Exam 1

normal BP

normal BP

< 120 and < 80

elevated BP

120-129 or <80

stage 1 HTN

130-139 and 80-89

stage 2 HTN

≥ 140 and ≥ 90

determining BP stage

go with the higher number

modifiable risk factors for HTN

• Diet 

  • Salt 

  • High sodium 

  • Processed foods 

• Smoking 

• Alcohol

non-modifiable risk factors for HTN

• Age 

• Genetics 

• Family history 

• Race 

secondary HTN

• Results from another disease 

  • kidney disease

• Side effects of medications 

  • Steroids 

  • Immunosuppressants 

complications of HTN

• Prevent end stage organ damage 

• Renal failure 

HTN treatment

• Lifestyle modifications 

  • 2300mg of Na 

  • AHA - < 1500 

  • Average intake is 3900 

  • Exercise 150 mins/week 

  • BP goals <130/80 if they are HTN 

  • Lose weight 

  • Eat fruits and veggies 

  • moderate ETOH intake

• DASH diet 

  • High in grains and fruits 

  • Low in fat 

first line treatments

• Thiazide –type diuretics 

  • do not give with kidney disease

• Calcium Channel Blockers 

  • Limit rate at which Ca flows into arterial walls 

  • Relaxes and widens vessels 

• Angiotensin-converting enzyme (ACE) Inhibitors 

  • Interfere with renin-angiotensin mechanism 

  • Reduce ace activity 

• Angiotensin Receptor Blockers (ARBs) 

  • Block action of angiotensin on vessels and other tissues 

  • never give ACE and ARBs together

• beta-blockers

  • given with heart disease

treatments for different stages

• Stage 1 hypertension 

  • Single antihypertensive drug 

  • Blood pressure goal of <130/80 

• Stage 2 hypertension 

  • Combination of 2 first-line antihypertensive drugs with an average BP more than 20/10 mm Hg above the BP target 

malignant HTN

• Sx = blurred vision, headache, confusion 

  • Or may have NO symptoms 

• Requires immediate treatment 

  • Target BP <160/<100 short term 

  • Mean arterial pressure should not be lowered more than 10% -20 % first hour 

  • Then approximately 25% during next 23 hours 

  • Want to take it down slowly to avoid causing ischemia 

side effects of HTN meds

• All cause fatigue 

• ACE 

  • Cough (chronic and dry) 

• Beta blockers 

  • ED 

malignant HTN basics

Adverse outcomes 

• Cerebral edema 

• Retinal hemorrhage 

• Acute renal damage 

Causes 

• Unknown 

• Pt. abruptly discontinues meds 

• Preeclampsia of pregnancy 

Therapy = medications immediate actions 

• Medications may include: 

  • Nitrates 

  • Clonidine 

  • Captopril 

  • Furosemide (Patients that are fluid overloaded) 

• Monitor BP q 5-30 minutes 

• Bedrest, quiet environment 

pre op teaching

Better post op outcomes with teaching

• IS

• cough/deep breath

• pain management

• post-op drains

• compression devices

mobility exercises

• foot

• leg

why mobility

• prevent Constipation 

• Increase circulation 

• improve Respiratory status 

• prevent DVT 

NPO

• No gum 

• No hard candy 

NPO guidelines

• Fasting Period for healthy patients of all ages undergoing

  elective surgery (not including women in labor)

• Clear liquids-2 hours (e.g. water, fruit juices without pulp,

  carbonated beverages, clear tea, and black coffee)

• Breast milk-4 hours

• Infant formula-6 hours

• Nonhuman milk-6 hours (amount needs to be considered)

• Light meal-6 hours (e.g. toast and clear liquids)

• Meals that include fried, fatty food, meats-8 hours

• Guidelines does not guarantee complete gastric emptying

emergent

• Life or death situation 

• Level 1 trauma needs to have an OR ready to go with staff  

• Severe bleeding, trauma, gunshot wounds, subdural hematomas 

urgent

• Needs prompt attention 

• 24-30 hours until surgery becomes emergent 

• Acute cholecystitis (inflamed gallbladder), Fractures, abscesses 

elective

• Patient should have surgery but failure to would not have dire consequences 

• Cysts, hernia repair 

required

• Needs the surgery but can be done in weeks and months 

• Needs it done before it can cause extreme health issues 

• Prostate hyperplasia, breast mass, thyroid disorders 

optional

cosmetic

pain management

• Teaching pain communication skills preoperatively results in greater pain relief 

