lOMoARcPSD|41646858 Adult Health 1 Exam 1 - study guide for exam 1 NR 324 Adult Health I (Chamberlain University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by awkwurd gurl (raachelb@aol.com) lOMoARcPSD|41646858 Adult Health: Exam 1 Fluids: o o o Electrolyte imbalances: Isotonic: - 0.9% saline (NS), Lactated Ringers (LR), 5% dextrose (D5W) Hypotonic: - 0.45% NS, 0.33% NS, 2.5% Dextrose - can cause Cerebral edema (b/c makes the cells swell) Hypertonic: - 3% NaCl, 5% NaCl - can cause pulmonary edema o Fluid volume imbalances: Hypovolemia/ fluid volume deficit (dehydrated, increased electrolytes) § Vitals: tachycardia, weak thready pulse, hypotension, tachypnea § S/S: dry mucus membranes, poor skin turgor, decreased urine output § Labs: ­urine specific gravity, ­hematocrit, ­serum sodium, ­BUN § Nursing interventions: I&O, daily weights, oral/IV fluids, vitals, alertness, fall precautions(change positions slow) o Hypervolemia/ fluid volume excess (fluid overload) § Vitals: tachycardia, bounding pulse, hypertension, tachypnea, ­central venous pressure § S/S: crackles in lungs, dyspnea, distended neck vein(JVD), edema, polyuria, ascites § Labs: ¯urine specific gravity, ¯hematocrit, ¯serum sodium, ¯BUN § Nursing interventions: I&O, daily weights, breath sounds, fluid restrictions, low sodium diet, monitor diuretics, high/semi-fowler’s position(easier to breath), pressure reducing mattress o o o o ABG’s pH PACO2 HCO3 PAO2 o o o o By: Beth Ryan :) regulated by lungs & kidneys regulated by lungs (ACID) regulated by kidneys (BASE) regulated by lungs (Oxygen in blood) 7.35-7.45 35-45 22-26 80-100 Respiratory ALKALOSIS: ­pH ¯CO2 § hyperventilating, tingling Respiratory ACIDOSIS: ¯pH ­CO2 § rapid shallow respirations, hypoventilation Metabolic ALKALOSIS: ­pH ­HCO3 § caused by vomiting, NG suction, numbness Metabolic ACIDOSIS: ¯pH ¯HCO3 § Kussmaul’s respirations, caused by diarrhea, DKA o o Nursing considerations & complications: Central & PICC lines, Peripheral IVs o If pH out of range & CO2 or HCO3 is in range = UNCOMPENSATED If CO2 & HCO3 both out of range & pH out of range = PARTIALLY COMPENSATED If pH is in range (7.35 – 7.45) = FULLY COMPENSATED HYPOnatremia: sodium below 135 mEq/L HYPOvolemic hyponatremia: ¯ of fluid & sodium HYPERvolemic hyponatremia: ­ body water greater than sodium § S/S: headache, confusion, lethargy, lightheaded, ¯DTR, seizures, muscle weakness (¯ lung), hypothermia, tachycardia, rapid weak pulse § Causes: (4 D’s): diaphoresis (high fever), diuretics(thiazides & loop), diarrhea/vomiting, drains(NGT suction), SIADH, adrenal insufficient, too much water, kidney disease, heart failure, low intake of sodium § Nursing interventions: IV Na+ w/ normal saline or lactated ringers (sodium lactate solution for low BP), restrict fluids, daily weights, Fall risk HYPERnatremia: BIG & BLOATED sodium above 145 mEq/L § S/S: thirst, restlessness, irritability, muscle twitching, ¯DTR, seizures, coma, hyperthermia, orthostatic hypotension, tachycardia, anorexia § Nursing interventions: monitor LOC & safety, vitals & heart rhythm, listen to lungs, oral hygiene, I&O HYPOkalemia: LOW & SLOW § S/S: hypotension, thready weak pulse, altered mental status, coma, hypoactive bowels, N/V, constipation, paralytic ileus, shallow breathing, low DTRs § What to monitor: cardiac, assessments, potassium levels § Pt education: High K+ foods: citrus fruits, legumes, whole grains, lean meats, soda, eggs, milk, cocoa, avocados. § Nursing interventions: replace K+ oral or IV (NEVER PUSH MAX RATE 10mEq/hr), monitor ECG, watch for digoxin toxicity, muscle hand grips/weakness, fall precautions HYPERkalemia: TIGHT & CONTRACTED § S/S: slow irregular pulse, hypotension, ECG (peaked T wave & wide QRS), diarrhea, weakness, irritability, paresthesia § What to monitor: cardiac, potassium levels, assessments (I&O, EKG, muscle weakness, K+ labs, ABGs-metabolic acidosis, GI symptoms) § Pt education: decrease high K+ foods, increase low K+ foods (apples, cranberries, grapes, canned peaches, lettuce, cabbage, cucumbers, green peppers, sweet onions, peas, root beer, coffee, refined grains) § Nursing interventions: I&O, monitor tachycardia, chest pain, monitor ECG, monitor serum K+, monitor diuretics, fall precautions HYPOcalcemia: § Causes: lack