COMP3_Tissue Perfusion2

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Author:
vanwin
ID:
210429
Filename:
COMP3_Tissue Perfusion2
Updated:
2013-03-31 02:34:58
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COMP
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competencies
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  1. Preload vs. Afterload
    • Preload: pressure inside the ventricle caused by filling
    • Afterload: pressure that the heart has to pump against to get blood out
  2. Tachycardia
    • Assess: syncolpolt episodes, SOB/ dysnic
    • Causes:
    • - fever: give PRN meds, acetaminophen/ ibuprofen
    •  - pain
    •  - hypovolemia
    • O2 supplement, 2L nasal cannula
    • Patient Safety:
    • - syncopolt episode
    • - valsalva maneuver
    •  - cardioversion
  3. Bradycardia
    • S&S: syncopolt episodes, LOC changes, SOB/ dysnea
    • Pt safety: falls
    • O2 supplement
  4. Atrial fibrillation
    • Assessment: risk for stroke, irreg pulse, pooling of blood
    • Medications: anticoagulants, Calcium channel blockers- diltiazem
    • O2 supplement
  5. Premature Ventricular contraction
    • Assess: xtra heart beat, determine how frequent
    • ECG
    • Continuous monitoring
    • O2 supplement
  6. Ventricular Fibrillation vs Ventricular Tachycardia
    • Assess pulse
    • call code if no pulse
    • Chest compression - 30/ 2 breaths or 100/ 1min
    • De-fibrillation
    • Meds: epinephrine
  7. Nursing interventions: conduction disturbances
    • Assess:
    • VS,
    • IV access,
    • patent air way,
    • BLS if needed,
    • 12 lead EKG (10 electrodes,
    • ICD (implantable cardioversion defib),
    • ACLS (synchronized cardioversion, defib), telementery,
    • pace maker status
    • Meds:
    • metoprolol,
    • fursosemide,
    • nitroglycerin,
    • epinephrin,
    • glucagon,
    • lidocane,
    • albuterol
  8. Heart failure caused and causes
    • caused by: heart's inability to pump blood to satisfy body's demand
    • -MI
    • -demand > supply
    • lead to: fluid overload
  9. LHF vs RHF
    • Left: fluid backs up into respiratory circulation
    • - pink, phrothy sputum
    • -lung sounds
    • -SOB
    • Right: fluid backs up into systemic circulation,
    • - peripheral edema
    • - JVD
  10. Goals for heart failure nursing interventions
    • Decrease preload:
    • - diuretics
    • - fluids & sodium restriction
    • - positioning, sit up
    • Decrease afterload:
    • - vasodilators
    • -HTN drugs
    • Increase contractility: digoxin
  11. Heart Failure Nursing Interventions
    • Assess: Respiratory status, peripheral edema, vital signs, fatigue
    • Medications: diuretics, digoxin, O2 supplement
    • Pt teaching: weight loss, diet, decrease demand on heart, schedule activity & rest
    • monitor I & O
    • decrease fluids & electrolytes (Na & IV intake)
    • Diagnostic testing: BNP, chest xray, EKG, echocardiogram
  12. TJC core measures: Heart Failure
    • Discharge instructions
    • monitor left ventricular systolic function
    • ARB & ACE inhibitors
    • smoking cessation counseling
  13. Types of Angina
    • stable: predictable, occurs with exertion, nitro works
    • prizmetal: vasospasms
    • unstable: occurs at rest, nitro does not work
  14. Nursing Interventions: Angina
    • Assess:
    • -pain ( where is it? radiating? what were you doing? quality/ quanity)
    • - SOB
    • - Diaphoresis
    • Meds: aspirin, nitro, beta blockers, statin, ACE inhibitors, heparin, cardiac cathederization
    • Diagnostic testing:
    • -troponin x3 Q6H
    • -ECG
    • - chest xray
    • - Hemoglobin
    • - hematocrit
    • -lipid panel
    • - electrolytes
  15. Nursing Interventions: MI
    • Assess:
    • -vital signs
    • -chest pain
    • - SOB
    • - anxiety
    • PCI: percutaneous coronary intervention
    • Diagnostic testing:
    • -troponin x3 Q6H
    • -ECG
    • - chest xray
    • - Hemoglobin
    • - hematocrit
    • -lipid panel
    • - electrolytes
  16. TJC Core Measures: MI
    • Aspirin upon arrival
    • Fibrinolysis within 30 mins
    • PCI within 90 mins
    • ACE inhibitors/ ARB for Left ventricular systolic dysfunction
    • Discharge meds: Aspirin, beta blocker, statin, ACE inhibitor/ ARB
  17. Hypovolemia vs Hypervolemia
    • Hypo:
    • -dehyrdation
    • -hemorrhage
    • -obstruction at the venous end
    • -decreased vasculature
    • - shock
    • Hyper:
    • - edema
    • - fluid overload
  18. Nursing Interventions: hyper & Hypovolemia
    • Hypo:
    • - VS - O2 - I&O - Daily weight
    • -give IV fluids/ blood products
    • - orthostatic hypotension
    • -hemoccult/gastrocult
    • -pt. teaching & safety

