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
NSG 308 Adult Health
Exam 2 study guide s
| Question | Answer |
|---|---|
| 1st Degree Burns | -Superficial (Epidermis layer only) - Painful Signs: red/dry skin, blanchable, no blisters |
| 2nd Degree Burns | - Partial thickness (Epidermis + partial dermis) - Very painful (nerves intact) Signs: red/moist + blisters |
| 3rd Degree Burns | - Full thickness (Epidermis + Dermis + SQ) - Painless (nerves destroyed) Signs: Dry, leathery, white/charred |
| 4th Degree Burns | - Extends to muscle/bone - Charred appearance - Painless |
| Rules of 9s (Adults) | - Head/Neck: 9% - Arms: 9% - Anterior trunk: 18% - Posterior trunk: 18% - Legs: 18% - Genitalia: 1% |
| Palmar method | palm = 1% total body surface area - use for scattered/irregular burn |
| Phases of Burn Care | 1. Emergent/Resuscitative (0 -> 48 Hrs) 2. Acute/Intermediate (48 hr -> wound closure) 3. Rehabilitation (wound closure -> max recovery) |
| Emergent Stage (Burns) | Airway risk - 100% oxygen with non-rebreather mask for face/neck burn - Assess, auscultate lungs, ABG (if needed) 35% TSBA burns: oliguria/anuria, hypotension, anasarca, increased hematocrit |
| Anasarca | generalized edema from head to toe |
| Signs of Respiratory Distress (Burns) | - Singed nasal hair - Sooty sputum -> black sputum - Dry cough |
| Burn Fluid Resuscitation | - Emergent stage - Rapid IV fluid admin -> increase blood volume/tissue perfusion Monitor: URINE OUTPUT (fluid overload risk), capillary refill, mucus membrane, vital sign S/S: Third spacing, edema, fluid shifts |
| Conduction | electrical stimulation (heart beat) - electrical impulse travel from SA node to AV node to contract ventricles |
| Chronotropy | Sympathetic stimulation causing increased HR |
| Dromotropy | increase in conduction |
| Inotrophy | Increase in force of heart contraction |
| Depolarization | - Contraction/electrical stimulation - Systole |
| Repolarization | - Resting/Relaxation - Diastole |
| Ectopic | - Means abnormally placed - Any impulse not originating from SA node = ectopic |
| SA node | - Normal pacemaker (impulse from SA node -> AV node -> bundle of His -> L/R bundle branch -> Purkinje fibers) - 60-100 BPM normally |
| Dysarrhythmia definition | Disorder of impulse formation, conduction of impulse or both - Controlled via ANS |
| P wave | time it takes for electrical impulse to pass thru atria causing atrial depolarization/contraction |
| PR interval | time it takes for impulse to travel thru atria -> AV node -> bundle of His -> bundle branches -> Purkinje fibers until before ventricular contraction |
| QRS complex | Q wave: first downward deflection (not seen in every lead) R wave: first upward deflection S wave: 2nd downward deflection after R wave |
| QRS interval | Represents depolarization of both ventricles (aka ventricular systole) - number of QRS complexes counted = ventricular contraction rate |
| ST segment | - time between ventricular depolarization and repolarization, ventricular diastole - normally flat or isoelectric |
| T wave | ventricular repolarization - normally upright |
| QT interval | total time for depolarization/repolarization of ventricles |
| Calculating HR from ECG leads | Count R-R intervals in 6 second strip x 10 |
| Assessing cardiac rhythm of ECG | - determine rate - assess rhythm irregularity - identify/evaluate P wave - measure PR interval - measure QRS duration - assess overall pattern |
| Assessment of overall heart rhythm | - interpret ECG rhythm AND pt clinical status - hemodynamically stable = adequate BP, A&O, good perfusion - determine cause of dysrhythmia - Assess patient and pulse |
