Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
ah2 ex 2
| Question | Answer |
|---|---|
| first-degree AV block | - PR interval longer than 0.20 seconds, usually does not need treatment e.g. P ----- QRS, P ----- QRS |
| second-degree AV block type 1 (aka Mobitz I, or Wenckebach) | - blocked QRS complex - PR intervals have different lengths e.g. P--QRS P---QRS P----QRS P (no QRS) |
| second-degree AV block type 2 (aka Mobitz II) | - P wave is not followed by a QRS - blocked QRS waves occur e.g. P--QRS P--QRS P (no QRS) P--QRS |
| third-degree AV block | - no pattern between P waves and QRS complexes - P waves “march through” QRS complexes and T waves - serious block e.g. P P P P QRS QRS |
| general nursing interventions for dysrhythmias | - do not only look at the monitor - look at the patient - after looking at the rhythm, assess the patient and pulse |
| nursing interventions for sinus bradycardia | - atropine - pacemaker - stop offending drugs like beta blockers and calcium channel blockers |
| nursing interventions for sinus tachycardia | - beta blockers - calcium channel blockers - vagal maneuvers (can stimulate the vagus nerve and slow the HR) |
| nursing interventions for premature atrial contractions (PACs) | - monitor for serious dysrhythmias - withhold sources of stimulation (like caffeine, stress) - medications may include beta blockers, calcium channel blockers |
| nursing interventions for atrial flutter | - beta blockers - calcium channel blockers - anti-arrhythmics - anticoagulants - digoxin - electrical cardioversion - radiofrequency ablation |
| nursing interventions for atrial fibrillation | - beta blockers - calcium channel blockers - antiarrhythmics - electrical cardioversion - radiofrequency ablation - Maze procedure (using heat/cold to block electrical signals) |
| what is the appropriate action right after AFib is identified? | - administer meds to control ventricular rate (beta blockers, calcium channel blockers, digoxin) |
| nursing interventions for AV blocks | first degree: no treatment second and third degree: atropine and may need permanent pacemaker |
| CAD non-modifiable risk factors | age, gender, ethnicity, family history, genetic predisposition |
| what is coronary artery disease (CAD)? | plaque buildup in the arteries that supply blood to the heart |
| CAD modifiable risk factors | elevated lipids, elevated LDL, low HDL, hypertension, smoking, lack of physical activity, obesity, diabetes, alcohol, drugs |
| plan of care/discharge teaching for CAD | teach pt to stop smoking, be more physically active, eat a heart-healthy diet (low saturated fat, low cholesterol), and take prescribed medications |
| what is the purpose of a balloon angioplasty (aka cardiac cath/angiogram)? | - opens an occlusion in an artery - restores blood flow - relieves chest pain - can treat myocardial infarction |
| what does a stent do in a balloon angioplasty? | keeps the artery open after angioplasty |
| post-procedure teaching for a balloon angioplasty | - drink plenty of fluids to flush out dye - avoid strenuous exercise and heavy lifting for 24-48 hours - keep incision site clean and dry - some bruising is normal - take prescribed anti-platelet medications to prevent clots (e.g. Plavix) |
| what is chronic stable angina? | intermittent chest pain that occurs over a long period with the same pattern of onset, duration, and intensity |
| nursing interventions for chronic stable angina | - maintain client in upright sitting position - obtain 12-lead EKG - administer nitroglycerin sublingual if chest pain occurs - frequently assess BP and HR |
| teaching for chronic stable angina | - patient may take short-acting nitroglycerin prophylactically before activity - patient should continue long-acting nitroglycerin to reduce angina episodes - lifestyle modification is needed |
| nitroglycerin teaching part 1 | - if chest pain occurs: stop activity, sit down, place nitroglycerin tablet under tongue - keep tablets in original dark bottle - do not store in pill organizer |
| nitroglycerin teaching part 2 | Light, moisture, and air can make nitroglycerin ineffective If nitroglycerin does not work after 3 pills, go to the emergency room Do not combine nitroglycerin with erectile dysfunction medications |
| why erectile dysfunction medications are C/I with nitroglycerin | both relax blood vessels can cause sudden, severe, potentially fatal drop in blood pressure |
| what is a STEMI? | ST elevation myocardial infarction |
