscle contraction of atria follows
risk factors for atherosclerosis
genetics cholesterol-related diabetes obesity sedentary lifestyle smoking stress age
factors impacting growth and development
genetics environment culture nutrition health status family parental attitudes child-rearing philosophies
ACE inhibitor first dose instructions
get out of bed slowly (can cause severe hypotension)
PDA affects _______ more than _________
girls more than boys
subcutaneous injections
give any place there is SQ tissue inject volumes of less than 0.5 mL use 1 mL syringe with 26-30 gauge needle insert at 90 degree angle, use 45 degree angle for thin children back of arm, fatty party of thigh
rectal medication administration
given if vomiting or NPO use if oral route is unavailable position on left side, right leg slightly bent use index or pinky to insert suppository into rectum help hold buttock together so as not to expel the suppository
IVGG for Kawasaki disease
given withing first 10 days of illness (best if within first 7 days) goal: reduce incidence of coronary artery abnormalities even with treatment, up to 25% can have CA abnormalities singel dose of 2g/kg over 10 to 12 hours - administered similar to blood - stay with pt - 2 RN signatures, etc retreatment in pts with continued fever after treatment
what will help kids be more compliant?
giving them the ability to make choices, have some control
NTG storage
glass, light-resistant container replace every 3-5 months
regulatory functions of the kidney
glomerular filtration tubular reabsorption tubular secretion
shock nonsurgical management
goal: maintain tissue oxygenation, increase vascular volume, support compensatory mechanisms oxygen therapy IV fluid therapy (0.9% NS, Ringer's Lactate) Blood products Drug therapy
PDA treatment
goal: to close PDA (if rest of heart and blood flow is normal) if baby has certain other heart problems, keeping DA open may be lifesaving. Meds may be used to stop it from closing get an echo to evaluate presence of other heart problems may close on its own - in premature babies, it often closes within the first 2 years of life - full term, rarely closes on its own after first few weeks medications transcatheter device closure surgery may be needed
management of venous insufficiency
goals - promote venous return - decrease edema - if ulcer: healing, preventing infection, preventing recurrence modalities 1. compression therapy (SCD) 2. nutrition: high protein, zinc, vitamin A & C 3. wound care - occlusive dressing: hydrocolloid (Duoderm), artificial skin products (provide biologic cover that secretes growth factors) - Unna boot: gauze moistened with zinc oxide hardens like a cast when applied. Increases venous return, provides sterile environment. 4. surgery to debride the wound 5. health teaching (chart 36-9) - elevation of lower extremities - wearing compression stockings during day - optimal weight
preschool age, kids are preparing for what significant life change
going to school
rate of growth and development in school age child
gradual progress with physical and emotional maturity
post-op PAD surgery complications
graft occlusion - emergency severe, continuous and aching pain (throbbing pain can be normal r/t revascularization) monitor patency of graft every 15 minutes (extremity color, temp, pulse)
teach pts taking statins, especially atorvastatin, lovastain, and simvastatin, to avoid
grapefruit and grapefruit juice. causes toxic levels of med in blood, kidney failure, HF, GI bleeding, or even death.
aspiration foods
grapes hotdogs mashed potatoes button batteries
how to stop PAD progression
halt the process of plaque developing on vessel walls
nasal medication administration
head extended football hold for infants insert vertically, then angle the device prior to administration (angle out towards ear) use distraction (play games, sing, count)
malignant hypertension/hypertensive crisis s/s
headache chest pain neck pain
what is the most common cause of death in US
heart disease
what is the most common cause of hospital admission in those 65+
heart disease
causes of pericarditis
heart surgery heart attack respiratory infection malignancy can occur chronically (not common)
what is eventually needed with cardiomyopathy
heart transplant
surgical management of HF
heart transplantation ventricular assist device - entails implanting mechanical pump - used on short-term or long-term bases
baby height increases in first year
height increases by nearly 50% in first year
general nursing care of child with CHD
help family adjust educate family help family manage illness at home preparation for invasive procedures post-op care - close monitoring - respiratory support - fluid support - providing rest - comfort, emotional support - discharge teaching
managing heart failure for pt with MI
hemodynamic monitoring drug therapy: reduce preload, afterload - IV nitrate, diuretic - beta blocker, ACE inhibitor - IV dopamine surgery (CABG)
PTT used for what med
heparin
what is the initial drug therapy for PE?
heparin
HCO3 in metabolic alkalosis
high
pH in metabolic alkalosis
high
respiratory acidosis PaCO2
high
respiratory alkalosis pH
high
secondary hypertension
high blood pressure caused by the effects of another disease
elevated INR meaning
higher than 4.5 pt at risk for bleeding hold warfarin or decrease dose
How to take sublingual nitroglycerin
hold the NTG tablet under the tongue and drink 5 mL (1 t) of water, if necessary, to allow tablet to dissolve instruct pt to lie down (dramatic hypotension) up to 3 tablets, 5 minutes apart shelf life = 3-5 months
Erythropoietin
hormone produced by kidney parenchyma that stimulates bone marrow to make RBCs
prostaglandins (renal)
hormone produced by kidney tissues that regulates intrerenal blood flow by vasodilation or vasoconstriction
natriuretic hormones
hormone produced in the cardiac atria, cardiac ventricles, and brain that cases tubular secretion of sodium
bradykinins (renal)
hormone produced in the juxtaglomerular cells of the arterioles that increases blood flow (vasodilation) and vascular permeability
activated vitamin D (renal)
hormone produced in the kidney parenchyma that promotes absorption of calcium in the GI tract
aldosterone
hormone released from the adrenal cortex that promotes sodium reabsorption and potassium secretion in DCT and CD; water and choloride follow sodium movement
vasopressin (ADH)
hormone released from the posterior pituitary that makes DCT and CD permeable to water to maximize reabsorption and produce a concentrated urine
renin
hormone secreted by kidney that raises blood pressure as result of angiotensin (local vasoconstriction) and aldosterone (volume expansion) secretion
meds for urinary incontinence
hormones estrogen vaginal cream daily or an estrogen-containing ring inserted monthly anticholingergics darifenacin (Enablex) fesoterodine (Toviaz) oxybutynin (Ditropan) propiverine (Detrunorm) solifenacin (Vesicare) trospium (Sanctura) alpha-adrenergic agonists midorine (ProAmatine, Orvaten) beta agonist mirabegron (Myerbetriq) antidepressants: tricyclics and SNRIs tricyclics imipramine (Tofranil, Novo-Pramine) amitriptyline (Elavil, Levate) SNRI duloxetine (Cymbalta)
How long do the kidneys take to correct pH imbalance?