| NSR | normal sinus rhythm - 60-100 BPM w/ normal conduction pathway |
| Sinus bradycardia pathophysiology | - normal sinus rhythm but slower rate (<60 BPM) - normal in athletes/sleep + parasympathetic/vagal + medication S/S: hypotension, pale/cool skin, weakness, angina, dizziness, syncope, confusion, dyspnea Tx: atropine, pacemaker, D/C pharmacotherapy (eg. BB, CCB med) |
| Sinus tachycardia pathophysiology | - regular rhythm + faster rate (100+ BPM) - d/t vagal inhibition/parasympathetic stimulation + physiologic/psychologic stressor or drug Tx: B-blocker, vagal maneuver, treat causes |
| Premature Atrial Contraction pathophysiology | - ectopic contraction from location other than SA node - distorted P wave with varying QRST from abnormal contraction -> can be asymptomatic Cause: stress, fatigue, caffeine/tobacco/EtOH, hypoxia, electrolyte, disease S/S: palpitations, heart skip beat Tx: monitor for dysrhythmia, D/C drug, B-blocker |
| Atrial Flutter (Aflutter) pathophyiology | - saw tooth pattern - high ventricular rate/reduced atrial contraction = decrease CO -> HF/increase stroke risk - blood pooling = clots in atria -> emboli Tx: electrical cardioversion, radiofrequency ablation, pharmacologic agent (AC, BB, CCB, digoxin) |
| Atrial Fibrillation pathophysiology | - Paroxysmal vs persistent - increased risk w/ age + underlying heart disease (HTN/CAD/HF) - cause decrease Cardiac Output/increase stroke risk Tx: anticoagulants, rate/rhythm control drug (eg. amiadarone/ibutilide), electrical cardioversion, RF ablation, maze procedure w/ cryoablation |
| First Dg AV heart block | - PR interval longer than 0.2 s - No tx needed |
| Second Degree AV Block Type 1 | - AKA Mobitz I/Wenckebach - Blocked QRS - PR intervals with different lengths (eg. PR interval 0.24s, others 0.32s) Tx: Atropine, PPM placement |
| Second Degree AV Block Type 2 | - AKA Mobitz II - P wave not followed by QRS (blocked QRS waves) Tx: Atropine, PPM placement |
| Third Degree AV Block | - No pattern between P waves and QRS complex - P waves march thru QRS complex/T waves - Serious block Tx: Atropine, PPM placement |
| Coronary Artery Disease pathophysiology | - Plaque buildup in cardiac arteries - Modifiable risk factor: EtOH/drug/smoking cessation, HTN, HLD, sedentary lifestyle/obesity, DM - Discharge teaching: physical activity, healthy lifestyle, heart healthy diet (low sat fat, low cholesterol), medication compliance |
| Unstable Angina w/ balloon angioplasty + stent | - Balloon angioplasty/Cardiac cath/Cardiac angiogram - opens occlusion in artery -> restore blood flow/relieve chest pain - Treats MI - Stent keeps artery open after angioplasty |
| Cardiac cath/angioplasty post-op teaching | - Fluids to flush dye - Avoid lifting/weights for 24-48 hr - Keep incision clean/dry - Bruising = normal - antiplatelets for clot prevention (eg. ASA, plavix) |
| Chronic stable angina intervention | - intermittent CP over long period time with same pattern of onset/duration/intensity Intervention: upright sitting position, 12-lead EKG, nitroglycerin SL, BP/HR monitoring Teaching: |
| Chronic stable angina patient teaching | - short acting NG ppx before activity - long acting NG for reducing episodes - Lifestyle modifications |
| Nitroglycerin teaching | During chest pain: stop activity, sit down, Nitro SL tablet under tongue - keep tablets in original dark bottle (no pill organizer) - Avoid light/moisture/air (makes ineffective) - ER if chest pain not better after 3 doses - Avoid ED medication (eg. sildenafil) -> both relax blood vessel -> potential fatal BP drop |
