NUR-2115 EXAM 1
<18 hypoxemia pao2 respiratory alkalosis to acidosis diffuse
bilateral pulmonary infiltrates - Diagnostics for ARDs: -PCWP:
___________________ -Refractory _________________ -Decrease _______________
(less than 50-60 with supplemental supply) -ABG: ______________ to
___________________ -CXR:________________ (white out) <50 >50 <7.35
<10 <25 <10 - Indications for Mechanical Ventilation with
Respiratory Failure: PaO2: ______________ PCO2: _____________
pH:___________ Vital Capacity: ___________ Neg. Inspiratory
Force:____________ FEV1:___________________ -Apnea or bradypnea -
Respiratory distress with confusion -Increased WOB not relieved by
interventions -Confusion with need to protect airway -Circulatory
shock <100, thrombus and embolism amiodorone, metoprolol,
cardizem, digoxin multaq radiofrequency catheter ablation - Long-
Term Management for Persistent A Fib: Goals: Slow ventricular
rate to ______________ and prevent _______________ &______________
formation Control rate and rhythm with antiarrhythmics: -
______________,______________,_________________,__________________ -New drug
now used:________________ -Anticoagulation therapy: ASA, Lovenox,
Coumadin, Heparin -Do ______________________________ in EP lab, r/o
clots first 10-14 positive layngoscope carina - The endotracheal
tube is a short term (_________ days) artificial airway -Delivers
______________ pressure -Protects airway -Inserted with the aide of a
____________ -Rests 1-2 cm above ____________ (bifibrication of brochus)
12 lead - Type of ECG Monitor: -Identifies myocardial ishemia and
infarction -Evaluates rhythm and conduction abnormalities -
Detects chamber enlargement -Need to further assess electrolyte
disturbances and drug toxicity -Provides baseline assessment -Only
typically views left ventricle -Difficult to see anterior side of heart
,to evaluate for damage -Patient has to be still to attain clear
image 12 lead - Type of ECG Monitor: Reflects the electrical
activity primarily in the left ventricle, placed at the patients side
for immediate recording -6 electrodes on chest & 4 electrodes on
limbs --Place on areas that aren't bony and do not have significant
movement 15 min, pulse ox, ABGs diaphragmatic and pursed lip
breathing 30-40 degrees emphysema petroleum gauze > 100
bright red to serous bright red - Client with Chest Drainage
System: Nursing Interventions: - Repiratory assessment: VS
q_________, __________& _______ -Teach ______________ & ____________ -
Elevate HOB ___________, go from flat to semi-upright ASAP -Assess
around insertion site for crepitus, give SUBQ ____________ if necessary
-Change dressing q 48-72 hrs w/ ______________________ -Monitor and
record drainage: ---Notify Dr. if ____________ ---Color should go
from _____________________ ----Notify Dr. if color is _______________ -
Monitor for S&S of infection 21-100 40 7-10 bpm 10-14 -
Ventilator Controls and Settings: Fraction of inspired O2: - Vent
provides ___________% O2 --- Cut off for O2 toxicity is around
_________% --- Goal= Use least amount of O2 Tidal Volume: -
Volume of air received with each breath - __________mL/kg (add 0 to
weight in kg for estimate) Rate: - Number of ventilator _____________
- Usually ______________ bpm 80-100 35-45 22-26 7.35-7.45
compensated - Normal ABG Values: PaO2: ________ PCO2:________
HCO3:_______ pH:________ HCO3 and CO2 are both outside of normal
ranges= ___________ Full= pH within norms Partial= pH not within
norms 100% O2 and PEEP permissive hypercapnia pco2 bicarb
nitric oxide prone - ARDs Nursing and Medical Management: -
Correct underlying disorder -Mechanical ventilation:
_________________________ -To minimize barotrauma, ____________________ -
--Low tidal volumes and low peak pressures increase ____________ --
-Give ____________ to correct acidosis -Inhaled _______________ to dilate
pulmonary vessels -For severe hypoxia position in ____________________
, to allow air to rise to a depressed aveoli A fib - Atrial Dysrhythmia:
