Adults Exam 1 Study Guide PAIN & OBESITY: 11 questions How and when do you assess pain? Subjective vs Objective? The Concept of Pain ● “Unpleasant sensory, emotional experience with actual or potential tissue damage” ● Personal/subjective experience ● Patient is the m ost reliable indicator of pain and essential component of pain assessment ● Most common reason for seeking health care Assessing Pain for Specific Populations The Hierarchy of Pain Measures - nonverbal patient FLACC - young children PAINAD - patients with advanced dementia CPOT - patients in critical care units What are different types of pain? How do they present? What are long and short term effects of pain? Types of Pain Acute Pain Differs from chronic pain by duration Short duration, usually resolves with treatment Result of tissue damage; surgery; trauma Chronic Pain Can be time limited or last a lifetime Cancer Noncancer: peripheral neuropathy, back pain, osteoarthritis Breakthrough Pain Chronic pain with acute exacerbations Chronic back pain from war + associated symptoms (weakness) Adults Exam 1 Study Guide Classifications of Pain Nociceptive (Physiologic) Pain Neuropathic (Pathophysiologic) Pain Tissue injury Somatic (bone, joint, skin, connective tissue, burn) and visceral (organ, GI tract, ulcerative colitis) Damage to the peripheral or central nervous system (phantom pain or back pain from compressed nerve) Mixed Pain Poorly defined Fibromyalgia, Lyme disease pain Difficult to plan care for Centrally or peripherally generated Treat with: Opioids Nonopioids Local anesthetics Treat with: Adjunctive pharmacologic therapy antidepressants, neuromodulators, lots of variability with response; What are your interventions (pharmacological and nonpharm). If pharm, focus on the NURSING considerations! What do you need to know before and during administration of pain meds, whether po, IV, IM, topical / patches. For the medications, again, focus on the nursing interventions – are there parameters, what would you assess first? I won’t focus on aspects like mechanism of action or onsets and peaks for these meds. But know what to monitor for. Know how to monitor an epidural as well – what are potential side effects? What would you do if a patient has an adverse effect? Physiologic Basis for Pain Relief ● Opioid analgesics act on the CNS to inhibit activity of ascending nociceptive pathways ● NSAIDS decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin) ● Local anesthetics block nerve conduction when applied to nerve fibers Adults Exam 1 Study Guide Analgesic Agents NONOPIOID OPIOID Acetaminophen NSAIDS ● Ibuprofen ● Naproxen ● Celecoxib Mu agonist ● Morphine ● Hydromorphone ● Fentanyl ● Oxycodone Agonist-antagonist ○ Buprenorphine ○ Nalbuphine ○ Butorphanol What are age related considerations for both pain and analgesic agents? Gerontologic Considerations Sensitive to agents that produce sedation and CNS effects Initiate with low dose and titrate slowly Increased risk for NSAID-induced GI toxicity Acetaminophen preferred for mild pain Opioid dose should be reduced 25-50% Consider side effects, pt teaching, adjunctive / nonpharmacological therapy, what if the effect isn’t working? Are there any special considerations for the different routes? Consider the nursing process and a plan or care for someone with pain Nursing Process Framework for Pain Management Identify goals for pain management Establish nurse-patient relationship, teaching Provide physical care Manage anxiety related to pain Evaluate pain management strategies Adults Exam 1 Study Guide Medications to focus on: NSAIDS, Tylenol, morphine, fentanyl, oxycodone, and opioids in general – know the classes, and particular patient teaching, monitoring, assessments, contraindications NSAIDS Ibuprofen (Motrin, Advil), Naproxen (Aleve), Celebrex Actions: Analgesic effects Inhibits prostaglandin synthesis by blocking COX1 and 2 sites leading to anti-inflammatory effect, analgesia, antipyretic Side Effects: HA, Nausea, Dyspnea GI pain, Diarrhea Constipation, Rash Bleeding Bone marrow depression Considerations: teach signs of GI bleed tarry stools, low energy PPI or H2 blockers for GI protection Contraindications: Allergy CV dysfunction Hypertension GI bleeding/ulcer Pregnancy/lactation Renal/hepatic dysfunction AVOID: Beta blockers, loop diuretics Acetaminophen (Tylenol) ● ● ● ● ● ● Mild to moderate pain relief Reduction of fever Lacks anti-inflammatory effect DOES NOT CAUSE BLEEDING OR GI PROBLEMS CAN CAUSE HEPATOTOXICITY Antidote: acetylcysteine (Acetadote) Oxycodone ● With aspirin - Percodan ● With acetaminophen - Percocet ● Long acting form: OxyContin ○ Should be taken whole, never crushed ○ High abuse potential ○ Very useful for chronic pain