Medsurg ATI Notes/ATI Adult Medical Surgical Care Summary

Chapter 1 Health, Wellness, and Illness ● Health and Wellness ○ Unique to each individual ■ Variables include: ● Modifiable (smoking, diet, exercise) ● Non-modifiable ( sex, age, genetic) ● Aspects of health and wellness ○ Physical ○ Emotional ○ Social ○ Intellectual ○ Spiritual ○ Occupational ○ Environmental ● Internal vs. External environment effects ○ External ■ Social ex: ● Crime v. Safety ■ Physical ex: ● Access to healthcare or clean water ○ Internal ■ Spiritual beliefs, age, gender. ● Illness- Wellness Continuum ○ Assessment tool used to measure the level of wellness to premature death. ■ The center is of the continuum is normal state of health. ■ Ranges from optimal to severe ■ To help improve clients wellness Chapter 2 Emergency Nursing Principles and Management ● Triage (5 levels) ○ Resuscitation (cardiac arrest) ○ Emergent (head injury) ○ Urgent (kidney stone) ○ Less urgent (bladder infection) ○ Nonurgent (rash) ● Primary Survey ○ Rapid assessment of life-threatening conditions ○ Should be completed systematically so nothing is missed ○ Standard precautions must be worn ■ Glove, gown, eye, shoe and face protection ● ABCDE Principle ○ Airway/Clearance ■ Most important step! ■ Brain injury can occur in 3-5 mins if airway is not patent ■ If a client is unresponsive without sign of trauma airway should be opened by head-tilt/chin-lift maneuver ● DO NOT perform on potential cervical spinal injury ■ If the client is unresponsive with suspected trauma used jaw thrust maneuver. ■ Bag valve 100% =pt needs support during resuscitation ■ Non Rebreather 100% = pt spontaneously breathing ○ Breathing ○ Circulation ■ Interventions geared toward restoring circulation ● CPR ■ Shock can develop if circulation is compromised. ● Administer 02 ● Apply pressure to bleed● Elevate extremities to shunt organ ● IV fluids and blood products ● Vitals ○ Disability (LOC) ■ AVPU mnemonic ● ALERT ● Responsive to VOICE ● Responsive to PAIN ● UNRESPONSIVE ■ Glasgow Coma Scale ■ Neuro Assessment ○ Exposure ■ All clothing removed during resuscitation ■ Hypothermia is primary concern ● Occurs when core temperature is 35 degrees C or less ■ Prevent Hypothermia ● Remove wet clothes ● Cover pt with warm blankets ● Increase room temperature ● Use heat lamp ● Warm IV fluids ● Poisoning ○ Children 1 to 9 are highest risk for snakebites. ■ Ice, heparin, and corticosteroids are contraindicated in first 6 to 8 hours after bite. ■ Antivenom most effective if given within 4-12 hours. ○ Interventions for ingested poison ■ Activated charcoal ■ Gastric lavage (within 1 hour of ingestion) ■ Aspiration ■ SYRUP IPECAC IS NO LONGER USED. ■ IV fluids ○ Heroin and opiates toxicity ■ Naloxone ● Rapid Response Team ○ Group of critical care experts( ICU nurse, RT, hospitalist) ○ Call when pt is rapidly declining ● Cardiac Emergency ○ Cardiac arrest ■ Cessation of cardiac function ● Most commonly VFIB or VAsystole ○ VFIB ■ Fluttering of ventricles causing LOC, pulselessness, and no breathing. ● Defibrillate ○ Pulseless VTach ■ 140-180 beats per min ● Will become unconscious and deteriorate to VF ● AHA ACLS Protocols ○ VF/ Pulseless VTach ■ CPR ■ Defibrillate ■ IV access ■ Administer Epi or Vasopressin ■ Also these antidysrhythmics: Amiodarone, Lidocaine, and Mg. ○ Asystole ■ CPR ■ IV access■ Give Epi 1 mg IV push q 3-5 mins. Chapter 3 Neuro Diagnostic Procedures ● Cerebral angiography ○ Provides visual of cerebral blood vessels ■ Hides bones and tissues from images showing only vessels ■ Shows defect, narrowing, and obstruction ■ Uses contrast dye ○ Indications ■ Identify blood flow within brain, aneurysms, and vascularity of tumors. ○ Considerations ■ PreOp (pregnant women) ● NPO 4-6 hrs prior ● shellfish/iodine allergy ● HX of bleeding or taking anticoagulants ● Assess BUN and CR to determine kidneys can excrete dye ● No jewelry ● Instruct pt not move during test, void immediately prior, and effects of dye (like metallic taste) ■ Intra Procedure ● Cath is placed in artery (usually groin or neck) ■ PostOp ● Monitor area for clotting ● Movement is restricted ○ Complications ■ Risk for bleeding or hematoma at site ● If bleeding occurs apply pressure then call provider ● CT Scan ○ Used to identify tumors/infarctions, abnormalities, and guide needles in biopsy. ○ Considerations ■ PreOp (pregnant women) ● Same as above ○ Consider placing pillow in small of pt back for comfort while supine ■ Intra and Post Op ● Sedation can be provided if needed ○ Monitor post if sedation given ● Monitor for allergy to dye ● Electroencephalography ○ Noninvasive , determines electrical activity in brain. ○ Used to determine seizure activity, sleep disorders, and behavior changes. ○ Considerations ■ Preop ● Instruct pt wash hair to rid oils, sprays, etc. ● Pt should be sleep deprived to increase abnormal activity ● Electrical activity can be stimulated by flashing lights or having pt hyperventilate for 3-4 mins. ● Instruct pt to avoid stimulants or sedative 12-24 hrs prior ■ Intra Procedure/ Post Op ● Takes 1 hr. ● No risks associated ● Pt can resume normal activity ● Glasgow Coma Scale ○ Test Eye(4-1), Verbal(5-1), and Motor(6-1) and add for score. ■ Best score is 15 ■ Less than 8 is severe head injury and coma ■ 9-12 moderate head injury■ 13 or more mild head injury ○ If pt is intubated score will read ex: GCS 5t (t means intubated) ● ICP monitoring ○ If pt has low GCS then ICP needed. (8 or less) ○ ICP monitor placed by neurosurgeon in OR, ER, or CCU. ■ Very invasive ■ High risk for infection ○ Three types of ICP monitors are ■ Intraventricular catheter ■ Subarachnoid screw/bolt ■ Epidural or subdural sensor ● Early signs of ICP ○ Irritability ○ Severe headache ○ Decreased LOC ○ Dilated or pinpoint pupils ○ Cheyne stokes breathing, apnea, or hyperventilation. ○ Decorticate or Decerebrate posture ■ Core (arms turned to chest) adducted and flexed ● Normal ICP ○ 10-15 mm Hg ● Lumbar Puncture ○ Procedure to remove small amount of CSF from spinal canal to analyze for things like meningitis, MS, syphilis, etc. ○ Pre and Intra procedure ■ Have pt empty bladder ■ Lay on side in “cannonball” position ■ MD will apply local anesthesia and apply needle ○ Post op ■ Monitor puncture site ■ Have pt remain lying for several hours to make sure site clots ● Decreases risk of post lumbar headache due to CSF leakage ○ Complications ■ If clotting doesn't occur to seal dura puncture site, CSF can leak, resulting in headache and increase risk for infection ● Encourage pt to lie flat in bed. (Give fluids and pain meds) ● Prep pt for epidural blood patch to seal hole in dura if headache continues. ● MRI ○ Preop ■ Some use contrast dye some don't. (Use precautions like above it is does) ■ Remove jewelry ■ Check for claustrophobia ● may need sedation ■ Check for implants containing metal ● Pacemakers, surgical clips, iv access port, ortho joints, heart valve, intrauterine devices, etc. ■ Give pt. earplugs for loud noise of MRI ● PET scan ○ Nuclear procedure that depicts images of the brain in 3D. ○ Useful in determining tumor activity or response to treatment. ● Radiography (x- ray) ○ Sometimes used with neuro issues ■ Skull and spine can reveal fractures, curvatures, bone erosion and dislocation ■ All above can damage nervous system Chapter 4 Pain Management● Acute pain ○ Temporary, protective, and usually resolves with tissue healing ● Chronic pain ○ Lasting longer than 3 months ■ Associated with depression, fatigue, decreased level of functioning. ● Nociceptive pain ○ Arises from damage or inflammation of tissue ■ Described as throbbing or aching and is usually localized ○ 2 types are Somatic and Visceral ■ Somatic ● Bones, joints, muscles, skin, or connective tissues ■ Visceral ● Internal organs like stomach or intestines ● Neuropathic Pain ○ Due to abnormal or damaged pain nerves. ■ Ex: diabetic neuropathy ○ Described as intense shooting, burning, or “pins and needles” ○ Treatment meds include ■ Antidepressants ■ Antispasmodic ■ Muscle relaxants ● Pain assessment ○ Location of the pain ○ Quality of the pain “how it feels” ○ Measures 0-10 scale ○ Timing “Onset, duration, frequency” ○ Setting “how is affecting daily life” ○ Associated manifestations “nausea, fatigue” ○ Aggravating/ relieving factors ● Non Pharm pain management ○ Imagery, acupuncture, relaxation, heat/cold, and therapeutic massage. ○ TENS (transcutaneous electrical nerve stimulation) ● Pharmacological intervention ○ Mild to moderate 1 to 3 ■ NSAIDs, acetaminophen, salicylates ● Be aware of amount of tylenol pt receives in day to avoid hepatotoxicity. No more than 4g/ day ○ Opioids like hydrocodone bitartrate contain 5mg acetaminophen per 500 mg tab. ● With salicylates toxicity pt can complain of tinnitus, vertigo, decreased hearing acuity. ● Gastric upset with NSAIDS give food ● Monitor bleeding with long-term NSAID use. (GI) ● NSAIDS increased effects of warfarin. ○ Mod 4-6 to Severe 7- 10 ■ Morphine, fentanyl (cancer or end of life pain), dilaudid. Oxycodone ● Around the clock administration to maintain pain ■ Adverse effects of opioid analgesics ● Constipation, orthostatic hypotension, urinary retention, nausea/vomiting, sedation, and respiratory depression. ■ Have order for Naloxone if necessary to reverse effects. Chapter 5 Meningitis ● Inflammation of the meninges, which are the membranes that protect the brain and spinal cord. ○ Viral (aseptic) is most common and usually resolves on its own ○ Bacterial (septic) is contagious with a high mortality rate. ■ Needs antibiotic treatment○ Fungal is common to AIDS pt’s. ● Vaccines given for prevention ○ Hib ■ Infants starting at 2 months ○ MCV4 ■ Teenagers usually receive prior to going to college ■ Crowded living conditions (like dorms) are risk factor ● Symptoms ○ Excruciating headache ○ Nuchal rigidity (stiff neck) ○ Photophobia (light sensitive) ○ Fever/chills ○ Nausea/vomit ○ Altered LOC ○ Positive Kernig's (K&K) ■ Knee flexed, try to straighten leg ○ Positive Brudzinski ■ Pull up head causes knees to flex in ○ Tachycardic ○ Seizures ○ Red macular rash ○ ICP can result in irritability ● Diagnosis ○ CSF analysis is most definitive ■ Bacterial =cloudy ● Decreased glucose ■ Viral= clear ○ Elevated WBC, and protein ● Nursing care ○ Droplet precaution initially for all suspected ■ After 24 hr on antibiotics can move to standard precautions for Viral ■ Bacterial stays on droplet ○ Maintain quiet environment ○ No bright lights ○ Monitor for ICP and minimize ■ HOB 30 degrees ■ Discourage coughing, sneezing (increases ICP) ■ Seizure precautions ● Medications ○ Antibiotic (vanco/ceftriaxone) ○ Anti Seizure (phenytoin) ○ Prophylactics (cipro, rifampin) ○ Pain meds (tylenol, ibuprofen) ● Complications ○ Increased ICP ■ Monitor for decrease LOC, pupil change ○ SIADH ■ Monitor concentrated urine ■ Dilute blood ○ Septic emboli Chapter 6 Seizures and Epilepsy ● Seizure is an abrupt, abnormal, uncontrolled electrical discharge of the neurons of the brain. ○ Causes decreased LOC and motor and sensory changes ● Epilepsy is chronic recurring abnormal brain electrical activity ○ Resulting in 2 or more seizures ● Risk Factors○ Genetics ○ Fever (under 2) ○ Head trauma (late onset- can be up to 9 months after) ○ Cerebral edema ○ Abrupt cessation of antiepileptic drugs ○ Infection (meningitis) ○ Metabolic disorder (hypoglycemia) ○ Exposure to toxins ○ Stroke ○ Heart disease ○ Brain tumor ○ Hypoxia ○ Substance withdrawal ○ Fluid and electrolyte imbalances ● Triggering Factors ○ Excessive stress, fatigue, excessive caffeine, exposure to lights ● Types of Seizures ○ Generalized seizures ■ Involves both hemispheres ■ Sometimes can begin with Aura (altered sensory) ○ Tonic-clonic ■ Stiffening of muscles and LOC (tonic) ■ 1-2 minute jerking occurs (clonic) ■ (postictal phase) confusion and sleepiness follows seizure ○ Tonic seizure ○ Clonic Seizure ○ Myoclonic seizure ■ Brief jerking and stiffening ○ Atonic/ akinetic ■ Few seconds where muscle tone is lost ● Usually results in falling ● Diagnostic Procedures ○ EEG may identify origin ○ CAT scan ○ MRI ○ Sample of CSF to check for infection ● Nursing Interventions During seizure ○ If standing, lower to floor and lay on side to decrease risk for aspiration ■ Move furniture out of way ○ Loosen restrictive clothing ○ Do not put anything in mouth ○ Document onset and duration ● After seizure ○ Keep side lying ○ Take vitals ○ Neuro check ○ Reorient pt ○ Possible trigger ○ Seizure precautions if pt wasn't before ● Medications ○ Antiepileptics= Phenytoin ■ Periodic blood checks needed for therapeutic Phenytoin levels ■ Can cause oral gum overgrowth ○ Decreases effectiveness of oral contraceptives, and Warfarin/Coumadin ● Therapeutic Procedures ○ Vagal nerve stimulator indicated for partial seizures (one hemisphere)■ Can hold magnet over device if they feel seizure coming on ■ Avoid MRI and microwaves ● Complications ○ Status Epilepticus ■ Repeat seizure activity within 30 min time frame or seizure lasting more than 5 mins. ● Maintain airway, provide 02 ● Establish IV access ● ECG monitoring ● Pulse Ox and ABG’s ● Administer diazepam/lorazepam IVP followed by IV phenytoin Chapter 7 Parkinson’s ● Disease that affects motor function. ○ Balance between dopamine and acetylcholine is off. (acetylcholine is higher) ○ This occurs due to degeneration of substantia nigra (results in decreased dopamine production) and acetylcholine over stimulates basal ganglia. ● Stages of PD ○ Stage 1: Unilateral shaking/tremor one limb ○ Stage 2: Bilateral limb making balance difficult ○ Stage 3: Physical movements slow down ○ Stage 4: Tremors cna decrease but akinesia and rigidity make ADL’s difficult ○ Stage 5: Unable to walk, may have dementia. ● Symptoms ○ Tremor and Pill rolling ○ Muscle rigidity ○ Bradykinesia ○ Stooped posture ○ Slow/shuffling gait ○ Masklike expression ○ Difficulty chewing and swallowing (aspiration risk) ○ Drooling ○ Difficulty with ADL’s ○ Eventually mood swings and cognitive impairment (dementia) ● Diagnostics ○ No definitive diagnostic procedure ○ Diagnosis made based on symptoms ● Nursing Care ○ Monitor swallowing ○ Maintain adequate nutrition ■ Thicken liquids if needed for easier swallowing ○ Encourage exercise and ROM ■ Yoga ■ Teach pt to slow down when walking to reduce risk of injury ○ May need alternate forms of communication as they progress ■ Teach them to speak slowly ● Medications ○ Levodopa (typically combined with Carbidopa) ■ Most commonly given to PD pt ■ Levodopa increases dopamine levels in body ■ Combined with Carbidopa because you can use less Levodopa which results in less side effects. ● Monitor for “wearing off” periods (problems with movement) can indicate change in dose or a need for a medication holiday. ○ Anticholinergics ■ Decreases acetylcholine ■ Ex: Benztropine● Monitor for dry mouth, constipation, urinary retention, and acute confusion. ● Complications ○ Aspiration Pneumonia ■ As disease progresses increases risk for aspiration ● Be in attendance while pt is eating ● Have suction neat by ● Keep HOB elevated Chapter 8 Alzheimer’s Disease ● Is responsible for 60- 90% of dementia cases ● Usually occurs after 65 (age is #1 known risk) ○ Can be diagnosed as early as 40 ○ Usually diagnosed 60-70 years of age ● Characterized by memory loss, problems with judgement, and personality changes ● Risk Factors ○ Age ○ Exposure to herpes, metal, or toxic waste ○ Previous head injury ○ Females ● 7 stages of AD ○ Stage 1: No impairment ○ Stage 2: Very mild cognitive decline (little forgetful) ○ Stage 3: Mild cognitive decline (short term memory loss evident) ○ Stage 4: Moderate cognitive decline (personality change, obvious memory loss) ○ Stage 5: Moderately severe (needs help with ADLS) ○ Stage 6: Severe (frequent episodes of incontinence) ○ Stage 7: Very severe (ability to speak/move, cant swallow, speech unrecognizable) ● Diagnostics ○ No definitive except brain tissue exam upon death ○ MRI, CAT scan to rule out other condition ● Nursing interventions ○ Reorient with simple calendar ○ Provide short/simple directions ○ Repetition and consistent with instruction ○ Reminiscing is therapeutic ○ Avoid overstimulation ■ Maintain scheduled routine ■ Including toileting routine ● Gradually change routine if needed ● Home safety ○ Remove scatter rugs ○ Door locks that cannot be easily opened/ alarms ○ Have good lighting especially on stairs ■ Use color tape on edge of stairs to mark for pt ○ Remove clutter ○ Place mattress on floor to prevent falls ● Medications ○ Donepezil ■ Increases ACh by preventing its breakdown ● Improves cognition, behavior, and function Chapter 9 Brain Tumors ● Often the Hypothalamus can be damaged due to pressure from nearby tumor ○ Can lead to SIADH or diabetes insipidus Chapter 10 Multiple Sclerosis ● Autoimmune disorder ○ Results in plaque in the white matter of CNS■ Plaque damages myelin sheath and interferes with impulse transmission between CNS and the body ● Risk Factors ○ Chronic ○ No known cure ○ Typically ages 20-40 ○ Women 2x greater risk ● Normal course of MS is period of relapsing and remitting ○ Relapse Triggers include: ■ Viruses ■ Cold climate ■ Physical injury ■ Pregnancy ■ Fatigue ■ Hot shower/bath ● S/S ○ Diplopia (double vision) and decreased visual acuity ○ Tinnitus and decreased hearing acuity ○ Dysphagia (difficulty swallowing) ○ Dysarthria (slurred and nasal speech) ○ Muscle spasticity ○ Ataxia or muscle weakness ○ Nystagmus (rapid movement of eyes) ○ Bowel and bladder dysfunction ○ Cognitive changes (memory loss) ○ Sexual dysfunction ● Diagnosis ○ MRI will show plaques in brain and spine ● Nursing care ○ Medications ■ Cyclosporine ● Immunosuppressant to reduce frequency of relapse ■ Prednisone ● Steroid to decrease inflammation ■ Dantrolene or Baclofen ● Muscle relaxers used to treat muscle spasticity ○ Baclofen can cause jaundice Chapter 11 Headaches ● Migraine or Cluster ○ Can be triggered by ■ Environmental factors ■ Allergens ■ Intense odors ■ Bright lights ■ Fatigues, anxiety, depression, stress ■ Menstrual changes and hormones ■ Tyramine, MSG, nitrates, and milk products (educate) ○ Migraine ■ S/S ● Photophobia ● Phonophobia ● nausea/ vomiting ● Unilateral pain (usually behind ear or eye) ● Family hx is strong risk factor ● Usually between 4- 72 hrs ● Occur when higher stress or during certain times of month■ Some people get it with Aura (like visual flashing lights behind eye) ○ Nursing interventions for Migraine ■ Cool, dark, quiet environment ■ Elevate HOB 30 degrees ■ Meds as prescribed ● Medications for Migraine ○ Mild ■ NSAIDS ■ Antiemetic for nausea ● Metoclopramide ○ Severe ■ “Triptans” ● Produce vasoconstriction effect to decrease pain ● Can cause facial flushing, or warmth ■ Ergotamine ● Narrow blood vessels and reduce inflammations ● Cluster Headaches ○ Brief episodes of intense, throbbing, unilateral pain ■ Lasting 30 mins- 2hr. ■ Can radiate to forehead, temple, or cheek. ○ Occur daily at same time for 4-12 weeks ○ More frequent in spring and fall ○ No warnings sign ○ Less common ○ Found in men between 20- 50 ○ Altered sleep-wake cycle can trigger ● S/S of Clusters ○ Tearing of eye with runny nose, and nasal congestion ○ Facial sweating ○ Drooping eyelid ● Medications ○ Same as above for migraines Chapter 12 Disorders of the Eye ● Macular degeneration ○ #1 cause of vision loss in older adults (usually over 60) ○ No cure ○ Two types MD ■ Dry MD: most common ■ Wet MD: less common ○ S/S ■ Blurred vision ■ Loss of central vision ■ Can cause blindness ○ Nursing Care ■ Encourage foods high in antioxidants, carotene (yellow and orange veggies), vitamins E and B12. ■ Refer to community resource for help with ADL’s like transportation. ● Cataracts ○ Opacity in lens of eye that impair vision ■ Common, painless ○ S/S ■ Blurred vision ■ Diplopia ■ Light sensitivity ■ White pupils ○ Absent red reflex upon assessment○ Requires cataract surgery to improve vision ■ Remove lens of eye and put in replacement ○ Post-op education and care ■ Wear sunglasses outside and brightly lit areas ■ Report signs of infection ● yellow/green discharge of eye ■ Avoid activities that increase IOP (ocular pressure) ● Bending over at waist ● Sneezing and coughing ● Straining ● Head hyperflexion ● Restrictive clothing (tight collar shirt) ● Sex ■ Limit activities ● Tilting head back to wash hair ● Cooking and housekeeping ● Rapid movements (vacuuming) ● Driving ● Playing sports ■ Best vision will not be obtained until about 4-6 weeks after surgery ● Glaucoma ○ Disturbance of functional/structural integrity of optic nerve ■ Leading cause of blindness ● Genetics, HTN, DM, and Age can all be risk factors ○ Primary open-angle glaucoma ■ Aqueous humor outflow decreased due to blockage in eyes drainage system ○ “Kitchen sink partially blocked” ■ S/S ● Mild eye pain ● Loss of peripheral vision ● Elevated IOP (usually greater than 21 mm Hg) ○ If you go over “21 in blackjack it's a bust” ○ Primary angle-closure glaucoma ■ Angle between iris and sclera closes ● IOP rises very suddenly ■ Onset is sudden and requires immediate treatment ○ “Kitchen sink blocked, and fills quickly” ■ S/S ● Severe pain ● Nausea ● Photophobia ● Elevated of IOP of 30 mm Hg or higher ○ Tonometry ■ Measures IOP ■ Normal range 10-21 mm Hg ○ Nursing interventions ■ Give prescribed eye medication q12 hr. ■ Wait 5-10 mins between eye drops if more than one is prescribed to prevent dilution ■ Avoid touching eye with bottle and hands ■ Put pressure on inner corner of eye after instilling drop ○ Medications ■ Pilocarpine ● Constricts pupil ● Second line for POAG ■ Beta-blockers● Timolol ○ First line for glaucoma ○ Decreases IOP ■ IV mannitol ● Diuretic ○ Used for emergency treatment for PACG to quickly decrease IOP ■ Acetazolamide ● Diuretic ○ Decreases IOP ○ Ask pt for sulfa allergy Chapter 13 Middle and Inner ear disorders ● Middle ear infection= otitis media ○ Risk factors ■ Current colds ■ Respiratory infections ■ Enlarged adenoids ■ Changes in air pressure (flying) ○ S/S ■ Red, inflamed ear canal and tympanic membrane (TM) ■ Bulging TM ■ Fluid or bubble behind ™ ● Inner ear infection= Meniere’s Disease ■ Characterized by tinnitus, unilateral hearing loss, and vertigo ○ Risk factors ■ Viral or Bacterial INfection ■ Damage due to ototoxic medications ○ S/S ■ Tinnitus ■ Vertigo ■ Alteration in balance ■ Vomiting ■ Nystagmus ○ Adults- up and back ○ Kids- down and back ○ Light reflex (5 o’clock Right ear and 7 o’clock left ear) ● Ototoxic Medications ○ Antibiotics ■ Gentamicin ■ Erythromycin ○ Diuretics ■ Furosemide ■ Ethacrynic acid ○ NSAIDS ■ Aspirin ■ Ibuprofen ○ Chemo agents ■ Cisplatin ● Medications ○ Meclizine ■ Antihistamine and ACh ■ Used to treat vertigo ○ Ondansetron ■ Antibiotics ● Contraindicated in certain cardiac rhythm disorders ○ Benadryl■ Vertigo and nausea ● Observe for urinary retention ● Avoid driving, sedative effects ○ Scopolamine ■ ACh ● Transdermally for motion sickness ● Watch for urinary retention, dry mouth, constipation ● Vertigo-reducing activities ○ Avoid caffeine and alcohol ○ Rest in quiet, dark area when severe ○ Space out fluid intake evenly to avoid overload ○ Decrease salt consumption ● Surgical Interventions ○ Stapedectomy ○ Cochlear implant ○ Labyrinthectomy Chapter 14 Head Injury ● A cervical spine injury should always be suspected when a head injury occurs. ○ Must be ruled out prior to removing any devices used to stabilize the cervical spine ● Expected findings ○ Increased ICP Normal range 10-15 ■ S/S of increased ICP ● Severe headache ● Deteriorating LOC use GCS to identify ● Irritability (first sign if the option on test) ● Dilated or pinpoint nonreactive pupils ● Alteration in breathing (cheyne-stokes) ○ Cushing’s triad (severe HTN, widening pulse pressure, and bradycardia) sign of severe ICP ■ CSF leakage from nose and ears can indicate skull fracture ● Makes “halo” sign. Blood with yellow ring around it. ○ Will test positive for glucose ● Asses/ Monitor ○ ABC’s ○ Hypercarbia ■ Leads to cerebral vasodilation ■ Leads to increased ICP ● Hyperventilate pt. ● PaO2 greater than 60 ○ Do not suction ○ Avoid coughing, sneezing, straining ○ Maintain HOB less than 30 degrees ○ Avoid neck flexing or extending ○ Non restrictive clothing ● Medications ○ Mannitol ■ Diuretic ● Used to treat cerebral edema ○ Monitor for electrolyte imbalance (like hyponatremia) ○ Barbiturates ■ Can put pt in coma which decreases metabolic demands of body until ICP decreases ○ Phenytoin ■ anticonvulsant ○ Morphine ■ To control pain and restlessness● Surgical Interventions ○ Craniotomy ■ Supratentorial ● Front of head ● HOB at 30 ■ Infratentorial ● Keep flat on either side for 24-48 hrs ○ Complications ■ Brain herniation ● Downward shift of brain tissue due to cerebral edema ○ Fixed dilated pupils, deteriorating LOC, cheyne-stokes, abnormal posturing ■ Hematoma ■ Intracranial hemorrhage ■ Diabetes insipidus or SIADH ● Due to pressure on hypothalamus ■ Cerebral Salt Wasting (CWS) ● Due to effects of atrial natriuretic factor on hypothalamus ○ Can cause hypovolemia and hyponatremia (because of the pressure) Chapter 15 Stroke ● AKA cerebral vascular accident ○ Three types of Stroke ■ Hemorrhagic ● Ruptured artery or aneurysm ■ Thrombotic ● Blood clot develops in cerebral artery ■ Embolic ● Embolus travels from other part of body to cerebral artery ○ Risk factors ■ HTN ■ Diabetes Mellitus ■ Smoker ■ Obesity ○ S/S ■ Visual disturbances ■ Dizziness ■ Slurred speech ■ Weak extremity ○ Left sided ■ Language ■ Math ■ Analytical thinking ● May have expressive and receptive aphasia (inability to speak/understand language) ● Alexia (reading difficulty) ● Agraphia (writing difficulty) ● Right sided (hemiplegia) paralysis or weakness (hemiparesis) ● Hemianopsia (loss of visual field in one or both eyes) ○ Right sided ■ Visual and spatial awareness ● May overestimate abilities (loss of depth perception) ● Poor impulse control and judgement ● Unilateral neglect syndrome ○ Ignore left side of body ○ Cant see, feel, or move○ Can happen in left sided stroke also but more common in right ● Left paralysis/weakness ○ Diagnosis ■ MRI, CT, or CAT scan ○ Nursing Care ■ Monitor BP closely ● Notify provider ASAP if systolic greater than 180 ● diastolic greater than 110 ● Pt could be having ischemic stroke ■ Assess swallowing and gag reflex ● Have suction ready when feeding ● Start with sip of water and see how they do ● Involve speech therapy ○ They will do swallow evaluation ● May need to thicken liquids for easier swallowing ● Pt should be sitting all the way upright ○ Swallow with head and neck flexed slightly fwd ○ Feed on unaffected side of mouth ■ Maintain skin integrity ● Reposition pt frequently and use padding ■ Maintain safe environment to prevent fall risk ■ Teach pt scanning technique for homonymous hemianopsia ● Turn head from unaffected side to affected side when eating and ambulating ○ Medications ■ Thrombolytic medications (reteplase recombinant) ● All end in “plase” ○ Give within 4.5 hours of initial symptoms ○ Surgical intervention ■ Carotid artery angioplasty with stenting (CAS) ● Retrieves the clot and opens the artery back up ○ Complications ■ Dysphagia and aspiration Chapter 16 Spinal Cord Injury ● Injury to cervical region causes quadriplegia ● Injury below T1 results in paraplegia ○ Lower extremities ● Damage of C4 or above greater risk for respiratory issues ○ Due to phrenic nerve involvement ○ ABC’s ■ intubate/ mechanical ventilation if needed ● Assessment Findings ○ Inability to feel light touch ■ Can't tell difference between sharp and dull ○ Absent deep tendon reflexes ○ Flaccidity of muscles ○ Hypotension ● Nursing care ○ Neurogenic shock ■ Can occur within 24 hr of SCI ● Can last several days to weeks ■ Causes total loss of autonomic function ● Hypotension ● Dependent edema ● Loss of temperature regulation ○ Following NS■ If injury is to upper motor neurons (above L1/L2) ● Will convert to spastic muscle tone ● Spastic neurogenic bladder (condom cath) ■ Lower motor (below L1/L2) ● Flaccid type of paralysis ● Flaccid neurogenic bladder (intermittent cath or Crede’s) ○ Give pt daily stool softener ■ Maintain schedule for bowel and urine eliminations ● Medications ○ Glucocorticoids ■ To decrease edema of spinal cord ○ Vasopressors ■ Especially neurogenic shock for hypotension ● Norepinephrine and dopamine ○ Muscle relaxers ■ For spastic muscles ● Baclofen and dantrolene ○ Antimuscarinic ■ For bradycardia ● Atropine ● Complications ○ Orthostatic hypotension ■ Change pt position slowly ■ Give thigh-high elastic hose to increase venous return ○ Autonomic dysreflexia ■ Injury above T6 ● Severe HTN ● Sudden extreme headache ● Pallor ● Blurred vision ● Diaphoresis (sweating) ○ Sit pt up right to decrease BP ○ Notify provider ○ Check for distended bladder ■ Most common cause kinked catheter ■ Or may need catheter ○ Check for fecal impaction ■ May need to remove ○ Loosen any tight clothing ○ May have undiagnosed injury/illness ■ Kidney infection or stone ■ Lower extremity fracture ○ Administer antihypertensives ■ Nitrates or hydralazine Chapter 17 Respiratory Diagnostic Procedures ● ABG’S ○ Know how to analyze ○ Obtained by an arterial puncture or through arterial line. ■ Perform Allen’s test prior to puncture ● Compress radial and ulnar arteries and then let one go to determine patency. ● Let pt know they will experience some pain ● Hold pressure to site for at least 5 mins after puncture ○ 20 mins if on anticoagulants ○ Complications■ Hematoma ■ Air embolism ● Place pt on left side in Trendelenburg position (first action) ● Monitor for SOB, decreased 02 levels, chest pain, anxiety, and air hunger. ● Bronchoscopy ○ Allows provider to visualize larynx, trachea, and bronchi through flexible fiber-optic or rigid bronchoscope. ■ Can be done for biopsy ■ Removal of excess fluids ■ Removal of lesions ○ NPO for 4-8 hr prior ○ May administer ■ Local anesthetic throat spray ■ Viscous lidocaine ■ Anxiolytic ■ Atropine ○ Post-op ■ Check for gag reflex before resuming oral intake.