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Describe what is happening during preload? So if you change the preload in the heart what happens when:
1. you increase circulating blood vol.?
2. you decrease circulating blood vol.?
The ventricles are stretching to fill with blood. The greater the stretch = the greater the contraction (Starling's law).
1. When you INCREASE or circulating blood volume = increased preload, SV and CO
2. When you DECREASE circulating blood volume OR blood volume not replaced= preload and CO decrease
HINT: think of a hemorrage
Describe what is happening during afterload? So if you change the afterload in the heard what happens when:
1. a client has hypertension?
1. With hypertension afterload increases = cardiac workload increases (CO increases)
Myocardial contractily affect stroke volume and cardiac output:
1. When there is poor contraction what occurs in the heart?
2. When drugs in are present what occurs to the contraction of the heart?
1. poor contraction decreases the amount of blood ejected by the ventricles
2. Some drugs increase the force of MI contaction
This rhythm is uncoordinated electrical activity with no identifiable waves, and circulating blood is not going anywhere; causes include sudden cardiac death, electrical shock, acute MI,drowning or trauma?
Ventricular Fibrillation (V-fib)
If someone is in V-fib what are the nursing implications to follow?
After clients ABC are assessed or CPR attempts are assessed, defibrillation is administered immediately (shocking client)
This rhythm is slightly irregular, rate 100-200 beats/min, the conduction of the heart is off and no blood is going anywhere; causes include changes in the normal pacemaker of the heart such as decrease in blood flow, ischemia, or embolus?
Ventricular Tachycardia (V-tach)
If someone is in V-tach what are the nursing implications to follow? What does V-tach do to CO?
V-tach decreases CO due to decreased ventricular filling time = leading the heard to severe hypotension and loss of pulse and consciousness. This too (like v-fib) is a shockable dysrhythmia
When evaluating a client they state they are fatigued and you notice they have distended jugular veins and have apparent signs of swelling in hands and fingers (peripheral edema). After running tests you note they have both an enlarged liver and spleen. Before receiving lab results you suspect they have:
Right-sided OR Left-sided heart failure
Is usually related (secondary to) pulmonary problems. Right-sided heart failure is often resulting from left-sided heart failure or problems. Therefore, if left side is backing up into the lungs it will continue to back up to the right ventricle/atria/vena cava/systemic circulationg presenting with clinical signs of weight gain, distended neck veins, enlarged liver and spleen, and peripheral edema
When evaluating a client they state they are fatigued, dizzy and confused on events of the day. Upon assessment you notice they have bilateral crackles in the lungs and are having difficulties breathing. Before receiving lab results you suspect they have:
Right-sided OR Left-sided heart failure
As the left ventricle in the heart fails the tissues in the body become hypoxic from diminshed CO causing pulmonary congestion. Left-sided heart failure means blood is backing up into the lungs which would present in clinical findings with crackles in lungs, hypoxia, SOB on exertion and standing still, caugh and paroxysmal nocturnal dyspnea.
Dyspnea (a clinical sign of hypoxia) is associated with many clinical conditions such as, pulmonary disease, cardiovascular disease, neuromuscular conditions, and anemia. So what can you as a RN due to manage dyspnea?
1st and foremost treat the underlying cause first...
- 1. FIRST...manage airway
- Ways to manage airway include:
- - Pharmalogical (bronchodilators, inhaled steroids)
- - Oxygen therapy: (exercise, O2 masks)
- - Physical techniques: (exercise, conditioning, biofeedback)
- -Psychosocial techniques: (relaxation, massage, meditation, biofeedback)
2. Mobilize the pulmonary secretions
- move them around so they don't end up blocking the airway - Maintain normal airway
3. Add humidification
if necessary: ( add water to O2 being administered to client on 02 therapy)
(add moisture/medicine to inspired air
: (this includes chest vibration, percussion, and postural drainage)
When is chest physiotherapy recommended?
Recommended on clients who produce greater than 30mL of sputum /day or have evidence of atelectasis by chest x-ray
"Types" of dyspnea management a HCT/nurse may use include?
- Airway Maintenance
- Mobiilzation of pulmonary secreations
When suctioning clients with the various types of suctioning techniques nursing implications to watch for include?
- -Suctioning too frequently can put the client at risk for devlopment of hypoxemia, hypotension, arrhythmias, and possible trauma to the mucosa of the lungs.
- - Suctioning should be intermittent, no longer than 10-15 seconds. Longer than that can cause cardiopulmonary compromis, usually from hypoxemia or vagal overload
When a nurse clearly sees that a client can cough on their own, but are unable to clear the secretions, the following type of suctioning technique should be used?
Oropharyngeal or nasopharyngeal
When a nurse sees that a client is unable to mange secretions by coughing and are unable to move the secretions on their own, the following type of suctioning technique should be used?
