Complex EXAM FINAL

Cervical spinal cord injuries

• alteration in bowel sounds

  • absent or diminished

• hypotension

• coughing, drooling, gag reflex may be altered

• I and O

Hyperkalemia

• hyperkalemic pt, receiving insulin therapy

  • monitor for hypoglycemia

• blood glucose usually 70-100 normal range

  • Hyperkalemia EKG findings

    • tall, tented T-waves

Hypokalemia

• inverted T waves, U waves on EKG

spironolactone

• potassium sparring diuretic

  • put a HF patient at risk for hyperkalemia and hyponatremia

Hyponatremia

• pt with SIADH, manifestations of hypokalemia

  • headache

  • tremors

  • muscle cramps

  • depressed reflexes

  • sodium below 115, likely respiratory failure

  • N/V

  • low urinary output

  • low appetite

hypomagnesemia

• pt presentation

  • confusion

  • muscle weakeness

  • cardiac dysrhythmias

Medication for hypomagnesemia

• Mag Sulfate IV piggyback, continuously monitor cardiac rhythms

• V fib needs Defib

• EKG findings:

  • very wide QRS complex, unresponsive and pulseless, what do you do

    • defib, then call ACLS

Sinus bradycardia

• symptomatic:

  • dizziness and hypotension

• Nursing Interventions

  • first, atropine

  • still unstable, transcutaneous pacing

Adenosine

• Given for SVT and other arrhythmias, slows AV node conduction

• asystole will be seen before rhythm correction

Dehydration

• Urine osmolarity range ( 50-1200)

• Normal specific gravity range ( 1.010-1.025)

• Osmolarity is high, urine is more concentrated

• specific gravity high, urine more concentration

Hypovolemia

• pt presentation

  • tachycardia

  • hypotensive

  • decreased urinary output

  • decreased cap refill

  • confusion

Hypovolemic shock after MVA

• tachycardia

• pulse pressure narrowing

• diminished DTR’s

• pulse ox below 95%

• blood for hypovolemic shock: packed RBC’s

Septic Shock

• Q: pt has fever, hypotensive and tachycardia, o2 sat is low, after o2, give what?

  • A: IV fluids to improve BP and tissue perfusion

Interventions for Septic Shock

• wound cultures

• antipyretics

• IV antibiotics

• pain management

Neurogenic Shock

• Guillain-Barré puts pt at higher risk for neurogenic shock

  • Other manifestations:

    • hypotension

    • bradycardia

    • hypothermic

Guillian Barre Syndrome

• autonomic nervous system disorder

• dysautonomia puts pt at higher risk for neurogenic shock

Stages of shock

• Initial

• compensatory

• progressive

• refractory

compensatory stage

• blood pressure still normal

• only slight increase in heart rate

• only slight increase in diastolic blood pressure

• watch for hyperkalemia

Refractory stage

• MAP decreased by 10-15 or more

• no longer compensating

  • hypotension

  • bradycardia

  • probably unresponsive

  • organ failure

  • treatments no effective

Congestive heart failure

• Interventions:

  • monitor urinary output and blood pressure

  • elevate head of bed

  • low sodium diet

  • BNP levels

Findings of CHF

• elevated BP, pulse, and respirations

• CXR shows heart enlarged, fluid accumulation in lungs

Blood Transfusion

• hemolytic reaction findings

  • febrile

  • chills

  • blood in urine

Burns

• pt with severe burns, on IV fluid therapy, signs of improvement

  • heart rate will decrease as fluid volume is replaced

Burn complication

• paralytic ileus

• fluid imbalance

• infection

Intervention for Burns on chest

• airway

• fluid resus

• Foley cath

• pain

Chest Tubes

• A closed drainage system after a thoracotomy, bubbling should be present in the suction control chamber

