514 Exam 1
Terms
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- the pump action of the heart
- contractility
- the electrical system in the heart
- conduction
- even though the heart loses function because of this condition, the conduction system still works
- heart failure
- even though there's nothing wrong with the contractility of the heart, the patient needs a pacemaker because of loss of
- conduction
- changes in the intimal lining of blood vessels in the heart; total or partial obstruction of an artery in the heart or a branch of an artery (referred to in % blockage)
-
arteriosclerotic heart disease
(aka Coronary Artery Disease CAD) - with this disease there is a 30-40% increase in risk for CAD because blood vessels harden, kidneys are at risk
- diabetes mellitus
- take # of years x # of packs per day
-
calculate "pack years" for smoking
ex: 2ppd x 30 years = 60 pack years - 30 minutes of exercise to increase heart rate to 80% of capability, 3x a week
- amount of exercise necessary to lower heart disease risk
-
smoking
obesity
HTN
lifestyle
stress
cholesterol - modifiable risk factors for cardiovascular disease
-
age
gender
family history
race/ethnicity
diabetes mellitus (*except how you control it)
post-menopausal women - nonmodifiable risk factors for cardiovascular disease
-
"squeezing" pain the chest or nearby area due to lack of O2 to cardiac cells
caused by atherosclerosis -
angina pectoris
*doesn't necessarily mean someone is having a heart attack -
angina pain occurs every so often
relieve by nitroglycerin or rest
stays the same over time - stable angina
- worsening angina pain, important to look for changes
- unstable angina
-
angina pain increasing in frequency, severity, and/or duration
at night - blood pools in heart and chest, shortness of breath
nitroglycerin/rest may not relieve pain - acute coronary syndrome
-
cause:arterial spasms, not blockage
occurs early am
occurs at rest
common during REM sleep
90% seen in women
rare to infarct - Prinzmetal's (variant) angina
- how long does it take for a cardiac cell to die from lack of O2?
- 4-6 minutes
-
1.Location - where at(chest, jaw, left arm, back, shoulders, epigastric)
2.Radiation - does it move?
3.Onset - how does it start?
4.Severity - how bad does it hurt?
5.Sensation - how does it feel? (sharp, knifelike, heavy, "sitti - Nursing assessment of angina pain
- dyspnea, orthopnea (sit up to breathe), shortness of breath, dizzy, palpitations, lightheaded, GI (vagus nerve), perspiration, diaphoresis, pallor, anxiety, increase in weight (sign of heart failure)
- Other symptoms with angina
-
cardiac catherterization
stress test (changes in ST segment)
EKG
Echocardiogram
TEE (like Echo, with scope in esophagus) - diagnostic tests for cardiac function
-
-If NPO
-are meds to be held
-can pt. have caffeine
-allergy to iodine or shellfish
post procedure:
assess airway, vital signs, cardiac fct, pulses in extremities, cap refill
push fluids after dye injections - The nursing responsibilities with cardiac testing
-
this is the medication of choice for treatment of angina; if it's potent it stings or burns when put in mouth; med is sensitive to heat, cold, light
*taken sublingually every 5 minutes; if pain is still there after 3 tablets, go to the emergen - Nitroglycerin
-
for treatment of angina, po, sometimes IV drip (NEVER push), topically with patches or ointment, spray
Side Effect: headache - Isodril, Isosorbide
-
morphine sulfate - 2 to 6 mg until pain relieved (IV push)
Beta Blockers-decrease work of heart
Ca Channel Blockers-vasodilators
Antiplatelets-aspirin - other medications for angina
- what is an antidote to coumadin
- vitamin K
- PTT
-
Partial Thromboplastin Time
norm: 25-35 seconds - If you are on coumadin, what will your PTT likely be?
- 60-90
- What is an antidote to Heparin?
- protamine sulfate
- what food can interfere with coumadin?