| nursing interventions for STEMI with thrombocytopenia | teach client ways to minimize bleeding assess for signs of reperfusion (relief of chest pain) assess mental status for signs of cerebrovascular hemorrhage keep client on continuous cardiac monitor manage pain initially bedrest |
| characteristics of a STEMI | severe life-threatening caused by complete coronary blockage causes myocardial necrosis |
| myocardial necrosis | irreversible death of heart muscle due to prolonged lack of oxygen/blood supply |
| expected findings of myocardial necrosis | persistent ST segment elevation on EKG elevated biomarkers (troponin) crushing chest pain/angina that may radiate to the jaw, neck, arm diaphoresis dyspnea severe chest pain often unrelieved by rest |
| what can cause a myocardial necrosis | usually caused by completely occlusive thrombus, and if patient has a history of CAD |
| CABG | coronary artery bypass graft treats severe CAD uses veins or arteries to create a detour around blocked arteries restores blood flow |
| cardiopulmonary bypass (CPB) | machine-based process used during CABG purpose is to take over heart and lung function and circulate oxygenated blood while the heart is stopped |
| post-CABG findings/complications to watch for | main concern: severe shortness of breath and chest pain post-op afib, pain, fatigue, pleural effusion, infection, pneumonia, renal failure, neuro deficits |
| congestive heart failure (CHF) | insufficient blood supply and oxygen to tissues and organs |
| right-sided heart failure findings | rapid weight gain increased abdominal girth asictes bilateral ankle edema fatigue with activity enlarged liver (hepatomegaly) enlarged spleen (splenomegaly) distended jugular veins anorexia |
| what are patients with CHF most likely medicated with? | diuretics to get rid of fluid overload |
| important electrolyte to monitor on diuretics | potassium; do not want hypokalemia, especially if below 3.0 mEq/L normal levels are 3.5-5.0 mEq/L |
| possible findings with diuretics | increased urination, dizziness, lightheadedness, dehydration, muscle cramps, fatigue, headaches, dry mouth, increased thirst, hypokalemia, hyponatremia all findings can be expected EXCEPT if the patient is on potassium-sparing diuretics |
| examples of potassium-sparing diuretics | aldactone/spironolactone usually does not cause hypokalemia |
| CHF diet and nutrition teaching | restrict sodium to 2g/day low saturated fats diet check nutrition labels foods <140 mg sodium per serving eat fresh, whole foods monitor daily weight for fluid overload |
| daily weight teaching for patients with CHF | same time every day, same scale, same clothing if possible |
| findings of the prodromal phase of hepatitis (aka pre-icteric) | nausea, vomiting, anorexia, diarrhea, weight loss, fatigue, fever prodromal phase ends when jaundice begins |
| findings of the icteric phase of hepatitis | pt is jaundiced yellow skin, yellow sclera, dark tea-colored urine, clay-colored stool, generalized pruritus (itching) |
| findings of the post-icteric phase of hepatitis | jaundice resolves symptoms diminish liver function returns to normal |
| key points of hepatitis A | hep A has a vaccine transmitted through fecal-oral route strict hand hygiene is important avoid alcohol |
| effective teaching example of hep A | Patient understands: “I probably got hepatitis A from something I ate." (Patient knows they can still get other types of hepatitis) Travel: If going to a foreign country where Hep A is common, get vaccine |
| hep A vs hep B/C | Hepatitis A is from fecal-oral route Hepatitis B and C are not from eating contaminated food |
| hepatitis B risk factors | dialysis, sharing needles, needle stick injury, phlebotomist with needle stick injury, living with someone w/ hep B without precautions, unprotected sex with multiple partners |
| how to prevent Hep B | vaccine, condoms, avoid sharing needles, proper screening of blood products |
| blood transfusions are screened for: | hepatitis and HIV |
| hepatitis C risk factors | sharing needles, infected blood transfusion, needle stick injuries, unprotected sex, unsterile tattooing, unsterile piercing, perinatal transmission, prison or facilities with unsafe practices High-priority: pt drinks often and has elevated liver enzymes |
| general nursing interventions for hepatitis part 1 | Encourage rest Activity as tolerated Well-balanced diet Small frequent meals Avoid alcohol Avoid hepatotoxic medications when possible |