Trach Care

• while suctioning, pt HR become irregular

  • hyperoxygenate with 100% o2

  • preoxygenate next times

Long bone fracture complications

• fat embolism

  • sudden shortness of breath and chest pain

  • provide high flow o2, ventilate if not effective

Flail Chest

• pt reporting dyspnea, severe pain

• chest moves inward inspiration, outward during expiration ( flail chest)

• 3 or more rib fractures in different places

Warfarin

• PT, INR monitoring

Pulmonary Embolism

• Heparin therapy

• Heparin antidote is protamine sulfate

Pneumothorax

• after a thoracentesis, pt has decreased lung sounds and is tachycardic

  • subcutaneous emphysema ( crepitus) means a persistent air leak caused by a tear in the pleura

  • feels like a rice krispies

Diabetes Insipidus

• lower ADH in body, is not reseptive to insulin therapy any longer

• normal in older and dehydrated patients

Manifestations of Diabetes Insipidus

• dehydration

• polydipsia

• polyuria

• hypotension

• very diluted urine

Radiation therapy

• patient will be fatigued

• don’t share bathrooms

• stay 6 feet away from everyone

• stay away from the elderly, pregnant, and children

Chemotherapy

• pt nauseous and vomiting

  • dehydration

  • metabolic alkalosis

  • electrolyte imbalances

Pt unresponsive and pulseless

— CPR, then administer IV EPI

HHS

• seizure activity

  • dehydration

• HHS Indicator

• normal range for plasma osmolarity 275-295

• HHS osmolarity: will be 320+

DKA

What to assess for in a t1d patient with 550 blood glucose to evaluate for DKA

• altered mental status

• N/V

• Kussmaul respirations

• electrolyte imbalances

DKA nursing interventions

• fluids: 15-20 ml/kg/hr for the first hour, then adjust

• NS bolus

Mannitol Therapy

• monitor for electrolytes and fluid imbalances

CVA

-= pt in rehab after stroke, what is a realistic goal

• regain function for ADLs

• educate the patient that may not ever recover to how they were prior to the stroke

• pt in LTC post CVA, what to tell CNA to focus on?

  • passive ROM

  • repositioning

  • monitor for pressure ulcers

MI

• Nursing Interventions:

  • first priority: oxygen

  • second: 12 lead EKG

  • IV access, blood sample

Labs for MI

• troponin measures cardiac injury and increases very quickly

• Other cardiac enzymes are more delayed in responding

• also, CPK, myoglobin

Dilated Cardiomyopathy

• excessive stretching of the heart muscle, specifically the ventricles

• your ventricles are stretching excessively, weakening the muscle and its ability contact

Cardiogenic Shock

• pt presentation:

  • cool clammy skin

  • weak peripheral pulses

  • altered mental status ( indicative or poor perfusion)

Cardiac Tamponade

• fluid in pericardial space, ventricles cannot adequately fill

• becks triad:

  • JVD

  • Muffled heart sounds

  • hypotensive

Anemias

• sickle cell:

  • crescent shape blood cells cause them to stick together and cause pain

• Which factor stimulates production of RBC’s

  • Erythropoetin is produced in the kidneys

Croup-contrecoup

• monitor for increased ICP

• monitor for seizures

• priority: neuro assessment

Hypocalcemia

pt presentation:

• tetany

• seizure risk

• extreme muscle weakness

Hypocalcemia signs

• posiCtive trousseau’s

• positive chvostek’s

ABG’s ranges

• CO2: 35-45

• HCO3: 22-26

• PaCO2: 80-100

• pH: 7.35-7.45

Cardiac Rhythms to defibrillate

• V-fib

• V-tach pulseless

Signs of SIADH

• fluid overload

• hypertension

• tachycardia

• hyponatremia

• confusion : brain tissue swelling due to overload of water

pt presentation of hypercalcemia

• groans: nausea, vomiting, abdominal pain

• Bones: bone pain, osteoporosis

• Stones: kidney stones

• Moans: fatigue and malaise

• Thrones: polydipsia, polyuria, constipation

• Psychotic overtones: confusion, lethargy, depression