Adults Exam 1 Study Guide Morphine Class: schedule II Narcotic Actions: Reduces moderate to severe pain Produces analgesia, CNS depression Respiratory depression GI Depressant Contraindications: Respiratory depression Liver disease Lung disease ICP/head injury Hypersensitivity Applying heat (heat packs, heating pads, showers), directly over transdermal patch leads to increased absorption → life-threatening respiratory depression Fentanyl Indications: Analgesia before, during, after surgery Chronic/breakthrough pain Actions: Binds to opioids receptors Increases dopamine Route: IM, IV, nasal spray, transdermal Adverse Effects: Respiratory depression Dizziness Sedation Cardiac arrest Patient Teaching: Opioids ● Educate effects of analgesic agents ● Effects are dose dependent → always consider decreasing dose as a way to reduce an adverse effect + add non opioid analgesics ● Address fears of addiction Nursing Considerations: Opioids ● Be aware of potential for withdrawal (rhinitis, abdominal cramping, diarrhea, agitation) ● Need tapering schedule for patients receiving opioid therapy for several days ● Prevent respiratory depression by monitoring sedation levels & respiratory status frequently; decrease dose as soon as increased sedation is detected Adults Exam 1 Study Guide For obesity, review the risk factors and the complications. Consider how you might respond to patients and what might be important patient teaching. Obesity: Management Interventions ● ● ● ● Lifestyle modifications Pharmacologic Nonsurgical Surgery Obesity: Lifestyle Modifications ● ● ● ● ● ● ● Aimed at weight loss and maintenance Setting weight-loss goals Improving diet habits Increasing physical activity Addressing barriers to change Self-monitoring and strategizing ongoing lifestyle changes aimed at a healthy weight Health sleep habits Obesity: Nursing Interventions Mechanics of ventilation and circulation ● Low Fowler position to maximize chest expansion ● Continuous pulse oximetry ● Supplemental oxygen ● CPAP Central and Peripheral Circulatory Compromise ● Use appropriate size BP cuff* ● Monitor for DVT Pharmacokinetics and Pharmacodynamics ● Some drugs have enhanced effects while others have diminished effects with patients with obesity (require more opioid for pain relief) ● Weight-based calculations of drug dosages for obese patients may need to be altered Skin Integrity & Body Mechanics ● Assess for pressure ulcers ● Specialty bariatric equipment Adults Exam 1 Study Guide RESPIRATORY: approx. 12 questions Asthma, COPD, TB, PNA, PE What are the S&S for both asthma and COPD? What are the risk factors? For what and how will you assess? Depending on presenting symptoms, how will you act? What is the intervention if pt is symptomatic? What might you expect to assess / see in patients with asthma and COPD (chronic and acute)? How do the signs and symptoms relate to the pathophysiology? There may be questions related to the case studies as well (which is also from the text). Be able to identify nursing management for patients receiving oxygen therapy, incentive spirometry, and nebulizer therapy. What would be patient teaching if one is to go home on oxygen? Asthma Chronic inflammatory disease of airways that causes hyper-responsiveness, mucosal edema, mucus production Inflammation leads to cough, chest tightness, wheezing, dyspnea Reversible → spontaneously or with treatment Allergy is the strongest predisposing factor Manifestations: Cough Dyspnea Wheezing Exacerbations Cough, productive or not Chest tightness Diaphoresis Tachycardia Hypoxemia, central cyanosis Management: 24-7 Figure Monitor for sx severity (status asthmaticus) Lung sounds Peak flow Pulse ox Vitals IV fluid Manage anxiety Medications: Quick-Relief: Beta 2 adrenergic agonists Anticholinergics Long Acting: Corticosteroids Long acting Beta 2 adrenergic agonists Leukotriene modifiers Adults Exam 1 Study Guide Asthma: Patient Teaching Patient Teaching: How to identify/avoid triggers Proper inhalation techniques How to perform peak flow monitoring How to implement an action plan When/how to seek assistance Video: Using a Peak Flow Meter Nurses Will: Teach the patient about their asthma Teach the purpose and action of each medication Discuss triggers Teach inhalers techniques Teach how to perform Peak Flow Meter Asthma Action Plan Teach Back Methods Chronic Obstructive Pulmonary Disease (COPD) Slowly progressive respiratory disease of airflow obstruction Emphysema/Chronic Bronchitis Preventable and treatable → not fully reversible Involves airways, pulmonary parenchyma Pathophysiology: Airflow limitation is progressive, associated w/ abnormal inflammatory response to noxious particles or gases Chronic inflammation damages tissue