Fundamentals Final

Congestive Heart Failure

Heart cannot pump enough blood forward causing decreased cardiac output causing blood to back up causing fluid overload

decreased CO and BP

daily weight gain >2-3 lbs = fluid retention from HF

Left heart failure

pulmonary edema, crackles

L ventricle not pumping effectively so pressure builds in L atrium pulmonary veins ans capillaries1 m h causing fluid to leak out and gas exchange harder

left ventricular hypertrophy

Right Heart Failure

JVD, peripheral edema

Causes for HF

Chronic HTN

mitral or aortic valve stenosis

MI

CAD

Diabetes

Nursing diagnoses for HF

Activity intolerance

Decreased CO

Decreased cardiac tissue perfusion

Excess fluid volume

Impaired gas exchange

Ineffective health maintenance

Risk for unstable BP

Hypertension

Over time it damages arteries, heart, kidneys, brain

damages vessels and increases after load

Risk factors: obesity, diabetes, family hx

NORM: < 120/<80

ELEVATED: 120-129/ <80

STG 1 HTN: 130-139/80-89

Nursing Diagnoses for HTN

Activity intolerance

Decreased CO

Decreased cardiac tissue perfusion tissue perfusion

Excess fluid volume

Impaired gas exchange

Ineffective health maintenance

Risk for unstable BP

HTN Tx

Sodium restriction and DASH diet

diuretics, ACEi, ARBs, CCB

second choice: beta blocker, direct vasodilators

Stroke nursing diagnoses

Impaired verbal communication

Ineffective cerebral tissue perfusion

Risk for injury

Self care deficit

Unilateral Neglect

COPD : Chronic obstructive pulmonary disease

chronic cough, sputum production, dyspnea, barrel chest, clubbing

emphysema and chronic bronchitis

TX: smoking cessation, bronchodilators, corticosteroids, oxygen

(88-92%)

Lung sounds” wheezes, rhonchi, diminished breath sounds

COPD nursing diagnoses

Activity intolerance

Deficient knowledge

Impaired gas exchange

Ineffective airway clearance

Ineffective breathing pattern

CKD nursing diagnoses

Excess fluid volume

Imbalanced nutrition (less than body requirements)

Impaired urinary elimination

Risk for decreased CO

Risk for electorlyte imbalance

Diabetes

damages microvasculature

polyuria, polydipsia, polyphagia

exercise and diet for TII then drugs

TI: pancrease does not make insulin

rotate sub cut insulin injections

get BGL

Diabetes nursing diagnoses

Decreased CO

Ineffective tissue perfusion

Risk for unstable blood glucose level

GI assessment questions

N/V/D?

onset, durration, symptoms

Last BM, consistency size shape

Bristol Stool Form Scale

color, odor, consistency, shape, frequency, constituents (bile, lipid, food, bacteria)

Implementations for GI

Constipation: cathartics, laxatives, enemas, fiber, water

Diarrhea: anti-diarrheal, fluids, find cause

Dementia

generalized impairment of intellectual functioning that interferes with social and occupational functioning

irreversible, slow decline of cerebral function

Need assistance with ADLS and IADLS

Delirium

acute confusional state: agitation, restlessness, hallucinations

from electrolyte imbalences, uncontrolled pain, infection, medications, hypoglycemia

Reversible

Ensure safety, fall and injury risk

Neuro changes in older adults

voluntary reflexes are slower and have less of an ability to respond to multiple stimuli

visual and auditory impairmentsa

Alzheimers

neuronal degeneration, ACH low

memory loss

confusion

disoriented

hallucinations

unable to carry out ADLS

Joint replacement

Elective surgery

Major surgery invasive, penetrative

Pain management for post op

Pain can cause delayed ambulation

Decreased ventilation

Decreased appetite

Pre/post op teaching

Pain relief

Resumption of activities

Rest

DVT prevention

S/S of infection

Type of surgery

When to contact provider

Wound care

Med schedule

Meds can cause constipation

Dehydration S/S

Urine output 20 ml/hr

Capillary refill slow (<2-3s is norm)