hours to days
metabolic defects that commonly cause kidney stones
hypercalcemia hyperoxaluria hyperuricemia struvite cystinuria
most common cause of heart failure
hypertension in 75% of cases Other causes - MI - valve disease - dysrhythmias - COPD
cause of respiratory alkalosis
hyperventilation
MAP hypotension and hypertension
hypo <40 hyper > 85 ????
most frequent side effect of thiazide and loop diuretics
hypokalemia monitor levels, assess for irregular pulse, dysrhythmias, muscle weakness eat foods high in potassium
Lisinopril adverse effects
hypotension esp 1st dose, COUGH, hyperkalemia, angioedema
contractility is decreased by
hypovolemia, some medications, acidosis
types of shock
hypovolemic cardiogenic distributive obstructive ??
most common types of shock
hypovolemic and septic
hypoxia vs hypoxemia
hypoxia = low tissue O2 hypoxemia = low blood O2
acute respiratory distress syndrome (ARDS)
hypoxia that persists even when oxygen is administered at 100%
elevated lactate indicates
hypoxia, exercise, insulin infusion, alcoholism, pregnancy
sinus tachycardia treatment
identify and respond to cause beta blockers digoxin
interventions for dysrhythmias
identify the dysrhythmia assess hemodynamic status evaluate for discomfort
treatment for sinus bradycardia
identify, respond to underlying cause administer supplemental O2 Atropine
hematocrit in shock
if increased fluid shift dehydration if decreased hemorrhage
hemoglobin in shock
if increased fluid shift dehydration if decreased hemorrhage
when are fibrinolytic drugs used with PE?
if massive PE is obstructing blood flow to a lobe or hemodynamic instability
PVC treatment
if no underlying heart disease: eliminate cause if myocardial ischemia: - oxygen - amiodarone (Cordarone) (prolong repolarization)
pulmonary edema critical rescue
if not hypotensive, sit up with legs down to decrease venous return tot he heart PRIORITY - administer O2 at 5-12 L/min by simple facemask or 6-10 L/min by nonrebreather mask with reservoir apply pulse oximeter and titrate O2 to keep pt's saturation above 90% If O2 doesn't help, collaborate for more aggressive therapy (CPAP, BiPAP). Intubation and mechanical vent may be needed
PDA prognosis
if small PDA stays open, baby may eventually develop other heart symptoms babies with larger PDA are at risk for heart problems - HF - increased BP in pulmonary arteries (pulmonary hypertension d/t blood recirculation through L heart, pulmonary congestion, pulmonary overload) - infection in inner lining of heart: endocarditis
options for urinary diversions
ileal conduit continent pouch bladder reconstruction (neobladder)
anticipatory guidance in adolescence
immunizations - HPV, Menactra, TDaP nutrition eating habits and behaviors sleep and rest exercise dental health
any problem that ___________________ can start the syndrome of shock and lead to __________________
impairs oxygen delivery to tissues a life threatening emergency
HF treatment goals
improve cardiac function remove accumulated fluid and sodium decrease cardiac demands improve tissue oxygenation
after an arterial thrombectomy, observe the affected extremity for
improvement in color, temp, and pulse every hour for the first 24 hours. monitor for s/s of new thrombi or emboli, especially PE chest pain, dyspnea, and acute confusion typically occur in pts with PE. Call HCP or RRT
1st degree AV block
impulses are delayed
AV block
impulses are delayed or blocked in the AV node
bulimia nervosa
in older adolescents and young women eating disorder characterized by binge eating may be followed by purging behaviors - laxative abuse - self-induced vomiting - diuretic abuse - rigorous exercise regimens as many as eight or more cycles per day
Heart failure definition
inability of heart to pump an adequate amount of blood into systemic circulation
urinary incontinence
inability to control urination
congenital heart disease rate
incidence: 5-8 per 1000 live births 2-3 of these are symptomatic in first year of life is the major cause of death in first year of life (after prematurity) most common anomaly is ventricular septal defect (VSD) often children with CHD have another recognized anomaly (trisomy 21, 13, 18 Downs)
R-sided HF weight
increased (retaining fluid)
what might be the only sign of the initial stage of shock?
increased heart and respiratory rates or a slight increase in diastolic BP
affect of activity on HDL
increases HDL
affect of acidosis on potassium
increases as potassium moves out of the cell H+ is moving into the cells because of the high concentration of H+ in blood. K+ moves out to try to balance the electrical charges. This increases the K+ in the blood
smoking and birth control
increases risk of DVT don't combine the two after age 35
atypical angina manifests as
indigestion pain between the shoulders an aching jaw a choking sensation that occurs with exertion typically manifest during stressful circumstances or ADLs ask about changes in routine symptoms in women typically include chest discomfort, unusual fatigue, and dyspnea
D-Dimer: measures what
indirect measure of fibrinolysis indicates blood clot
communal family
individuals who share common ownership of property and goods and exchange services without monetary consideration
meds for PDA
indomethacin (Indocin) or a special form of ibuprofen (closes PDA) - can work very well for some newborns (with few adverse effects( - the earlier treatment is initiated, more likely to succeed - if not successful, surgery or cath is called for
most common cause of UTI in inpatient setting
indwelling catheter
development is most rapid in
infancy and puberty
developing a sense of trust (Erikson)
infants trust that their comfort needs will be met - feeding - stimulation mistrust - occurs when gratification of needs is delayed social modifications - grapsing - biting if they don't get it they can develop reactive attachment disorder
ischemia will lead to ___________ if allowed to persist
infarction
cystitis
inflammation of the bladder usually caused by inflammation most commonly caused by e. coli
infective endocarditis
inflammation of the inner layer of heart tissue as a result of an infectious microorganism
urethritis
inflammation of urethra, but without lab evidence of UTI may cause similar s/s to UTI male - burning with urination - urethral discharge - often d/t STD (GC, chlamydia) female - most commonly a/w tissue changes d/t low estrogen in menopause
PE respiratory acidosis or alkalosis?
initially alkalosis r/t hyperventilation progresses to acidosis as hypoxemia progresses
CAD and alcohol: what happens when you drink?