Complications: Respiratory insufficiency/failure Pneumonia Chronic atelectasis Pneumothorax Heart failure (cor pulmonale) Manifestations: Chronic cough Sputum production Dyspnea (weight loss due to dyspnea) Barrel Chest Adults Exam 1 Study Guide COPD Management Assessment & Diagnosis: Pulmonary function tests Spirometry Arterial blood gas Chest X-Ray Medications Bronchodilators, MDIs - Beta adrenergic agonists - Muscarinic antagonists (anticholinergics) - Combination agents Corticosteroids Antibiotics Mucolytics Antitussives Nursing Management Obtain hx Review of diagnostic tests Achieve airway clearance Improve breathing pattern/activity tolerance MDI patient education (Chart 24-2 and 4) Nursing care plan 24-5 Chart Medical Management Promote smoking cessation Manage exacerbations Supplemental O2 therapy Pneumococcal/Influenza vaccine Adults Exam 1 Study Guide TB – what is TB and who is at risk? What are special nursing precautions and what might be priority for nursing management. Tuberculosis (TB) Infectious disease that affects lung parenchyma Airborne transmission (coughing, sneezing, laughing) Manifestations: Insidious S&S Low grade fever Unproductive or mucopurulent cough Hemoptysis Night sweats Fatigue Weight loss Risk Factors: Close contact w/ active TB Immunocompromised status Substance abuse Health care worker performing high-risk activities (intubation, bronchoscopy) Assessment: TB Skin test - Mantoux Method Chest X-Ray Sputum testing *23-4 first-line medications Management: Promoting airway clearance Advocating adherence to the treatment regimen Promoting activity and nutrition Preventing transmission Prevention: AFB (acid-fast bacilli negative pressure room) isolation precautions for all confirmed/suspected pts Early identification Adults Exam 1 Study Guide Pneumonia – what are risk factors? How can we prevent it? Focus on the nursing care and prevention! Pneumonia Inflammation of lung parenchyma Cause: Bacteria Mycobacteria Fungi Viruses Classification: Community Acquired (CAP) Healthcare Associated (HCAP) Hospital Acquired (HAP) Ventilator Associated (VAP) Assessment & Diagnosis: Chest X-ray Blood culture Sputum examination Bronchoscopy → acute severe infection Management: Antibiotic (after culture results) Fluids Oxygen for hypoxia Antipyretics/Antitussives Decongestants Antihistamines Antibiotics are NOT indicated for viral infections but for secondary bacterial infection Risk Factors: Heart failure Diabetes Alcoholism COPD AIDS Influenza Manifestations: Orthopnea, crackles, increased tactile fremitus, purulent sputum, tachypnea Streptococcal: sudden onset of chills, fever, pleuritic chest pain, tachypnea, respiratory distress Viral/Mycoplasma/Legionella: bradycardia Other: Respiratory tract infection, HA, fever, pleuritic pain, myalgia, rash, pharyngitis Prevention: Pneumococcal Vaccine 65 years of age or older 19 years or older with conditions that weaken the immune system Adults Exam 1 Study Guide PE – What are the risk factors? What is a PE? How can they be prevented? How are they treated and what are important assessments and assessment findings? Pulmonary Emboli Obstruction of the pulmonary artery by a thrombus Inflammatory process obstructs area → results in diminished or absent blood flow Bronchioles constrict → increase pulmonary vascular resistance/pressure & R. ventricular workload Ventilation-perfusion imbalance, R. Ventricular failure, shock occurs Risk Factors: Trauma Surgery Pregnancy Heart failure Hypercoagulability Immobility, venous stasis Dyspnea is the most common symptom Prevention: Exercises to avoid venous stasis ● Early ambulation ● Anti-embolism stockings Treatment: ● Anticoagulant & thrombolytic therapy ● Surgical interventions Adults Exam 1 Study Guide Which patients are at risk for atelectasis? How is prevented? What might be assessment findings? What nursing interventions can be done to prevent aspiration? Who is at risk for aspiration? Atelectasis Closure or collapse of alveoli Most common is acute → postop setting Symptoms: Insidious Increasing dyspnea Cough Sputum production Assessment & Dx: Increased work of breathing Hypoxemia ↓ Breath sounds Crackles Chest x-ray may show atelectasis before symptoms appear SpO2 → low saturation of hemoglobin with oxygen (less than 90%) Acute Atelectasis Tachycardia Tachypnea Pleural pain Central cyanosis if large areas of lung are affected Management: Improve ventilation/remove secretions First line: frequent turning, early ambulation, lung volume expansion maneuvers, coughing ICOUGH PEEP, CPAB, Bronchoscopy Endotracheal intubation/mechanical ventilation Thoracentesis to relieve compression Prevention: Frequent turning/Early mobilization Incentive spirometer Voluntary deep