• Explain use of pain scale preoperatively 

• Instruct patient to ask for pain medication as frequently as needed for pain relief 

• Very subjective 

• Cannot compare two patient's pain 

• Ask what an acceptable pain level 

PCA pump

• Patient controlled analgesia 

• Self-medicate 

• How much it can give them in a single dose, over a specific time frame 

• Need to monitor respiratory status 

• Administer Narcan to reverse 

• Patient needs to be cognitively intact enough to give themselves their pain meds 

preop holding area

• Upon arrival to holding area, patient checked in by preop holding area nurse

• Two identifiers used to identify patient

• Verification of

  • correct person

  • correct site

  • correct procedure

joint commission

• Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery

• Requirements

  • Pre-procedure verification

  • Mark the Procedure Site

  • Time Out

  • 2004- Pennsylvania Patient Safety Authority initiated mandatory wrong-site surgery reporting

PACU assessment

• ABC, LOC, Vital Signs 

• Drains, Dressings 

• Fluids, Pain, Nausea 

• Assessing the patient 

• Maintaining a Patent Airway 

• Maintaining Cardiovascular Stability 

• Pain Relief

• Stable vital signs, pain controlled 

• Other dependent on type of surgery 

neuro assessment

• Monitor the patient’s neurological status 

• Observe for ability to maintain airway 

• Patient may be sedated but should be easy to arouse by verbal stimuli 

• Check patient’s orientation level (person, place, time) 

time out

• Prior the starting the procedure 

• Standardized throughout the hospital

• Initiated by a designated member of the team. 

• Involves all the immediate members of the procedure team. 

• Involves interactive verbal between all team members 

• Any team member can express concerns about procedure verification 

• It has a defined process for reconciling differences in response. 

• During the time-out all other activities are suspended

CV assessment

• Monitor heart rate and regularity. 

• Monitor Blood pressure 

• Can be affected by 

  • Pain 

  • Anesthesia 

respiratory assessment

• Observe patients' ability to maintain airway 

• Observe patient’s respiratory rate and depth 

• Monitor oxygen saturations with pulse oximeter 

O2 delivery systems

• Nasal cannula 

  • 2L = 20% 

  • 2-6L 

  • Higher concentrations need to be humidified 

• Can dry out lung secretions, and airway 

• Face mask 

  • 40-60% at 5-8L 

  • Need at least 5L so they do not re-inhale their CO2 

  • Switch to aerosol face mask 

• Nonrebreather 

  • Last ditch effort before intubation and CPAP 

  • At least 10L 

atelectasis

• Part of lung becomes airless and collapses. 

• Causes 

  • Patients are not taking deep breaths 

  • Respiratory depression from pot op opioids 

  • Pt not moving 

• Symptoms 

  • Decreased breath sounds 

  • Decreased sats 

  • Anxious 

  • No pain 

• Treatment 

  • Get them up and moving 

  • Deep breathing exercises 

  • IS 

pneumonia

3^rd most common post op infection 

• Cause 

  • Microbial infection 

• Symptoms 

  • Increase in WBC 

  • Fever 

  • Chills 

  • Chest pain on inspiration 

  • Decreased breath sounds 

  • Decreased sats 

hyperthermia

• Cause 

  • Early – body inflammatory response to surgery 

  • Will resolve in 2-3 days 

• Serious complications 

  • UTI 

  • Pneumonia 

  • Surgical site infection 

  • Intervascular catheters 

  • thrombitis 

pain

• Have to know patients pain level 

• Increase HR and BP 

DVT

Symptoms 

• Circumference will be bigger 

• Pain 

• Redness 

• Warm 

• Tenderness  

Nurse Interventions 

• Stop SCDs 

• Have pt remain in bed 

• Call MD for doppler studies 

• assess lungs

prevent clotting

• Low molecular weight 

  • Enoxaparin (lovenox) 

