Adults II exam 1 review

High-Acuity Definition

Refers to complex patients with unpredictable outcomes, often found in critical care or intensive care units.

What factors Contribute to High-Acuity Admissions

Includes acute issues (trauma, stroke, aneurysm), age (really young and really old), exacerbation of chronic conditions (HF, kidney disease, DM, COPD), lack of access to care, economic factors, and noncompliance.

Nursing Care Considerations

Care must be individualized due to diverse cultural and educational backgrounds of clients and families.

What are the major areas to consider when caring for high-acuity patients?

• High-acuity environment

• Pharmacological management and issues

• Nutritional support

• Older adult considerations

• Palliative and end of life care

High-Acuity Environment - The Good

Features rapid access to labs, specialists, 24-hour care, and quick medication access.

High-Acuity Environment - Not So Good

Characterized by overcrowding, excessive equipment, information overload, and limited communication.

Physical Stressors in High-acuity environments Environments

Include lack of sleep, isolation, pain, immobility, overstimulation, and pharmacological effects (sedatives, antipsychotics)

Social and Psychological Stressors in High-acuity environments

Encompasses anxiety, grief, family dynamics, financial stress, and post-stay concerns.

Common Complications from Stressors

Include venous thromboembolism (VTE) due to lack of mobility, GI bleed, and delirium.

How are the common stressors treated?

• VTE: prophylaxis, anticoagulants, compression stockings, sequential devices

• GI bleed: PPI for stress prophylaxis

• Delirium: address the main issue

Delirium

An acute disorder marked by confusion, attention deficits, and fluctuating mental status, often misinterpreted stimuli. Developed QUICKLY

What are common causes of delirium?

Infectious process, adverse drug reactions, metabolic conditions, lack of sleep

Delirium Assessment and Treatment

Involves identifying and treating underlying causes, with prevention as the primary goal.

Why are antipsychotics the last resort for treatment of deliurm?

Meds like Haldol and benzos can have dangerous side effects

Nurse’s Role in Facilitating Care

Involves acknowledging stressors, assessing clients, managing stressors, and connecting to resources.

Areas for Pharmacological Management

Areas that deal with pain, sedation, chronic and acute illness management.

Pain in High-Acuity Clients

Can be acute or chronic, with varying perceptions influenced by psychosocial factors.

Common Pain Assessment Tools

Include numeric pain scale, FACES, Behavioral Observation Scale, and Critical Care Pain Observation Tool.

What’s the most reliable way to assess pain?

Patient report

Pain Management

Involves using opioids and non-opioids, with a focus on managing anxiety to alleviate pain.

Nurse’s Role in Pain Management

Includes frequent assessment, advocacy for pain control, look into potential side effects and complications, and education for clients and families (narcotic hesitancy)

High-Acuity Client Pain Management Complications

Include respiratory depression, altered consciousness, and polypharmacy.

Sedation for High-Acuity Clients

Commonly used in critical care, especially for ventilated patients or to manage delirium.

Common Sedation Assessment Tools

Include Richmond Agitation and Sedation Scale (RASS) and Pasero Opioid-Induced Sedation Scale (POSS).

Nutritional Support Importance

Essential for recovery, with many high-acuity clients unable to take in nutrition independently.

What complications can occur from sedation to high-acuity patients?

• Long-term PTSD, increased delirium, resp distress, and drug interactions

Routes of Nutrition

Include oral, enteral, and parenteral feeding methods.

Why do high acuity patients usually have special nutritional needs?

D/t disease processes like liver failure, renal failure, and heart failure

Nurse’s Role in Nutritional Delivery

Involves checking orders, maintaining feeding tubes, and assessing for intolerance.

What are key notes to make for oral feedings for high-acuity patients?

• Preferred method

• Helps body maintain normal process

• Always assess client’s readiness to feed

• May require supplementation d/t lack of energy/appetite (Ensure drink for a calorie dense diet)

What are key notes to make for enteral/tube feedings for high-acuity patients?

• Different tubes have different functions

  • Nasogastric tube (NG): down the nare, esophagus, stomach

  • Dobhoff tube: goes down nare, esophagus, stomach, and intestine

  • PEG tube: directly through the abd wall into the stomach

• They help maintain GI function and reduce metabolic stress

• Helps with inflammatory bowel disorders

What are key notes to make for parenteral feedings for high-acuity patients?

• Last resort for feeding. Commonly seen in patients with pancreatitis

• TPN is the most common, but poses a high risk for infection (change every 24-72 hrs)

• Taper d/t risk of hypo/hyperglycemia

Why must TPN be tapered on and off?