    • Hyper:
    • - VS - O2 - I&O - Daily weight
    • - dietary & fluid restriction
    • - slow IV/ blood product intake
    • - pt teaching & safety
  19. Nursing Implications Hypertension
    • Assess:
    • -vs - I&O - daily weight - medication

    • Pt. teaching:
    • - lifestyle changes
    • - nutrition
    • - medication
    • - take blood pressure at home
    • - smoking cessation
  20. Nursing Intervention: Anemia
    • Assess: fatigue, O2 supplement, CBC, rest
    • maybe blood products
  21. Nursing Interventions: Neutropenia
    • Neutropenic precautions
    • Avoid raw meats, vegies & fruits
    • No live plants/ flowers
    • PPE to protect patient
    • Avoid dehydration
    • PT & family teaching
  22. Nursing Interventions: Thrombocytopenia
    Assess: bruising - petichiae - bleeding nose/ gums - occult bloodd

    Avoid Injury: razors, needle sticks, suppositories, wear shoes

    hold firm after blood drawn
  23. PAD/PVD
    • Assess:
    • -Pain (lower extremities, intermittent claudication)
    • - pulse
    • - cap refill
    • - wound care, possible complications
    • - amputations
    • - ABI
    • Pt Teaching:
    • - avoid standing/ sitting in dependent positions
    • - do not cross legs
    • Life style risk modifications:
    • - exercise - smoking cessation - ideal weight - hyperlipidedemia - glucose & BP monitoring
  24. Venous Leg Ulcers
    • Assess: lower extremities, wound, vital signs
    • wound vac
    • wear compression stockings
    • Pt Teaching/ safety
    • - compression stockings for life
    • - avoid standing/ sitting for prolonged period of time
    • - nutrition (protein, vit A & C, zinc)
    • - weight loss
    • - foot & leg care
    • - avoid additional trauma
    • - moisturizers
  25. Virchow's Triad
    • venous stasis
    • endothielial damage
    • hypercoagulable state
  26. Nursing Interventions: Venous Thromboemblism
    • Assess: high risk patients/ immobile pts/ pts in pain.
    • Immobile pts:
    • -move Q2H
    • -ROM exercises
    • - wear TED hose/ compression stockings
    • - intermittent compression machine
  27. Anticoagulant Therapy
    • assess bleeding
    • avoid needle stick
    • humidify oxygen
    • skin moisturizers
    • electric razors
    • minimize use of tape
    • stool softener
    • avoid moving pts with already established clots
  28. Green field filter
    • Inferior vena cava filter
    •  stops clots from going into the heart
  29. TJC Core Measures VTE
    Prophylaxis & discharge intructions
  30. Types of Stroke
    • Ischemic: blockage of blood
    • - blot buster
    • Hemorrhagic: HTN/ Hypertensive crisis
    • - want the blood to clot
    • -craniotomy to evacuate blood
  31. Stroke Assessment
    • LOC
    • gaze
    • visual fields
    • facial palsy
    • ataxia
    • language; dysarthria
    • drifting extremities
    • sensory
    • extinction/ attention
    • distal motor function
  32. Stroke Diagnostic Tests
    • CT
    • CTA
    • MRI
    • MRA
  33. Nursing Interventions: Stroke
    • manage HTN
    • seizure precaution
    • monitor neuro
    • constipation & incontinence
    • aspiration precaution
    • speech therapy
    • communication needs
    • sensory perception alterations
    • psychosocial needs
    • Assess: VS VTE skin breakdown
  34. TJC Core Measures: stroke
    • Prophylaxis VTE
    • Assessed for rehab
    • At Discharge:
    • -stroke education
    • - statin
    • -therapies (thombolytic, antithrombotic, anticoagulant for afib)

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