breathing Secretion management Chronic Atelectasis Similar to acute Pulmonary infection may be present Adults Exam 1 Study Guide Aspiration Inhalation of foreign material into the lungs Manifestations: Tachycardia Dyspnea Central cyanosis Hypertension Hypotension Potential death *Silent aspiration Nursing Interventions: HOB elevated > 30 degrees Avoid suctioning/anything that will stimulate gag reflex Check for placement before tube feedings Thickened fluids for swallowing problems Prevention: Pneumococcal Vaccine reduces incidence of pneumonia, hospitalizations for cardiac conditions, & deaths in older adult population - Recommended for all adults 65 years of age or older and 19 years or older with conditions that weaken the immune system Aspiration: Nursing Process Assessment: Vitals Secretions: Amount, Odor, Color (AOC) Cough: frequency & severity Tachypnea, shortness of breath Inspect/auscultate chest Changes in mental status, fatigue, edema, dehydration *especially in older patients Nursing Diagnosis: Ineffective Airway Clearance Fatigue & Activity Intolerance Risk for Fluid Volume Deficit Imbalanced Nutrition Knowledge Deficit Planning: Improved airway patency Increased activity Maintenance of proper fluid volume Understanding of the treatment Absence of complications Interventions: Oxygen w/humidification (face mask or cannula) Coughing techniques Position changes Incentive spirometry Expected Outcomes: Demonstrates improved airway patency Rests and conserves energy and slowly increasing activities Maintains adequate hydration; adequate dietary intake Verbalizes increased knowledge of management strategies Exhibits no complications Adults Exam 1 Study Guide Meds – what meds might you expect to give for Asthma or COPD? What if it’s an exacerbation? What are your nursing considerations for them? Refer to the list I put in your announcement. Medications to focus on: inhaled corticosteroids, anticholinergics, beta adrenergic agonists… so rescue vs daily Medications for Asthma Medications for COPD Quick-Relief: Bronchodilators, MDIs Beta 2 adrenergic agonists - Beta adrenergic agonists Anticholinergics - Muscarinic antagonists Long Acting: (anticholinergics) Corticosteroids - Combination agents Long acting Beta 2 adrenergic agonists Corticosteroids Leukotriene modifiers Antibiotics Mucolytics Antitussives Peak flow vs incentive spirometry – what’s the difference? What are they used for? Peak Flow Spirometry Incentive Spirometry Measures the highest airflow during a forced expiration Method of deep breathing Provides visual feedback to encourage patient to inhale slowly & deeply to maximize lung inflation and prevent/reduce atelectasis Used after surgery Purpose: to ensure the volume of air inhaled is increased gradually; used in post-operative patients Purpose: Helps measure asthma severity & indicates current degree of asthma control Adults Exam 1 Study Guide What is important pt teaching that goes along with these disorders? Know the difference between orthopneic position and orthopnea Orthopneic Position Orthopnea A position assumed to relieve orthopnea Shortness of breath when lying flat, relieved by sitting or standing Found in heart disease & COPD CARDIO: approx. 17 questions Hypertension – What are risk factors! What are the ranges? What are people with htn at risk for? What are your assessments? What are your interventions – this includes pharm and non-pharm. HTN: Major Risk Factors Majority of risk factors are modifiable Smoking Obesity Physical activity Dyslipidemia Diabetes mellitus Microalbuminuria or GFR < 60 mL/min Older age Family history Blood Pressure New Guidelines Normal Less than 120/80 mm Hg Elevated Systolic between 120-129 and diastolic less t han 80 Stage 1 Systolic between 130-139 or d iastolic between 80-89 Stage 2 Systolic at least 140 or d iastolic at least 90 mm Hg Hypertensive Crisis Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if signs of organ damage Adults Exam 1 Study Guide HTN: Collaborative Problems and Potential Complications ● ● ● ● ● ● ● Left ventricular hypertrophy Myocardial infarction Heart failure Transient Ischemic Attack (TIA) Cerebrovascular disease (CVA, stroke, brain attack) Renal insufficiency, chronic kidney disease Retinal hemorrhage Medical Management of Hypertension Maintain BP <140/90 mmHg < 150/90 mm Hg for older adult patients Lifestyle Modifications Weight reduction Dash diet, decreased sodium intake Regular physical activity Reduced alcohol consumption Pharmacologic Therapy ● Decrease peripheral resistance, blood volume ● Beta Blockers decrease strength and rate of cardiac contraction ● Diuretics, beta blockers, alpha 1 blockers, combined alpha and beta blockers, vasodilators, ACE inhibitors, ARBs, calcium