- green leafy vegetables (vitamin K)
-
-maintain oxygenation (w supplement)
-monitor chest pain
-instruct any needed lifestyle changes
-monitor vital signs, pulse oximetry (need a doctor's order, but can get that later)
-monitor electrolytes - K, Na
-teach medications - nursing interventions for angina
- What are the outcomes which are the goal of the medical and nursing treatemnt of Angina?
-
1.prevent progression of the disease
2.prevent MI - lack of oxygen to cardiac cells beyond the occlusion in a coronary artery due to blockage or spasm in the artery
- myocardial infarction (MI)
- main causes of death with MI
-
-50% die before reaching the hospital
-arrhythmias, dysrythmia - irregular
the longer the ischemia the greater cell death -
a test that looks for this protein in the bloodstream during an MI; takes 20 minutes and is very accurate; will eliminate unnecessary admission to the hospital if someone is not infarcting
-normal level is 0 to 1.5 U
(with MI it is in the 100s) - Troponin 1
- PTCA
- percutaneous transcoronary angioplasty
-
-arrhythmias - due to lack of O2 & cell death
-CHF - from scarring on heart
-pulmonary edema
-shock - cardiogenic shock
anxiety and fear - complications post MI
-
Monitor:
-pain level
-monitor cardiac rhythm, heart sounds
-intake and output
-anxiety level
-electrolytes, ABGs, oxygenation
& educate the family - nursing interventions post MI
-
-analgesics
-nitroglycerin
-thrombolic therapy (TPA, Streptokinase)
-PTCA or stents, or arthrectomy
-surgery - CABG, Laser, pacemaker, AICD impant(defibrillator) - medical treatment for MI
- what is lopressor?
- beta blocker
- tension of blood against arterial walls
- blood pressure
- cardiac output - the push of blood out of the heart to the blood vessels
- systolic blood pressure
- peripheral resistance to the flow of blood when heart is in rest and refilling
- diastolic blood pressure
-
-SNS activity (fight or flight)
-circulating epinephrine/norepinephrine
-Renin-Angiotensin-Aldosterone
-Peptides from atrial and smooth muscle cells
-hormones - ADH, vasopressin, pregnancy
-arterio, atherosclerosis - physiological mechanisms of blood pressure regulation
-
BP is consistently elevated above 140/90 mmHg
New guidelines - over 120 systolic
same risk factors as for CAD - hypertension
-
stress
obesity
use of salt *
low Ca, K, Mg *
sedentary lifestyle
glucose intolerance *
excessive alcohol use * - modifiable risk factors for HTN
-
family history
age
ethnicity
gender - nonmodifiable risk factors for HTN
-
often asymptomatic
no diagnostic tests other than BP cuff
headache in back of head, neck, nocturia, confusion, nausea, vomiting
examination of retina - manifestations of HTN
-
-teach modifiable risk factors
-screen in the community
-usual to have NO symptoms
-exercise
-stop smoking
-lose weight
-restrict alcohol, caffeine - nursing care for HTN
-
BP is so high, pt at risk for stroke
systolic:240, diastolic:130
pregnancy, drug abuse - main causes
constant BP monitoring, gradually decrease BP
use of IV push meds or drip meds, call titrating meds
monitor renal function-BUN, - hypertensive crisis
-
education
monitor patient for compliance
teach importance of taking meds, following diet, exercise, stress reduction
side effect of meds - impotence or lack of energy and sex drive, depression; makes people feel bad so they stop taking med - nursing responsibilities for hypertension
- a metabolic disorder; hyperglycemia because of either a lack of insulin or cellular resistance to insulin
- diabetes mellitus
- high blood glucose
- above 120
-
-high blood glucose
-high levels of glucose in urine
-frequent urination (polyuria)
-frequent thirst (polydipsia) - signs and symptoms of hyperglycemia
- what is the impact of diabetes on health?
