NUR 265 EXAM 2 - exam 2 (Galen College of Nursing

lOMoAR cPSD|8945469 lOMoAR cPSD|8945469 NUR 265 EXAM 2 - exam 2 Nur Med Surg (Galen College of Nursing) lOMoAR cPSD|8945469 EXAM 2 NUR 265 ● Pulmonary embolism: clot that travels to the lungs ○ Risk factors ■ Prolonged immobility ■ Central venous catheter surgery ■ Obesity ■ Advancing age ■ Conditions that increase blood clotting (DIC) ■ Distort of thromboembolism ■ Smoking ■ Pregnancy ■ Hormonal birth control (estrogen therapy) ■ Heart failure ■ Stroke ■ Cancer ■ Trauma ■ Afib ○ S/s: ■ Dyspnea - SUDDEN ONSET ■ Pleuritic chest pain (sharp, stabbing type pain on inspiration) ■ Crackles ■ Wheezes ■ Apprehension ■ Anxiety ● Give O2 ■ Restlessness ■ Impending doom ■ Cough (productive or dry) ■ Tachypnea ■ Pleural friction rub ■ S3 or s4 heart sound ■ Diaphoresis ■ Low grade fever ■ Petechiae (fat embolism , does not impede blood flow, causes actual damage to the blood vessels) over chest and a axillae ■ If really big you can see EKG changes ■ hemoptysis - bloody sputum ■ Decreased Sao2 ■ Sudden dyspnea and chest pain= immediately notify rapid response team ○ Labs: ■ Hyperventilation (caused from pain and hypoxia) = respiratory alkalosis (low paco2 <35, high PH >7.45) = blood shunting from right side to left lOMoAR cPSD|8945469 side without picking up O2 from the = respiratory acidosis (high paco2 >45, low PH <7.35)= build up of lactic acid = metabolic acidosis (low HCO3 <22, low PH <7.35) ■ D-dimer rises (positive) ○ Dx: ■ Pulmonary angiography = gold standard ● Only if stable ● Inject dye, use imaging ■ CT ■ Chest X -ray ■ Doppler ultrasound ○ Nursing intervention: ■ Call rapid ■ O2 - use pulse ox ● Nasal cannula ● Mask ● Mechanical ventilation ■ Tele ■ IV access ■ Monitor VS. lung sounds and cardiac/ respiratory status Q1 -2hrs ● Assess for and document increasing dyspnea, dysrhythmias, JVD, pedal or sacral edema, crackles, cyanosis ■ CTPA, pulmonary angiography ■ Bleeding precautions ● Monitor and record amount of ble eding ● Asses Q2 hours ■ Measure abdominal girth Q8 Hours ■ Monitor labs daily ● Monitor CBC to watch for blood loss ○ Blood loss= RBC, plasma ○ Monitor platelet count = decreased platelet count = HIIT ■ Drug therapy ■ Make sure antidote is on the floor ● Anticoagulants - keep clots from getting bigger ○ Unfractionated heparin ■ Check PTT (normal 20 -30) before administering ( range between 1.5 -2.5 times the control ) ( therapeutic 46 -70) (>75 = complication ) ■ 5-10 days (for 24 hours ) ■ Protamine sulfate = antidote ○ Then transferred to oral warfarin ■ Monitor INR (2.0 -3.0)