channel blockers dihydropyridines, direct renin inhibitors What are your goals for these patients (short term and long term)? How do you know if your interventions are working? What is important pt teaching for those with HTN? Planning and Goals ● ● ● ● Understanding of the disease process and its treatment Participation in a self-care program Absence of complications Lower and controlling BP without adverse effects or undue cost Adults Exam 1 Study Guide HTN: Interventions ● ● ● ● Support and educate patient about treatment regimen Reinforce and support lifestyle changes Taking medications as prescribed Follow up care HTN: Evaluation and Outcomes ● Reports knowledge of disease management sufficient to maintain adequate tissue perfusion ○ Make sure they know where to keep their BP ○ Maintains BP at less than 140/90 mm Hg (less than 150 mm Hg for adults older than 60 years of age) with lifestyle modifications, medications, or both ○ Demonstrates no symptoms of angina, palpitations or vision changes ○ Has palpable peripheral pulses ● Has no complications ○ No changes in vision, exhibits no retinal damage on vision testing ○ Maintains pulse rate and rhythm and respiratory rate within normal ranges; reports no dyspnea or edema ○ Maintains urine output consistent with intake; has renal function test results with normal range ○ Demonstrates no motor, speech, or sensory deficits ○ Reports no headaches, dizziness, weakness, changes in gait, or falls Know your antihypertensives (classes) and what are the nursing considerations for administration? Beta blockers, ACE inhibitors, diuretics (Lasix), ARBS Adults Exam 1 Study Guide Furosemide (Lasix) Diuretics are also known as “water pills” - they help increase the amount of urine production Loop-diuretics act at the loop of henle in the kidney. Primarily used to treat hypertension, pulmonary edema, and kidney disease. Actions: Diuretic Inhibits the reabsorption of sodium and chloride from distal renal tubules and the loop of henle. Leads to sodium rich diuresis Indications: Treatment of edema associated w/ heart failure, acute pulmonary edema, HTN. Contraindications: Allergies Electrolyte depletion Renal failure Hepatic coma Caution in diabetics Adverse Effects: Dizziness Anorexia Paresthesias Glycosuria *Can result in HYPOKALEMIA, HYPOCALCEMIA, due to loss of fluids Considerations: IV Slow push Assess I&O’s Monitor weight Check K+ before & dietary potassium Beta Blockers “-lol” *Metoprolol (Lopressor), Atenolol (Tenormin), Propranolol (Inderal) Indications: Angina HTN Acute MI A fib/flutter Actions: Inhibits SNS stimulation Beta 1: affects heart Beta 2: drugs that block B2 receptors can cause bronchoconstriction (do not give to asthmatic patients) Adverse Effects: Dizziness Fatigue N/V/D Cautions: Diabetes - can mask signs of hypoglycemia Hypothyroidism Considerations: Monitor vital signs Assess lung sounds Adults Exam 1 Study Guide Angiotensin-II Receptor Blockers (ARBs) *Losartan (Cozaar) Indications: Heart failure Adverse Effects: Less likely to cause hyperkalemia or persistent cough Actions: Allows Angiotensin II to be made but PREVENTS body from responding to it Prevents vasoconstriction Prevents aldosterone secretion Considerations: Monitor renal fxn, BP Interactions with Phenobarbital, Diltiazem, Azoles DON’T USE WITH ACE INHIBITORS Angiotensin-Converting Enzyme (ACE) Inhibitors “-pril” *Enalapril (Vasotec), Lisinopril Indications: Heart failure LV dysfunction Adverse Effects: Dry hacking cough → use different ACE (Switch to Arbs to get rid of cough) Dizziness Actions: Block conversion of Angiotensin I to Angiotensin II Decrease vasoconstriction Considerations: Monitor tachycardia, angina, heart failure Interactions with NSAIDS & Allopurinol **TAKE ON AN EMPTY STOMACH** For someone with angina or any chest pain – what and how will you assess? Know the pathophysiology, clinical manifestations and treatment for angina. Know the types of angina. Chest Pain Assessment ● OLDCART ○ Onset, Location/Radiation, Duration, Character, Aggravating factors, Relieving factors, Timing ● Setting in which chest pain occurred (home or work, post-exercise) ● If patient takes medication for chest pain (i.e. nitroglycerin) Adults Exam 1 Study Guide What is pertinent pt teaching for angina? If they’re taking nitro, what teaching goes along with it? How do you assess a pt with chest pain? Remember to prioritize! What are possible interventions? How do we know if it’s an MI? Diagnostics? For all angina, CAD, ACS, MI – know signs and symptoms, risk factors Angina Pectoris Definition: syndrome characterized by episodes or paroxysmal pain/pressure in anterior chest caused by insufficient coronary blood flow Pathophysiology: Physical