NUR 212: Exam 2 (Revised)

RBC Value

4.2-6.1

Activated Partial Thromboplastin seconds (aPTT)

• 30-40

• low = clotting fast

• high = clotting slow

hemoglobin

• F: 12-16

• M: 14-18

Platelet Count

• 150,000-400,000

WBC

5,000-10,000

LDL Lab

more than 130 = bad

Troponin Lab

• greater than 20 = bad

BNP

• heart failure indicator

• more than 100 = bad

Myocardial Ischemia

• decreased blood flow to the heart → decrease oxygen

• cause of angina

Coronary Atherosclerosis (CAD): Manifestation

• plaques in vessels

• decreased blood flow → decreased oxygen

• SOB, angina radiating to the jaw and/or left arm

Coronary Atherosclerosis (CAD): Nursing Interventions

• Low cholesterol diet → decrease built up

• Lower LDL → with statin

• Exercise

• watch for ruptures → body will clot as a result → can lead to MI

• Statin

Angina Treatment

• Nitro and Rest

• Oxygenate

• Beta-Blocker to decrease workload

• EKG & Troponin levels if not stable angina

Acute Coronary Syndrome: Manifestations

• Angina not relieved by nitro or rest

• emergent

• SOB, N/V, Anxiety, increased HR and RR

• unstable

  • no increase in troponin or abnormal EKG

• NSTEMI

  • normal troponin, abnormal EKG

• STEMI

  • ST elevation, elevated troponin

Acute Coronary Syndrome: Nursing Interventions

• MONA: morphine, oxygen, nitro, aspirin

• oxygenate

• give heparin

• IV access

• EKG leads, troponin levels

• prepare for Cath lab

  • thrombolytics (end in plase) → given if not long wait for cath

STEMI treatments

• Thrombolytics → used if you cannot get the patient to CATH within 120 minutes → end in PLASE → stops the blockage in hopes to increase perfusion

• Percutaneous Coronary Intervention: balloon inflated in artery (preferred method)

• Coronary artery stent or Grafts (CABG) → bypasses blockage

Percutaneous Coronary Intervention: post-op

• monitor bleeding (internal as well; don’t forget to check for bruising) and infection

• lay patient flat for 4-6 hours

• hydrate patient to get AKI dye out of the system used in surgery

Coronary artery stent or Grafts (CABG) : post-op

• Watch BP!

  • low = decreased circulation may be due to donor site

  • high = suture can burst

• Maintain stable fluids

• Pain control

What is a sign of a heart valve issue?

murmur

Mitral Valve Prolapse: manifestations/diagnostic

• minimal symptoms

• mitral click

• genetic

• echo for diagnostics

Mitral Regurgitation: manifestations

• Regurgitating back into the upper left chamber

• Systolic murmur

• Respiratory symptoms!

  • SOB, crackles, orthopnea

• Left atrial hypertrophy

Mitral Stenosis: manifestations

• Thickening of valve → harder for blood to get through → decreased cardiac output

• Diastolic Murmur

• A-FIB, Fatigue

• Linked to strep and rheumatic fever

Aortic Regurgitations: manifestations

• Regurgitating back into the lower left chamber

• Diastolic Murmur

• Visible, bounding pulses

• pounding heart → patient will report

Aortic Stenosis: manifestations

• Thickening of valve → harder for blood to get through → decreased cardiac output

• Systolic Murmur

• Syncope→ worsens with activity → think the blood is having trouble getting to the body

• Low BP

Valve Disorders: nursing considerations and treatment

• fix valve through replacement or suture

• diuretics to reduce fluid volume and fluid restrictions if needed

• beta-blocker to decreased workload

• prevent infection → endocarditis risk

Dilated Cardiomyopathy: Manifestations and Diagnostic

• Muscles are stretched thin → loss of pumping function and more blood

• Confirmed by severely reduced ejection fraction (less than 50)