of absorption, kidney disease, diarrhea, wound drainage § S/S: convulsions, arrhythmias, tetany, spasms, finger numbness, positive Trousseau’s & Chvostek’s signs, little tornados on ECG (Torsade’s Depointes) HYPERcalcemia: § Causes: ­ Ca+ absorption, ¯ Ca+ excretion, kidney disease, thiazide diuretics, hyperthyroid, malignancy § S/S: bone pain, arrhythmias, cardiac arrest, kidney stones, ¯DTR, polyuria o Central & PICC: educate pt on care, assess site for redness/edema/etc., confirm placement of PICC w/ x-ray, hand hygiene. Complications: can float to different spaces, infection, occlusion/blockage Peripheral IV: change every 72hrs, aseptic technique, monitor sight for edema/infection/etc. Complications: infiltration, phlebitis, fluid overload Downloaded by awkwurd gurl (raachelb@aol.com) lOMoARcPSD|41646858 Adult Health: Exam 1 Respiratory system: CH. 25-28 o o o o o o Pneumonia: inflamed alveoli sacs & full of fluid § S/S: wheezing, crackles, yellow-tinged sputum, fever, sharp chest pains, chills, low-grade viral, high fever bacterial § Nursing interventions: high fowlers, O2 therapy, high protein/calorie/fluid diet, admin antibiotics if bacterial & bronchodilators anti-inflammatory, incentive spirometer, cough up sputum § Pt teaching: get vaccines, increase fluid intake Pneumothorax (collapsed lung): § S/S: tracheal deviation to unaffected side, reduced breath sounds on affected side, dyspnea, tachycardia, respiratory distress § Nursing interventions: O2, auscultate heart and lungs, ABGs & labs, high fowlers, monitor vent or chest tube, deep breathing § Pt teaching: proper hydration, pain PCA pump, pain management strategies, distraction therapy Pulmonary embolism: § S/S: anxiety, impending doom, chest pressure, air hunger, cough, hemoptysis, heart murmur S3 & S4, lowgrade fever, plural friction rub § Nursing interventions: O2, high fowlers, IV access, monitor respiratory status q30 mins, BP both arms, examine for JVD, petechiae (red splotches), emotional support § Pt teaching: weekly blood draws, portable O2, smoking cessation, ­ physical activity, no crossing legs, ROM, do not ­ or ¯ K+ if taking warfarin, monitor for bleeds, no other blood thinners Asthma: inflamed bronchi/bronchioles(triggers/acute attacks) § S/S: dyspnea, chest tightness, anxiety, wheezing, accessory muscle use, cough, barrel chest(chronic), mucus production § Nursing interventions: assess pt’s airway, high fowlers, short-acting bronchodilator(albuterol), rest periods, O2, decrease stress/calming measures § Pt teaching: bronchodilator BEFORE corticosteroid, proper inhaler use, notify provider if need rescue inhaler more than 2x/week, peak flow meter, rinse mouth to prevent thrush w/ steroid Chronic Bronchitis (COPD): § S/S: barrel chest, clubbing, edema, productive cough/morning, activity intolerance, hyperinflation of lungs, cyanosis, accessory muscle use, wheezing, fever § Nursing interventions: ­ calories & protein, small meals, diet ¯ in carbs, incentive spirometer, high fowlers/tripod, deep breathing techniques & coughing, pursed lip breathing, O2 § Pt teaching: smoking cessation, small meals, pulse ox @ meals, vaccinations o o o o By: Beth Ryan :) Emphysema (COPD): § S/S: thin, quiet lung sounds, dyspnea, hyperinflation of lungs § Nursing interventions: ­ calories & protein, small meals, diet ¯ in carbs, incentive spirometer, high fowlers/tripod, deep breathing techniques & coughing, pursed lip breathing, O2 § Pt teaching: smoking cessation, small meals, pulse ox @ meals, vaccinations Tuberculosis: caused by mycobacterium tuberculosis § S/S: dry cough that becomes productive, crackles, fatigue, malaise, anorexia/weight loss, low grade fever. LATE SIGNS: dyspnea, hemoptysis § Nursing interventions: AIRBORNE precaution, mask @ all times (nurse=N95), negative pressure rm, skin test, chest x-ray, TB culture sputum (early morning) § Pt teaching: treatment between 3-9mo long, active TB infectious until 2-3 negative cultures, drugs can cause hepatitis/orange body fluids/ocular toxicity, direct observed therapy(DOT) for high risk & nonadherence pt Lung Cancer: smoking is major cause § S/S: chronic cough w/ sputum, hemoptysis, dyspnea, wheezing, chest pain, N/V, anorexia/weight loss § Nursing interventions/diagnosis: chest x-ray, CT scan, sputum