• Unfractionated heparin 

• SCDs 

• Compression garments 

• Ambulation 

first intention

• surgical site

second intention

• Seen with abscess 

• Pressure ulcer 

third intention

• Delayed closing 

• Granulation starts and then closure 

dehiscence

• Incision opens up 

• RF 

• Obesity 

• Poor nutrition 

• Diabetes 

• Old adults 

• Steroids 

Interventions 

• Let physician know 

• Not emergent unless wide open 

• Monitor for expansion 

• Monitor for infection 

• Use binder for abdominal support if abdominal 

evisceration

• Emergent 

• Organs come through incision 

Intervention 

• Notify MD immediately 

• Sterile saline and sterile gauze 

• Soaked in NS 

• Put dry dressing over sterile gauze  

• Make sure they have patent IV 

• Low fowlers if abdominal (knees up) 

surgical infections

• Teach pts what to look for 

• Can educate while monitoring incision 

• Approximated well 

• Its closed 

Signs and symptoms 

• Increase WBC 

• Purulent discharge 

• Fever 

• Warm 

• Red 

• Swelling 

• Odor 

surgical dressings

• First dressing is done by surgical team 

• Post first change will be the nurse 

• Sterile technique 

  • Protect incision site 

  • Absorb drainage 

• Physical and mental comfort for pt 

• Document amount of drainage 

  • Color of drainage 

  • Signs of infection 

  • Dehiscence 

  • Odor

fluid volume deficit

• Loss > 500 need blood or surgery 

• Causes 

  • N/V 

  • NG tube 

  • Decrease in vascular volume 

• interventions

  • Lower HOB, then vitals, Increase perfusion

  • Then call MD

    • And ask for fluids

      • Oral replacements are preferred

      • May need IV fluids (isotonic in vascular space)

  • Hgb 7 or below – give blood

  • Teach about sitting on edge of bed and go slow when OOB

  • Monitor BUN, Cr, electrolytes, hct, Hypokalemia, hyponatremia, Urine output

  • Good IV access

urinary retention

• 240mL in 8 hours 

• May occur due to: 

  • Anesthetics, anticholinergic drugs, opioids 

  • Pain 

  • Difficulty in using bedpan or urinal 

  • Can be mental 

• How to know its retention not deficit 

  • Bladder scan 

  • Do not need doctor's order 

  • More than 400mL ask MD for a straight cath 

• Nursing Interventions 

  • Bladder scan 

  • Straight cath 

constipation

• Manipulation of abdominal organs may cause loss of normal peristalsis for 24-48 hours 

• Anesthesia and opioids decrease peristalsis 

• Immobility decreases peristalsis 

• Can have paralytic ileus with liquid stool

• Interventions 

  • Encourage fluids 

  • Eary ambulation 

  • Stool softeners 

  • Notify MD if BS are present but no BM 

sodium

• Normal range: 135- 145 mEq/L 

• Recommended daily intake: 

• CDC dietary guidelines < 2300

  • American Heart Association < 1500mg 

  • 1 tsp is 2300mg 

hyponatremia

Results in 

• Swelling of cells 

• Cells have higher concentration of sodium than vascular space 

Depletional (Excess sodium loss) 

• Kidney disease 

• Adrenal insufficiency 

• Diuretics 

• N/V 

• GI suction 

• Repeated tap water enemas 

• Excessive sweating 

Dilutional (Excess water gain) 

• HF 

• Liver disease 

• Hypotonic IV fluids 

• Self-induced water intoxication 

hypernatremia

Causes 

• Water deprivation 

• Elderly 

• Babies 

• Neurological disorders 

  • Stroke 

• Water loss 

• Fever 

• Burns 

• Diarrhea 

• Osmotic diuresis 

• Excessive intake 

Results in 

• Solute inside the cell is lower than the vascular space 

• Water leaves the cell and cell shrinks

hypernatremia assessment, treatment and promotion

Health History 

• Duration of sx 

• Precipitating factors 

Physical assessment 

• Neuro assessment 

• vitals 

Treatment  

• Water 

• Hypotonic solution 

• D5 and ½ NS 

• BP checks 

• Neuro status check 

• Monitor labs 

• Oral care 

Health promotion/patient education 

• Need to offer fluids on regular intervals 

• What foods are high in sodium 

• Canned, frozen, lunch meat, pickles, ketchup, processed 

• If on tube feeds 

  • Ordered free water flush 

hyponatremia assessment, treatment, and promotion

Assessment 

• Current symptoms 

• Duration of sx 

• Precipitating factors 

• Neuro status 

• VS 

• Pulses 

• Edema 

• Daily weight 

  • 2.2 lbs for every 1L 

Treatment: 

• Depletional 

  • Isotonic IV fluids 

  • NS, lactated ringers 

  • If 110-150 then 3% sodium chloride 

  • Can end up with central pontine myelinolysis 

• Dilutional 

  • Diuretics 

  • Lasix (loop diuretic) 

