INTER-MS EXAM 2 REVIEW (ABGs, electrolytes, atrial dysrhythmias, ch. 17/20)

Atrial Fibrillation

WHAT: rapid, disorganized twitching of the atrial muscle; causes pooling or "swooshing" of blood --> major risk of blood clots (PE, DVTs etc.)

(SA node has lost control)

S/S: low oxygen symptoms (decreased O2, chest pain, dizziness, low BP, elevated HR, and anxiety/weakness)

INTEVRENTIONS:

A- anticoagulants (watch INR)

B- beta blockers (to decrease HR)

C- cardiac ablation

D- digoxin (to increase contracitlity/decrease HR)

E- electro cardioversion (50-200 jules)

**patient should have a TTE to assess for blood clots before starting anticoagulants (b/c they could already have clots that could then travel to lungs etc.)

signs of atrial fibrillation on an EKG:

the patients heart rate would be over 100, with an irregular rhythm and no P wave or PR interval present/measurable

-QRS complex = normal

Atrial Flutter

WHAT: similar to A fib, but the rhythm is regular (still fast heart rate)

(SA node lost control as primary pacemaker)

**rhythm is in unison like birds FLUTTERing

S/S: low oxygen (chest pain, SOB, dizziness/weakness, fast HR, etc.)

INTERVENTIONS: (same as A fib.)

A- anticoagulants (rule out clots first with TTE)

B- beta blockers

C- cardiac ablation

D- digoxin

E- electro cardioversion (NOT defibrillation)

signs of atrial flutter on EKG:

rate is usually over 100, regular rhythm, and absent p wave/PR interval

-QRS complex = normal

Premature Atrial contractions (PAC)

WHAT: atrial contraction that occurs early and before the next normal impulse

S/S: usually none in mild cases; in severe cases, low BP and a pulse deficit

EKG signs= can be any HR, regular rhythm with early P waves, shortened PR interval (but still between 0.12-0.20 seconds)

INTERVENTIONS: treat the underlying causes:

-stress, sepsis, or stimulants (cessation of cigarettes/caffeine)

-correct hypokalemia

-discontinue digoxin if patient is taking it

*give amiodarone procainamide, or lidocaine

Supra ventricular Tachycardia (SVT)

WHAT: episodes of rapid HR that starts above the ventricles

(SA node fires normally, but impulse somehow backs into atrium instead of going to the ventricles, leading to double the bpm)

S/S: low oxygen (chest pain, dizziness, fast HR, low BP etc.)

EKG signs: HR of 150-250 bpm, regular rhythm, P wave that is buried in T wave, PR not measurable (b/c P wave is hidden), and normal QRS

INTERVENTIONS: valsava maneuver (bare down/carotid massage), adenosine**, cardiac ablation, and electro cardioversion

3rd spacing

accumulation of fluids (may be in lungs or abdomen called ascites, or hands)

how does the Renin-angiotensin pathway contribute to fluid balance?

the RAAS system is activated when blood pressure is low, which then leads to the retention of sodium and water

-aldosterone decreases sodium release and prevents excretion

-ADH increases sodium and fluid levels in the body

Hypovolemia

loss of blood, plasma, water, and electrolytes from GI losses such as N/V, renal losses, sweating, hemorrhages, or deficient fluid intake

S/S: N/V, low BP, elevated HR (to compensate), increase temperature, increased respirations, dry skin, and a high urine specific gravity

LABS: increased BUN, increased proteinuria, and increased hemoglobin/hematocrit

INTERVENTIONS: isotonic fluids, correct V/D, stop any diuretics or blood transfusions, and monitor I/O's

Hypervolemia

excess fluid in body: (blood, water, plasma) caused by factors such as kidney/liver failure, HF, and sodium retention

S/S: weight gain, edema, dyspnea, crackles, distended neck veins, increased HR/BP, and bounding pulses

LABS: hemoglobin/hematocrit may be normal or increased, and a decreased BUN

INTERVENTIONS: chest x-ray, diuretics, digoxin to increase cardiac output in HF patients, restriction of fluids, stopping any IV infusions, monitor I/O's and daily weights, decrease salt in diet, and assess cardiovascular status