• Too much fluid

  • JVD

  • Lung crackles

  • Edema

  • SOB

Hypertrophic Cardiomyopathy

• Thick heart muscles → result in arrhythmia

• Arrhythmias can be life-threatening

• Upon exertion

  • SOB

  • Dizziness

  • Feeling faint/weak

  • Chest Pressure

  • Racing heart

• genetic → seen in young athletes

Restrictive Cardiomyopathy: Manifestations

• Stiff ventricles → the heart doesn’t expand as it should

• High diastolic BP → diastolic complications (resting and filling)

• Dyspnea, nonproductive cough, and chest pain

Cardiomyopathy Nursing Interventions

• Cardiac assessment

• oxygenate

• Rest

• low-sodium diet

• CPR education

• Beta-Blockers (LOL)

• ACE (PRIL)

• Diltiazem

• LVAD that mechanically pumps the heart for you → improved pumping is the issue here

Infective Endocarditis: manifestations, risk, interventions

• Infection of heart valves

• Common in IV drug users; a risk for recent dental work, piercings, and tattoos that allow bacteria in

• Fever, weight loss, Janeway lesions (red spots on palms/soles)

Long term IV Antibiotics (PICC line) and acetaminophen for fever

Retest after treatment

Myocarditis: Manifestations, Cause, Diagnostic

• Inflammation of the heart muscle

• Commonly caused by viral infection → vaccines for viral infection and prevention

• No symptoms → if they occur, inflammation is severe

  • Flu-like symptoms

• Biopsy to confirm

Pericarditis: Manifestations and Treatment

• Access fluid surrounding heart → reducing expansion

• PAIN! very painful

  • improves when leaning forward

• Friction Rub, SOB, palpitations, cough

Lean forward to decrease pain, Pericardiocentesis (ACUTE), Pericardial window (Chronic)

Cardiac Tamponade: Manifestation and Treatment

• Pericarditis complication

• Rapid buildup of fluid compressing the heart

• Collapsing cardiac output

• Pericardiocentesis → needle to remove fluid

Diminished heart sounds, JVD, decreased arterial pressure

Left-Sided vs. Right-Sided Heart Failure

• Left-sided HF → backs up into the lungs

  • SOB, crackles, orthpnea

• Ride-sides HF → backs up into the body

  • JVD, edema, weight gain

Heart Failure Nursing Considerations

• Maintain oxygen status

• Low sodium

• Daily weight

• Fluid restriction

• Check HR before meds

• Meds: diaretics, vasodilators, beta blockers, RAAS

Nitro

• for Angina

• 3 times every 5 minutes

• causes headache

• check bp and hr before admin

Statin

• decreases LDL

• CAD treatment

Thrombolytics

• end in PLASE

• clot buster

• given if STEMI patient cannot make it to CATH in time

Acute Pulmonary Edema: Manifestations

• acute fluid buildup in lungs

• “I feel like I’m drowning”

• Pink, frothy sputum

DVT: manifestation, risk, diagnostic

• blood clot in a deep vein

• commonly seen in the lower legs

• redness, swelling

• risk: not moving around (bed rest), long drives, long plane rides

• USE DOPPLER FOR DIAGNOSIS

Hemorrhage: manifestations

• feeling tired

• altered mental status

• bad headache

• syncope

• orthostatic hypotension

• High HR really low BP

Hemorrhage: nursing considerations

• order CT stat to ensure no intracranial bleed

• Give fluids! Oxygen, whole blood, apply pressure to the bleeding if you can see the source

• Assess LOC

Anemia symptoms

• fatigue, weakness

• pale

• Tachy

• SOB

• Dizziness → syncope

• cold intolerance

• headaches

Iron Deficiency Anemia: Manifestations and Treatment

• low RBC production due to low iron (intake or blood loss)

• RBCs carry oxygen

  • SOB, fatigue, pale

• Low hemoglobin, ferritin, and small RBCs

IV Iron (Ferrous Sulfate), Oral Iron (black stool), increase iron diet (spinach, meat, eggs), find bleeding source

