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)