| general nursing interventions for hepatitis part 2 | Ask provider about all prescribed and OTC medications Maintain blood and body fluid precautions Increase fluids Observe stool color Check mental status Watch for medication side effects |
| important things to remember for hepatitis interventions | antivirals are not given for every type of hepatitis hepatitis B and C may receive antivirals antivirals are not a general intervention for all hepatitis types |
| what can cause cirrhosis | hepatitis, alcohol, other causes not all cirrhosis is from alcohol |
| alcohol-related cirrhosis | Laennec cirrhosis |
| clinical findings of cirrhosis | anorexia, nausea, vomiting, fatty stools (steatorrhea), jaundice, pruritis (itching), RUQ tenderness, CNS changes (lethargy), asterixis, bleeding tendencies, spider angiomas, palmar erhythema |
| lab findings in cirrhosis | increased AST and ALT, decreased albumin and platelets, elevated bilirubin |
| medications for cirrhosis part 1 | aldactone/spironolactone lactulose/cephulac (reduces ammonia) antacids (manage reflux due to portal HTN, prevent/heal esophageal ulcers) chelating agents (excrete metals, used if cause is Wilson's disease or hemochromatosis) |
| medications for cirrhosis part 2 | steroids (for inflammation) cholesytramine (for itching/pruritus) antiemetics (for nausea/vomiting) antivirals (if it's virus-caused cirrhosis) |
| chelating agents for cirrhosis | used to remove metals Wilson's disease: copper buildup Hemochromatosis: iron buildup |
| hepatic encephalopathy | when the liver cannot convert ammonia (CNS toxin) into glutamine, causing increased serum ammonia and increased cerebral ammonia |
| findings of hepatic encephalopathy | asterixis, altered mental status, slurred speech (resembles stroke), lethargy, confusion, fetor hepaticus (musty or sweet breath odor, associated w/ end-stage liver disease) |
| severe hepatic encephalopathy may be called: | hepatic coma |
| lactulose for hepatic encephalopathy | osmotic laxative that draws ammonia from the blood into the gut, ammonia leaves the body through stool expect a lot of stool from patient |
| how to know if lactulose is effective | 3 or more stools in 24 hours ammonia level decreases client becomes alert and orientated no asterixis |
| sengstaken-blakemore tube purpose | emergency/temporary last-resort intervention to prevent GI hemorrhage from esophageal varices |
| what is an esophageal varices | caused by obstructed blood flow through the portal vein can cause a backup of blood into vessels of stomach and esophagus main concern is that varices can rupture and cause hemorrhage |
| sengstaken-blakemore tube function | applies pressure inside esophagus, squeezes bleeding vessels, helps control hemorrhage important to note it is a temporary measure |
| hiv vs aids | human immunodeficiency virus, acquired immunodeficiency syndrome |
| HIV transmission | blood, semen, vaginal secretions, breast milk, rectal fluids |
| HIV teaching | correct and consistent condom use, routine HIV testing, testing even when asymptomatic, pre-exposure prophylaxis (PrEP) for high-risk individuals |
| HIV patient assessment | flu-like symptoms, fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle pain, joint pain, diarrhea, diffuse rash, shortness of breath, cough, anorexia, candidiasis, skin issues (Kaposi sarcoma), neuro deficits, depression |
| HIV patient assessment part 2 | high priority finding: abnormally high diarrhea puts patient at risk for dehydration, fluid and electrolyte imbalance |
| HIV harm reduction strategies | community needle exchange programs, syringe service programs, access to sterile injection equipment, condom distribution, safe sex practices |
| what is PCP | pneumocystis carinii pneumonia, often seen in AIDS |
| CDC criteria for AIDS | based on CD4 count and presence of AIDS-defining conditions like: PCP, recurrent pneumonia, pulmonary tuberculosis, candidiasis, cytomegalaovirus, mycobacterium avium complex, Kaposi sarcoma, Burkitt lymphoma, invasive cervical cancer, HIV encephalopathy |
| AIDS formula | PCP + CD4<200 |
| goal of antiretroviral therapy | decrease viral load, maintain or increase CD4 count, prevent HIV-related symptoms, prevent opportunistic diseases, delay disease progression, prevent HIV transmission |
| antiretroviral therapy teaching | - avoid herbal therapies and OTC drugs unless approved by provider - tell doctor all medications being taken - do not miss doses - taking ART consistently keeps viral load undetectable (helps prevent HIV transmission to sexual partners) |
| example of ART medication | Abacavir |