Hyponatremia (below 135)

low sodium levels in the blood caused by excessive fluid loss , excessive water gain, or inadequate sodium intake

S/S: confusion, N/V, weak pulses, and muscle weakness

INTERVENTIONS: increase sodium intake, prevention of fluid overload/hypernatremia, assessment of labs often, daily weights, and isotonic/hypertonic IV solutions given (NOT hypotonic)

Hypernatremia (above 145)

high sodium levels in the blood caused by excessive sodium intake, or water loss (diarrhea or DI)

S/S: ALOC, muscle weakness, twitching, lethargy, weak/bounding pulses, and seizures

INTERVENTIONS: monitor I/O's and daily weights, prevent dehydration, hypotonic solutions given, decrease sodium in diet, and monitor labs

Hypokalemia (below 3.5)

low potassium in the blood caused by decreased potassium intake, increased aldosterone, GI losses, trauma/burns, or diuretics

S/S: shallow RR, decreased BP, ST depression, lethargy, and confusion

INTERVENTIONS: oral potassium supplement or IV potassium infusion (NEVER IV PUSH), correct any N/V/D, monitor RR and muscle weakness, and give potassium rich foods (oranges, avocados, potatoes, and bananas)

-hold digoxin, b/c hypokalemic patients are more likely to get digoxin toxicity

what is the max dose of potassium given with an IV piggyback?

10mg per hour is MAX and must be an IV infusion, not IV push

Hyperkalemia (above 5.0)

high levels of potassium in the blood caused by an increase in potassium intake

S/S: muscle weakness, N/V/D, cramping, decreased HR/BP, and EKG changes

INTERVENTIONS: kayexelate (works within 4-6 hours), insulin + glucose given, diuretics, IV calcium guconate, or potassium restriction in diet

Hypocalcemia (below 9.0)

low calcium levels in the blood caused by inadequate intake, hypothyroidism, or vitamin D deficiency

S/S: osteoporosis, fractures, muscle spasms, cramps, Chvostek's/trousseau's sign, and increased DTRs/convulsions

INTEVRENTIONS: IV calcium gluconate, calcium/vitamin D supplements, thyroidectomy, seizure precautions, and prevention of falls

Hypercalcemia (above 10.5)

high levels of calcium in the blood caused by excessive intake of calcium

S/S: decreased muscle tone, bone pain, lethargy, comas, decreased motility, arrhythmias, and EKG changes

INTERVENTIONS: sodium chloride and diuretics, diet high in fiber, avoiding calcium supplements, prevention of falls, and monitor bone function

Hypophosphatemia (below 3.0)

Low phosphate levels in the blood caused by decreased intake, hyperparathyroidism, or renal failure

S/S: muscle weakness, decreased RR/HR and BP, rhabdomyolysis, and decreased bone function

INTERVENTIONS: stop any antacids/diuretics/calcium supplements, increase phosphate-rich foods, and fall prevention

Hyperphosphatemia (above 4.5)

high levels of phosphate in the blood caused by increased oral intake, renal insufficiency, and hypoparathyroidism

S/S: same as hypocalcemia (Chvostek's/trousseau's sign, and increased DTRs/convulsions etc.)

INTERVENTIONS: calcium/vitamin D supplements, IV calcium gluconate, seizure precautions, prevention of falls or bleeding

Hypomagnesemia (below 1.3)

Low magnesium levels in the blood caused by prolonged malnutrition, TPN without magnesium, or prolonged NG tube suctioning

S/S: increased HR, decreased BP, arrhthymias, tremors, seizures, memory loss, cramps, tetany, increased DTRs, Chvostek's/Treausseau's sign, and decreased GI motility

INTERVENTIONS: IV magnesium sulfate, magnesium rich foods, seizure precautions, and avoid the use of diuretics/laxatives

Hypermagnesemia (above 2.1)

high magnesium levels in the blood caused by excessive intake, use of laxatives or antacids, or renal failure

S/S: decreased impulses, lethargy, cramps, decreased DTRs, weakness, and decreased RR