initially vasodilate, activates SNS, results in vasoconstriction and increased BP
how does smoking increase risk for CAD
injured vessel wall leads to increased clotting (platelet activity) less O2 when smoking
how does high BP increase risk for CAD
injures vessel walls, creates spots for platelets to aggregate. also causes scarring
what effect does ARDS have on lungs
injury due to inflammatory response injuring the alveolar-capillary membrane membrane becomes permeable to protein. water follows protein, alveoli fill with fluid nursing priority: identify those at risk and monitor
ischemia
insufficient blood supply to meet requirements of muscle reversible
coronary artery flow and hypertrophy
insufficient coronary artery flow, cannot keep up with larger mass of heart muscle
PAD physical assessment
intermittent claudication pain athat occurs even at rest, numbness and burning (no longer just intermittent) inflow disease (above inguinal area) -affects distal aorta, iliac arteries -discomfort in lower back, buttocks, thighs outflow disease (below inguinal area) -affects femoral, popliteal, tibial arteries -burning or cramping in calves, ankles, feet, toes pulses (pedal) skin changes - pale, dusky - hair loss - shiny skin r/t decreased blood flow - dark skin: ashy severe arterial disease - extremity is ??? cool - color changes: gray-blue or darkened - pallor with elevation - dependent rubor - sometimes sleep with legs hanging over side of bed to improve blood flow - ulcer on/between toes, painful, small, round with well-defined borders (p. 734) (chart 36-4)
moral development in adolescence
internalized set of moral principles - questioning of existing moral values and relevance to society - understanding of duty and obligation, reciprocal rights of others - concepts of justice, reparation
nonsurgical management of urolithelial cancer
intravesical chemotherapy (for superficial disease) - chemo is given directly into bladder via catheter chemotherapy (for advanced disease/metastasis)
radiofrequency catheter ablation
invasive goal is to destroy irritable focus by delivering radiofrequency waves elecrophysiology study is conducted first to locate the irritable area
EPS is an
invasive procedure during which electrical stimulation of the heart is employed to cause and evaluate serious dysrhythmias performed in special lab - controlled - immediate treatment is available complications are similar to those for cardiac cath
flail chest movement
inward during inspiration outward during expiration
prevalence of HT in African Americans
is among the highest in the owrld
what is key about sinus tachycardia?
is the pt symptomatic? SOB, bounding pulse?
what happens to CO2 in the lungs
it diffuses across the alveolar membrane and is released by exhalation
how does PTCA dilate the vessel?
it flattens plaque against the artery wall, which dilates the internal diameter of the blood vessel
urinary incontinence and aging
it is not a normal process of aging don't just put up with it
as acidosis is corrected, what happens to K+
it moves back into the cell and hyperkalemia is corrected
renal/urinary system changes associated with aging
kidney function is decreased - renal blood flow is decreased - thickening of glomerular and tubular basement memrbanes glomerular filtration rate (GFR) decreases bladder capacity decreases (more bathroom trips) prostate enlarges (difficulty urinating) urinary sphincter muscles weaken
urolithiasis
kidney stones
Infective Endocarditis affects what kids
kids with CHD or acquired heart disease
thrombolytic therapy contraindications
known bleeding disorders uncontrolled hypertension active bleed peptic ulcer disease history of stroke recent trauma or surgery pregnancy
U wave
late ventricular repolarization
causes low pressure ventilator alarm
leak in ventilator circuit or airway cuff
which side of the heart usually fails first
left
types of heart failure
left sided and right sided
most heart failure begins with failure of
left ventricle - has bigger job, hardest working
L or R? increased pulmonary pressure decreased CO
left-sided HF
hot water tank set to
less than 120
how long should capillary refill be
less than 3 seconds
crib slats
less than 6 cm apart, no bed clothing
myoglobin normal range
less than 90 ??
pulmonary contusion can be
lethal
the progressive stage of shock is a
life threatening emergency vital organs tolerate this situation for only a short time before developing MODS with permanent damage immediate interventions are needed to reverse the effects of this stage of shock
incidence of CAD has declined d/t
lifestyle better dx and treatment
2 types interventions for HT
lifestyle modifications medications
manifestations of respiratory alkalosis
lightheadedness, inability to concentrate, numbness and tingling, palpitations, chest pain, dysrhythmia
combine which meds to manage K+?
lisinipril (hyperkalemia) furosemide (hypokalemia)
ACE inhibitor for MI
lisinopril vasodilator decreases BP, vasodilates coronary arteries too
meds for BP to balance K+
lisinopril and HCTZ
communicating with adolescents
listen, be open minded, avoid criticism, make expectations clear
common progression of events leading to septic shock
local infection systemic infection SIRS (systemic inflammatory response syndrome) Organ failure (sepsis) Multiple organ dysfunction syndrome (MODS) (septic shock)
coarctation of the aorta definition incidence risk factors
local narrowing at aorta's insertion to the ductus arteriosus is a common heart condition present at birth (CHD) more common in: - genetic disorders: Turner syndrome (44XO) usually dx in children/adults under 40 (mild if dx in adulthood) may be related to cerebral aneurysm (r/t increased pressure in head) may be seen with other CHD such as: - bicuspid aortic valve - defects in which only one ventricle is present - VSD
prosthetic valves longevity
longer than biologic valves but require anticoagulants for life (blood experiences valve as "damaged" and platelets aggregate)
review normal anatomic structure of coronary arteries
look in book
furosemide is
loop diuretic
which diuretics are not often used for older adults
loop diuretics cause dehydration and orthostatic hypotension (increased risk for falls)
air in the pleural space causes
loss of negative pressure
distributive shock
loss of sympathetic tone may be neurologically induced (SNS impulses decrease causing vasodilationg_: head trauma can be caused by anything that inhibits the stress response may be chemical-induced: 3 common origins 1. anaphylaxis 2. sepsis 3. capillary leak syndrome - injury (and chemical mediators) increase capillary membrane permeability - fluids move into interstitial tissues: why? - example: severe burn injury
HCO3 in metabolic acidosis
low
pH in metabolic acidosis
low
respiratory acidosis pH
low
respiratory alkalosis PaCO2
low
S/S of a Cardiac tamponade
low BP, shortness of breath, lightheadedness, pain in chest, fast pulse, sensation of abnormal HR, fast breathing, faint heart sounds, swelling in extremities
lab assessment of PE
low pulse oximetry ABGs - respiratory alkalosis If hypoxemia develops, respiratory acidosis???
t-PA intended effect
lyses formed clot that is causing complete bock of coronary artery
pulmonary contusion treatment
maintenance of ventilation and oxygenation
what does clopidogrel do for CAD?