cytology, pleural fluid analysis, CBC, MRI, bone PET scan. Assess airway, provide support, high calorie/frequent small meals, daily weights, vitals/resp status, HEALTH PROMOTION, COMFORT § Treatments: surgery, radiation, chemo, target therapy Tracheostomy Tube Care: § Reasons for trach: to breath, when obstruction of upper airway, fenestrated helps pt to be able to speak § STERILE TECHNIQUE § Suctioning: insert & suction on way OUT no more than 10 seconds, reoxygenate in between § Air pressure warning light low = assess for leaks § Nursing interventions: chest X-ray verifies placement, extra trach kits nearby, resuscitation equipment, leave old ties on while putting on new ones, sterile water nearby, obturator to insert, skin integrity Chest Tube Care: § Reasons for chest tube: surgery/trauma to chest, pneumothorax, fluid in chest (plural effusion); to drain fluid/blood from plural space/ to re-expand the lungs § Nursing interventions: NEVER CLAMP, keep 2-3ft below pts chest, make sure no kinks/clots present, record amount of drainage, ensure dressing around tube on patient intact, assess resp sounds/pulse ox frequently Downloaded by awkwurd gurl (raachelb@aol.com) lOMoARcPSD|41646858 Adult Health: Exam 1 Cardiovascular system: CH. 31-37 o o o o o o Hypertension: § S/S: usually asymptomatic HA, blurry vision, kidney issues, arteriosclerosis, dyspnea, chest pain § Nursing interventions: patient education & dietary considerations, reduce stress, smoking cessation, regular exercise, weight loss, limit/reduce alcohol Ø DASH diet (low sodium diet): ­ fruits & veggies, ¯dairy & fatty foods Coronary artery disease (CAD): blood vessel disease § S/S: hypertension & bruits, can pain late stages § Labs: ­ LDL & triglycerides, ¯ HDL § Nursing interventions: monitor BP, HTN interventions, diet, exercise, cholesterol lowering meds Stable Angina: § S/S: occurs w/ exercise, relieved by rest & nitroglycerine § Labs: no elevated troponin § Nursing interventions: call 911 if no relief after first dose of nitro or only mild relief after 3 doses, consistent pattern, monitor ECG, educate client on rest before angina hits Ø Use nitroglycerine with aspirin Unstable Angina: § S/S: tight squeezing, heavy pressure, constricting, jaw pain happen w/ exercise or @ rest, increases in duration/frequency & severity over time § Labs: ­ cardiac enzymes, troponin, can have ­ ST § Nursing interventions: heart healthy diet, lose weight, low stress, stop smoking, bed rest, continuous hemodynamic monitoring Ø Meds: use nitro with aspirin, Beta Blockers(monitor apical pulse), CCBs, statins, anticoagulants Myocardial Infarction: § S/S: tight squeezing, heavy pressure, constricting, jaw pain, nausea, epigastric pain, dyspnea, diaphoresis, fatigue § Labs/Diagnostics: ­ cardiac enzymes, ­ troponins, CKMB, myoglobin, T wave inversion(ischemia), abnormal Q wave(necrosis), ST elevation(damage) § Nursing interventions: O2, heart cath consent, NPO, monitor for cardiogenic shock, monitor vitals q5 minutes till stable, analgesics, IV access, bed rest Ø Meds: aspirin, thrombolytics, beta blockers, ACE inhibitors, statins, anticoagulants, opioids (morphine sulfate) Ø STEMI: (ST elevation on ECG & looks like tombstone) = occlusive Ø NSTEMI: (non-ST elevation) = partial occlusive or non-occlusive o By: Beth Ryan :) Congestive Heart Failure: causes= defect, HTN, MI, dec. CO § Left-sided S/S: pulmonary congestion, crackles, dyspnea, fatigue, pink/frothy sputum. (LEFT=LUNGS) § Right-sided S/S: systemic edema, ascites, JVD, hepatomegaly § Labs/Diagnostics: ­ hBNP, echo, hemodynamic monitoring § Nursing interventions: daily weights, I&O, ECG, high fowlers(left-sided), lungs & vitals, O2, restrict fluid/sodium, monitor for pulmonary edema/peripheral edema Atrial Fibrillation: rapid twitching in atria (HUGE risk for clots) § S/S: (all stem from LOW O2) chest pain, low O2, hypotension, tachycardia, lethargy, anxiety, SOB, dizzy § ECG: rate(over 100), rhythm(irregular), NO P wave, NO PR, QRS normal but unevenly spaced § Nursing interventions: anticoagulants(WATCH INR), beta blockers, cardiac ablation, Digoxin(take apical pulse), watch for dig toxicity(green halos, LOW K+), Electro cardioversion(50-200 joules) done after TTE, Downloaded by awkwurd gurl (raachelb@aol.com)