- may take a while (especially older PTs) ● Ice chips first → eventually fluids ● Blood tinged sputum, dry cough, and sore throat are all normal findings ● Thoracentesis ○ Perforate the chest wall and pleural space to obtain specimen, instill medication into pleural space, and remove fluid (effusion) or air from pleural space. ■ If pt has pleural effusion they will present with SOB, cough, and chest pain. ○ Nursing care ■ Position pt upright with arms and shoulders raised and supported by pillows ● Or leaning over bedside table ■ Instruct to remain absolutely still during procedure ● Risk for needle damage ● Do not talk or cough ■ Can only remove 1L of fluid per session ● Prevents re-expansion pulmonary edema ■ Monitor respiratory status post-op ● Hourly for first several hours ○ Complications ■ Mediastinal Shift ● Shift or structures to one side of body ■ Pneumothorax ● Collapsed lung ○ Monitor for deviated trachea ○ Pain on affected side that worsens at the end of inhalation/exhalation. ○ No movement on affected side while breathing in and out ● Increased heart rate and shallow respirations are also signs ■ Bleeding ● Monitor for hypotension as sign of internal bleeding ■ Infection ● Fever, elevated WBC Chapter 18 Chest Tube Insertion and Monitoring ● Inserted into pleural space to drain fluid, blood, or air ○ Pneumothorax- tip of chest tube will face up and toward shoulder ○ Hemothorax or Pleural effusion- tip will face down and toward posterior ● 3 chamber drainage system ○ Drainage collection○ Water seal ■ Should have 2cm of sterile water ■ Lets air come out of pleural space, but not back into when pt inhales ● If chest tube is working correctly you will see light tidaling ○ If tidaling stops lung has expanded, or there is further obstruction ■ Should NOT bubble, could be sign of air leak ○ Suction control (can be wet or dry) ■ Suction pressure of -20 is most common ■ Should see continuous gentle bubbling ● Nursing care ○ Encourage coughing and deep breathing every 2 hrs. ○ Check water seal level every 2 hrs. and fluid if needed ○ Document amount and color of drainage hourly for first 24 hrs, then at least every 8hr ■ Mark date, hr, and drainage level at end of each shift ■ Report excess greater than 70 ml/hr or drainage that is cloudy or red to provider ○ Monitor insertion site ■ Redness, pain, crepitus ○ Position pt in semi to high fowler's ■ promotes optimal lung expansion and drainage of fluids from lungs. ○ Xray to ensure placement post op ○ Keep 2 enclosed hemostats, sterile water, and occlusive dressing at beside at all times ● Chest tubes should only be clamped when prescribed ○ Like in the case of an air leak ● Never strip or milk tubing; unless prescribed. ● Complications ○ If chest tube drainage is compromised, immerse the end of the chest tube in sterile water to restore water seal. ○ If chest tube is accidentally removed, dress the area with dry, sterile gauze ■ Tape only 3 sides. ● Allows air to escape and reduces risk of tension pneumothorax ○ Tension pneumothorax ■ Usually occurs because of kink in tubing, or prolonged clamping ● Signs include tracheal deviation, absent breath sounds on one side, distended neck veins, respiratory distress, cyanosis, asymmetry of chest. ● Chest tube removal ○ Instruct pt to deep breathe, exhale, and bear down (valsalva) upon removal ○ Apply airtight sterile petroleum jelly gauze dressing ○ Give pain med 30min before removing chest tube Chapter 19 Respiratory management and mechanical ventilation ● Nasal Cannula ○ 1-6 L/min ● Simple face mask ○ 5-8 L/min ● Partial rebreather ○ 6-11 L/min ■ Keep reservoir bag from deflating by adjusting the 02 flow rate to keep it inflated ● Non Rebreather ○ 10-15 L/min ■ Reservoir bag should be two-thirds full ■ Perform hourly assessment of the valve and flap ● Venturi Mask ○ 4-10L/min ○ Delivers most precise oxygen concentration ● Aerosol/face tent ○ Useful for client who have facial trauma or burns ● Indications for 02○ Hypoxemia/ Hypoxia ■ Not enough 02 in blood ● Early signs ○ Tachypnea ○ Tachycardia ○ Restlessness ○ Pale skin and mucous membrane ○ Elevated BP ○ Signs of respiratory distress (use of accessory muscles, nasal flaring,adventitious sounds) ● Late signs ○ Confusion and stupor ○ Cyanotic skin and membrane ○ Bradypnea ○ Bradycardia ○ Hypotension ○ Cardiac dysrhythmias ● Complications ○ Oxygen toxicity ■ Manifestations include: nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, headache, sore throat, and hypoventilation ● Use lowest flow of 02 to necessary to maintain adequate 02 sat. ● Especially COPD pt. They range in low 90’s do not over oxygenate ● Safety measures ○ No smoking ○ Wear cotton rather than synthetics or wool due to static electricity ○ Don't use volatile, flammable materials near 02 ● Endotracheal tube and intubation ○ Tube that is inserted into pt nose or mouth into trachea ● CPAP ○ Given to pt with sleep apnea ● BiPAP ○ Used to wean pt from vent ● Mechanical Ventilation ○ Suction secretions to maintain airway and tube patency ○ Frequent oral and skin care ○ Manual resuscitation bag with face mask and 02 at bedside ○ Have reintubation material at bedside ■ Encourage coughing and deep breathing upon extubation ■ Monitor for 02 and vitals every 5 mins ■ Change position to remove secretions ○ Administer medications ■ Analgesics (morphine) ■ Sedatives (diazepam) ■ Neuromuscular agents (pancuronium) ● Ventilator alarms ○ Volume (low pressure) alarm ■ Indicates a low exhaled volume ● Disconnection ● Cuff leak ● Tube displacement ○ Pressure (high pressure) alarm ■ Indicates excess secretions ■ Pt biting tubing ■ Kinks in tubing ■ Pt coughing■ Pulmonary edema ■ Bronchospasm ■ Pneumothorax Chapter 20 Acute Respiratory Disorders ● Rhinitis ○ Inflammation of nasal mucosa ■ Can be due to viral or bacterial infection or allergens ○ Runny nose and nasal congestion ○ If continues will lead to sinusitis (multiple sinuses in nasal mucosa inflamed) ● Treatment ○ Increase fluid intake 2000ml/day ○ Encourage rest 8-10hr/day ○ Humidifier ○ Promote proper disposal of tissues and cough etiquette ○ Hand hygiene ● Medications ○ Antihistamines ○ Decongestants ■ Phenylephrine: Constrict blood vessels/decrease edema ○ Broad-spectrum antibiotics (sinusitis only) ■ Amoxicillin ● Influenza ○ Highly contagious viral infection ○ S/S ■ Severe headache and muscle aches ■ Chills ■ Fever ■ Diarrhea, nausea ○ Medications ■ Antivirals like rimantadine ● Needs to be given 24-48 hr after onset of manifestations ■ Flu vaccine ● Any over 6 months old ○ Complications ■ Older pt is likely to develop pneumonia ● Pneumonia ○ S/S ■ In older pt confusion is most common sign of pneumonia due to hypoxia ■ Fever ■ chills ■ SOB ■ Tachypnea ■ Sharp chest pain ■ Crackles and wheezes ■ Cough and yellow-tinged sputum ○ Tests ■ Sputum culture sample ● Obtain before antibiotic therapy ■ Chest X-ray ● Shows consolidation of lungs ■ Pulse ox ● Levels below 95% ○ Nursing interventions ■ High fowler's - 90 degrees ■ Encourage coughing and deep breathing ■ Administer breathing treatments and meds as prescribed■ 02 therapy ■ Incentive spirometer ● Suck in and hold ■ Additional calories ● Due to increased work of breathing ■ Fluid in take 2-3L/day ● Promote thinning of