makes platelets less sticky stronger than ASA increased risk of bleeding
what happens with ruptures central arterial aneurysm
massive internal bleeding
surgical management of shock
may be needed to correct cause procedures: - vascular repair - revision closure of bleeding ulcers - hemostasis of major wounds
percutaneous transluminal coronary angioplasty (PTCA)
may be used to treat MI to dilate coronary artery entails inserting balloon-tipped catheter to site of occlusion where it is inflated may be followed by placement of a stent, an expandable metallic mesh device that maintains vessel lumen IV heparin and vasodilator therapy follow (Nitro of diltiazem) cardiologist usually prescribes beta blocker, ACE inhibitor
HLHS symptoms
may initially appear normal, symptoms develop in first hours of life - mild cyanosis until PDA closes, then condition worsens - cold hands and feet - lethargy - poor pulse - poor suckling and feeding - pounding heart - rapid breathing - SOB - signs of HF (tachycardia, lethargy, hepatomegaly, tachypnea) - may have: weak pulse, abnormal heart sounds
Coarctation of the Aorta: complications
may occur before, during, or soon after surgery include: - aortic aneurysm - aortic dissection - aortic rupture - bleeding in the brain - early development of coronary artery disease - endocarditis - HF - hoarseness - kidney problems - paraplegia (rare) - severe high BP - stroke
if D-dimer is elevated, is there a PE?
maybe, needs further testing
MAP
mean arterial pressure average blood pressure normal 60-70 mmHg (necessary to maintain perfusion)
measuring head circumference
measure above the eye brows and pinna of ears
measuring abdominal circumference
measure around level of umbilicus
measuring chest circumference
measure around the rib cage at nipple line
monitoring bleeding after CABG
measure mediastinal and pleural chest tube drainage at least hourly report drainage amounts over 150 mL/hr to the surgeon pts with internal mammary artery grafts may have more chest drainage than those with saphenous vein grafts (from the leg)
severe flail chest - what may be needed
mechanical ventilation
sexuality education and guidance in adolescence
media influences are pervasive (7 hours/day) knowledge is often inaccurate adolescents whose parents limit television are less likely to engage in early sex factual information is available from these sources - parents - schools, nurses - planned parenthood (when they don't want their parents to know)
average of of first MI
men: 64.7 women: 72.2
growth and maturity affect the
metabolism and excretion of meds in the pediatric pt
biological development of school age child
middle childhood: - height: 2"/year - total height gain: 1-2 feet - weight increase: 2-3 kg/year - weight almost doubles
alpha-adrenergic agonists for urinary incontinence
midorine (ProAmatine, Orvaten) increases contractile force of the urethral sphincter, increasing resistance to urine outflow - teach to monitor BP, can cause severe supine HT
pacemaker teaching
minimize shoulder movement intially, assess hiccup, make sure grounded connection - permanent: carry ID card, first 2 weeks (wear sling, avoid raising arm above shoulder), no heavy lifting for 2 mo. - dont place alarm, magnet, stereo speaker, generators, garage opener on top of pacemaker -inform dentist
beta agonist for urinary incontinence
mirabegron (Myrbetriq) relax the deterusor smooth muscle to increase bladder capacity and urine storage - teach to periodically obtain BP, call HCP if elevated - warfarin? d/c or increased monitoring (can potentiate effect of warfarin)
oxygenated blood enters the left ventricle through the ___________ valve
mitral
what is the most worrisome complication of rheumatic fever?
mitral valve problems
SvO2
mixed venous oxygen saturation 60-80%
to prevent bacterial contamination, do not allow _________ in the ventilator tubing to _______________
moisture enter the humidifier
HTN Calcium Channel Blockers nursing implications
monitor HR and BP before taking each day (slows SA and AV conduction, decreases HR, vasodilates, decreases BP) avoid grapefruit (enhances action of drug - organ dysfunction/death)
nursing concerns for pt with HF after MI
monitor for inadequate tissue perfusion a/w decreased CO (signs of HF!) - crackles in lungs - SOB - fatigue - decreasing urine output
nonsurgical management of abdominal aortic aneurysm
monitor growth of aneurysm - via CT scan or US - when 5cm in diameter surgery is indicated keep BP in normal range - too high = rupture
CABG with radial artery graft donor considerations
monitor neurovascular status of donor arm every hour: - hand color - temp - pulse (ulnar and radial) - cap refill every 4 hours - sensation in fingertips, hand, and arm nitroglycerin is often given for first 24 hrs to promote vasodilation in the donor arm and therefore maintain circulation
health teaching for infective endocarditis pt at home on antibiotics with PICC
monitor temp daily report fever and s/s of HF good oral hygiene: bacteria can travel to heart antibiotic prophylaxis before invasive procedures
evolocumab (Repatha)
monoclonal antibody that inhibits PCSK9 and lowers LDL helps people on statins whose chol remains high subcut q 2 weeks
preschooler/school age nutrition
more agreeable to try new foods 1/2 adult portion likes and dislikes are established encourage child to make good choices
goal of valve surgery
more functional valve
nitroglycerin spray
more quickly absorbed than tablet pain relief should begin within 1 to 2 minutes and should be clearly evident in 3 to 5 minutes instruct pt to lie down (dramatic hypotension) shelf life = 3-5 months
a-fib
most common dysrhythmia multiple impulses from many atrial foci depolarize atria in a disorganized manner at rate of 350-600 times/minute causes atrial fibrillation blood pools (1/3) heart rate increases rhythm irregular CO decreased coronary artery perfusion decreased
activity in preschooler
motor activity levels: remain high - emphasis on fun and safety - readiness to participate in sports - sedentary activity such as TV and computer time: should be limited
Arrythmogenic right ventricular cardiomyopathy
myocardium is replaced with fibrous and fatty tissue affects young adults
complementary/alternative therapy for atherosclerosis
nicotinic acid or niacin (Niaspan) omega 3 fatty acids or fish oil (Lovaza) they don't work all that well
how might you know that nitro is expired?
no headache
juice?