Vitamin B12 Deficiency (Pernicious Anemia): Manifestations and Treatment

• Low B12 and/or no intrinsic factor

• smooth, beefy-red tongue and neurological numbness

• recent gastric by pass surgery → wont have intrinsic factor

SUBQ B12 (if no intrinsic factor), B12 Diet (eggs, meat, fish)

Sickle Cell Disease: Manifestations

• sickle shape RBC → stick together → clotting

• PAINFUL

• Swelling

• low hemoglobin → very low baseline

Sickle Cell: Interventions

• reduce infection risk → huge risk

• avoid dehydration, stress, extreme temps, and intense physical exertion

• IV fluids, supplemental oxygen, and aggressive IV opioid pain control

• Long-term maintenance uses hydroxyurea

Thalassemia: Manifestations and Treatments

• RBC are shaped oddly → body attacks them

• These patients will have frequent transfusion → iron overload risk →iron chelation therapy to get extra iron off

• chronic fatigue, weakness, developmental delays, and splenomegaly (enlarged spleen)

Heparin-Induced Thrombocytopenia: manifestations and nursing considerations

• Response to Heparin → body forms small clots everywhere → platelets working everywhere → increase clotting risk still since they are being used up

• Stop heparin

Immune Thrombocytopenic Purpura: Manifestations and Treatment

• body attacks platelets → cannot get transfusion → body will destroy them

• very low platelet count

• Easy bruising (ecchymosis), petechiae on the trunk and extremities, epistaxis (nosebleeds), and heavy menses

Corticosteroids to suppress the immune system

huge bleeding risk → monitor this

Hemophilia: Manifestations and Considerations/Treatment

• long clotting time due to a missing clotting factor 5

• Delayed, prolonged, or persistent bleeding following minor cuts, dental work, or trauma → often seen in kids

IV factor for treatment

• DO NOT USE HEPARIN (blood thinners on these patients)

• head injury? get CT STAT due to bleeding riskl

Disseminated Intravascular Coagulation (DIC): manifestations and treatment

• life-threatening

• The body creates clots, all of which consume platelets → bleeding risk → causes hemorrhage

• Spontaneous bleeding from multiple sites simultaneously (IV insertion sites, mucosal gums, nose, urinary catheter hematuria, petechiae)

• Low platelets + elevated D-dimer + prolonged clotting time

• Septic patient, pregnant patient

Heparin therapy and blood transfusion

Ferrous Sulfate

• IV Iron

• anemia

Steroids: Hemo treatment

• ITP

• They cannot get transfusion

• Reduce immune system reaction

Hydrozyura

• long term sickle cell treatment

4 C’s (Burns)

• cool it → tap water or saline

• clean it → mild soap

• cover it → antimicrobial ointment and absorbent dressing

• comfort it → pain meds

Classification of burns 1-6th degree

• first → epidermis only (like a sunburn)

• second → entire epidermis and top of dermis → BLISTER and WET

• third → complete damage of epidermis and deep into dermis → usually white/yellow and dry → may require skin grafting

All the way through epidermis and dermis (requires skin grafting)'

white/black/brown, dry and leathery, nonblanchable, no pain

• fourth → same as third but goes in subcutaneous tissue

• fifth → same as third but goes to muscle

• sixth → same as third but it goes into bone

Rule of 9s

Effects of burns

• Stop GI and Kidney function

• Infection risk

• Hypothermia

• Increased potassium, low sodium

• cardiovascular and respiratory effects → increased HR, plasma leakage (hypovelmia), decreased cardiac output, low RR status

compartment syndrome

• burn causing so much swelling it pushes on nerves and blood vessels

• Escharotomy or Fasciotomy

Upper airway VS lower airway (burns)

• upper → edema causing reduced oxygenation

• lower → carbon monoxide → pink face → give them 100 oxygen stat → pulse ox will be normal

What to do for burns?