-
-6th leading cause of death due to CV damage resulting in ASHD, CAD, CVA
-leading cause of end-stage renal failure
-blindness
-amputation - incidence and prevalence of diabetes
-
15.7 million (10.3 diagnosed, 5.4 undiagnosed)
increase in Type 2 in native american, hispanic
11% of people 65-74 have DM -
beta cells of pancreas don't produce insulin; autoimmune disease where beta cells get destroyed
-genetic
-viral infection trigger
-chemical toxin trigger - Diabetes Type 1
- high blood glucose despite availability of insulin; body is getting insulin but not enough to lower glucose levels; resistance to insulin caused by obesity, inactivity, illness, agen, medications
- Type 2 Diabetes
-
family history
obesity (especially upper body)
inactivity
race/ethnic group - AA, AI, Hispanic
gestational DM
polycystic ovary syndrome
woman who delivered baby with birth weight over 9 lbs. - risk factors for diabetes type 2
-
hyperglycemia
polyuria
polydipsia
blurred vision
fatigue
parasthesia
skin infections - symptoms
-
-symptoms
-casual plasma glucose greater than 200 mg/dl
-fasting plasma glucose >126 mg/dl (norm=110)
-2 hr. plasma glucose >200 mg/dl
-glycosylated hemoglobin(A1C)-determines average blood sugar over past 2-3 months; >7-9% i - diagnosing DM2
- results from breakdown of fat, overproduction of ketones by the liver, loss of bicarbonate; occurs in undiagnosed Type 1 or in Type 2 if treatment is not effective or body is under stress causing increase energy needs by the body
- diabetic ketoacidosis (DKA)
-
"fruity" breath
nausea and vomiting
dry mouth - symptoms of diabetic ketoacidosis
-
this test:
-reflects blood sugard for past 120 days
-5% of all Hb is glycated (normal)
-range from normal to high as 25% if DM in badly out of control
-should be measured at least 2x a year - glycated hemoglobin (A1C)
- why do you do fluid replacement slowly, when treating diabetic ketoacidosis?
- because putting patient into hypoglycemia too quickly can result in fatal cerebral edema
-
-fluid replacement (9% normal saline): when blood sugar is down to 250 mg/dl some dextrose is added to IV
-regular insulin IV or SC
-K replacement (in IV) 3.5-5 is normal (alteration in K could cause heart attack)
-monitor blood glucose fr - treatment for diabetic ketoacidosis
-
a serious, life-threatening medical emergency, has a higher mortality rate than DKA.
-precipitating factors: infection, therapeutic agents, therpeutic procedures, chronic illness
-pathophysiology: brain cell shrinkage - hyperosmolar hyperglycemic state
-
-altered level of consciousness (lethargy to coma)
-neurological deficits (hyperthermia, motor or sensory impairments, seizures)
-dehydration (extreme thirst, dry skin & mucous membranes) - symptoms of hyperosmolar hyperglycemic state
-
-lower blood sugar levels
-replace fluids & electrolyte
-treat underlying conditions - treatment of hyperosmolar hyperglycemic state
- formation of glucose from lipids in adipose & liver tissue
-
gluconeogenesis
*initiated when BS < 70 mg/dl - renal threshold for glucose 180 mg/dl above which glucose will be excreted in urine.
- glucosuria
-
if you had a patient with:
BS>250mg/dl
plasma pH<7.3
bicarbonate<15 mEq/L
serum ketones
urine ketones
abnormal Na, Cl, K
what is the condition - Diabetic Ketoacidosis
-
if you had a patient with:
BS >600 mg/dl
plasma osmolarity >340 MOsm/L
altered consciousness
high Na in serum
severe dehydration
what is the condition? -
Hyperosmolar Hyperglycemic State (HHS)
*precipitated by illness, infection, therapeutic agents. - what are complications of diabetes?
-
1.BS alterations (hyper or hypo)
2.macrocirculation problems-atherosclerosis
3.microcirculation problems-basement membrane of small blood vessels (eyes, kidneys) - what is the goal of diabetes treatment?
-
1.manage BS (<60-120 range most of the time) using meds, diet, exercise
2.lower risk factors for condition
3.routine screening for complications
4.implementing early Tx
5.Insulin -
1.rapid acting
onset 0.25h, peak-1-1.5h,duration 3-4h
2.short acting
onset 0.5-1h, peak 2-3h, duration 4-6h
3.intermediate acting
onset 2h, peak 6-8h, duration 12-16h
4.long acting
onset 2h, peak 16-20h, duration 24+h < - insulin preparations
- listpro is an example of what kind of insulin preparation?