  • Fluid restriction 

  • Sodium tablets 

Health Promotion/ Patient Education 

• Educate on signs and symptoms 

• Drink fluids with electrolytes during exercise 

hyponatremia sx

• Headache 

• Fatigue 

• Stupor 

• Tremors 

• Hyperreflexia 

• Coma 

• convulsions 

potassium

• Normal range: 3.5 – 5 mEq/L 

• Primary cation in intracellular fluid

hypokalemia

• Value: < 3.5 

• Results from 

  • Loop diuretics 

  • Bumex and furosemide 

  • NG tube 

  • Ileostomy 

    • High risk for hypokalemia and hyponatremia 

      • Liquid stool 

Signs and symptoms 

• Cardiac dysrhythmias  

  • Flattened t waves 

  • Prominent u wave 

  • Prolonged PR interval 

  • ST depression 

• Decreased CO 

• Digoxin 

  • Increased risk for dig toxicity 

• Muscle weakness 

• N/V 

• Decreased BS 

• Altered kidney function 

hypokalemia assessment, treatment, and promotion

Diagnostic Tests  

• EKG 

• Electrolytes 

• ABGs 

  • Increased pH 

• Renal  

  • BUN, Cr 

Assessment 

• VS 

• Pulses 

• Orthostatic Hypotension 

• Mental status 

• GI assessment 

• Musculoskeletal assessment 

Treatment 

• Call MD 

• Potassium supplement  

• Runs of K 

  • 10mEq/100mls/hr 

hyperkalemia

Value: > 5.0 

• Results from 

  • Chronic kidney disease 

  • Excessive intake 

Signs and Symptoms 

• Peaked T waves 

• Prolonged QRS 

• Can arrest 

• Numbness 

• Muscle tremors 

• Weakness 

• Abdominal cramping 

hyperkalemia treatment, asessment, and promotion

Assessment: 

• Health history 

• Symptoms and duration 

• Precipitating factors 

• GI assessment 

• CV assessment 

• Monitor reduced urine output 

• EKG 

• Check pulses 

• Labs - electrolytes 

Treatment: 

• Diuretics 

• Binding Agents 

• Veltessa (patiromer)

  • Binds potassium in exchange for calcium so it is passed out through feces

• Lokelma (sodium zirconium cyclosilicate)

  • Binds in exchange with H and Na and potassium is excreted

    • Not used in emergencies

• Insulin, hypertonic dextrose 

  • In emergencies 

    • D50 to counteract hypoglycemia 

• Albuterol 

  • Potassium shifts into cells 

  • Contraindicated in pts with acute MI and unstable angina 

    • causes tachycardia 

• Calcium Gluconate and Calcium Chloride 

  • For cardiac arrythmias 

• Dialysis 

Health Promotion/Patient Education 

• Pseudo hyperkalemia 

• If someone uses a needle too small, they can hemolyze the blood and gives false high K 

• Assess pt to see if it is false high or not 

calcium

• Normal Range: 8.5-10 mg/dL 

Function 

• Supports structure and function 

• Helps with muscle movement 

• Neuro transmission 

• Hormonal secretion 

• 99% is found in the bone 

hypercalcemia

• Level: > 10 mg/dL 

Results from: 

• Increased bone resorption 

• Hyperparathyroidism 

• Malignancies 

• inactivity 

Signs and Symptom 

• Muscle weakness 

• Anorexia 

• Fatigue 

• n/v 

• Neuro changes 

  • Confusion 

  • Lethargy 

• Ekg dysrhythmias 

• Increase urine output 

• Kidney stones 

hypercalcemia assessment, treatment, and promotion

Assessment 

• Excessive intake, immobility, malignancy, endocrine disorder 

• Symptoms and duration of symptoms 

• Precipitating factor 

• Vitals 

• Apical pulse 

• Mental status 

• GI 

• Muscle strain 

• Deep tendon reflexes 

Diagnostic Tests 

• PTH 

• Ekg 

  • Shortened QT 

  • Shortened ST 

  • Wide T waves 

  • Wide QR 

• Monitor bone density 

Treatment 

• Depends on severity 

• Low < 12  

• Moderate 12-14 

  • Increase food intake 

  • Weight bearing activity 

  • Medications 

• Moderate to severe 

  • IV 

  • IV fluids (2-3L) 