INTERVENTIONS: stop all magnesium intake, magnesium free IV fluids, diuretics, monitor LOC, fall prevention, and monitor DTRs/RR

_____________ imbalances occur usually as a result of other electrolyte imbalances

chloride

normal electrolyte levels:

sodium= 135-145

potassium= 3.5-5.0

calcium= 9-10.5

phosphate= 3-4.5

magnesium= 1.3-2.1

chloride= 98-106

Hypoventilation

retention of CO2 due to factors such as atelectasis, COPD, drug overdoses, or chronic pain

(causes CO2 levels to be greater than 45, leading to respiratory acidosis)

*HYPO=ACIDO*

Hyperventilation

rapid breathing that leads to excessive expiration of CO2 due to factors such as anxiety/panic attacks, asthma attacks, and acute pain

(causes CO2 levels to be under 35, leading to respiratory alkalosis)

hyperkalemia, hypernatremia, hypercalcemia etc. all lead to ACIDOSIS True or false?

true

hyperkalemia, hypernatremia, hypercalcemia etc. all lead to ACIDOSIS

all the _________ electrolyte imbalances lead to alkalosis

"hypo"

Respiratory acidosis

low pH, high CO2 caused by hypoventilation/depressed respirations

could be due to: trauma to medulla, lung diseases, or airway obstruction

S/S: restlessness, confusion, dyspnea, hypoventilation

INTERVENTIONS: bronchodilators, anti-inflammatory drugs, mucolytics, and oxygen therapy

-post-op early ambulation

-pulmonary toileting (nebulizer treatment etc.)

-ventilation support in worst cases

Respiratory alkalosis

high pH, low CO2 due to hyperventilation

could be due to: anxiety, hypoxemia, or brain tumors

S/S: hyperventilation, lightheadedness, tingling in fingers, tetany, or convulsions

INTERVENTIONS: treat underlying cause (anxiety/pain etc.), oxygen given for hypoxemia, or a rebreathing bag

Metabolic acidosis

low pH and low bicarb (HCO3)

due to: DKA, sepsis, renal failure, or severe diarrhea

S/S: ALOC, coma, hyperkalemia, N/V, and Kussmal's respirations (rapid and labored breathing)

INTERVENTIONS: treat underlying cause: treat sepsis, insulin for DKA, prevention of diarrhea

Metabolic alkalosis

high pH and high bicarb (HCO3) caused by NG tube suctioning/vomiting, and excessive antacids such as tums

S/S: ALOC, dizziness, numbness/tingling, muscle twitching, tetany, hypokalemia, and tetany

INTERVENTIONS: treat underlying cause: restore potassium levels, seizure precautions, and drugs such as diamox

indications for isotonic IV fluids:

low blood pressure, shock, hyponetrmia/hypovolemia, and/or severe metabolic acidosis

indications for hypertonic IV fluids:

low blood pressure, hyponatremia, edema, and brain injuries (to help decrease ICP)

indications for hypotonic IV fluids:

severe dehydration, hypernatremia, and for possible HF patients

indications for colloid IV solutions:

patients who need rapid/significant plasma volume expansion (such as those with hemorrhages, severe shock, or major burns)

-often used as a second-line solution due to increased potential for allergic reactions

COPD

WHAT: chronic air trapping leading to reduced gas exchange (due to inflammatory damage to the lungs) which causes high levels of CO2

*most commonly caused by smoking (as well as chemical fume exposure)

Types: emphysema and chronic bronchitis

S/S: depends on type; clubbing fingers (emphysema), cyanosis and cough (chronic bronchitis), pursed lips/barrel chest (emphysema)

LABS: ABGs will show low O2 and high CO2 (showing respiratory acidosis) in patients with worsening COPD

INTERVENTIONS: smoking cessation, incentive spirometry, oxygenation (2-4 L using Venturi mask), pulmonary rehabilitation (incentive spirometry, postural drainage, chest percussion/vibration), bronchodilators, mucolytics, reducing risk factors, and in severe cases, lung transplants

COPD is reversible. True or false?