• NG tube and Foley

• IV pain meds → GI not working

• Oxygen

• Fluids

• wash burn if chemical

• EKG if electrical

Parkland fluid resuscitation formula burns

2mL LR patients weight (Kg) * TBSA burn (rule of 9s)

• give first half in the first 8 HOURS

• give second half over the next 16 HOURS

• FROM BURN! if you see patient 1 hour after burn you will only have 7 hours to get first half in

Osteoarthritis: manifestations and treatment

• Damage to cartilage from use

• Asymmetrical joint pain

• Worsens with activity, improves with rest

• Stiffness, deformities

Pain meds, NSAIDS, corticosteroid injection (limited), replacements, mobility aids, rest

Rheumatoid Arthritis (RA): manifestations and treatment

• Chronic autoimmune inflammation of cartilage

• Symmetric affect

• Does not improve with rest

• Swan-neck hands

• Morning stiffness

NSAID, Biologicals, Corticosteroids (for exacerbation)

Lupus: Manifestations and Treatment

• butterfly rash + photosensitivity (UV light trigger) and multi-system organ involvement

• remission and flare-ups

• Managed with hydroxychloroquine (Plaquenil), topical steroids, avoiding sun exposure, and decreasing stress

Gout: manifestations and treatment

• buildup of urate crystals in joint spaces

• PAINFUL!

• swelling, redness, warmth

• once you have what is in the photo → it will not go away

Colchicine (acute), Alloprinol (chronic), Low-purine diet (no meats, selfish, alcohol)

Fibromyalgia: manifestations

• chronic central pain and stiffness

• brain frog and GI issues

HIV / AIDS: Manifestations and Treatment

• Acute: Flu-like symptoms

• Progression: swollen lymph nodes, severe weight loss, chronic diarrhea, and opportunistic diseases

  • CD4 below 200 = AIDS

• Viral load below 75 → low transmission risk

Antiretroviral therapy, prep for prevention

Flu vs common cold: flu interventions

Flu: Fever, aches, chills, tiredness, sudden onset → severe muscle aches

• spreads by droplets

• antiviral within 48 hours after symptoms (Tamiflu) → or end in VIR

• vaccine

Sinusitis: manifestations and treatment

• inflammation of the sinus cavity

• facial pain/pressure, nasal congestion, postnasal drip, headache, fatigue

• Differentiated from seasonal allergies by the presence of fever, bad breath, and thick green or yellow nasal mucus

• Steroid nasal sprays, antibiotics, moisturize nasal passages, avoid triggers, warm compress

Meningitis: Manifestations

• infection of the meninges

• High fever, severe throbbing headache, nuchal rigidity (stiff neck), photophobia, rash, and confusion

• Positive Kernig sign (pain when extending the knee) and Positive Brudzinski sign (hip/knee flexes when neck is flexed)

Meningitis: Nursing Considerations/Interventions

• high-dose steroid

• reduce fever → Acetaminophen

• Lumbar puncture to test CSF fluid → cloudy if bacterial cause

• Requires droplet isolation precautions for at least 24 hours post-antibiotic initiation

Herpes Zoster (Shingles)

• reaction to chickenpox

• Severe pain, burning, and vesicular rash

• give antiviral agents → end in vir

Fungal Skin Infections (Tinea / Ringworm)

• Superficial fungal infection (dermatophytosis) creating characteristic circular lesions

• Red, itchy, ring-shaped rash with raised borders and a clear center

• Can occur on the scalp, body, groin, foot, and nails/toenails

Biologics

• RA treatment

Colchicine vs Allopurinol

Colchicine → acute gout

Allopurinol → chronic gout

Hydroxychloroquine

• lupus treatment

Antivirals

• end in VIR

• herpes, HIV, Flu

Osletmivir (Tamiflu)

• antiviral

• take within 48 hours of symptoms

• for flu

IV opoids

• burns

• sickle cell

What does the liver primarily do?

Metabolism!