no juice, or max 4 oz if parents insist
s/s of v-fib
no pulse no CO
types of temporary pacing
noninvasive - 2 large external electrodes that deliver electrical impulses - used in an emergency in profound bradycardia - review procedure - complications are discomfort, skin irritation invasive - surgically implanted in chest - consists of pulse generator that delivers stimuli via pacing electrodes directly to the heart
urine RBCs
normal: 0-2 increased is normal with catheterization or menses may reflect tumor, stones, trauma, glomerular disorders, cystitis, or bleeding disorders
urine WBCs
normal: 0-4 increased may indicate an infection or inflammation in the kidney and urinary tract, kidney transplant rejection, or exercise
urine specific gravity
normal: 1.005-1.030 increased: decreased kidney perfusion, inappropriate ADH secretion, heart failure decreased: CKD, diabetes insipidus, malignant hypertension, diuretic administration, lithium toxicity
urine pH
normal: 4.6-8, average 6 changes are caused by diet, drugs, infection, age of specimen, acid-base imbalance, and kidney disease
urine bacteria
normal: <1000 colonies increased indicates the need for urine culture to determine the presence of urinary tract infection
is sinus bradycardia worrisome?
not always worrisome if pt has decreased BP, CO, or is SOB
s/s of HT
not very symptomatic "the silent killer" anxiety headache
acute arterial occlusion nursing care
nursing care: assess: revascularization, bleeding post-op: - color, temp, pulse, pain - check for compartment syndrome (increased pressure in a confined space, potentially restricts blood flow
family centered nursing
nursing that considers the health of the family as a unit in addition to the health of individual family members
lifestyle modifications for atherosclerosis
nutrition: - limit fat <30% of total calories - limit cholesterol to 300 mg smoking cessation weight loss exercise
UTI drug therapy
o Trimethoprim-sulfamethoxazole or nitrofurantion • Used to treat uncomplicated UTI o Pyridium: OTC, provides soothing effect on urinary tract mucosa • Does not treat infection, but provides symptom relief • Stains urine reddish-orange o Prophylactic or suppressive antibiotics: patients with repeated UTIs • Prevent reoccurrence, or a single dose prior to events likely to cause UTI •On a strictly individual basis
nursing care for pt receiving t-PA
observe for/prevent bleeding! Monitor neurologic status IV sites clotting studies Hgb/Hct stool/urine/emesis for blood (PLT, aPTT, D-dimer, INR)
factors contributing to UTI
obstruction stones (calculi) vesicoureteral reflux DM characteristics of urine gender age sexual activity recent use of antibiotics
CABG
occluded coronary arteries are bypassed with synthetic graft or patient's own vessel internal mammary gland is graft of choice
weaning
ok once baby can hold a bottle one feeding at a time bedtime
what can run with blood products
only normal saline calcium in Ringer's lactate causes clotting of infusing blood
temp route under 12 weeks
only rectal
aortic stenosis pathophysiology
opening narrows, obstructs blood flow L ventricle is overworked
if pH and PaCO2 are moving in ________ __________, then the problem is primarily respiratory
opposite
what is the preferred route of drug administration for kids
oral
what is the best intervention to prevent endocarditis
oral hygiene
growth is
orderly and systemic simple to complex many critical periods in growth and development
what method is used for heart transplant for cardiomyopathy pt
orthotopic part of left, right atria attached to donor's atria
PVCs and widened QRS complexes
other dysrhythmias can cause widened QRS complexes too assess peripheral perfusion
venous insufficiency
outcome of prolonged increased venous pressure that causes stretching of veins and damages valves effects - edema - stasis dermatitis: brown discoloration of skin (RBC lysis) - stasis ulcer: occurs over malleolus, usually medially. Ulcer bed is pink with granulation tissue. Uneven edges. Tends to be chronic and difficult to heal increased risk - standing/sitting all day - DVT - anything that increases pressure in veins
anticholinergics for urinary incontinence
oxybutynin solifenacin suppresses involuntary bladder contraction and increases bladder capacity - glaucoma? - can worsen - increase fluid intake and fiber to prevent constipation - increase fluid intake and use hard candy to reduce dry mouth - monitor urine output and report lower output (can cause urinary retention, especially with BPH) - do not chew/crush time-released drugs
how does patent ductus arteriosus and ASD help HLHS
oxygenated blood from LA mixes with desaturated blood from RA and flows through RV to pulmonary artery to lungs and also through ductus arteriosus to arorta, bypassing LV PDA temporarily fixes problem, when it closes = cardiac collapse
diseased bronchioles and alveoli cause
oxygenation failure
treatment for AV block
pacemaker (fixed rate)
MI key features
pain or discomfort - substernal chest pain/pressure radiating to the elft arm - pain or discomfort in jaw, back, shoulder, or abdomen - occurring without cause, usually in the morning - relieved only by opioids - lasting 30 minutes or more frequent associated symptoms - nausea/vomiting - diaphoresis - dyspnea - feelings of fear and anxiety - dysrythmias - fatigue - palpitations - epigastric distress - anxiety - dizziness - disorientation/acute confusion - feeling "short of breath"
physical assessment of cystitis
pain/dysuria frequency urgency confusion hematuria leukocytes nitrates
urolithelial cancer assessment
painless hematuria (classic manifestation) Diagnositcs - cystoscopy with biopsy - urography - CT scan identifies invasion of surrounding tissues
democratic parenting style
parent directs behavior by setting rules and offering detailed explanation regarding rules
factors predisposing to physical abuse
parental characteristics - socially isolated - young - single characteristics of child - younger than 1 year - disabled - preterm environmental characteristics - divorce, poverty, unemployment - poor housing, frequent relocation - alcoholism, drug addiction
dictational/authoritarian parenting style
parents try to control the child's behaviors and attitudes through unquestioned rules and expectations
which nitrate is for prevention of angina
patch (Nitro-Dur)
obstructed hypertrophic cardiomyopathy patho s/s treatment
patho (same as for nonobstructed except for obstruction of left ventricular outflow tract associated with the hypertrophied septum and mitral valve incompetence) hypertrophy of all walls hypertrophied septum relatively small chamber size s/s (same as for nonobstructed except with mitral regurgitation murmur) a-fib dyspnea angina fatigue, syncope, palpitations mild cardiomegaly S4 gallop ventricular dysrhythmias sudden death common HF treatment same as for nonobstructed: -symptomatic treatment -beta blockers -conversion of a-fib -surgery: ventriculomyotomy or muscle resection with mitral valve replacement -nitrates adn other vasodilators contraindicated with the obstructed form