secretions ○ Medications ■ Antibiotics ● First IV meds → Oral once improving ■ Bronchodilator (albuterol) ■ Glucocorticosteroids ● End in “sone” ● Monitor for immunosuppression, hyperglycemia, fluid retention, hypokalemia, GI bleed (black tarry stool), canker sores in mouth. Chapter 21 Asthma ● Chronic inflammatory disorder of the airway ○ Intermittent and reversible ● Triggers ○ Allergens ○ Smoking ○ Air pollutants ○ Environmental factors ● S/S ○ Wheezing ○ Coughing ○ Prolonged exhalation ○ Poor 02 sat ○ If chronic, may have barrel chest ● Peak flow meter ○ Test 3 times and take the highest reading ● Nursing Interventions ○ Position in High- fowler’s ○ Give 02 as prescribed ○ Provide rest periods ○ Administer meds as prescribed ● Medications ○ Bronchodilators (inhalers) ■ Short-acting beta2 ● Albuterol ○ Watch for tremors and tachycardia ■ Anticholinergic ● Ipratropium ○ Dry mouth ■ Encourage pt to suck on hard candy and increase fluid intake ■ Methylxanthines ● Theophylline ○ Monitor serum levels for toxicity ○ Tachycardia, nausea, and diarrhea ■ Last resort medication ■ Long-acting beta2 ● Salmeterol ○ Will help prevent asthma attack not for onset attack ○ Anti-inflammatory agents ■ Prophylaxis to decrease airway inflammation● Corticosteroids ○ Fluticasone/Prednisone ■ Monitor for decreased immunity, hyperglycemia, black tarry stools, fluid retention, and canker sores ● Leukotriene ○ Montelukast ● Mast cell stabilizers ○ Cromolyn ● Monoclonal antibodies ○ Omalizumab ■ Can cause anaphylaxis ● Complications ○ Status asthmaticus ■ Life-threatening airway obstruction ■ Unresponsive to treatment ● Prepare emergency intubation, administer 02, bronchodilator,and Epi. Chapter 22 COPD ● Encompasses 2 diseases ○ Emphysema and chronic bronchitis ■ Emphysema ● Loss of lung elasticity ● Hyperinflation of lung tissue ○ Causes destruction of alveoli leading to decrease area for gas exchange, CO2 retention and respiratory acidosis ■ Bronchitis ● Inflammation of bronchi due to chronic exposure to irritants ● Risk factors ○ Smoking (#1) ○ Advanced age ○ Air pollution ○ Alpha 1-antitrypsin deficiency ● S/S ○ Dyspnea on exertion ○ Crackles and wheezes ○ Rapid and shallow respirations ○ Use of accessory muscles ○ Barrel chest ○ Hyperresonance on percussion ■ Due to “trapped air” from emphysema ○ Dependent edema ■ Due to right sided heart failure ○ Clubbing ○ Pulse Ox below 95% ● Tests ○ Increased hematocrit ○ ABG’s ■ PaO2 less than 80 ■ PaCO2 greater than 40 ● Nursing care ○ Position in high-fowler’s ○ Encourage coughing and deep breathing ○ Incentive spirometer ○ Promote adequate nutrition and calorie/protein increase ■ Due to work of breathing ○ Teach 2 kinds of breathing techniques ■ Abdominal breathing● Lie on back with knee bent ● Rest hands over abdomen to create resistance ● Hand should raise and lower upon inhale/exhale ■ Pursed lip-breathing ● Form mouth like preparing to whistle ● Breath through nose and out mouth ● Do not puff cheeks ● Breathe deep and slow ● Medications ○ Bronchodilators ■ Albuterol ● Tremors and tachycardia ■ Ipratropium ● Dry mouth ○ Educate to suck on hard candies and increase fluids ■ Theophylline ● Last resort medication ○ Anti-inflammatory ■ Corticosteroids ● Fluticasone/Prednisone ○ Monitor for decreased immunity, hyperglycemia, black tarry stools, fluid retention, and canker sores ■ Leukotriene ● Montelukast ■ Mast cell stabilizers ● Cromolyn ■ Monoclonal antibodies ● Omalizumab ○ Can cause anaphylaxis ○ Mucolytic agents ■ Acetylcysteine ● Used to loosen secretions ○ Also antidote for tylenol overdose ● Chest physiotherapy ○ Percuss and vibrate chest to loosen secretions ○ Foot of the bed slightly higher than head→ facilitate drainage/removal of secretions by gravity ● Assist upon D/C with home O2 and referral services (like food delivery) ● Complications ○ Respiratory infections ○ Right sided heart failure ■ Dependent edema ■ Distended neck veins ■ Enlarged and tender liver Chapter 23 TB ● Infectious disease caused by Mycobacterium TB ● Transmitted through airborne route ○ Negative airflow room ○ Wear N95 mask ● Screen family members for TB also ● Risk factors ○ Close crowded living environments (like prisons) ○ Immunocompromised status (HIV, chemo, DM) ○ Homeless ● S/S ○ Cough longer than 3 wks○ Unexplained weight loss ○ Tired and lethargic ○ Night sweat ○ Purulent sputum ● Tests ○ Quantiferon Gold-blood ○ Mantoux-skin ■ Read 48-72 hrs ■ Induration of 10 mm or greater is positive for TB ■ Induration of 5 mm is considered positive for immunocompromised pt ○ BCG vaccine can cause false-positive skin test ● Xray will be ordered if positive ○ Detects lesions in lungs ● Acid-fast bacilli smear/culture ○ Positive smear suggests active infection ○ Confirmed diagnosis with positive culture of Mycobacterium TB ■ Collect 3 different samples in AM ● Medications ○ Due to the resistance pt will receive 2 or more meds at one time ■ Taken for 6-12 months, causes noncompliance, which results in TB resistance ○ Current 4 meds are rifampin, isoniazid, pyrazinamide, and ethambutol ■ “RIPE” ○ Isoniazid ■ Monitor for hepatotoxicity (jaundice, increase liver values) ■ Can cause neurotoxicity (numbness and tingling in hands and feet) ● Give vitamin b6 to prevent neurotoxicity ○ Rifampin ■ Hepatotoxicity ■ Orange urine ■ Interferes with birth control pills ○ Pyrazinamide ■ hepatotoxicity ○ Ethambutol ■ Vision issues ● “Ethambutol messes with your Eyes” ○ Streptomycin ■ Given for multi-drug resistant TB only ● Causes Ototoxicity ● Sputum samples will be taken every 2-4 weeks ○ Once 3 negative sputum samples pt no longer has TB Chapter 24 Pulmonary Embolism ● Substance that enters venous circulation that goes into lungs and blocks blood flow to lungs ○ Most common cause of PE is DVT ● Risk factors ○ Oral contraceptives and estrogen therapy ○ Tobacco use ○ Obesity ○ Hypercoagulability (elevated PLT count) ○ Surgery ○ Fracture in long bone ○ AFib ■ Put on anticoagulant ● S/S ○ Dyspnea and air hunger ○ Anxiety ○ Feeling of doom○ Tachycardia ○ Hypotension ○ Tachypnea ○ Petechiae (little red dots on chest) ● Tests ○ D-dimer ■ Evidence of clot if elevated ■ Normal range 0.43-2.33 ○ CT Scan ■ Most common ● Medications ○ Anticoagulant ■ Heparin, warfarin, Enoxaparin ● Prevent clots from getting larger or forming new clots ○ Heparin monitor PTT ○ Warfarin monitor PT/INR ○ Thrombolytic ■ End in “ase” ■ Alteplase, reteplase, and tenecteplase, streptokinase ● Used to dissolve clots and restore pulmonary flow ● Monitor for bleeding ● Shouldn’t have within 3 weeks of surgery ● Surgical Procedures ○ Embolectomy ■ Surgical removal of embolus ○ Vena cava filter ■ Prevents further emboli from reaching pulmonary vasculature ● Education ○ Weekly blood draws to monitor PT and PTT ○ Smoking cessation ○ Stay mobile ○ Wear compression stockings ○ Avoid crossing leg ○ If taking warfarin monitor vit K ■ Reduces level of warfarin ■ Dark leafy green veggies ○ Avoid aspirin ○ Use electric shaver ○ Use soft bristle toothbrush ○ Avoid blowing nose too hard ■ Precautions to prevent a lot of bleeding ● Biggest risk is bleeding (hemorrhage) Chapter 25 Pneumothorax, Hemothorax, and Flail Chest ● Pneumothorax ○ Air or gas in pleural space causing lung collapse ■ Tension pneumothorax ● Air enters through one way valve, but can’t exit ● Hemothorax ○ Blood in pleural space ● Flail Chest ○ 2 neighboring ribs, usually one one side, sustain multiple fractures causing unstable wall movement. ● S/S ○ Tachypnea ○ Dyspnea ○ Use of accessory muscles○ Tachycardia ○ Hypoxia ■ All signs of respiratory distress in all above conditions ○ Trachial deviation ■ Tension pneumothorax ○ Reduced/ absent breath sounds ○ Assymetrical chest wall movement ○ Hyperresonance on percussion ■ Pneumothorax ○ Dull percussion ■ Hemothorax ● Tests ○ ABG, PaO2 less than 80 ○ Chest x-ray ■ Pneumo and hemo ○ Thoracentesis ■ Hemo ● Medications ○ Benzodiazipines ■ Lorazepam ○ Opiods ■ Morphine ● POC ○ Insert chest tube for pneumothorax Chapter 26 Respiratory Failure (She said focus on the s/s and nursing interventions which is the maintaining the airway open → ABCs) ● S/S Resp. Fail ○ Rapid shallow breathing ○ Tachycardia ○ hypotension ○ decreased O2 sat. ○ Adventitious sounds (Wheezing/Rales) ○ Cardiac dysrhythmias ○ Cyanosis, Nasal flaring, Substernal retractions ■ Respiratory emergency ■ Getting worse ● NURSING INTERVENTION: ○ Keep in mind the ABC ■ MAINTAIN PATENT AIRWAY/MONITOR RESPIRATORY STATUS ■ Oxygenate before suctioning secretions to prevent further hypoxemia ● Acute respiratory failure (ARF) ○ Failure to adequately ventilate and/or oxygenate ● Acute respiratory distress syndrome (ARDS) ○ Acute state of respiratory failure with mortality rate of 60% ■ Systemic inflammatory response injures the alveolar-capillary membrane→ Permeable to large molecules and lungs space fills with fluid ■ Reduction in surfactant weakens alveoli→ collapse or filling of fluid leading to worsening edema ● Severe acute respiratory syndrome (SARS) ○ Result of a viral infection from mutated coronaviruses strain ■ Spread via airborne (Sneezing, coughing or talking) Chapter 27 Cardiovascular diagnostic/Therapeutic Procedures ● Cardiac enzymes ○ Ischemic event → release enzymes ■ Troponin T/I (elevated) -most sensitive to heart● T: (less than) <0.1ng/ml ○ Detectable 2-3hrs after MI ○ Duration of 10-14days ● I: (Less than) <0.03ng/mL ○ Detectable 2-3hs after MI ○ Duration of 7-10 days ■ Myoglobin (elevated)- First to be seen elevated following an MI ● Less than 90mcg/L ● Detectable for 2-3hrs ● Duration of 24hrs ■ CKMB (elevated) - 2nd sensitive ● 30-170 units/L ● Detectable for 3-6hrs ● Duration of 2-3 days ○ Cholesterol: Below 200 = good. ABOVE IS BAD ■ LDL (BAD type): (Less than) <130mg/dL ● Transports cholesterol → Body’s cells from liver ■ HDL (Healthy type) ● Female: Greater than 55mg/dl ● Male: greater than 45mg/dL ○ Protects coronary arteries by transporting cholesterol from boy’s cell → Liver ■ Triglycerides: Evaluates PT risk for heart disease ● Males: 40-160 ● Female: 35-135 ○ Echo ■ Determine ejection fraction ■ Noninvasive ○ Stress test ■ On treadmill ● OR ■ Pharmacological (adenosine) while hooked to EKG ■ Fast 2-4 hrs before ■ No alcohol, caffeine or tobacco ○ Hemodynamics monitoring ■ Pressures all elevated and decreased cardiac output = indicative of HEART FAILURE ● CVP: 2-6 (Expected range) ■ NURSING: ● Level transducer with the phlebostatic axis with the 4th intercostal space ● Then zero system ● Xray to confirm catheter placement ○ Coronary angiogram ■ Look at coronary artery for any blockage ■ Insert from femoral artery or brachial artery ● INVASIVE ○ NURSING: ■ PT NPO 8 hrs b4 ■ Iodine/shellfish allergy ■ Renal function (BUN/Creatinine) ○ AFTER PROCEDURE ■ VS q15min first hour → q30min next hour→ q1hr next four hrs ■ Assess SITE FOR BLEEDING ■ Pedal pulse, color, temperature■ Administer antiplatelet ■ IV fluid to flush dye ● COMPILATIONS (with coronary angiogram) ○ Cardiac Tamponade ■ Fluid accumulation in pericardial sac ■ S/S: Hypotension, JVD, muffled heart sounds, Paradoxical pulse: variance of 10mm hg or more in Systolic BP between expiration and inspiration ● NURSING: ○ Notify HCP immediately ○ IV fluids to combat hypotension ○ Xray or echo to confirm Dx ○ Prepare for pericardiocentesis- informed consent ○ Monitor hemodynamic pressures ○ Monitor heart rhythm- changes may mean improper positioning of the needle ● IF STENT: ○ Anticoagulation therapy 6-8 weeks (PTT/PT/INR) ○ Avoid activities causing bleeding, electric razor and soft brush ● Vascular access ○ PICC line ■ Up to 12 months in placed ■ Long term antibiotics, chemo, TPN ■ Accessing PICC line= 10ml syringe (smaller creates more pressure into line) ■ Basilic or cephalic vein at least one fingerbreadth below or above AC fossa ■ Advance catheter until tip is positioned in the lower of the Superior vena cava ⅓ ■ Xray to ensure placement ■ Draw 10ml blood→ discard that→ draw 10 ml for sample and flush w 10ml NS ● PORT ○ Chemo mainly ○ Long term use (1yr or more) ○ Access w non-coring (Huber) needle ○ Flush 5ml heparin 100 units/ml every use and at least once per month ● COMPLICATIONS (Vascular access) ○ Monitor for phlebitis ■ Warmth, redness, pain or burning, edema at site ■ Indurated vein ■ NEVER FORCE FLUID IF RESISTANCE ○ Infiltration ■ Swelling, edema, sensation of coolness on site ○ Air embolism ■ SOB. ● Trendelenburg position on left side ● Notify HCP ● O2 supplement Chapter 28 ECG and dysrhythmia monitoring ● Symptomatic bradycardia→ medication given is atropine ○ Pacemaker ● AFib,SVT, Vtac w pulse: ○ amiodarone , adenosine, verapamil- dysrhythmic drugs ○ Synchronized cardioversion ● Vtac without pulse, Ventricular Fibrillation ○ Amiodarone, lidocaine, epinephrine ○ Defibrillation ● Cardioversion: Afib: Anticoagulation therapy 3 weeks before Cardioversion○ Sedative administered ○ Proper placement/low joules setting ○ Staff must stand clear of PT ○ Synchronize button ON ■ AFTER ● VS, airway patency, ECG ● Advise PT to report palpitations or irregularities COMPLICATIONS: ● Embolism ● CVA or MI Chapter 29 PACEMAKERS ● Fire if natural pacemaker does not ● Permanent Pacemakers ○ Fixed rate: Fires at a constant rate without regard for hearts electrical activity ○ Demand mode: Detects heart's electrical impulses and fires at aa present rate only if the heart's intrinsic rate is below a certain level ■ Inhibited: Pacemaker activity is inhibited/does NOT fire ■ Triggered: Can overpace a tachydysrhythmia and or deliver an electrical shock ● ASSESS FOR HICCUPS ○ Pacemaker not functioning right ■ ITS Pacing the diaphragm ○ ABNORMAL ONCE PACEMAKER INSTALLED ● Permanent Pacemakers ○ Pacemaker ID card, pulse daily, Touching PT slight impulse- Pacemakerdefibrillators ○ No contact sport or heavy lifting for 2 months ○ Don't raise arm above shoulder for 1-2 weeks after implantation ○ No strong magnet or garage door over pacemaker ○ MRI may be contraindicated ○ Set off airport→ let tsa know ○ Infection, arrhythmias, pneumothorax and hemothorax are complications Chapter 30 Cardio invasive procedures ● Percutaneous coronary intervention (PCI): within 90min of MI onset ○ Nonsurgical procedure to open coronary arteries thru ■ Atherectomy: used to break up and remove plaques within cardiac vessel ■ Stent: Placement of mesh-wire device to hold an artery open and prevent restenosis ■ Percutaneous transluminal coronary angioplasty: AKA angioplastyinflating a balloon to dilate the arterial lumen/the adhering plaque → widening the arterial lumen. This can include stent placement ○ ST elevation or depression- (EKG sign) ○ NURSING: ■ NPO 8 hrs (if possible) ■ Shellfish/iodine allergy check ■ Renal function ■ sedation/pain med- midazolam and fentanyl ■ Tell PT he might be awake or sedated ■ Small incision in groin to insert catheter ■ Warmth when flushing dye in ● AFTER: PT to keep affected leg straight ● Pressure (a sandbag) may