To prevent hyper/hypoglycemia

Older Adult High-Acuity Client Considerations

Focus on physiological changes, atypical presentations, comorbidities, and cognitive changes.

What are expected system changed in older adult clients?

• Neuro: decreased neurotransmitter production, permeable BBB, dilation of ventricles

• Cardio: decreased elasticity and increased stiffness of walls

• Resp: calcification of costal cartilage, decreased chest wall compliance, decreased RBCs O2 carrying capacity, loss of lung elasticity

• GI: decreased saliva, thirst response, Lower Esophageal Sphincter function, digestive function, GI tract absorption, decreased blood flow to liver

• GU: decreased GFR, creatinine clearance, UTI risk, incontinence

• Integ: loss of elasticity, decreased subq tissue, thinning of skin, fragile blood vessels, reduction of lean body mass

• Musculo: decreased muscle mass, joint stiffness, decreased mobility, loss of bone mass

What can extreme confusion indicate in older adults?

UTI

What are some pharmacological considerations that nurses should consider when caring for older clients?

• Physiological changes like decreased absorption and liver and kidney changes

• Polypharmacy

• Adverse reactions that certain drugs can cause. Like delirium, hypotension, renal or hepatic impairment

Palliative Care

An interdisciplinary approach aimed at relieving suffering and improving quality of life without withdrawing care. Ex. cancer, HF, dementia

Hospice Care

A form of palliative care for patients with a prognosis of six months or less to live.

End of Life Care

Focuses on comfort and support during the final phase of a patient’s illness. Clients can receive both hospice and palliative care

Withdrawal of Care

Involves stopping life-supporting measures (dialysis, ventilator support, vasopressor support), often accompanied by medications to ease symptoms.

Bereavement and Grief

Each person experiences these differently; nurses facilitate and normalize the process for families.

Self-Care in High-Acuity Environment

Caregivers must prioritize their well-being and seek help to process their feelings.

How is body perfusion measured?

Cardiac Output (CO)

How does blood flow through the heart?

■           Return through IVC and SVC

■           RA through TCV to RV

■           RV through PV out the PA

■           O2-CO2 exchange in lungs

■           Back by PV to LA

■           Through MV to LV

■           Through AV and out the Aorta

■           Systemic perfusion

What is CO? stroke volume? heart rate?

• CO:  amount of blood ejected by each ventricle per minute. Normal is 5-6L/min

• Stroke volume: volume of blood pumped with each beat (contraction of the ventricle) so it depends on the contractility of the heart and end-diastolic volume

• Heart Rate: # of times the heart beats per min

  
  

What’s the equation of CO?

   CO = SV*HR

What factors affect CO (HR, SV)?

• HR

  • SNS and PSNS can either lead to tachy which increased CO or induces relaxation whcih decreased CO

  • Positive chronotropes (epinephrine, atropine) increase HR which increased CO and negative chronotropes (beta blockers) decrease HR

  • Dysrhythmias

• SV

  • Preload, Afterload, and Contractility affected SV which affects CO

What are preload, afterload, and contractility?

• Preload: blood volume entering the ventricle after they’ve filled up. Affected by venous return, volume, or Afib

• Afterload: pressure ventricles undergo to pump blood out of the ventricle. Affected by HTN (increased pressure to heart), atherosclerosis/blockages (narrowing of vessels affected blood flow), vasoconstriction

• Contractility: strength of heart during a contraction, so if it’s decreased, so will CO

What does CO compensation look like?

• Increased HR

  • The body will try to maintain the SV, but compensation will fail with sustained increase in HR and SV will drop

• Decreased SV

  • HR will increase. Ex. hypovolemia

• Increased SV

  • HR will decrease as is noted in endurance athletes

What are modifiable RFs of cardiovascular issues?

• Smoking: causes vasoconstriction which decreases CO

• HTN

• Hyperlipidemia: plaque build up

• Inactivity

• Obesity

• Diabetes

What are common manifestations of cardiovascular issues?

■           Neuro: Lethargy, dizziness, altered LOC, syncope (not enough blood/oxygen to brain)

■           CV: hypotension, weak and thready pulse (body is going to perfuse the main organs), angina, edema

■           Resp: Dyspnea (fluid accumulation), tachypnea

■           GI: Nausea

■           GU: oliguria (no kidney perfusion) this is usually the first system affected

■           Integ/Musc: cool, clammy skin, possible diaphoresis (d/t increased heart workload)

■           Psychosocial: anxiety

What do labs show with cardiovascular issues?