dilated cardiomyopathy pathophysiology s/s treatment
patho fibrosis of myocardium and endocardium dilates chambers mural wall thrombi prevalent s/s fatigue/weakness HF (left side) dysrhythmias or heaert block systemic or pulmonary emboli S3 and S4 gallops moderate to severe cardiomegaly treatment symptomatic treatment of HF vasodilators control of dysrhythmias surgery: heart transplant
nonobstructed hypertrophic cardiomyopathy pathophysiology s/s treatment
patho hypertrophy of all walls hypertrophied septum relatively small chamber size s/s dyspnea angina fatigue, syncope, palpitations mild cardiomegaly S4 gallop ventricular dysrhythmias sudden death common HF treatment -symptomatic treatment -beta blockers -conversion of a-fib -surgery: ventriculomyotomy or muscle resection with mitral valve replacement -nitrates adn other vasodilators contraindicated with the obstructed form
Raynaud's
pathologic event is vasospasms of arterioles of hands, feet (bilateral, painful) Classifications Phenomenon - >30 yo - s/s unilateral Disease - 17-50 yo - s/s bilateral s/s pallor-cyanosis-rubor (progression when symptomatic) treatment vasodilator drug therapy (not very effective) - Nifedepine (Procardia) - cyclandelate (Cyclospasmol) surgery for severe symptoms: sympathectomy nursing care health teaching: - avoid exposure to cold - avoid triggers: cold, stress
vent settings: PIP
peak airway inspiratory pressure - "work that the ventilator accomplishes - the pressure that must be overcome to provide a breath
what to assess before cardiac cath
pedal pulses (pedal and posterior tibial) - mark where the pulse is felt so it can be evaluated after the procedure height/weight allergies
ejection fraction
percentage of the end-diastolic blood volume ejected from the ventricle with each heartbeat usually 55-75%
pericardial effusion can occur because of
pericarditis
toddler nutrition
phenomenon of physiologic anorexia - picky, playful and variable - combo of autonomy and ritualism - too busy to sit and eat - bring finger foods to play area nutritional counseling - three meals and two snacks - overfilled plates, and mixed foods are unappealing PICA - eating non-food items Food as reward? - NO Dietary guidelines - myplate and 1 T of food per year or 1/4 of adult serving milk - don't give before food juice - no brown diet - what the toddler would choose - toast, pizza, mac and cheese, nuggets
urinary incontinence physical assessment, labs, imaging
physical assessment intake/output abdominal/skin uterine prolapse, cystocele or rectocele? PVR (post void residual) labs GFR BUN creatinine UA imaging urodynamic testing (voiding cystourethrogram: assess urine flow)
objective cardiac assessment of child
physical exam - pulses - heart sounds - cyanosis - tachycardia while eating - hepatosplenomegaly - crackles diagnostic study - ECG (electrical activity) - echocardiogram (structure) - labs cardiac catheterization
challenges of oral medications
pills are hard to swallow taste or smell oral or sensory issues
Kawasaki disease symptoms
pink eye (no discharge, just pink) oral mucosal change (red lips, strawberry tongue) enlarged lymph nodes patchy rash peeling skin
smokeless tobacco in adolescence
place in mouth by not ignitied increasing popularity serious hazards carcinogenic periodontal disease, tooth erosion, soft-tissue damage
endotracheal intubation
placement of a tube through the mouth into the pharynx, larynx, and trachea to establish an airway cuff is inflated at distal end to create a seal, which allows set amoutn of air to be delivered and stabilizes the tube
for pts receiving any platelet inhibitor, monitor
platelet counts for the first 3, 6, and 12 hours after the start of the infusion. If they drop below 100,000, d/c or adjust infusion and call HCP or RRT
__________ is the work of children
play
cooperative play
play in which children genuinely interact with one another, taking turns, playing games, or devising contests
S/S of pneumothorax
pleuritic chest pain dyspnea tachypnea reduced breath sounds
chronic hypoxemia clinical manifestations
polycythemia (kidneys larted of decreaed O2, secrete erythropoietin to increase RBC) clubbing hypercyanotic (TET) spells
what does uncorrected respiratory acidosis lead to
poor oxygenation and lactic acidosis (combined metabolic and respiratory acidosis)
deltoid
position child sitting or standing inject up to 1 mL
what is key to an accurate ECG?
positioning of electrodes
PEEP
positive end expiratory pressure - exerted at the end of exhalation - keeps alveoli open
most ventilators are what kind of ventilator?
positive-pressure ventilators
what is the pulmonary collaborative problem in HF?
potential for pulmonary edema
moral development of preschooler
preconventional or premoral level - basic level of moral judgement: good v. bad - punishment and obedience orientation - very concrete sense of justice and fairness
factors controlling stroke volume
prelaod afterload contractility
PVC
premature ventricular contraction result from increased irritability of ventricular cells may: - be unifocal or multifocal - occur in repetitive patterns (bigeminy, trigeminy, quadrigeminy) occur commonly (stress, caffeine) may be a/w disease (myocardial ischemia, CHF, anemia, hypokalemia) s/s none palpitations chest discomfort
coping with concerns related to normal growth and development in preschooler
preschool and kindergarten - developmental screening tool to assess readiness for school (Denver screening) - importance of infection control in school setting - introduction of child to school and teachers
urine crystals
presence may indicate that the specimen has been allowed to stand
urine ketones
presence occurs with diabetic ketoacidosis, prolonged fasting, anorexia nervosa
urine parasites
presence of Trichomonas vaginalis indicates infection, usually of the urethra, prostate, or vagina
urine glucose
presence reflects hyperglycemia or a decrease in the kidney threshold for glucose
urine leukocyte esterase
presence suggests UTI
urine bilirubin
presence suggests liver or biliary disease or obstruction
what does an ECG tell us for MI
presence, location of ischemia/infarction ischemia: ST depression, T wave inversion infarction: ST elevation (STEMI) T wave inversion Non-ST elevation (NSTEMI) Abnormal Q wave
urine nitrites
present suggests urinary E. coli
s/s of MI in men
pressure pain arm pain
afterload is affected by
pressure in arteries
how well can drugs lower cholesterol?
pretty well, but you need to eat low fat. drugs can't do it all
purpose of anticoagulants
prevents enlargement of clot or formation of new clots
preventing shock
primary avoid dehydration use safe equipment, seatbelts secondary Nursing responsibility Identify those at risk for dehydration (NPO, redubed mobility or cognition) Monitor pts undergoing invasive procedures, S/P Health teaching re: s/s of shock
weaning
process of going fro ventilator dependence to spontaneous breathing
D-dimer is
product of body's clot-dissolving system following a thrombotic event <1.0 mcg/ml suggests NO PE
what does mechanical ventilation do?