| HIV nursing infection control | hand hygiene before and after all client contact use standard precautions with blood and body fluids dispose of sharps in puncture-resistant container |
| HIV and STI screening | patients with HIV/AIDS should be screened for syphilis, gonorrhea, and chlamydia |
| highest-priority concern when screening for HIV/STI | inconsistent condom use because of the possibility of HIV acquisition/transmission |
| thrombocytopenia | low platelet count |
| assessment findings for thrombocytopenia | weakness, fatigue, fainting, decreased LOC, tachycardia, tachypnea, abdominal pain, HTN, dark tarry stool, purpura (large purple marks), petechiae (tiny purple marks), ecchymosis (bruising) |
| main concern for thrombocytopenia | bleeding, especially internal tell-tale sign will be dizziness and fatigue |
| why is bleeding a concern for thrombocytopenia? | may signal decreased oxygen/blood supply, may indicate hemorrhage, and may lead to shock |
| signs of internal bleeding for patients with thrombocytopenia | decreased BP, increased HR, increased RR, severe organ pain, dizziness, fainting, SOB, tachycardia, pale clammy skin |
| enoxaparin (Lovenox) | low-molecular weight heparin |
| heparin-induced thrombocytopenia (HIT) | enoxaparin is contraindicated for patients w/ HIT Because platelet count is low, medication reduces blood's ability to clot, and can cause bleeding |
| concerns when inserting a central line catheter | acute chest pain, dyspnea |
| central line catheter nursing actions | first thing is to auscultate lung sounds to determine if something was punctured after auscultating, act based on findings |
| who gets total parenteral nutrition? | patients who are NPO for a long period of time can be pt with cancer, gastric bypass, wounds, or need nutritional support |
| how to know if TPN is effective | stable albumin level, weight gain, improved wound healing, more energy |
| why are face and neck burns serious? | airway/breathing risk |
| nursing interventions of a face/neck burn | place patient on 100% oxygen using a non-rebreather mask then assess, check lungs, and check ABGs if needed |
| place patient on 100% oxygen using a non-rebreather mask then assess, check lungs, and check ABGs if needed | singed nasal hair, sooty sputum (black in color), dry cough |
| findings in patients with burns in the emergent phase with 35% TBSA | decreased urine output, hypotension, generalized edema (anasarca- head to toe edema), increased hematocrit |
| rule of nines | Front and Back of Both Legs: 9% + 9% + 9% + 9% = 36% Chest and Back: 18% + 18% = 36% Front and Back of Head: 4.5% + 4.5% = 9% Front and Back of Both Arms: 4.5% + 4.5% + 4.5% + 4.5% = 18% |
| purpose of burn fluid resuscitation | rapid IV fluid administration is to restore circulating blood volume and correct tissue perfusion because burn patients may have third spacing, edema, and fluid shifts |
| most important assessment during fluid resuscitation | urine output because if you're giving large amounts of fluid with no output, the patient is at risk for fluid overload |
| assessment during fluid resuscitation | capillary refill, skin turgor, mucous membranes, vital signs |
| positive cross-match | recipient has pre-formed antibodies against donor cells can lead to immediate/severe rejection and then rapid organ failure/loss |
| what do we want before organ transplant? | negative cross-match |
| blood type incompatibility example | donor blood type A, recipient blood type O must report because organ should not be transplanted |
| nursing intervention for donor serum positive for HIV | report immediately |
| organ transplant roommate assignment | do not place organ transplant patient with someone who has infection the best roommate: pt with no infection (heart disease patient w/ no infection, stroke patient w/ no infection) transplant patients may need a private room, or roommate w/o infection |
| tacrolimus (Prograf) | potent immunosuppressive drug, helps prevent organ rejection |
| anti-rejection medication teaching part 1 | take the medication for life if acute rejection occurs, additional drugs may be needed pt may be on more than one anti-rejection medication drugs are combined to block different ways the organ can be rejected |
| anti-rejection medication teaching part 2 | important to note: fever is NOT normal in a transplant patient, may indicate rejection or infection patients may take 10-15 meds/day, antivirals antibiotics med amount depends on type of organ transplanted, time since surgery, other health factors |
Created by:
user-2035248
Popular Nursing sets