■          Total cholesterol: elevated levels increase risk of plaque formation leading to lack of perfusion 

■          Triglycerides

■          Chemistry panel: gives info on the contractility of the heart. Focus is on potassium, calcium, and magnesium

■          CBC: look at Hgb or Hct to determine oxygen-carrying capacity of blood 

■          BNP: enzyme released when the body senses a large stretch in the artery. Increased levels show individuals dealing with fluid overload  

■          Cardiac Enzymes: enzymes released when there’s muscle damage

What diagnostics are taken to determine cardiovascular issues?

■          EKG/ECG: look at electrical conduction of the heart 

■          Echocardiogram: ultrasound of the heart showing the structure of the heart and measuring the output of the different ventricles, see valve function 

■          Cardiac stress test: look at ECG reading to determine changes in heart rhythm 

■          Calcium scan: helps identify plaques or hardening in the heart usually in coronary arteries

■          Cardiac catheterization

■          Chest X-ray

What is the purpose of cardiac catherization?

It allows for blood flow to be restored, usually d/t an obstruction in the coronary artery

What are the different techniques of cardiac catherization?

• Percutaneous Transluminal Coronary Angioplasty (PTCA): balloon that widens the artery

• Directional Coronary Atherectomy (DCA): digs plaque out of artery

• Intracoronary Stents: most common and has stents widen the artery

• Coronary Artery Bypass Graft (CABG): alternate cath in case obstruction is too big

What allergy should the nurse be on the look out for if a patient is going through cardiac catherization?

iodine/shellfish

What are the main things to observe in a patient following a cardiac cath procedure?

• VS q15min then q30min, then q1hr

• Check for bleeding

• Make sure patient lays flat following a femoral artery procedure

• Check site distal to cath insertion for sensation

• Check for adequate perfusion (LOC, BP, UOP, cap refill)

• Monitor weight for retention

What does nursing care for a CABG patient look like?

• ICU right after surgery with chest tubes (monitor Output)

• Check sugar, chem panels, and other tests

What does nutrition for a patient with cardiovascular issues look like?

• Low saturated fat, high complex carb diet

• High fiber

• Possible fluid or sodium retention

• Diabetes control

• Reduced alcohol d/t risk of cardiomegaly

• No smoking

What is Coronary Artery Disease (CAD)?

Deposition of lipids that cause narrowing of arteries IN THE HEART

What’s the patho of CAD?

• Damage to the tunica intima allows for lipids to deposit into the wall forming a plaque.

• The plaque attracts more lipids which further narrows the vessel. If the plaque gets thick enough, the tissue distal to it gets less perfused and can ultimately lead to tissue ischemia.

• Additionally, piece of the plaque can break off and become a clot/thrombus that can further occlude vessels further down and lead to tissue death

Why does location matter when discussing CAD?

The higher the occlusion the more dangerous it is since it determines how much of the vessel doesn’t get perfused

What are manifestations of CAD?

■          Neuro: Fatigue

■          CV: Angina possible

■          Resp: SOB

■          Other: There are often not many manifestations until there is a severe compromise, especially if the plaque has built slowly over time.

What labs are done with CAD?

• C-reactive protein: for inflammation

• Total cholesterol: determines lipid deposit

  • LDL (bad)

  • HDL (good)

• Triglycerides

What diagnostics are done for CAD?

• EKG: determines if the occlusion is severe enough to cause ischemia

• Echocardiogram: look at function of heart, not show occlusions (TEE or TTE)

• Doppler flow: looks for occlusions in arteries

• Stress Test: determine abnormalities in the EKG

• Angiogram: cath placed to visualize a reduction of flow in the arteries

• Coronary artery calcium scan: determine calcification of arteries

How is CAD managed?

• Meds

  • “__statin” to lower lipid levels

  • Niacin to lower LDL

  • Antiplatelet/coagulant therapy for clots

• Cardiac cath or CABG

• Low fat, high fiber diet

• No need for sodium restriction

What is angina pectoris?

Pain in the chest d/t the heart needing more oxygen than it’s getting

What’s the patho of angina pectoris?

• An underlying disease causes the myocardial oxygen demand to exceed the supply available, so the tissue becomes ischemic since it’s not being properly perfused

• This ischemia of tissues triggers pain usually around the chest region

What are the 3 types of angina?