Hypotension

Weight loss of 0.5 lb in 24hr

Sodium function and lab value

135-145 mEq/L

maintain fluid balance

nerve impulses and mm contraction

acid base balance

Hyponatremia

low sodium

confusion, HA, nausea, sz, weakness, edema

causes: GI loss, diuretics, excess water

Hypernatremia

thirst, dry mucous membranes, restlessness, sz

causes: dehydration, excess sodium intake

Potassium range and function

3.5-5.0 mEg/L

key in cardiac conduction and mm contraction

acid base balance

Hypokalemia

Low potassium

mm weakness, arrhythmia, flat T waves

causes: diuretics, GI loss, inadequate intake

Hyperkalemia

high potassium

mm ramps, arrhythmia, peaked T waves

causes: renal failure, potassium sparing diuretics, tissue damage

Calcium range and function

8.5-10.5 mg/dL

Bone/teeth strength

Blood clotting

Nerve impulse transmission and muscle contraction

Hypocalcemia

Low calcium

Tetany (mm tension)

Chvostek(cheek mm contraction)/Trousseau (hand contraction from BP cuff) signs, sz

Causes: hypoparathyroidism, vitamin D deficiency, renal failure

Hypercalcemia

High calcium

Mm weakness, kidney stones, decreased reflexes

Causes: hyperparathyroidism, malignancy, excessive intake

Magnesium range and function

1.3-2.1 mEq/L

Nerve/mm function

Maintain cardiac rhythm

Cofactor in enzyme systems

Hypomagnesemia

Low mag

Tremors, mm contraction, hyperreflexia, sz, dysrhythmias

Causes: alcoholism, GI loss, diuretics

Hypermagnesemia

High mag

More relaxed

Hyporeflexia, hypotension, respiratory depression, cardiac arrest

Causes: renal failure, excessive mg intake (laxatives, antacids)

Carbon dioxide

Acid waste product of cell metabolism

35-45mmHg

Respiratory acidosis > 45

Blood pH

Normal: 7.35-7.45

<7.35= acidic

>7.45= alkalotic

Bicarbonate HCO3

Normal: 22-26 men/L

< 22 = acidic

> 26= alkalotic

Metabolic acidosis HCO3 < 22

Stage 1 pressure injury

Non-blanchable erythema

Stage 2 pressure injury

Partial thickness skin loss

-shallow open ulcer or blister

Stage 3 pressure injury

Full thickness skin loss

Stage 4 pressure injury

Exposed bone, mm, or tendon

Undermining and tunneling may be present

Require intensive care, refer to wound team

Unstageable pressure injury

Obscured by slough or Eschar

deep tissue injury

Dark, non-blanchable, intact skin

Pressure injury prevention

Repositioning

Barrier cream

Reduced friction

Keep pt dry

Protein intake and BGL control

ROM/ ambulate

Sanguenous drainage

Red blood

Serous sanguanous

Light pink serous fluid and blood

Purulent discharge

Green, brown, yellow

Infection

Urinary retention

Inability to empty full bladder

Causes: obstruction, medications, post-op, neuroimpairment

Signs: small frequent voids, suprapubic distention

Post void residual: >300 mL indicates retention

Events or diagnoses that have urinary retention as a complication

-post op procedure

-BPH

-prostate enlargement for older men

-removal of catheter pt should void in 6-8hr

Urine Output

Normal: 1000-2000 mL/day

30 mL/ hour is minimum output that is okay

Urinary Nursing Diagnoses

Urinary Retetnion

Stress/urge/overflow incontinence

Risk for infection

Impaired skin integrity

UTI

Most common healthcare infection

Risks: female anatomy, catheters, poor hygiene

Symptoms: dysuria, frequency, urgency, cloudy/foul urine

Prevention: peri-care, fluid, avoid unnecessary caths, 8-10 glasses of water

Preventions for LOC declining pts

Fall risk

Ploy pharm

Assisted devices

Low bed

Right lighting

Call light

Yellow socks

Photos calendars clocks and signs

Metabolic acidosis

Too many acids in blood/body and not enough bicarb

PH low < 7.35

Bicarbonate low <22 HCO3

Kussmaul respirations

Confused , weak, low BP, hyperkalemia

Metabolic alkalosis

Loss of acid or increase in bicarbonate

PH high >7.45 (alkaline)

Bicarbonate high >26 (HCO3)

Hypoventilation, mm spasms and cramping, tired

Respiratory Acidosis

Body retaining CO2 from Hypoventilation

CO2 high > 45

PH low < 7.35

Confuse, drowsy, HA, Hypoventilation, tachy

Respiratory alkalosis

Increased ventilation And CO2 levels drop

CO2 Low < 35

PH High > 7.45

Tachypnea

Isolation types and PPE

Contact: eye protection, mask, gown gloves

Droplet: eye protection, mask, gloves

Airborne: N95, gloves