An uncoordinated atrial electrical activation that causes a rapid
disorganized and uncoordinated twitching of atrial musculature -
Rate: Atrial 300-600, Ventricular 120-200 -Rhythm: Regular -P
wave is indiscernible, with different sizes and shapes -PR cannot be
measured -P:QRS: many:1 -Patient will be symptomatic with RVR,
new diagnosis, or inability to tolerate rhythm: SOB, chest pain, or
low BP -If hemodynamically unstable do cardioversion with
warfarin for atleast 4 weeks to decrease risk for clots ABGs
sedation - Medical Management for Mechanical Ventilation: -
Ventilation adjustments based on _____________ to enhance O2 -
Adjustments to _____________ ABGs wean - Collaborative Care Goals
of Mechanical Ventilation: -Monitor and evaluate response to
medications and mechanical ventilation with ______________ -Manage
ventilator system safely -Prevent complications -_____________ the
patient from the vent ABGs and auscultation respiratory rate
repositioning suction humidification incisor <25 chlorahexidine
above stomach communication - Nursing Interventions for
Mechanical Ventilation: -Top priority= ___________ & pulmonary
____________ -Assess vital signs for changes and patterns -Give
analgesics for pain w/o suppressing ___________ -Frequent ___________
to decrease pulmonary effects of immobility -Adequate fluids, I&O,
daily weights -For increased secretions, PIP, and wheezing:________ -
To liquifey secretions: ______________ -Mark level of tube with patients
______________ -Reposition and retape tube daily -Position with
minimal pull/distortion of tube in trachea -Cuff pressure checks
with pressure _________ -Mouth care with __________ and suction -
HOB= ____________ to avoid aspiration -Plan methods of ______________
ACE inhibitors - Medication Therapy for ACS: -Give to decrease
demand & prevent ventricular remodeling Give for: -Acute MI with
ST segment elevation in 2 or more leads -STEMI -Acute MI with
left ventricle EF <40% -Acute MI with clinical S&S of CHF Start: -
<18 hypoxemia pao2 respiratory alkalosis to acidosis diffuse
bilateral pulmonary infiltrates - Diagnostics for ARDs: -PCWP:
___________________ -Refractory _________________ -Decrease _______________
(less than 50-60 with supplemental supply) -ABG: ______________ to
___________________ -CXR:________________ (white out) <50 >50 <7.35
<10 <25 <10 - Indications for Mechanical Ventilation with
Respiratory Failure: PaO2: ______________ PCO2: _____________
pH:___________ Vital Capacity: ___________ Neg. Inspiratory
Force:____________ FEV1:___________________ -Apnea or bradypnea -
Respiratory distress with confusion -Increased WOB not relieved by
interventions -Confusion with need to protect airway -Circulatory
shock <100, thrombus and embolism amiodorone, metoprolol,
cardizem, digoxin multaq radiofrequency catheter ablation - Long-
Term Management for Persistent A Fib: Goals: Slow ventricular
rate to ______________ and prevent _______________ &______________
formation Control rate and rhythm with antiarrhythmics: -
______________,______________,_________________,__________________ -New drug
now used:________________ -Anticoagulation therapy: ASA, Lovenox,
Coumadin, Heparin -Do ______________________________ in EP lab, r/o
clots first 10-14 positive layngoscope carina - The endotracheal
tube is a short term (_________ days) artificial airway -Delivers
______________ pressure -Protects airway -Inserted with the aide of a
____________ -Rests 1-2 cm above ____________ (bifibrication of brochus)
12 lead - Type of ECG Monitor: -Identifies myocardial ishemia and
infarction -Evaluates rhythm and conduction abnormalities -
Detects chamber enlargement -Need to further assess electrolyte
disturbances and drug toxicity -Provides baseline assessment -Only
typically views left ventricle -Difficult to see anterior side of heart
,to evaluate for damage -Patient has to be still to attain clear
image 12 lead - Type of ECG Monitor: Reflects the electrical