- rapid acting
- ultralente is an example of what type of insulin preparation?
- long acting
-
1.monitor glucose 4x a day
2.test urine for ketones if BS>240
3.continue insulin or oral hypoglycemic
4.sip 8-12 oz. of fluid hourly
5.substitute easily digested food/liquid with carb. equivalents if unable to take solid food
- diabetes sick day management
- low blood sugar or "insulin reaction"
- hypoglycemia
-
shaky
dizzy
clumsy, jerky
sweating
hunger
headache
mood changes
confusion
seizure -
symptoms of hypoglycemic (insulin reaction)
*sometimes there are no symptoms in people who had DM for years from neuropathy -
-0.5 c.juice (followed by a normal meal)
-hard candy
-glucose tablets
-IV of dextrose
-glucagon -
Tx for hypoglycemia - Sugar
*educated family members - indicators of tight diabetes control
-
BS 90-130 mg/dl
post parandial BS (after eating) <180
A1C <7% -
decrease sys BP
increased HR
weak pulse
flat jugular vein
no edema
poor skin turgor
low urine output
high urine SpG
weight loss
normal respirations - Fluid Imbalance: Deficit
-
increased BP
increased HR
strong or bounding pulse
distended jugular vein
dependent edema
taut skin turgor
urine output may be low or normal
low urine Sp G
weight gain
resp: moist crackles, wheezes - Fluid Imbalance: Excess
-
Dx:
Deficit Fluid Volume
Decreased Cardiac Output - diagnoses with fluid deficit
- what are the commonly administered IV fluids for fluid deficit?
-
dextrose in water solutions (D5W)
saline solutions
combined
multiple electrolyte solutions (ringers) -
Excess Fluid Volume
Impaired Gas Exchange
Activity Intolerance - dizgnoses for Fluid Volume excess
- 3 categories of diuretics
-
loop
thiazide and thiazide-like
potassium-sparing - what are diuretics used for
- Diuretics are used to enhance renal function and to treat vascular fluid overload and edema.
- what are common side effects of diuretics?
- Common side effects: orthostatic hypotension, dehydration, electrolyte imbalance, and possible hyperglycemia.
-
Risk for impaired fluid volume
Fatigue
Risk for injury
Risk for impaired oral mucous membrane - dx with sodium imbalance
- hyponatremia and hypernatremia may lead to
- seizures
- what to do for possibility of seizures with hyponatremia and hypernatremia
-
start and IV
raise bed rails and pad bed -
Decreased Cardiac Output
Activity Intolerance
Risk for Ineffective Health Maintenance - Dx with potassium imbalance
-
Major symptom: leg cramps
(calcium too)
give K enema, IV (never IV push - cause heart attack), oral - potassium imbalance: hypokalemia
- NEVER administer undiluted potassium into the vein
- NEVER administer undiluted potassium into the vein
-
Risk for injury
Decreased cardiac output
Disturbed thought processes
Risk for ineffective breathing pattern - Dx with Ca imbalance
- increased neuromuscular excitability, muscle twitching, spasms, and possible tetany
- hypocalcemia
-
decreased neuromuscular excitability, muscle weakness, and fatigue, cramps
*can also lead to kidney stones - hypercalcemia
- evaluated primarily by measuring arterial blood gases
- acid base balance
-
Decreased pH
Decreased HCO3
Decreased Paco2 - Metabolic acidosis
-
Increased pH
Increased HCO3
Increased Paco2 - Metabolic alkalosis
-
Decreased pH
Increased Paco2
Increased HCO3 - Respiratory acidosis