exertion/emotional stress → increase myocardial oxygen demand and coronary vessels are unable to supply sufficient blood flow to meet the demand Findings: Tightness/choking/heavy sensation Retrosternal, radiate to neck/jaw/left back Dyspnea, SOB, dizziness, N/V Pain of typical angina subsides with rest or NTG Unstable angina → increased frequency/severity, NOT relieved by rest/NTG → medical intervention required Patient Teaching: Avoid activity that produces chest pain/dyspnea Avoid extreme heat/cold Stop smoking Engage in gradual physical activity Call 911 if pain is not relieved in 15 mins after taking 3 nitroglycerin tabs in 5 min intervals Stable Angina Unstable Angina Provoked by: Exercise/activity, emotion, heavy meal New onset or increase in frequency/severity Occurs at REST Acute Treatment: Rest, nitroglycerine (can pretreat before exercise) Acute Treatment: Rest, oxygen, nitroglycerin, aspirin Prinzmetal (Variant) Angina Coronary vasospasm Occurs at REST EKG changes Silent ischemia Adults Exam 1 Study Guide What is nitro, anyway? What are side effects and nursing considerations? For nitro – know the med, when and how it’s taken, patient teaching, MOA Nitroglycerin Action: Reduce preload & afterload Reduce oxygen demand of heart Treat angina pectoris Side Effects: Hypotension Tachycardia Flushing Headache Routes: Sublingual tablet/spray Capsule Topical IV Nursing Considerations: Place tab sublingually - wait 5 minutes before administering another dose (up to 3 max) Advise patient to sit down to avoid hypotension & syncope Renew Rx every 6 months Take proactively before an activity to prevent pain Adults Exam 1 Study Guide Know the patho, clinical manifestations and treatment for MI as well as coronary atherosclerosis. Myocardial Infarction/ACS Pathophysiology: Plaque rupture/thrombus formation leads to complete occlusion of the artery; leading to ischemia and necrosis of the myocardium Cells deprived of oxygen → ischemia develops → lack of oxygen results in infarction (death of cells) Causes: Vasospasm (sudden constriction/narrowing) of coronary artery Decreased oxygen supply (from acute blood loss, anemia, or low BP) Increased demand for oxygen (rapid HR, amphetamine use) Overall: Imbalance between myocardial oxygen supply and demand Assessment: SOB, indigestion, nausea, anxiety, cool pale skin, increased HR & RR Chest Pain Suddenly occurs, continues despite rest and medication ECG Changes ST elevation in two contiguous leads → key diagnostic indicator for MI Lab Studies: cardiac enzymes, troponin, creatine kinase, myoglobin Initial Management: Immediately receive supplemental oxygen, aspirin, nitroglycerin, morphine (mnemonic: MONA) Thrombolytics (Fibrinolytics): Administered IV Dissolves thrombus TNKase, Activase (do not use if patient has bleeding disorder) Adults Exam 1 Study Guide Know the signs and symptoms of ACS – what are important assessments you might note Acute Coronary Syndrome (ACS) and Myocardial Infarction (MI) ● Emergency ● Acute onset of myocardial ischemia that results in myocardial death if not intervened ● Coronary occlusion, heart attack, MI all used synonymously → MI preferred Assessment: Chest Pain ● Suddenly occurs, continues despite rest and medication ● SOB, ℅ indigestion, nausea, anxiety, cool pale skin, increased HR & RR ECG Changes ● ST elevation in two contiguous leads → key diagnostic indicator for MI Lab Studies: cardiac enzymes, troponin, creatine kinase, myoglobin Adults Exam 1 Study Guide Coronary Atherosclerosis Pathophysiology: Accumulation of lipid deposits/fibrous tissue within arterial walls & lumen Blockages & narrowing of the coronary vessels reduce blood flow to the myocardium Atherosclerosis leads to heart disease CVD is the leading cause of death in the US for men & women of all racial/ethnic groups CAD is the most prevalent cardiovascular disease in adults Cause: Myocardial ischemia Manifestations: Symptoms/complications r/t location & degree of vessel obstruction Angina pectoris (most common manifestation) Epigastric distress Pain radiates to jaw/left arm SOB Myocardial infarction Heart failure Sudden cardiac death Prevention: Control cholesterol Dietary measures Physical activity Medications Cessation of tobacco use Manage HTN Control diabetes Cholesterol Medications: Six types of lipid-lowering agents: 3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA/statins) Nicotinic acids Risk Factors Family history Age Gender Race High cholesterol (diet) Smoking Type II Diabetes Elevated LDL Framingham risk calculator Metabolic syndrome hs-CRP (high-sensitivity C-reactive protein) → inflammatory marker that shows the risk of having a cardiac event Fibric acids (fibrates) Bile acid sequestrants (resins) Cholesterol