  • Loop diuretics 

Patient education 

• Encourage weight-bearing activities 

• Fluid intake 

• Limit intake of dietary and over the counter Calcium 

hypocalcemia

• Value: < 8.5 

Results from 

• Risk Factors 

  • Older adults 

  • Women 

  • Lactose intolerance 

  • Bariatric surgery 

  • trousseaus 

Signs and Symptoms 

• Numbness and tingling 

• Hyperactive reflexes 

• Tetany 

• Carpal pedal spasms 

• Bone pain 

• fractures 

hypocalcemia assessment, treatment, and promotion

Assessment

• Symptoms and duration of symptoms 

• Precipitating factor 

• Older adults 

• Removal of parathyroid 

• Lactose intolerance 

• Laryngeal spasm 

• Dysrhythmias 

• Seizures 

• Monitor vitals 

Signs and Symptoms: 

• Chvostek's Sign 

• Trousseau’s 

Diagnostic Tests: 

• Total serum calcium 

• Serum albumin 

• Corrected calcium (mg/dL) = measured total Ca (mg/dL) + 0.8 (4.0 - serum albumin [g/dL]) 

• Low serum albumin can cause false low Ca 

• Serum magnesium level 

• Serum phosphate level 

  • Would be high 

• Parathyroid hormone level 

• ECG 

Treatment 

• Oral or IV Ca 

• Vitamin D 

• Monitor vitals 

• Monitor airway 

Health Promotion/ Patient Education 

• Bone screening 

• Weight bearing exercise 

• Diet 

  • Supplements need full glass of water 1-1.5 hours PC 

phosphate

• Normal Range: 2.5 - 4.5 mg/dL 

• Function 

  • O2 delivery 

hyperphosphatemia

• Value: > 4.5 mg/dL 

Results from: 

• Heat stroke 

• Hyperthermia 

• Disruptions in Ca level 

• Kidney disease 

Signs and Symptoms 

• Same as signs and symptoms of hypocalcemia 

hyperphosphatemia treatment

Treatment 

• Monitor labs 

• Monitor airway 

• Neuromuscular status 

• Limit phosphate intake 

hypophosphatemia

• Value: < 2.5 mg/dL 

Results from: 

• Increase in renal secretions 

• Respiratory alkalosis 

• IV glucose 

• Antacids 

• Steroids 

• Diuretics 

Signs and Symptoms 

• Intentional tremor – on movement 

• Bleeding disorder 

• Impaired WBC 

• Decreases O2 

• RBC destruction 

• Decrease in O2 in heart muscle 

• Dysrhythmias 

• Chest pain 

hypophosphatemia treatment, assessment, and promotion

Treatment 

• Dietary oral supplements 

• IV phosphate if less than 1 

• Monitor electrolyte 

Health promotion/Patient Education 

• Avoiding phosphate binding antacids 

magnesium

• Normal Range: 1.8-2.5 mEq/L 

• Function 

  • Enzyme reactions 

  • Protein synthesis 

  • Muscular and CV function 

hypermagnesemia

• Value: >2.5 

• Results from: 

  • Renal failure 

  • OTC laxatives

Signs and Symptoms 

• Brady cardia 

• Heart block 

• Cardiac arrest 

• Decreased CNS 

• Lethargy 

• Weakness 

• Confusion 

• Reflexes are weak or absent 

• Respiratory depression 

• HTN 

• Dysrhythmias  

hypermagnesemia treatment and assessment

Treatment 

• Underlying cause 

  • Calcium gluconate – for cardiac effects 

  • Respiratory support 

  • Pacer 

Assessment

• Monitor vs 

• Monitor CV status 

• I&O 

• reflexes 

hypomagnesemia

• Value: < 1.8 mEq/L 

Results from: 

• Deficit in intake 

• Starvation 

• Alcoholism 

• Ileostomy 

• Diarrhea 

• Excessive urination 

• DKA 

Signs and Symptoms: 

• Positive Babinskis 

• Increase in neuromuscular excitability 

• Decrease in CNS 

• Cardiac dysrhythmias 

  • Torsade's de pointes – lethal 

    • Cannot come out until mg level is normal 

hypomagnesemia treatment tests

Diagnostic Tests: 

• EKG 

• Lab tests 

Treatment: 

• Give Mag 

• What's causing it 

our job as nurses

• Identify pts who are likely to develop imbalances 

• Monitor pts who are likely to develop imbalances 

• Monitor pts for early manifestations 

• Implement interventions to correct and prevent imbalances 

• Education patients on prevention