-
Increased pH
Decreased Paco2
Decreased HCO3 - Respiratory alkalosis
-
Decreased cardiac output
Risk for excess fluid volume
Risk for injury - Dx Client with Metabolic Acidosis
-
Anorexia
Nausea and vomiting
Abdominal pain
Weakness
Fatique
General malaise
Decreased levels of consciousness
Dysrhythmias
Bradycardia
Warm, flushed skin
Hyperventilation - Manifestations of Metabolic Acidosis
-
Risk for impaired gas exchange
Deficient fluid volume
More confusion, decreased level of consciousness - Dx Client with Metabolic Alkalosis
-
Confusion
Decreased levels of consciousness
Hyperreflexia
Tetany
Dysrhythmias
Hypotension
Seizures
Respiratory failure - Manifestations of Metabolic Alkalosis
-
Impaired Gas Exchange
Ineffective airway clearance - Dx Client with Respiratory Acidosis
-
Headache
Warm, flushed skin
Blurred vision
Irritability, altered mental status
Decreasing levels of consciousness
Cardiac arrest - Manifestations of Acute Respiratory Acidosis
-
Weakness
Dull headache
Sleep disturbances with daytime sleepiness
Impaired memory
Personality changes - Manifestations of Chronic Respiratory Acidosis
-
Ineffective breathing pattern
Risk for injury - Dx Client with Respiratory Alkalosis
-
Dizziness
Numbness/tingling around mouth, of hands and feet
Palpitations
Dyspnea
Chest tightness
Anxiety/panic
Tremors
Tetany
Seizures, loss of consciousness - Manifestations of Respiratory Alkalosis
- Because of this, there is no such thing as “only diarrhea†or “simple diarrhea†in a child younger than 1 year.
- Because kids can get into metabolic acidosis when they have diarrhea
- In children, Vomiting can lead to
- metabolic alkalosis
- In children, Diarrhea can lead to
- metabolic acidosis
- signs of dehydration
- dry skin, depressed fontanelles, depressed eye globes, no tearing, increased hematocrit (resulting from less subcutaneous fluid)
- With Surgery: Depending on the degree of dehydration and/or type of electrolyte imbalance, cardiac dysrhythmia or heart failure may occur.
- Liver and renal failure may also result Administer IV fluids as ordered. Monitor I&O. Monitor client for evidence of electrolyte imbalance
-
thirst
warm, dry skin with poor turgor
soft eyeballs - sunken w/blackish ribs
dry mucous membranes
weakness
malaise
rapid, weak pulse
hypotension - Dehydration in Diabetes
- children need increased fluid to keep airway secretions moist after this event
- an asthma attack
- Why do CF kids need to be supervised during outside play
- to guard against overexertion or heat exposure; they lose excessive sodium and chloride through perspiration
- metabolic disturbances, such as diabetes, dehydration, severe hemorrhage, or drug ingestion also must be considered as possible causes of
- Coma in children
- If a patient is on TPN, which can be a problem?
- dehydration
-
Pain: Heartburn
Imbalanced nutrition: Less than body requirements
Ineffective Health Maintenance - Dx Client with GERD
-
Heartburn
Regurgitation
Pain after eating
Dysphagia - difficulty swallowing
Chest pain
Belching
**Eat small, frequent meals to help alleviate some of these manifestations - Manifestations of GERD
-
a neuromuscular disturbance in which the cardiac sphincter is lax, allowing for easy regurgitation of gastric contents into the esophagus.