false

(it is treatable but not reversible like asthma attacks, that come and go)

Emphysema

WHAT: the air sacs of the lungs (alveoli) are damaged and enlarged, causing breathlessness

"pink puffer"

S/S:

P- pink skin and pursed lip breathing

I- increased barrel chest

N- no/minimal cough

K- keeps tripoding (leaning forward to breathe)

others include: thin, SOB, and accessory muscle use

Chronic bronchitis

WHAT: inflammation of the airways (bronchi), that persists for a long period of time and leads to excessive mucus production and a persistent cough

"blue bloater"

S/S:

B- big & blue (cyanotic/obesity)

L- long term chronic cough/sputum

U- unusual lung sounds (crackles and wheezes)

E- edema

others include: hulmonary HTN, right sided HF, fatigue, hepatomegaly, and hypercapnia

what is considered the normal pulse oximetry reading on a patient who has COPD?

88-93% is considered normal for COPD patients

why can COPD lead to respiratory acidosis?

too much carbon dioxide in the blood leads to too much acid inside the body

what are deadly complications of COPD?

respiratory failure:

hypoxemic respiratory failure due to low oxygen

or

hypercapnic respiratory failure due to high carbon dioxide

(patient needs biPAP)

*monitor for mental status changes*

complications of COPD

-Cor Pulmonale: right-sided heart failure caused by pulmonary disease

-pneumonia

-pneumothorax

-respiratory failure

-chronic atelectasis

risk factors of COPD:

#1= smoking

-older age

-severe, recurring resp. infections

-exposure to chemical fumes/environmental pollution

-genetics

diagnostic testing for COPD

-Pulmonary Function Testing (spirometry etc.)

-ABGs

-chest X-rays

why do you not want to use a rebreather mask for a COPD patient?

it can lead to even more high levels of CO2 being retained which could lead to respiratory failure

patient teaching for COPD:

-complete oral hygiene BEFORE meals (moisten dry mouth)

-eat small, frequent meals (minced moist diet)

-increase fluid intake to 2-3L per day (have fluids between meals)

-report any increase in dyspnea or increased sputum

-stay up to date on flu and pneumococcal vaccinations

-promote pursed lip breathing

function of the respiratory system:

to supply the body with oxygen and dispose of carbon dioxide

(upper respiratory system warms/filters the air; lower respiratory system accomplishes gas exchange)

parts of the upper respiratory tract

nose, mouth, pharynx, epiglottis, larynx, and trachea

Respiration vs. Ventilation

Respiration= the action of breathing

Ventilation= the exchange of air between the lungs and the atmosphere so that oxygen can be exchanged for carbon dioxide in the alveoli

V/Q ratio (ventilation/perfusion)

A measurement that examines how much gas is being moved effectively and how much blood is flowing around the alveoli where gas exchange (perfusion) occurs

-an imbalanced V/Q ratio results in hypoxia

PaO2 vs. SaO2

PaO2 measures the partial pressure of oxygen dissolved in the plasma

SaO2 measures the percentage of hemoglobin saturated with oxygen

older adult respiratory considerations:

-alveolar changes (they have reduced area for gas exchange and a loss of elasticity)

-loss of chest wall mobility

-restriction in tidal flow of air

-decreased O2 diffusion (lower O2 in the plasma= low PaO2)

what are the "6 P's of dyspnea?"

1. Pulmonary Bronchial Constriction

2. Possible Foreign Body

3. Pulmonary Embolus

4. Pneumonia

5. Pneumothorax

6. Pump Failure

A physical respiratory assessment includes:

-monitoring mental status

-assessing skin, mucous membranes, and nail beds (clubbing?)

-use of accessory muscles when breathing?

-cough/sputum duration, amount, color, or odor

-assess breathing pattern (tachypnea, dyspnea etc.)

-chest configuration (barrel chest? etc.)

examples of adventitious lung sounds

Stridor, crackles, ronchi, wheezing, pleural friction rub

_________ breath sounds come from the alveoli

vesicular

__________ are low-pitched vibrating sounds due to air colliding with secretions in the larger airways

rhonchi

diagnostic tests for respiratory function:

-Spirometry or pulmonary fx tests (measures air volume and flow times)

-ABGs

-sputum tests

-Oximetry (O2 saturation)

-Imaging (x-ray etc.)