absorption inhibitors Omega-3 acid-ethyl esters Adults Exam 1 Study Guide Cholesterol – HDL, LDL, diet, medications, nursing consideration, pt teaching, diet? Diet for all! HDL Protein bound lipid that transports cholesterol to the liver for excretion in the bile Higher Protein:Lipid ratio Beneficial effect on arterial wall (GOOD cholesterol) LDL Protein-bound lipid that transports cholesterol to tissues in the body Strong association w/ CAD Lower Protein:Lipid ratio Harmful effect on arterial wall (BAD cholesterol) Heart Failure – Right sided vs. left sided– what’s happening with each? What is HF, what’s going on? What are signs and symptoms for each? How would assess the patient? Any diet considerations? What are your assessments and interventions? What assessment findings might you expect? Left-Sided HF Pulmonary congestion (ventricle can’t effectively pump blood out) S3 or “ventricular gallop” Dyspnea on exertion (DOE) Low O2 sat Dry, nonproductive cough initially Oliguria “Left → Lung” (mnemonic) Right-Sided HF Viscera and peripheral congestion JVD Dependent edema Hepatomegaly Ascites Weight gain Adults Exam 1 Study Guide Know digoxin – what is it, how does it act, contraindications, assessments, interactions Digoxin - Cardiac Glycoside Actions: Increases force of myocardial contraction Slows conduction through AV node Improves contractility Contraindications: AV Block Uncontrolled ventricular arrhythmias Risk for Toxicity: Elderly Excretion issues Diuretics/Lasix Assessments: Monitor serum potassium Digoxin effect is enhanced in hypokalemia, hypercalcemia, hypomagnesemia → lead to toxicity Observe for bradycardia Considerations: Hold Digoxin if HR is less than 60bpm Monitor I&O, daily weights Interactions: Thiazide/Loop Diuretics/Corticosteroids cause hypokalemia which increases r/o toxicity Digitalis Toxicity: Headaches → drowsiness, vision changes, “yellow halo” around objects → report any of these side effects immediately Fluid & Electrolytes: approx. 10 questions Fluid excess vs fluid deficit (overload vs dehydration) – Signs and symptoms of each. How do you know? Are there diagnostics (blood, urine)? What might be causes? For what symptoms and signs would you assess? Adults Exam 1 Study Guide Fluid Volume Deficit (FVD) Hypovolemia Loss of extracellular fluid volume that exceeds the intake of fluids When water and electrolytes are lost in the same proportion Ratio of serum electrolytes to water remains the same Causes: Vomiting Diarrhea Fever Fistulas Sweating Burns GI Suctioning ↓ fluid intake (nausea) Endocrine issues (Diabetes, DI) Symptoms: Weight loss Low BP Tachycardia Decreased skin turgor Concentrated urine Flat neck veins Dizziness Weakness Thirst Confusion Nursing Management: Assess I&O Q8h or hourly depending on severity Daily weights same time everyday wearing same thing Vitals strictly Qh, Q4h, or every shift Assess: Skin turgor, mucosa, mental status changes, giving fluids (PO or IV), minimize fluid loss *Shouldn’t be confused with dehydration: loss of water alone with increased serum sodium levels Adults Exam 1 Study Guide Fluid Volume Excess (FVE) Hypervolemia Isotonic expansion of the ECF caused by abnormal retention of water and sodium in the same proportions in which they normally exist in ECF There's MORE fluid and MORE sodium Can be life threatening Causes: Fluid overload Diminished homeostatic mechanism Heart failure Kidney failure Liver cirrhosis Consumption of excessive salt Sodium containing fluids Nursing Management: Restricting fluid Daily weights Strict I&Os Symptoms: Weight gain Crackles in lungs Changes in LOC ↑BP Shortness of breath Edema Adults Exam 1 Study Guide Electrolytes – what can happen with high (hyper) or low (hypo) of each? For what do you need to monitor? What are your priorities? What are potential causes? What labs and diagnostics will you need to monitor? What assessments will you perform? Electrolytes Electrolyte Functions in Body HYPER- HYPO- Calcium Necessary for muscle contraction, nerve function, blood clotting, cell division, healthy bones/teeth “Swollen & SLOW” Constipation, bone pain, kidney stones, DTR Trousseau’s (arm twerk) Chvostek’s (face twitch) Diarrhea Chloride Maintains fluid balance N/V, swollen dry tongue, confusion Diarrhea, Vomiting Fever, Sweating Potassium Regulates heart contraction, maintain fluid balance “Tight & Contracted” ST elevation Increased BP, pulse Diarrhea, Paralysis “Low and SLOW” Prominent U wave Flat T wave Muscle cramping Abdominal distention Magnesium Necessary for muscle contraction, nerve function, heart rhythm, bone strength, generating energy, building protein Decreased HR & BP Hypoactive bowel sounds Shallow RR Prolonged PR “WILD!” ST depression, T