It is treated by feeding a thickened formula and keeping the infant upright after feedings. - GERD (achalasia) in infants
- a condition in which the intestinal mucosa ineffectively absorbs nutrients including carbohydrates, proteins, fats, water, electrolytes, minerals, and vitamins resulting in their excretion in stool. Multiple different bowel disorders can lead to malabsor
- malabsorption
-
Imbalanced nutrition: less than body requirements
Diarrhea
Knowledge deficit - Dx client with Malabsorption syndrome
-
Pathogens usually enter the urinary tract by ascending from the mucous membranes of the perineal area into the lower urinary tract
Bacteria that have colonized the urethra, vagina, or perineal tissues are the usual source of infection - UTI
- inflammation of the urethra
- Urethritis
- inflammation of the prostate gland
- ostatitis
- inflammation of the urinary bladder
- cystitis
- inflammation of the kidney and renal pelvis
- Pyelonephritis
- More severe symptoms - very sick: fever, vomiting, hematuria - be hospitalized, need antibiotics
- pyelonephritis
-
Short, straight urethra
Proximity of urinary meatus to vagina and anus
Sexual intercourse
Use of diaphragm and spermicidal compounds for birth control - hold bacteria
Pregnancy - risk factors for UTI in female
-
Uncircumcised
Prostatic hypertrophy
Rectal intercourse - risk factors for UTI in male
-
Aging
Urinary tract obstruction
Neurogenic bladder dysfunction - paralysis
Vesicoureteral reflux - urine backs up into kidneys
Genetic factors
Catheterization (if a lot of residue in bladder, and if pt couldn’t pee) - risk factors for UT (female & male)
- the most common infection but also the leading cause of bacteremia and sepsis in older adults.
- UTI
- Factors that contribute to UTI include: poor hygiene, incomplete bladder emptying, inadequate fluid intake, and long-term indwelling catheters. In addition, chronic conditions and medications
- factors that contributed to UTI
-
Pain
Impaired urinary elimination
Ineffective Health Maintenance - Dx for client with UTI
- pain, burning, feel like you have to pee all the time, fever, vomiting, fatigue
- symtpoms of UTI
-
Dysuria (painful/difficult urination)
Frequency
Urgency
Nocturia (voiding two or more times a night)
Pyuria (foul odor/cloudy)
Hematuria (bloody)
Suprapubic discomfort, back pain - Manifestations of Cystitis
-
Urinary
Urinary frequency
Dysuria
Pyuria
Hematuria
Flank pain
Costovertebral tenderness - Manifestations of Acute Pyelonephritis
-
Systemic
Vomiting
Diarrhea
Acute fever
Shaking chills
Malaise - Dx Manifestations of Acute Pyelonephritis
-
Intravenous Pyelography (IVP): evaluates the structure and excretory function of the kidneys, ureters, and bladder
**assess for allergies to seafood or iodine (for the dyes)
Voiding Cystourethrography: can detect structural or functional abnorm - Dx tests for UTI
- Vesicoureteral reflux is the backflow of urine into ureters; It occurs because the valve that guards the entrance to the ureters is defective.
-
children with UTI
*this may require surgery to correct -
Adequate hydration
Urinate at least every 4 hours
Avoid bubble bath
Females should wipe from front to back
Wear cotton underwear
Females should wash vulva area at least daily
Sanitary pads should be changed at least every 4 - prevention of UTI
- Compliance w/med - how do you know if pt is complaint?
- count pills
- What do you do if NPO for BP med
- call physician
- PTT - Partial Thromboplastin Time
- 25-35 seconds is normal
- sodium
- 135-145 mEq/L is normal
- potassium
- 3.5 - 5.1 mEq/L is normal
- chloride
- 95-105 mEq/L is normal
- Calcium
- 4.5 - 5.5 mEq/L is normal
- Magnesium
- 1.5 - 2.5 mEq/L is normal
- Fasting Blood Sugar
- 70-110 mg/dl is normal
- White Blood Cells
- 5000 - 10000 per mcL is normal
- Neutrophils
- 1935 - 7942 abosulte count is normal
- Red Blood Cells
- 4.5 - 5.3 million is normal
- Hemoglobin
-
13.0 - 18.0 g/100mL (men)
12 - 16 g/100mL (women) - BUN Blood urea nitrogen
- 5 - 25 mg/dl
- serum creatinine
- 0.5 - 1.5 mg/dl
- Hematocrit
-
37-49% (men)
36-46% (women) - Platelet
- 150,000 - 400,000 /mcL (or mm3)
- ECG - P wave
- depolarization of atriua (diastole)
- ECG QRS complex
- depolarization of ventricles (systole)
- ECG QT interval
- time from ventricular depolarization until ventricles begin to repolarize