| STEMI | - ST elevation myocardial infarction - Severe, life threatening condition d/t complete coronary blockage (occlusive thrombus) -> myocardial necrosis - Usually w/ Hx CAD S/S: EKG persistent ST elevation, troponin elevation, severe angina (may radiate to jaw, neck, arm), diaphoresis, dyspnea Tx: thrombolytics |
| Thrombolytics nursing intervention | - teach methods to minimize bleed - Assess for reperfusion (chest pain relief) - Assess mental status -> check for cerebrovascular hemorrhage - Continuous cardiac monitor - Pain management - Initial bedrest |
| CABG | - Coronary artery bypass graft - Tx of severe CAD - Restore vein/artery to detour around blocked vessels -> restore blood flow |
| Cardiopulmonary bypass (CPB) | Machine based process used during CABG - Function as heart/lung during procedure - Circulate oxygenated blood when heart stops |
| Post CABG complications | - Severe SOB/chest pain - post-op Afib - pain, fatigue, pleural effusion, infection, PNA, renal failure, neuro deficits |
| CHF | - insufficient blood supply and oxygen to tissue and organs R sided HF S/S: rapid weight gain, ascites (increase abdominal girth), B/L ankle edema, DOE, hepatomegaly/splenomegaly, JVD, anorexia Tx: diuretics for fluid overload |
| Diuretic Nursing intervention | - Potassium monitoring (hypokalemia risk) S/S: polyuria, dizziness/lightheaded, dehydration, MSK cramp, fatigue, headache, dry mouth, polydipsia (increase thirst), hypokalemia/hyponatremia - Aldactone/Spironolactone = potassium sparing -> usually no low K |
| CHF diet/nutrition teaching | - Sodium 2g/daily restriction (<140 mg sodium/serving) - Low sat fat meals - Fresh whole foods - Monitor daily weight (fluid overload) -> same time, scale, clothing |
| Hepatitis phases | 1. Prodromal phase (pre-icteric) 2. Icteric phase 3. Post icteric phase |
| Prodromal phase (hepatitis) findings | - Pre-icteric = no jaundice S/S: N/V/D, anorexia, wt loss, fatigue, fever (all S/S end when jaundice begin) |
| Icteric phase (hepatitis) findings | - jaundice (skin + sclera) - dark urine - clay colored stool - generalized pruritis |
| Post icteric phase (hepatitis) findings | - jaundice resolution - diminished symptoms - Normal LFT |
| Hepatitis A teachings | - Prevention - Learn S/S - Diagnostics + teachings - Vaccination (especially during travel) - Transmission via fecal/oral route - EtOH avoidance |
| Hepatitis B/C risk factors/preventions | - Risk factors: dialysis, needle sticks, blood transfusions, Living with Hep B individuals w/o precaution, Unprotected sex, perinatal transmission, unsterile tattoo/piercing, prison - Prevention: vaccine, condoms, no needle sharing, blood product screening |
| Hepatitis Nursing Interventions | - Rest + activity as tolerated - Balanced diet w/ small frequent meals - EtOH/hepatotoxic drug avoidance - HCP consult for prescribed/OTC meds - Blood/body fluid precaution - Stool color check - Mental status checks - Antivirals mostly for Hep B/C |
| Cirrhosis | - Liver hardens - D/t hepatitis vs EtOH vs metabolic - EtOH cirrhosis = Laennec cirrhosis S/S: anorexia, N/V, steatorrhea, jaundice, pruritis, RUQ tenderness/pain, lethargy (CNS), asterixis, bleeding risk, spider angioma, palmar erythema |
| Asterixis | flapping tremor of hands |
| Cirrhosis labs | - LFT elevation (AST/ALT) - Decreased albumin + PLT - Elevated Bili |
| Medications for Cirrhosis | - Aldactone (Spironolactone) - Lactulose (cephulac - decrease ammonia) - Antacids (for portal HTN reflux, esophageal ulcers) - Chelating agents (excrete metals for Wilsons/Hemochromatosis) - Steroids - Cholestyramine (itching) - Antiemetics - Antivirals |