Orotracheal or nasotracheal
When a surgical incision is made in the clients trachea to open their airway for long-term breathing assistance, the following suctioning technique would be performed if the client was unable to move the secretions on their own?
Encourages voluntary deep breathing by providing visaul feedback to the client about their inspiratory volume. This is called?
An incentive Spirometer
When is an incentive spirometer used?
It is used in postoperative patients to help prevent complications following surgery. It promotes breathing, prevents or treats atelectasis and supports the use for lung expansion
If a chest-tube is ever clamped a RN should assess for what?
Pneumothorax; clamping a chest tube can retain air, pus, and fluid still in the lungs.
To drain/evacuate air from the lungs with a chest tube you place the client how?
To drain/evacuate blood from the lungs with a chest tube you place the client how?
1. semi-fowler's (30 degrees)
2. high-fowler's (45-90 degrees)
What is your role as a nurse when a patient has a chest tube in?
- - Priority = confirm patency of the tube
- - Vitals to compare to baseline prior to chest tube insertion - assess respirations frequently
- - Know where the chest tube is located, where it is coming out, and how to position client for appropriate drainage
- - Note the color of the drainage; if anything changes, and mark on the tube the amount of drainage per/shift, etc.
- -NEVER take out a chest tube, this is a physicians responsibility
A nasal cannula is used at a flow rate of and is used for?
- Flow rate of 1-6L/min
- Used for long-term oxygen use/needs
A simple face mask flows at a minimum rate of what and is used for?
- - A minimum flow rate of 5L/min
- - Used in emergencies
A partial rebreather mask is used at a flow rate of and is used for?
- Flow rate of 6-15L/min
- Used when patients have a need for high oxygen volumes. The mask is called a rebreather because it allows the patient to rebreathe 1/3 of the exhales tidal volume, which is high in oxygen, thus providing a high FlO2
A non-rebreather mask is used at a flow rate of and is used for?
- Highest flow rate concentration of oxygen
- Most frequently used in clients with a deteriorating respiratory status who might require intubation
A face-tent is used at a flow rate of and is used for?
- Flow rate/concentration of oxygen varies
- Used for clients who have facial trauma or burns as this is not a tight-fitting mask
A venturi-mask is used at a flow rate of and is used for?
- Has a high-flow rate oxygen delivery
- Used when specific amounts of air is needed (such as in a COPD patient)
This is an non-opiod medication used to treat breakthrough pain (can be used in conjunction with morphine). What should a nursed assess when a patient is on this medication?
- Assess for:
- - increased HR
- - priority= respiratory distress
These are opiod medications used to treat acute or chronic / moderate to severe pain. The nurse should assess for?
- Dilauded and Morphine
- Assess for:
- orthostatic hypotension
- urinary retention
- nausea and vomitting
- respiratory depression
When should a nurse assess pain?
- Pain is considered the 5th vital sign, so each time the nurse enters the clients room she should be asking about pain.
- Each time she gives meds - ask about pain
- Each time mobilizes - ask about pain
- Each time changes dressings on wounds - ask about pain
Nurse is always assessing pain and comfort level of client
After a nurse administers pain medication to a client, how soon after the nurse gives the medication should she go back in and check on the clients pain level?
1. in an hour or so after giving
2. 15-30 min after giving
3. 20-40 min after giving
4. 5-10 min after giving
15-30 min after giving
Describe what opiod medications are? What agonist medication should you administer if the client experiences respiratory depression?
They are an analgesic (most cmomon and effective method of pain relief). Opiods are generally prescribed for severe pain. They act on higher centers of the brain and spinal cord by binding with opiate receptors to modify perception of pain.
This analgesic has no antiinflammatory or antiplatelet effects. It works peripherally and centrally but its exact action is unknown. It is in a variety of OTC meds an is often combined with opiods (e.g., Percocet, Vicodin, etc.)?
You treat an overdose with?
This type of analgesic pain reliever provides relief for mild to moderate acute intermittent pain (headache, arthritis, muscle strain, etc.). Inhibit prostaglandin synthesis and act on peripheral nerve receptors to reduce transmission of pain?
When you assess this pain characteristic you might ask, "When did the pain being? How long has it lasted? Does it occur at the same time each day? How often does it recur?" These characteristic questions help to identify the _______of the pain?
The client states "the pain is centralized in the upper right quadrant of my abdomen." This indicates what characterstic identifier of pain?
When utilizing a pain scale to measure the level of pain a client is at, you are assessing the _________ of the clients pain?
Intensity level uses pain scale
When you ask a client to tell you what the pain feels like, and their response is "throbbing, crushing, piercing," the characteristic of pain you are evaluating is?