• Stable

  • Caused by a PREDICTABLE emotion or exertion

  • Plaque is fixed and stable

  • Relieved by rest, nitroglycerin, or both

• Unstable

  • Caused by an UNPREDICTABLE emotion or exertion

  • Pain is d/t further platelet aggregation and usually occurs at night

  • Not relieved with rest or nitro and is considered a medical emergency

• Variant (Prinzmetal’s)

  • Caused by CORONARY ARTERY SPASM during rest periods or randomly

  • No plaque build up, but the spasms narrow the vessel

  • Oftens occurs durinf times of rest (at night)

  • Related to stimulant use (cocaine) and can show elevated ST on an EKG

What can cause angina?

• Decreased O2 supply

  • CAD, coronary artery spasms, dysrhythmias, anemia, severe resp disease, substance use

• Increased O2 demand

  • Tachycardia, valvular disease, anxiety, hyperthermia, physical exertion

What are manifestations of angina?

■          Neuro: Lethargy, dizziness, altered LOC, syncope

■          CV: hypotension, weak and thready pulse (vasoconstriction), angina, tachycardia

■          Resp: SOB, tachypnea (to meet O2 demand)

■          GI: Nausea, vomiting

■          GU: oliguria

■          Integ/Musc: cool, clammy skin, possible diaphoresis

■          Psychosocial: anxiety

■          Pain-can be located in the chest, back or other areas of the torso. Can also have variations in severity and duration depending on the individual

What labs are taken for angina?

• Cardiac enzymes

  • Troponin (MOST INDICATIVE)

  • CK

  • CK-MB

  • Myoglobin

• CBC: RBCs and WBCs

• CRP: inflammation

• Chem panel: Mg, K, Ca

How is angina diagnosed?

• EKG: ST depression or T inversion with ischemia

• Echo: visualize ventricles and chambers of the heart

• Stress Test, Calcium Scan, Cardiac cath, angiography, chest x-ray

How is angina treated?

• Meds

  • Nitro: vasodilator that opens up arteries to increase flow. Monitor BP

  • “__pril”: ACE inhibitor

  • “__olol”: beta blockers decrease HR to decrease O2 demand

  • Nifedipine, verapamil: CCBs to regulate spasms

  • “__statins”: lipid lowering agent

  • ASA, heparin, warfarin: anticoagulant

  • Morphine: help with pain and dilates coronary arteries

  • Supplemental O2

How are the different types of aginna treated?

• Stable

  • nitro for breakthrough pain

  • Stent or CABG

• Unstable

  • nitro, aspirin for plaque, O2, IV

When should nitro stop being used?

If 5 doses are given 3 min apart and the pain isn’t relieved

What’s the nutrition for a person with angina?

• Low sat fat, high complex card, high fiber diet

• Reduce alcohol and simple sugars

• High Omega-3 fatty acids

• Strict diabetes control

What’s the patho of a myocardial infarction?

• Something causes the coronary artery to no longer be able to supply blood to the heart

  • Occlusion of vessel d/t stable CAD or plaque rupture

  • Spasms of arty d/t stimulant use

  • Supply-demand mismatch d/t hypovolemia, hemorrhage, or tachycardia

• The tissue distal to the blockage soon begins to die and cannot be reversed

• If enough tissue is affected, the person may die

What’s the difference between unstable angina, a STEMI and NSTEMI when discussing myocardial infarctions?

• Unstable angina: minimal occlusion, T wale inversion, no necrosis

• NSTEMI: severe occlusion, ST depression, necrosis

• STEMI: complete occlusion, ST elevation, transmural necrosis

What are manifestations of an MI?

■          Neuro: Lethargy, dizziness, altered LOC, syncope

■          CV: hypotension, weak and thready pulse, angina, tachycardia, possible early hypertension 

■          Resp: SOB, tachypnea, crackles (pressure backing up in left atrium, then to the lungs)

■          GI: Nausea, vomiting

■          GU: oliguria

■          Integ/Musc: cool, clammy skin, possible diaphoresis , JVD

■          Psychosocial: anxiety, feeling of impending doom

■          Other: There is often a difference in the presentation with men and women

What labs are taken for an MI?

• Cardiac enzymes: troponin, myoglobin, CK, CK-MB

• CBC

• PT/INR: bleeding times determine coagulant use

• Chem panel

How is an MI diagnosed?

• EKG: ST depression for NSTEMI and ST elevation for STEMI (elevated in 3 leads)

• Echo, TEE, Angiography

How are STEMIs and NSTEMIs managed?