| Hepatic Encephalopathy pathophysiology | D/t excess ammonia buildup (CNS toxin) as liver unable to convert to glutamine -> excess serum/cerebral ammonia S/S: asterixis, altered MS, slurred speech (stroke like), lethargy, confusion, fetor hepaticus - Severe liver encephalopathy = hepatic coma |
| Lactulose | - Osmotic laxative -> draws ammonia from blood to gut for excretion - Increased stool quantity (expect 3+ stools in 24/hr) - Effective when increased stool and improve mental status/asterixis in liver encephalopathy |
| Sengstaken-Blakemore Tube | Emergency/temp intervention for esophageal varices (GI bleeding) - Applies pressure inside esophagus + squeeze bleeding vessel = hemorrhage control - Not for long term |
| Esophageal Varices pathophysiology | D/t complication of portal HTN (cirrhosis) -> backup blood into stomach/esophagus vessels - Rupture/hemorrhage risk |
| HIV/AIDs pathophysiology | Human immunodeficiency virus vs Acquired immunodeficiency syndrome - Via bodily fluid transmission S/S: flu-like symptoms, fever, lymphadenopathy, sore throat, headache, malaise, N/V/D, MSK pain, joint pain, diffuse rash, SOB, cough, anorexia, candidiasis, depression, kaposi sarcoma, neuro deficit - heavy diarrhea = dehydration risk/electrolyte imbalance Tx: Antiretrovirals |
| HIV harm reduction strategies | - Community needle exchange program/Syringe service program - Condom distribution - Safe sex practice - PrEP |
| HIV w/ PCP PNA | PCP = pneumocystis carinii pneumonia - Common in aids |
| AIDS diagnostic criteria | - CD4+ count (<200) - PCP/recurrent PNA, Pulm TB, MAC - Candidiasis - CMV - Kaposi sarcoma (purple spots on skin) - Burkitt lymphoma - Invasive cervical CA (ICC) - HIV encephalopathy |
| Antiretroviral Therapy (ART) Goal/Teaching | - Decrease viral load + maintain/increase CD4 count - Prevent opportunistic disease - Delay disease prevention - Prevent HIV transmission - Avoid herbal/OTC drug - Med compliancy - Undetectable viral load = safe sex |
| HIV nursing consideration | - Hand hygiene (immunocompromised pt) - Standard precaution w/ blood/body fluid - Gloves - Sharps in sharps bin |
| HIV/STI screening | HIV/AIDS positive needs screening for: - Syphilis - CT/GC - inconsistent condom use |
| Thrombocytopenia | Low PLT count -> bleed concern (esp internal) - dizziness/fatigue important = decrease O2/perfusion + hemorrhage -> shock S/S: weakness, fatigue, syncope, decrease LOC, tachycardia/tachypnea, abd pain, hypotension, melena, purpura/petechiae (large vs small purple spots), ecchymosis |
| Signs of internal bleeding | - Decrease BP - Elevated HR/RR, severe organ pain, dizziness, syncope, SOB, diaphoresis |
| Enoxaparin | - AKA lovenox -> low molecular wt heparin - Contraindicated in HIT -> d/t low PLT + bleed risk |
| Central line cath considerations | - Acute chest pain/dyspnea = concerning - Auscultate lung sound + check breath sound (lung can be punctured) - Treatment based on finding |
| TPN | - Long period of NPO/Dysphagia (gastric bypass) - Cancer status - Wounds - Require nutrition support - result = stable serum albumin, weight gain, improve wound healing, energy |
| Organ transplant pre-checks | - Positive cross match = Ab attacks donor cells - ABO Rh incompatibility - HIV positive - Immunocompromised patient -> need roommate without infection or private room |
| Tacrolimus | - Immunosuppressive drug (lifelong) |
| Organ transplant Nursing Consideration | - Fever = rejection/infection - Acute rejection possible -> need extra immunosuppressives - May take multiple immunosuppressives, antivirals/abx -> dependent on organ type, time since surgery, health factors |
Created by:
sleepingbear