A client walks in with back pain and states the pain starts in the low back, radiates down the back of my butt, to my calf, and feels like pin pricks in my toes, the pain characteristic you are assessing is the__________ of the pain?
4. Contributing symptoms
How can you help provide relief measures (another pain characteristic) to your client?
- Ask the client what effective ways they have found to handle their pain
- Change clients position
- Gain the clients trust - try to work with them to find appropriate pain relief
- Help the client feel they have control of their pain
What are some contributing symptoms (another characteristic of pain) that come along with pain?
- sleep disruption
- spiritual distress
All these characteristics can worsen pain
This "type" of pain is protective, has an identifiable cause, is of short duration, and has limited tissue damage and emotional response...identifiable cause?
This "type" of pain is not protective and thus serves no purpose. It last longer than anticipated, does not always have an identifiable cause and leads to great personal suffering. Give some examples of this "type" of pain....
- low back pain
- myofascial pain
- peripher neuropathy
This "type" of pain occurs sporadically over an extended duration of time and is episodic. It can last for hours, days, or weeks. Examples include migraine headaches and pain related to sickle cell anemia?
Chronic episodic pain
This "type" of pain is specific to the disease and is usually due to tumor progression.
What are some nonpharmacological pain-relief interventions to try?
- RElaxation and guided imagery
- Cutaneous Stimulation (TENS unit)
- Removing painful stimuli
What is the most common type of dehydration?
Isotonic (hypovolemia) dehydration
When water loss exceeds electrolyte loss you have why type of FVD?
When electrolyte loss exceeds water loss you have what type of FVD?
A client has been vomitting for several hours now before they come into the hospital. After prolonge vomitting, what type of fluid solution would be administered to balance the fluid/electrolyte loss?
When there is excessive fluid in the ECF causing circulation overlod due to fluid NOT shifting correctly between the ICF and ECF ending in interstial edema you have what type of FVE?
When This is a RARE overhydration issue which is caused by excessive sodium intake. Fluid is drawn from the ICF to the ECF expanding the ECF and shrinking the ICF. This overhydration is called?
When there is excessive fluid moving into the intracellular space and ALL body compartments expand you have what type of FVE overhydration concern?
What should a nurse keep in mind when regulating fluids?
- Check IV line for patency
- Set rate of IV according to PCP orders
- -too slow could cause clotting
- -too rapid could cause overload
When a patient has a hypertonic fluid imbalance, what do you do to offset this imbalance?
1. Isotonic solution
2. Hypertonic solution
3. Hypotonic solution
A Hypotonic solution is given to a person who has a Hypertonic fluid imbalance. What does the hypertonic solution do?
the hypertonic solution dilutes the ECF and rehydrates the cells
A hypertonic solution has osmolality more than that of body fluid and usually has potassium added to it. Why would you give this to a patient?
Used for clients with normal renal function who are NPO; keeps from dehydration of cells and body tissue
When maintaining an IV therapy treatment, what is important to keep in mind accroding to the CDC?
- Keep the system sterile
- Change every 72 hours
- Need to change a "field" stick w/in 24 hr
When fluids enter tissue around the IV site causing swelling, pallor, coolness and pain the IV issue is what?
What do you do?
The IV line is infiltrated
Stop infusion and put a new IV in a different extremity
When inflammation occurs in the vein causing edema, increased skin temperature at the site, and redness along the path of the vein the IV issue is what?
Stop infusion and restart at a different site
Crystalloids a a form of therapy used to correct or prevent fluid and electrolyte disturbances. Another name for Crystalloid therapy is?
When a patient is receiving colloid therpay what is this therapy?
It is blood replacement
How long is blood tubing good for? How often should you change? How often should you monitor the patients vitals?
Good for two transfusions then needs to be switched. Monitor vitals during transfussion every 15 minutes
Bicarbonate is regulated by what organ? Normal values are what?
By the kidneys, 22-26
What are the normal lab values for:
- Sodium = 135-145
- Potassium = 3.5-5.1
- Calcium = 8.4 - 10.5
- Magnesium = 1.5 - 2.5
When regulating acid-base balance and the ECF becomes more acidic and pH decreases is this:
Acidosis OR Alkalosis?
When regulating acid-base balance and the ECE becomes more basic and the pH level increases is this:
Acidosis OR Alkalosis
Who is most at risk for fluid and electrolyte imbalances and why?
Elderly - more dehydrated due to age and organs/body not working as fast as it used to
Infants - because most of their body is water
When you have this type of overhydration it is called water intoxication; excessive fluid moves into ICF space and ALL body compartments expand?