Hepatic Dysfunction : Manifestations

• jaundice → high bilirubin level above 2

• Ascites → fluid buildup in the abdominal cavity

• Varices → swollen veins

• Itching

• edema

Hepatic Cirrhosis & Portal Hypertension

• Long-term liver disease → hard scar tissue blocking blood flow through the liver → causing high pressure in veins (Portal Hypertension)

• excess fluid around → fluid overload

  • Ascites

  • esophageal varices

  • liver and spleen enlargement

  • edema

Ascites: manifestations

• fluid in the peritoneal cavity caused by portal hypertension

• Abdominal distension, rapid weight gain, abdominal striae, distended abdominal veins, umbilical hernia, and shortness of breath

Ascities: Nursing Intervention

• paracentesis → needle to drain fluid

• TIPS (Transjugular Intrahepatic Portosystemic Shunt) → helps prevent buildup

• IV salt-poor albumin → pulls fluid out

• low-sodium diet

• diuretics

• daily weights

Esophageal Varices: manifestations

• fragile, dilated veins in the esophagus due to poor hematic function

• prone to rupture → life-threatening hemorrhage

• Hematemesis (vomiting blood), melena (dark, tarry stools), shock (hypotension, tachycardia), and general physical deterioration

Esophageal Varices: Nursing Considerations

• oxygen

• fluids

• stop bleeding

  • IV Octreotide → decrease bleeding

  • Sengstaken-Blakemore Tube → emergent, not preferred as the balloon can restrict airflow

  • Vasopressin

  • Endoscopic Sclerotherapy

  • Esophageal Banding

Hepatic Encephalopathy: Manifestations

• nervous system dysfunction → result in hepatic dysfunction → cannot filter toxic ammonia

• Mental status change, altered LOC, motor disturbances, progression to coma

• Asterixis (flapping tremor of the hands when wrists are extended) and Apraxia (deterioration of handwriting or inability to draw simple figures)

Hepatic Encephalopathy: Treatment

• Lactulose → poop out ammonia → very strong laxitive

• LIMIT PROTEIN AND SALT

Viral Hepatitis (Hep A, B, C, D, E)

• flu-like symptoms, jaundice, dark tea-colored urine, clay-colored stools

• Transmission:

  • Hep A&E → facal-oral

  • Hep B&C → blood, mucus membrane, sexual contact

  • Hep D → only if you have B

• Vaccine for A&B → only ones that have vaccines but Hep B stops you from getting D

Liver Biopsy (Key Diagnostic Procedure): What should the patient do?

• exhale and hold your breath for at least 10 seconds → so your lungs are small and the needle doesn’t puncture

• Goes on the RUQ

• No coughing or straining

• Lie on your right side afterward!

Acute Kidney Injury and Chronic: Manifestations

• Oliguria → low urine production

• Fluid overload

• Elevated Creatinine and BUN

• Fluid & Electrolyte Imbalances

  • high potassium

• Anemia

Polycystic Kidney Disease (PKD): Manifestations

• Cyst on the kidney that can compress it

• Flank or abdominal pain, hematuria, hypertension, and palpable enlarged kidneys

• can travel to brain and heart

Kidney diagnostics: eGFT

eGFT → shows damage

• want it above 90

• Below 15 is really bad → lost 90% kidney function

Treatments for Renal Dysfunction

• Sodium Polystyrene (Kayexalate) → removes potassium

• Epoetin Alfa & Ferrous Sulfate → anemia and low RBC

• Diuretics (Furosemide / Bumetanide)

• Dialysis

• transplant

• Low sodium, fluids protein diet

Hemodialysis (HD)

• Acts as the kidney to get waste out

• Vascular Access Types: Arteriovenous (AV) Fistula

  • should fill a thrill

  • hearing bruit

  • do not take BP, blood drawl or anything from that arm

Peritoneal Dialysis (PD)

• In abdomen

• Warm dialysate fluid is instilled into the abdominal cavity via a Tenckhoff catheter (Infuse → dwell → drain)

• What comes in must come out

Hepatic (Liver) Dysfunction Lab Profile

• low

  • Albumin

• high

  • Ammonia: greater than 45

  • AST & ALT: greater than 34

  • PT time → bleeding risk

Renal (Kidney) Dysfunction Lab Profile

• Low

  • H&H

  • Calcium

• High

  • BUN: greater than 20

  • Creatinine: greater than 1.3

  • Potassium: greater than 5

  • Phosphorus: greater than 4.5