-culture and sensitivity

arterial blood gases

a measurement of arterial oxygenation and carbon dioxide levels

-used to assess acid/base imbalances as well

what is the normal oxygen saturation level of a non-COPD patient?

95-100%

bronchoscopy

visual examination of the bronchi

-used to diagnose lung infections/diseases

-obtain informed consent

-NPO for 4-8 hours before procedure

-hoarseness/ a mild cough is normal after procedure

-fluids and soft foods okay AFTER gag reflex has returned a few hours after procedure

-monitor vitals often

-report increasing chest pain for difficulty breathing

thoracentesis

surgical puncture to remove fluid from the pleural space

-monitor for possible pneumothorax

-assess HR and breath sounds

funnel chest

depression of lower portion of sternum

Pink, frothy sputum may be an indication of

pulmonary edema

In which position should the client be placed for a thoracentesis?

sitting on the edge of the bed

Which measure may increase complications for a client with COPD?

increased oxygen supply

the ventilation-perfusion ratio (V/Q) imbalance occurs as a result of inadequate ventilation, inadequate perfusion, or both. True or false?

true

what are the major signs/symptoms of respiratory disease?

dyspnea, cough, sputum production, chest pain, wheezing, and hemoptysis (bloody mucus secretions)

what are the most common causes of hemoptysis?

-Pulmonary infection

-Carcinoma of the lung

-Abnormalities of the heart or blood vessels

-Pulmonary artery or vein abnormalities

-PE or infarction

the nasal mucosa appears ______ and ______ during allergic rhinitis

pale and swollen

(nasal mucosa is usually more red than the oral mucosa)

tactile fremitus

vibrations of the chest wall that result from speech detected on palpation

(patients are asked to repeat "ninety-nine" or "one, one, one" as the nurse's hands move down the thorax)

nursing interventions for patients going for a pulmonary angiography:

-verify informed consent

-assess for allergies to iodine and shellfish

-assess renal fx and anticoagulant status

signs and symptoms of oxygen toxicity:

substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, progressive respiratory difficulty, refractory hypoxemia, and alveolar atelectasis

due to older adult respiratory changes, they are more at risk for _______ and ________

aspiration and infections

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance?

metabolic acidosis

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

elevated blood pressure

With which condition should the nurse expect that a decrease in serum osmolality will occur?

kidney failure

(Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload)

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing?

metabolic alkalosis

Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

JVD

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen?

Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia

memory tricks for atrial EKG strip readings:

atrial fibrillation: no P wave = fibrillation floPPing

atrial flutter: fluTTer = sawTooTh: regular rhythm like birds FLUTTERing in unison

SVT: SUPRAventricular = SUPER fast

treatment for Asystole (flatline):

epinephrine, atropine, and CPR

(no defibrillation or shock)

_______ fluids are given for hypovolemia

isotonic

what is the normal BUN range?

10-20 mg/dL

-hypovolemic patients would have greater than 20

-hypervolemic patients would have decreased BUN

Wandering Atrial Pacemaker (WAP)

WHAT: when the electrical impulses of the heart come from multiple foci in the atrium

S/S: usually no symptoms; may experience palpitations

-on EKG: 3 different P wave shapes, HR is normal to slower, PR interval varies, and irregular rhythm

INTERVENTIONS: usually none because the heart rhythm is considered benign

Wolff-Parkinson-White Syndrome

WHAT: causes an extra electrical pathway in the heart that leads to tachycardia

S/S: tachycardia, palpitations, chest pain, SOB, and dizziness

INTERVENTIONS: vagal maneuvers, amiodarone or procainamide, stress tests, cardiac ablation, or cardioversion

pH, bicarb and CO2 levels:

pH: (acidic) 7.35-7.45 (alkaline)

CO2: (alkaline) 35-45 (acidic)

bicarb: (acidic) 22-26 (alkaline)