The patient presents with extreme thirst, dry flushed skin, fever, agitation, and convulsions and you know they've spent their day canning tomatos you might assume they are?
hypernatremia (water deprivation, too much salt in their system causing the water deprivation and diabetes insipidus can be cause)
The patient presents with personality changes, abdominal cramping, nausea/vomitting, tachycardia, convulsions and has said they've had extreme diarreha for days you might suspect (but with all the signs and symptoms that go along with this condition you'd need to confirm with a lab draw)?
Hyponatremia - many signs and symptoms so confirm with lab values.
The most common imbalance of the ICF is what?
Results from renal failure, FVD, cellular damage such as burns, and you might see a patient present with S&Sx of anxiety, dysrhythmias, weakness, abdominal crapming and potential cardiac arrest?
Note: FVD means Potassium is building up therefore "hyper"kalemia
Results from use of dieuretics like Lasix, extreme sweating, excessive use of isotonic solutions and a patient might present with S&Sx of weakness, fatigue, ECG changes, decreased deep tendon reflexes and an irregular pulse?
A patient is ordered to be on bedrest for an extended amount of time, presents with potential S&Sx to include anorexia, nausea/vomitting, flank pain, decreased level of consciousness or possible cardiac arrest could be dealing with?
Results from a patient being Vit. D deficient, has chronic renal failure, has NO thyroid and presents with S&Sx to include numbness, hyperactive reflexes, positive Trousseu's sign or a positive Chvostek's sign could be dealing with?
Define Trousseu's sign and Chovstek's sign
- Trousseu's = ticking of face
- Chovstek's = twitching of hand when BP being taken
Name some indidivuals (with a disease condition) who may be at risk for FVE?
- Patients with:
- - CHF
- - Renal failure
- - cirrohosis
- - too much salt intake
Name some signs and symptoms of patients in FVE?
- - rapid weight gain especially in CHF
- - neck vein distension
- - crackles in the lungs
- - hypertension (heart working fast to get the fluid out)
Name some individuals (with a disease condition) who may be at risk for FVD?
- Someone with
- - GI loss issues (consistent diarreha and vomiting)
- - fever
- - decreased oral intake (NPO patients)
- - using diuretics
Name some signs and symptoms of patients in FVD?
- tachycardia (heart pumping hard to circulate blood)
- poor skin turger (dehydrated)
- flat neck veins (again, dehydrated)
Lab values for:
- 7.35 - 7.45
When a person is hypoventilating resulting from primary respiratory problems such as atelactasis, pneumonia, airway obstruction, chest wall injury, COPD, or drug overdose you are dealing with this type of imbalance?
Resp Acidosis (holding on to CO2)
Resp. Alkalosis (ridding to much CO2)
When a person is hyperventilating resulting from anxiety, fever, exercise or in pain to the point their breathing is rapid you are dealing with this type of imbalance?
Resp. Acidosis (holding on to CO2)
Resp. Alkalosis (ridding to much CO2)
When a person is starving themselves, or is in renal failure or is experiencing diabetic ketoacidosis this type of imbalance is?
When a person is experiencing excessive vomiting, or has had prolonged NG tube suctioning or something in their body/procedure is causing heavy loss of acid this type of imbalance is?
If a person is experiencing Respiratory acidosis what interventions would you as a nurse do?
- Provide oxygen therapy
- maintain a patent airway
- enhance gas exchange
- positioning is important and least costly way to improve the situation when caring for a patient before moving to pharmacological efforts
If a person is experiencing Respiratory alkalosis what interventions would you as a nurse do/
- provide oxygen therapy
- reduce anxiety
- provide/assist in client rebreathing tech.
If a person is experiencing Metabolic acidosis what interventions would you as a nurse do?
- administer insulin if diabetic
- administer antidiarrheals a rehydrate if GI issue
- administer sodium bicarb due to low serum bicarb
If a person is experiencing Metabloic alkalosis what interventions would you as a nurse do/
- Usually related to GI so
- administer antiemetics, fluids, electrolytes, replace potassium and discontinue the causative agent that caused the imbalance
When afterload increases what else increases?
CO2 or O2
There are different types of chest tubes for a patient - define each?
closed drainage system =
two-chamber system =
dry chest tube system =
Closed = chamber serves as both collector and water seal
two chamber = chamber permits liquid to flow in as air flows into a water-sealed chamber
dry chest = does not use water in suction chamber has automatic control valve that continuously balances the force of the suction with the atmosphere
Clients take a slow deep breath, hold it for 2 seconds while contracting their expiratory muscles then the client opens their mouth and performs a series of coughs throughout exhalation progressively lowering lung volumes. This type of cough is?
Clients simulates a natural cough reflex that is effective for cleaing the airway?
3. Pursed lip?
Clients without abdominal muscle control use this while breathing out with a maximal effort.
2. Pursed lip?
3. Diaphragmatic breathing?
Hperactive bowel sounds are a symptom found in?
3. hypo kalcemia