NSG 3180 Fundamentals Exam 4
Units 9 & 10 Objectives
1. Hypoxia
Clinical Manifestations
Subjective:
• What would the patient be complaining about?
o Difficulty breathing
o Shortness of breath
o No energy
o Fatigue
o Dizzy
Hypoxia: Insufficient oxygen anywhere in the body
Signs/symptoms:
o Increased pulse o
Shallow respirations o
Dyspnea
o Increased restlessness o
Cyanosis (very late sign)
o Nasal flaring o
Retractions (substernal
or intercoastal)
Objective:
• What should the nurse assess?
o Labs especially lipid profile LDL and HDL and Hbg
• What would the nurse expect to see?
, o Listed under signs and symptoms
o Elevated serum lipid levels (increased Na and fats)
o Hbg: Low blood level (check when patient complains of no energy,
fatigue, dizzy)
o Hypertension
• What diagnostic exams/labs would the nurse expect to do?
o Blood tests
o Serum lipid level – fats can clog blood vessels and decrease the
circulation of the blood flow
o Serum electrolytes – different electrolytes can affect the
contraction of the heart
o Hemoglobin – this is the part of the RBC which carries the oxygen
o RBC – is the blood component which has the Hbg o Creatinine
kinase and Troponin – is elevated with cardiac cell death o
Hemodynamic studies – evaluate fluid status, cardiovascular
function – completed in cath lab
o Cardiac monitoring – recording of electrical conduction of heart
o Total Cholesterol: Higher than 200mg/dL is a risk factor for
atherosclerosis o LDL: Target less than 130mg/dL o HDL: Target
is Greater than 45mg/dL in males o Greater then 55mg/dL in
females
• What are the risk factors?
Nontraditional risk factors:
o Metabolic Syndrome
o C-Reactive Protein (CRP)
Indicates inflammation and is a predictor of who is at risk
Tx: Smoking cessation, diet and exercise can help reduce
CRP levels.
o Elevated Homocysteine Level
Indicates the presence of atherosclerosis and is a predictor
of who is at risk.
, Tx: Can be decreased by taking a multivitamin containing
folate, B6, B12, and riboflavin
Modifiable:
o Lifestyle: Smoking, Obesity/Increased BMI. Sedentary lifestyle
o Diseases: Diabetes/Hyperglycemia. Transient ischemia attack
(TIA) aka mini stroke.
o Lab Values (cholesterol levels)
o Stress: Elevates BP and HR (meditation)
o Hypertension
Non-modifiable:
o Heredity: Parent with heart disease lead to a higher risk.
o Ethnicity: African Americans have a higher risk o Age: Primarily
affects people 60 years or older
o Gender: Men are at a greater risk until after menopause. Estrogen
has a protective mechanism.
• How should care be prioritized?
• What type of breathing patterns would your patient have to have that
would warrant laying eyes on them ASAP?
o Cheyne-Stokes respirations: Are rhythmic and vary from deep to
shallow with periods of apnea (Brain tumors (ICP) and injuries,
end of life, drug overdose)
o Kussmaul’s: Fast and deep. Occurs with hyperventilation.
(acidosis, renal failure, diabetes)
o Biots: Deep breath with periods of apnea (spinal meningitis, head
injury) o CLUSTER?
• What are the nurse’s interventions?
• What should be evaluated?
Units 9 & 10 Objectives
1. Hypoxia
Clinical Manifestations
Subjective:
• What would the patient be complaining about?
o Difficulty breathing
o Shortness of breath
o No energy
o Fatigue
o Dizzy
Hypoxia: Insufficient oxygen anywhere in the body
Signs/symptoms:
o Increased pulse o
Shallow respirations o
Dyspnea
o Increased restlessness o
Cyanosis (very late sign)
o Nasal flaring o
Retractions (substernal
or intercoastal)
Objective:
• What should the nurse assess?
o Labs especially lipid profile LDL and HDL and Hbg
• What would the nurse expect to see?
, o Listed under signs and symptoms
o Elevated serum lipid levels (increased Na and fats)
o Hbg: Low blood level (check when patient complains of no energy,
fatigue, dizzy)
o Hypertension
• What diagnostic exams/labs would the nurse expect to do?
o Blood tests
o Serum lipid level – fats can clog blood vessels and decrease the
circulation of the blood flow
o Serum electrolytes – different electrolytes can affect the
contraction of the heart
o Hemoglobin – this is the part of the RBC which carries the oxygen
o RBC – is the blood component which has the Hbg o Creatinine
kinase and Troponin – is elevated with cardiac cell death o
Hemodynamic studies – evaluate fluid status, cardiovascular
function – completed in cath lab
o Cardiac monitoring – recording of electrical conduction of heart
o Total Cholesterol: Higher than 200mg/dL is a risk factor for
atherosclerosis o LDL: Target less than 130mg/dL o HDL: Target
is Greater than 45mg/dL in males o Greater then 55mg/dL in
females
• What are the risk factors?
Nontraditional risk factors:
o Metabolic Syndrome
o C-Reactive Protein (CRP)
Indicates inflammation and is a predictor of who is at risk
Tx: Smoking cessation, diet and exercise can help reduce
CRP levels.
o Elevated Homocysteine Level
Indicates the presence of atherosclerosis and is a predictor
of who is at risk.
, Tx: Can be decreased by taking a multivitamin containing
folate, B6, B12, and riboflavin
Modifiable:
o Lifestyle: Smoking, Obesity/Increased BMI. Sedentary lifestyle
o Diseases: Diabetes/Hyperglycemia. Transient ischemia attack
(TIA) aka mini stroke.
o Lab Values (cholesterol levels)
o Stress: Elevates BP and HR (meditation)
o Hypertension
Non-modifiable:
o Heredity: Parent with heart disease lead to a higher risk.
o Ethnicity: African Americans have a higher risk o Age: Primarily
affects people 60 years or older
o Gender: Men are at a greater risk until after menopause. Estrogen
has a protective mechanism.
• How should care be prioritized?
• What type of breathing patterns would your patient have to have that
would warrant laying eyes on them ASAP?
o Cheyne-Stokes respirations: Are rhythmic and vary from deep to
shallow with periods of apnea (Brain tumors (ICP) and injuries,
end of life, drug overdose)
o Kussmaul’s: Fast and deep. Occurs with hyperventilation.
(acidosis, renal failure, diabetes)
o Biots: Deep breath with periods of apnea (spinal meningitis, head
injury) o CLUSTER?
• What are the nurse’s interventions?
• What should be evaluated?