be placed on incision to prevent bleeding ○ POST-OP:■ VS- frequent ■ Assess s/s thrombosis ■ Document: pedal or radial pulse, Cap refill, color, temp of extremities ■ Lay 4-6hrs supine after ■ Administer antiplatelet of thrombolytic agent ■ IV fluids for hydration ■ Assists w removal of sheath from insertion site ○ EDUCATION ■ Avoid strenuous exercise for prescribed period of time ■ Report bleeding from insertion site, chest pain, SOB, changes in color of extremities ■ Restrict lifting (less than 5lbs) for prescribes time ■ STENT: anticoagulation therapy (6-8weeks) ● Take meds same time each day ● Reg labs done to check therapeutic levels ● No bleeding causing activities ○ Use soft toothbrush, wear shoes when getting outa bed, electric razor ■ Complications ● Artery dissection→ might cause cardiac tamponade ○ Severe hypotension/tachycardia- s/s of bleeding out(artery dissection) ○ Occlude artery w balloon catheter and reversal of anticoagulant ● cardiac tamponade ○ Fluid accumulation in pericadal sac ■ Hypotension, muffled heart sounds, JVD, paradoxical pulse (difference of 10 mm hg or more in systolic BP between expiration/inspiration) ● RECURRENT CHEST PAIN AFTER PRODUCE ○ DO EKG ○ INDICATION OF RESTENOSIS OF ARTERY ● CABG ○ Invasive procedure- consent form signed ■ To bypass an obstruction in or more of the coronary arteries ■ Most effective with Pt having sufficient ventricular function ● Ejection fraction of more than 50% ○ EDUCATION: ■ Tell pt and family about procedure and post op environment ■ Educate on coughing and deep breathing IMPORTANCE ■ Splint incision while coughing/deep breathing ● Make PT give a returned demonstration ■ POST OP: ● Endotracheal tube/mechanical vent for airway management for several hours following surgery ● Cant talk w endotrach ● Early ambulation to prevent complications ● sternal/leg incision ● Mediastinal chest tubes (1 or 2) ● Urinary catheter ● Pacemaker wires ● Hemodynamic monitoring decives ○ Artery line and pulmonary artery catheter ● Regular meds discontinued by HCP ● Meds discontinued for CABG○ Diuretics (2-3 days before procedure) ○ Aspirin/anticoagulants (1week before) ● Meds continued for CABG ○ K supplements ○ Antidysrhythmic drugs (amiodarone) ○ AntiHTN (metoprolol, beta-blocker, diltiazem, calciumchannel blocker) ○ Insulin (Insulin dependent→ give half the reg dose) ■ INTRA PROCEDURE: ● PT core temp lowered to decrease rate of metabolism and demand for O2 ■ NURSING ● ABC ● Monitor BP ○ Hypotension→ graft collapse ○ Hypertension→ bleeding from grafts/sutures ● Chest tube monitoring ○ 150ml/hr drainage→ NOtify DOC ○ Measure drainage at least once an hour ● Ambulate PT 25-100ft 3xs/day by first POST-OP day ● Assist PT to chair w/in 24 hrs ● Surgical aseptic technique w dressing changes and suctioning ● Peripheral bypass graft- Peripheral Artery Disease (PAD) ○ Use saphenous vein (like in CABG) ○ S/S ■ Numbness/burning pain when exercise to lower extremity ● Pain stops at rest (intermittent claudication) ■ Numbness/burning pain to lower extremity at rest→ wake PT at night ● Pain relieved by lowering extremity below the heart ○ Objective data: ■ Decreased or absent pulses to feet ■ Dry, hairless,shiny skin on calves ■ Atrophic muscles ■ Skin might be cold and dark blooded (if severe) ■ Skin mottled and dusty→ may just amputate ■ Toenails may be thick ■ Skin rubor when extremity is dropped to dependent position ■ Ulcers on TOES (arterial ulcers) or ANKLES (venous ulcers) ○ PRE-OP ■ NPO 8 hrs ■ Signed informed consent ■ baseline VS/peripheral pulses ■ Prophylactic antibiotics ○ EDUCATION ■ Pain management ■ teach deep breathing/incentive spirometer ■ DO NOT CROSS LEGS→ FURTHER OCCLUDES ■ Pedal pulses checked regularly ○ NURSING: ■ VS q15min for 1hr→ check hourly after that ■ Hypotension = reduced blood flow to graft ■ Hypertension = cause bleeding ■ Legs straight/ bed rest 18-24 hrs ■ Turn cough and breath 2hr■ Give anticoagulant meds ■ Operative limb→ monitor/assess q15min for 1hr then checked hourly ● Incision site bleeding ● Peripheral pulses, cap refill, skin color/temp, sensory and motor function for bypass graft occlusion ■ Pain ● Throbbing→ increase in blood flow to extremity ● Ischemic → difficult to relieve with opioid administration ■ Antiembolic stockings ■ Ambulate→ walker assistance encouraged ○ Complications ■ Compartment syndrome ● Pressure from tissue swelling or bleeding w in a compartment or restricted spaces→ reduced blood flow to that area. IF UNTREATED WILL TURN NECROTIC AND DIE ● Assess for worsening pain, swelling, and tense or taut skin ● Report unusual findings to doc immediately ● Prepare PT for a fasciotomy to releive compartmental pressure Chapter 31 Angina and Myocardial Infarction ● ANGINA ○ Stable: Exercise relieved by rest ○ Unstable: w exercise or stress→ increases in severity/occurrence and duration overtime ○ Variant: Coronary artery spasm during rest NOT exercise ○ Pain relieved by rest or nitroglycerin ● Pain unrelieved by rest or nitroglycerin and last MORE than 15 min = MI ● Myocardial Infarction - symptoms longer than 30min ○ Chest pain- opioids to relieve ■ Substernal or precordial ■ Radiate down the shoulder or arm or present as jaw pain ■ Crushing or aching pressure ○ Feeling impending doom ○ Diaphoresis, pallor cool/clammy skin ○ Tachycardia/heart palpitations ○ SOB/Tachypneic ■ RISK of MI ● HTN, postmenopausal, SMOKING, HYPERLIPIDEMIA, Diabetes, Stress ● Nitroglycerin ○ Used for the chest pain ○ Monitor BP as it can drop it ○ Inform of possible headache side effect ● EDUCATION ○ Pain during exercise ■ Stop ■ Rest/take Nitroglycerin ■ Pain unrelieved in 5 min → Call 911 ■ Take 2 more doses at 5 min intervals (3 in total) ● MEDS ○ Beta blocker ■ Decrease HR/BP ● Check HR b4 giving (below 60bpm→ HOLD→ CALL DOC)● Never give non-selective to asthma PT bc it causes bronchoconstriction ○ Metoprolol ○ PT to sit/lay down slowly ○ Notify DOC if SOB, edema and wgt gain or cough ○ Thrombolytic agent ■ Best if given w in 6 hrs ■ Contraindications ● Bleeding, peptic ulcer, Hx smoking, trauma ○ Antiplatelet ■ Prevents vasoconstriction → give w nitroglycerin at onset of chest pain ■ Cause GI upset (cautious w Hx of GI ulcers) ■ Tinnitus→ aspirin toxicity ■ Take tabs w EC coat and with food ■ Report ringing in ears ● MI COMPLICATIONS ○ HF/Cardiogenic shock ■ Tachycardia ■ Hypotension ■ LOC ■ Respiratory distress (Crackles/Tachypnea) ■ Cool/clammy skin ■ Chest pain ■ Decreased peripheral pulses ○ NURSING ■ Give O2 ■ Morphine, diuretics and/or nitroglycerin ■ Vasopressor Chapter 32 HF and Pulmonary Edema ● Something wrong with right side of heart ○ Peripheral edema ○ Ascites ○ Abdominal distention ○ Jugular vein distention ○ Liver enlargement ● Something wrong with left side of hear ○ Pulmonary congestion ○ Fatigue ○ Crackles ○ Difficulty breathing ○ Fluid overload in lungs ○ Orthopnea ○ Frothy pink tinged sputum ● Labs ○ Elevated BNP in heart failure (over 300 indicates HF) ○ CO decreased ○ Decreased ejection fraction (normal is between 50-70%) ● Nursing Care ○ Daily weights ○ I & O ○ Oxygen prn ○ High fowler's ○ Assist with ADLs ○ Restrict fluid intake (2L day) ○ Reduce sodium intake● Meds ○ Diuretics ■ Loop diuretics (lasix) ● Can cause drop in potassium ● Monitor electrolytes ● Potatoes, dark leafy greens, oranges ○ ACE inhibitor (-pril) ■ SE: facial edema, dry cough, elevated potassium ○ Calcium channel blocker ○ Angiotensin receptor 2 blocker ○ Inotropic agent ■