provides breathing support to pt with significant gas exchange difficulty usually temporary
PSC
psychiatric, social and learning development screens for depression and anxiety
decreased PTT meaning
pt not getting enough heparin increase dose is usually indicated
decreased INR meaning
pt not getting enough warfarin increased dose usually indicated
decreased PT meaning
pt not getting enough warfarin increased dose usually indicated
who is the IVC filter good for
pts that we don't want to put on blood thinners
statins are contraindicated for
pts with liver disease pregancy can cause muscle myopathis and marked decreases in liver function
PAS
pulmonary artery systolic (pressure) 15-26 mmHg
PAWP
pulmonary artery wedge pressure 4-12 mmHg
pts with mitral stenosis often have
pulmonary hypertension and stiff lungs monitor respiratory status closely during weaning from ventilator
deoxygenated blood enters the lungs through the ___________ valve
pulmonic
how often is lovenox given
q 12 hours
therapeutic management of infant colic
r/o acute problem probiotic herbal treatment parental diet
nuclear perfusion imaging entails use of
radioactive isotopes
a-flutter
rapid atrial depolarization occurring at a rate of 250-350 times/minute AV node blocks some of impulses P waves have characteristic "saw-tooth" appearance
what can happen with the first dose of ACEIs and ARBs
rapid drop in BP
adolescence is characterized by
rapid physical, cognitive, social, and emotional maturation
temp route under 6-12 months
rectal most appropriate
measuring length
recumbent length until 203, measure end points
after pericardiocentesis, closely monitor the pt for
recurrence of tamponade. pericardiocentesis alone often does not resolve tamponade be prepared to provide adequate fluid volumes to increase CO prepare pt for emergency sternotomy if tamponade recurs
improving cardiac output goals
reduce afterload reduce preload enhance contractility surgical management decreasing fatigue preventing/managing pulmonary edema health teaching
preschool fine motor skills
refinement in eye-hand and muscle coordination - beginning to write letters skillful manipulation - dressing, drawing, t-ball
pts with endocarditis must remember to
remind health care providers (including dentist) of their endocarditis prophylactic antibiotics before dental oral procedure if: - prosthetic valve - hx of infective endocarditis - unrepaired cyanotic congenital heart disease
what to do if mechanically ventilated pt shows signs of respiratory distress
remove the ventilator and provide ventilation with a bag-valve-mask device. This allows quick determination of whether the problem is with the ventilator or the pt
pregnancy and UTI
requires prompt and aggressive treatment - can lead to acute pyelonephritis during pregnancy pyelonephritis in pregnancy can cause preterm labor and adversely effect the fetus.
afterload
resistance to left ventricular ejection
left-sided HF symptoms are
respiratory
hyperventilation causes
respiratory alkalosis
Erikson's stages
trust vs mistrust (birth - 1) autonomy vs shame and doubt (1-3) initiative vs guilt (3-6) industry vs inferiority (6-12) identity vs role confusion (12-18) intimacy vs isolation generativity vs stagnation integrity vs despair
communicating with infant
responds to physical contact, gentle voice and high pitched, sing-song voices
review foot care
review foot care
what happens in right-sided heart failure
right ventricle not able to empty completely systemic venous congestion
L or R? edema
right-sided HF
elevated PTT meaning
risk for bleeding decrease or hold heparin dose
increased PT meaning
risk for bleeding hold warfarin, decrease dose eat foods high in vitamin K to help correct
as atherosclerotic plaque increases, it can
rupture - clot formation - vasocontriction
DVT assessment
s/s - some have no s/s - calf or groin tenderness or pain - unilateral swelling - Homan's sign: pain in calf with dorsiflexion of foot (NOT specific) - redness, warmth, induration Dx venous ultrasound d-dimer: marker for coagulation
what does D-dimer do?
says if there's a clot it's a measure of the body's own ability to break up a clot
MI: necrotic area becomes ____________ over ensuing months (___________) effect on CO?
scar tissue remodeling scar tissue does not participate in maintaining cardiac output = decreased CO and EJ
sex hormones
secreted by ovaries, testes, and adrenal glands produced in varying amounts by both sexes throughout the lifespan - adrenal cortex causes small amount of secretion before puberty - maturation of gonads produces biologic chnages of puberty
picture - name the ECG waves
see picture
milestone chart
see sheet
fibrinolytics action
selectively break down fibrin threads present in formed clots
psychosocial development in adolescence
sense of identity (Erikson) - early adolescence: group identity vs. alienation - development of personal identity vs. role diffusion - sex role identity - emotionality
Piaget stages
sensorimotor: birth - 2 pre-operational: 2-7 concrete operational: 7-11 formal operational: 11-18
toddler social development
separation - differentiation of self from mother and significant others (via school) individualization - achievements that mark the child's expression - major achievements: occur in the toddler years - transitional objects!! (teddy bear, blanket)
3 causes of distributive shock
sepsis anaphylaxis neurogenic
what happens in MODS
sequence of cell damage cuased by the massive release of toxic metabolites and enzymes metabolites are released from dead cells microthrombi form as a consequence = microthrobi block perfusion to organs. Can lead to DIC
kidney function blood studies
serum creatinine - males 0.6-1.2 - females 0.5-1.1 - may be decreased in older adults BUN - 10-20 - slightly higher in older adults BUN/creatinine ratio - 6-25
sex education in school age child
sex play is part of normal curiosity during preadolescence middle childhood is ideal time for formal sex education - lifespan approach - info on sexual maturity and process of reproduction - effective communication with parents
for safety, before cardioversion...
turn oxygen off and away from pt; fire could result shout "CLEAR" before shock delivery for electrical safety!