• STEMI

  • thrombins, thienopyridines (clopidogrel or aspirin), heparin, “__prils”, O2, morphine, beta blockers, CABG, PCI, nitro, statins

• NSTEMI

  • aspirin, ACEI, beta blocker, CCBs, heparin, statin, nitro, O2

What’s the difference in priority when dealing with a NSTEMI patient compared to a STEMI patient?

You want to try to reduce the stress of the heart and get them stable since there isn’t a complete occlusion

What’s an alternative for a CABG if the cath lab isn’t available when dealing with a STEMI?

• TpA since it can break down the clot

What’s the nutrition of an MI patient?

• NPO during the acute event

• Low-sodium, low-saturated fat, low-cholesterol diet after the acute period

What are common complications of an MI?

• Dysrhythmias (SVT, V-tach, V-fib)

• Cardiogenic shock

• HF and Pulmonary Edema(usually manifests weeks after an MI)

• Cardiac arrest

What are the S&S of cardiogenic shock following an MI?

• Hypotension, diaphoresis, tachycardia

• Give vasopressors, O2, etc. to help heart recover

What’s the patho of heart failure (HF)?

• Weakening of the heart leads to decreased CO which leads to the body not being adequately perfused.

• The kidneys try to compensate by retaining Na and water which further stresses the heart

• Additionally, the blood not being pumped out of the LV starts to back up into the PV and into the lungs and soon to the right side

What’s the kidney involvement in HF?

When the body isn’t getting properly perfused, the kidneys see it as hypovolemia, so they active the RAAS system to release AHD which increases sodium and water retention. This puts more pressure to the heart that’s already having issues perfusing the body

What is ejection fraction (EF) and how is it measured?

• It’s how much blood the left ventricle pumps out with each contraction. Normal (55%-65%)

• EF=(Stroke Volume/End-Diastolic Volume) x 100

What’s the difference between HFrEF and HFpEF?

• HFrEF (reduced)

  • “systolic” HF and involves the LV being WEAK which decreases the EF (<55%-65%)

• HFpEF (preserved)

  • “diastolic” HF and involves the LV being stiff and smaller which means that when with an EF of 55%-65%, there isn’t enough total volume to meet the metabolic needs of the body

What are causes of HF?

• CAD, MI, HTN, valvular heart disease, congenital heart defects, cardiomyopathy

• Causes of exacerbations

  • anemia, dysrhythmias, hypervolemia, infection, PE, thyroid disorders

What are manifestations of HF?

• LSHF

  ■          Neuro: Lethargy, dizziness, altered LOC, syncope

  ■          CV: hypotension (llittle blood beating), weak and thready pulse, angina, tachycardia

  ■          Resp: SOB, tachypnea, dyspnea, orthopnea, crackles, non-productive cough, wheezes, pink and frothy sputum (related to fluid accumulation to the lungs)

  ■          GI: Nausea, vomiting

  ■          GU: oliguria

  ■          Integ/Musc: cool, clammy skin, possible diaphoresis , weight gain (fluid overload0

  ■          Psychosocial: anxiety?

• RSHF

  ■          Neuro: Lethargy, dizziness, altered LOC, syncope

  ■          CV: hypotension, weak and thready pulse, angina, tachycardia

  ■          Resp: SOB, tachypnea

  ■          GI: Nausea, vomiting, ascites (big belly), hepatomegaly 

  ■          GU: oliguria

  ■          Integ/Musc: cool, clammy skin, possible diaphoresis , JVD, edema, weight gain

  ■          Psychosocial: anxiety, fatigue

What labs are taken for HF?

• BNP: determine the stretch of vessels which helps determine fluid overload

• Chem panel: looks for hemodilution and renal labs

• CBC: risk for anemia d/t kidney injury

• ABGs: looking for metabolic acidosis

• LFTs: seen in RSHF

What diagnostics are taken for HF?

EKG, CXR, Echocardiogram (MEASURES EJECTION FRACTION), central venous pressure (MEASURES PRESSURE OF RIGHT HEART), exercise stress test, cardiac cath/angiogram

How is HF managed?

• Meds

  • diuretics: furosemide but monitor for electrolytes imbalance (potassium)

  • vasodilators: nitro helps increase heart perfusion but monitor BP

  • morphine: decreases afterload

  • beta blockers: “__olol” decrease HR

  • ACEI: cardio protective

  • Positive inotropes: dopamine, dobutamine, milrinone increase contractility

What’s the nutrition of a HF patient?

• sodium and fluid restriction

What are nursing considerations for a HF patient?

• Check electrolytes and ABCs

• Monitor I&Os

• Give supplemental O2, elevate bed, elevate feet is edema is present

• Maintain diet restrictions and cluster care