inversion, increased HR, diarrhea, hyperreflexia Sodium Maintains fluid balance and necessary for muscle contraction & nerve function “BIG & BLOATED” Red skin, edema, low fever, THIRSTY, N/V, swollen dry tongue “Depressed/Deflated” Seizures, coma, weak thready pulse, respiratory arrest Adults Exam 1 Study Guide Hyponatremia Serum sodium < 135 mEq/L Think NEURO Causes: Excess water Increased sodium loss GI suctioning Diarrhea Inadequate salt intake Fluid shift from certain IV fluid administrations Diuretics (Lasix) Vomiting Symptoms: Lethargy HA Confusion Apprehension Seizures Coma Nursing Management: Monitor labs I&O Urine specific gravity Pulses (bounding or bulging neck veins) Changes in BP/respirations Changes in sensorium as a result of cerebral edema Daily weights Edema/determine if it’s pitting Report any changes! Adults Exam 1 Study Guide Hypernatremia Serum sodium > 145 mEq/L Occurs in patients with normal fluid volume, FVD or FVE Most affected are very old/young, and cognitively impaired Causes: M - Medications/meals O - Osmotic diuretics D - Diabetes Insipidus E - Excessive H2O loss L - Low water intake Symptoms: Thirst Weakness Nausea ↑HR Nursing Management: Monitor changes in LOC Hypokalemia Serum potassium < 3.5 mEq/L Think HEART Causes: Respiratory alkalosis from hyperventilation Diuretics Increased urine output NG suctioning Severe vomiting/diarrhea Symptoms: Alkalosis Shallow Respirations Irritability Weakness, Fatigue Arrhythmias - Tachy, irregular, and/or Brady Lethargy Thready pulse ↓ Intestinal motility Nausea/Vomiting Ileus (inability for bowel to contract) Nursing Management: Watch for skeletal muscle weakness (starts at arms/legs and progresses → paralysis) Telemetry/EKG changes Watch for labs, look for changes in motility, vital signs, LOC Watch for “A SICK WALT” Adults Exam 1 Study Guide IV Potassium Replacement NEVER DONE IV PUSH or IM - sometimes PO - always administered on a pump and at SLOW rates When is IV potassium replacement necessary? ● Life-threatening situations ○ Severe weakness ○ Respiratory distress ○ Cardiac arrhythmias ○ Rhabdomyolysis ○ When oral administration is not possible ● Infusion rates should be limited to 20 mEq/hr to prevent catastrophic effect of a potassium bolus to the heart ● Patient education: infusion burns so you want to monitor the infusion site ○ Turn the rate down ○ Place a cool pack Hyperkalemia Serum potassium > 5 mEq/L Think HEART Symptoms: Changes in mood Anxiety EKG changes Decreased urine output Muscle twitches Cramps Nursing Management: Monitor for EKG changes Monitor labs Treatment: Diuresis Calcium Insulin Albuterol K Oxalate → laxative helps pull potassium out Dialysis Adults Exam 1 Study Guide Hypocalcemia Serum calcium level < 8.6 mg/dL Must be considered in conjunction with serum albumin level Serum calcium level controlled by parathyroid hormone and calcitonin Symptoms: Convulsions Arrhythmias Tetany Spasms and Stridor Treatment: IV calcium gluconate for emergency Oral calcium and Vitamin D supplements Nursing Management: Seizure precautions Exercises to decrease bone calcium loss (weight-bearing) More calcium in diet Patient teaching related to diet and medications If parathyroid is HIGH, calcium will be high/vice versa (monitor labs) Hypercalcemia Serum calcium > 10.5 mg/dL Causes: Hyperparathyroidism Cancers Too much calcium/vit D in diet Corticosteroids Thiazide diuretics Nursing Management: Monitor labs Report EKG changes Symptoms: Stones (lower back/flank pain) Bones (fractures) Groans Psychiatric Moans Weakness Constipation GI symptoms (N/V/anorexia) Polyuria Polydipsia Dehydration Hypoactive DTR HTN Bradycardia EKG Changes Adults Exam 1 Study Guide For IV fluids, what are the main fluids and what are they used for – isotonic, hypertonic, hypotonic? IV Fluids Isotonic Hypotonic SAME osmolarity as body fluids Normal saline Expand volume Dilute medications/antibiotics Keep vein OPEN Lactated Ringer’s Fluid resuscitation D5W Isotonic until INSIDE body then it metabolizes glucose and becomes HYPOTONIC Never give to infants or head injury pts → can cause cerebral edema Hypertonic D5 half normal saline or D5 normal saline Sodium and volume replacement Caution: go slow, monitor BP, rate, quality of lung sounds, serum sodium and urine output Adults Exam 1 Study Guide WORDS/TERMS/STUFF TO KNOW: the nitty gritty PCA pump Metoprolol / Lopressor Coreg Capotin Digoxin Other words! Orthopneia / orthopneic position Cardiac enzymes Angina Atherosclerosis Coronary artery disease Cardiac output (decreased) Acute coronary syndrome Electrolyte imbalance Potassium, Sodium, Calcium, magnesium (hyper and hypo and value range, signs & symptoms) Fluid volume deficit Fluid volume overload Dehydration Edema