characteristics of abusers
typical abuser: male whom victim knows but may be anyone siblings and mothers people at all levels of society 80% adults, 20% male adolescent
heparin therapy for MI
typically prescribed for 3-5 days following thrombolytic therapy to maintain vessel patency monitor aPTT (checked every 4-6 hrs until therapeutic range, then daily) (stay below 70-80)
vastus lateralis
site recommended for infants and small children position child supine, side lying, or sitting inject up to 0.5 mL for infants inject up to 2 mL for children chunkiest piece of thigh
surviving sepsis care bundle
within 3 hrs of suspecting severe sepsis 1. measure lactate level 2. obtain blood cultures (before antibiotics) 3. give broad-spectrum antibiotics 4. 30 mL/kg crystalloids IV for hypotension or lactate >or= 4 within 6 hrs of initial indications of suspected septic shock 5. give vasopressors for hypotension that does not respond to initial fluid resuscitation measures to maintain MAP >or= 65 6. if arterial hypotension persists despite fluids or lactate remains >or= 4, reassess volume status and tissue perfusion and document findings 7. remeasure lactate level if initial value was elevated document reassessment of volume status and tissue perfusion with EITHER: - repeat focused exam (after fluids), including vs, cardiopulmonary, capillary refill, pulse, and skin findings or TWO OF THE FOLLOWING - measure of CVP - measure of central venous oxygen saturation - bedside cardiovascular ultrasound - dynamic assessment of fluid responsiveness with passige leg raise or fluid challenge
nephron
working unit of the kidney produces urine about 1 million nephrons per kidney
PA line placement confirmed by
x-ray
biologic valve replacement types
xenograft from cadavers pulmonary valve autografts
urine color
yellow: normal dark amber: concentrated urine very pale yellow: dilute urine dark red or brown: blood in urine. brown may indicate increased bilirubin level. Red also may indicate the presence of myoglobin
acute respiratory failure - is the pt hypoxemic?
yes
is an artificial airway needed for mechanical ventilation?
yes
can parents help give medications
yes, if appropriate don't leave until kid takes it
does infective endocarditis pt need prophylactic antibiotics before invasive procedures?
yes, if significant disease occurs
if the vascular bed is dilated, will tissue perfusion be impacted?
yes, tissue perfusion will be decreased
septic shock: stage of sepsis when
you lose BP even with intervention, death rate >60%
The patient receiving anticoagulant therapy
• Carefully check the dosage of anticoagulant to be administered, even if the pharmacy prepared the drug. • Monitor the patient for signs and symptoms of bleeding, including hematuria, frank or occult blood in the stool, ecchymosis, petechiae, altered mental status (indicating possible cranial bleeding), or pain (especially abdominal pain, which could indicate abdominal bleeding). • Monitor vital signs frequently for decreased blood pressure and increased pulse (indicating possible internal bleeding). • Have antidotes available as needed (e.g., protamine sulfate for heparin; vitamin K for warfarin [Coumadin, Warfilone]). • Monitor activated partial thromboplastin time (aPTT) for patients receiving unfractionated heparin. Monitor prothrombin time (PT) or international normalized ratio (INR) for patients receiving warfarin or low- molecular weight heparin (LMWH). • Apply prolonged pressure over venipuncture sites and injection sites. • When administering subcutaneous heparin, apply pressure over the site and do not massage. • Teach the patient going home while taking an anticoagulant to: • Use only an electric razor • Take precautions to avoid injury; for example, do not use tools such as hammers or saws, where accidents commonly occur • Report signs and symptoms of bleeding, such as blood in the urine or stool, nosebleeds, ecchymosis, or altered mental status • Take the prescribed dosage of drug at the precise time that it was prescribed to be given • Not stop taking the drug abruptly; the physician usually tapers the anticoagulant gradually
conditions predisposing to sepsis and septic shock
• Malnutrition • Immunosuppression • Large, open wounds • Mucous membrane fissures in prolonged contact with bloody or drainage-soaked packing • GI ischemia • Exposure to invasive procedures • Cancer • Older than 80 years • Infection with resistant microorganisms • Receiving cancer chemotherapy • Alcoholism • Diabetes mellitus • Chronic kidney disease • Transplantation recipient • Hepatitis • HIV/AIDS
pediatric indicators of cardiac dysfunction
• Poor Feeding (sleepy, decreased intake, hungry after eating, increased RR, increased HR) • Tachypnea/Tachycardia • Failure to Thrive / Poor Wt. Gain / Activity Intolerance • Developmental Delays (poor cerebral perfusion) • Prenatal History: Alcohol, Diabetes Mellitus, Substance Abuse • Family History long echmo = increased rate of developmental delays
graduated compression stockings
• Wear stockings as prescribed, usually during the day and evening. • Put the stockings on upon awakening and before getting out of bed. • When applying the stockings, do not "bunch up" and apply like socks. Instead, place your hand inside the stocking and pull out the heel. Then place the foot of the stocking over your foot and slide the rest of the stocking up. Be sure that rough seams on the stocking are on the outside, not next to your skin. • Do not push stockings down for comfort, because they may function like a tourniquet and further impair venous return. • Put on a clean pair of stockings each day. Wash them by hand (not in a washing machine) in a gentle detergent and warm water. • If the stockings seem to be "stretched out," replace them with a new pair. - be sure to assess sizing if the pt has gained or lost weight Dos and Don'ts • Elevate your legs for at least 20 minutes four or five times a day. When in bed, elevate your legs above the level of your heart. • Avoid prolonged sitting or standing. • Do not cross your legs. Crossing at the ankles is acceptable for short periods. • Do not wear tight, restrictive pants. Avoid girdles and garters.
•A nurse reviews lab studies of a patient receiving digoxin. Intervention by the nurse is required if the results include a: •A serum digoxin level of 1.2 ng/dL •B serum potassium level of 3.0 mEq/L •C hemoglobin q4.4 g/dL •D serum sodium level of 140 mEq/L
•B serum potassium level of 3.0 mEq/L decreased K+ = increaesd risk of digoxin toxicity
•A nurse reviews lab studies of a patient receiving digoxin. Intervention by the nurse is required if the results include a: •A serum digoxin level of 1.2 ng/dL •B serum potassium level of 3.0 mEq/L •C hemoglobin q4.4 g/dL •D serum sodium level of 140 mEq/L
•B serum potassium level of 3.0 mEq/L low sodium increases risk for digoxin toxicity
when is surgical management of valvular disease performed
•Performed after symptoms of left ventricular failure develop
R or L? •Shortness of breath •Edema •Jugular venous distention •Cough •Difficulty sleeping while lying flat •Easily fatigued •Weight gain •Nocturia
•Shortness of breath L •Edema R •Jugular venous distention R •Cough L •Difficulty sleeping while lying flat L •Easily fatigued L (decreased CO/perfusion) •Weight gain R (fluid) •Nocturia L (kidneys are better perfused at night because muscles are resting)
family assessment
History: family medical history of siblings, parents, and grandparents - eg asthma, ear infections Structure: family members and living situation Developmental Tasks: tasks a family works on as the child grows - potty training, etc Family Characteristics: cultural, religious and economic influences on behaviors, attitudes, and actions Environment: availability of resources Family Support: availability of extended family, work and peer relationships as well as social systems and community resources to assist the family in meeting needs or adapting to a stressor