activity primarily in the left ventricle, placed at the patients side
for immediate recording -6 electrodes on chest & 4 electrodes on
limbs --Place on areas that aren't bony and do not have significant
movement 15 min, pulse ox, ABGs diaphragmatic and pursed lip
breathing 30-40 degrees emphysema petroleum gauze > 100
bright red to serous bright red - Client with Chest Drainage
System: Nursing Interventions: - Repiratory assessment: VS
q_________, __________& _______ -Teach ______________ & ____________ -
Elevate HOB ___________, go from flat to semi-upright ASAP -Assess
around insertion site for crepitus, give SUBQ ____________ if necessary
-Change dressing q 48-72 hrs w/ ______________________ -Monitor and
record drainage: ---Notify Dr. if ____________ ---Color should go
from _____________________ ----Notify Dr. if color is _______________ -
Monitor for S&S of infection 21-100 40 7-10 bpm 10-14 -
Ventilator Controls and Settings: Fraction of inspired O2: - Vent
provides ___________% O2 --- Cut off for O2 toxicity is around
_________% --- Goal= Use least amount of O2 Tidal Volume: -
Volume of air received with each breath - __________mL/kg (add 0 to
weight in kg for estimate) Rate: - Number of ventilator _____________
- Usually ______________ bpm 80-100 35-45 22-26 7.35-7.45
compensated - Normal ABG Values: PaO2: ________ PCO2:________
HCO3:_______ pH:________ HCO3 and CO2 are both outside of normal
ranges= ___________ Full= pH within norms Partial= pH not within
norms 100% O2 and PEEP permissive hypercapnia pco2 bicarb
nitric oxide prone - ARDs Nursing and Medical Management: -
Correct underlying disorder -Mechanical ventilation:
_________________________ -To minimize barotrauma, ____________________ -
--Low tidal volumes and low peak pressures increase ____________ --
-Give ____________ to correct acidosis -Inhaled _______________ to dilate
pulmonary vessels -For severe hypoxia position in ____________________
, to allow air to rise to a depressed aveoli A fib - Atrial Dysrhythmia:
An uncoordinated atrial electrical activation that causes a rapid
disorganized and uncoordinated twitching of atrial musculature -
Rate: Atrial 300-600, Ventricular 120-200 -Rhythm: Regular -P
wave is indiscernible, with different sizes and shapes -PR cannot be
measured -P:QRS: many:1 -Patient will be symptomatic with RVR,
new diagnosis, or inability to tolerate rhythm: SOB, chest pain, or
low BP -If hemodynamically unstable do cardioversion with
warfarin for atleast 4 weeks to decrease risk for clots ABGs
sedation - Medical Management for Mechanical Ventilation: -
Ventilation adjustments based on _____________ to enhance O2 -
Adjustments to _____________ ABGs wean - Collaborative Care Goals
of Mechanical Ventilation: -Monitor and evaluate response to
medications and mechanical ventilation with ______________ -Manage
ventilator system safely -Prevent complications -_____________ the
patient from the vent ABGs and auscultation respiratory rate
repositioning suction humidification incisor <25 chlorahexidine
above stomach communication - Nursing Interventions for
Mechanical Ventilation: -Top priority= ___________ & pulmonary
____________ -Assess vital signs for changes and patterns -Give
analgesics for pain w/o suppressing ___________ -Frequent ___________
to decrease pulmonary effects of immobility -Adequate fluids, I&O,
daily weights -For increased secretions, PIP, and wheezing:________ -
To liquifey secretions: ______________ -Mark level of tube with patients
______________ -Reposition and retape tube daily -Position with
minimal pull/distortion of tube in trachea -Cuff pressure checks
with pressure _________ -Mouth care with __________ and suction -
HOB= ____________ to avoid aspiration -Plan methods of ______________
ACE inhibitors - Medication Therapy for ACS: -Give to decrease
demand & prevent ventricular remodeling Give for: -Acute MI with
ST segment elevation in 2 or more leads -STEMI -Acute MI with
left ventricle EF <40% -Acute MI with clinical S&S of CHF Start: -
