ADVANCED CLINICAL CONCEPTS HESI HINTS DOCUMENT

ADVANCED CLINICAL CONCEPTS HESI HINTS DOCUMENT • ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. The mortality rate is high (50%) • In ARDS, a common laboratory finding is lowered PO2. However, these clients are not very responsive to high concentrations of oxygen. • Think about the physiology of the lungs by remembering PEEP: Positive End Expiratory Pressure is the instillation and maintenance of small amounts of air into the alveolar sacs to prevent them from collapsing each time the client exhales. The amount of pressure can be set with the ventilator and is usually around 5 to 10 cm of water. • Suction only when secretions are present. • Before drawing arterial blood gases from the radial artery, perform the Allen test to assess collateral circulation. Make the client’s hand blanch by obliterating both the radial and ulnar pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is good, flushing will be seen immediately. The Allen test is then positive, and the radial artery can be used for puncture. If the Allen test is negative, repeat on the other arm. If this test is also negative, seek another site for arterial puncture. The Allen test ensures collateral circulation to the hand if thrombosis of the radial artery should follow the puncture. • If the client does not have O2 to his/her brain, the rest of the injuries do not matter because death will occur. However, they must be removed from any source of imminent danger, such as a fire. • PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure. • A child in severe distress should be on 100% O2. • Early signs of shock are agitation and restlessness resulting from cerebral hypoxia. • If cardiogenic shock exists with the presence of pulmonary edema, i.e., from pump failure, position client to REDUCE venous return (HIGH FOWLER’s with legs down) in order to decrease venous return further to the left ventricle. • Severe shock leads to widespread cellular injury and impairs the integrity of the capillary membranes. Fluid and osmotic proteins seep into the extra vascular spaces, further reducing cardiac output. A vicious cycle of decreased perfusion to ALL cellular level activities ensues. All organs are damaged, and if perfusion problems exist, the damage can be permanent. • All vasopressors/vasodilator drugs are potent and dangerous and require weaning on and off. Do not change infusion rates simultaneously. • A client is brought into the hospital suffering shock symptoms as a result of a bee sting. What is the first priority? Maintaining an open airway (the allergic reaction damages the lining of the airways causing edema). Also, keep the client warm without constricting clothing; keep legs elevated (not Trendelenburg because the weight of the lower organs restricts breathing). • Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild • Epinephrine: 1:10,000, or 5ml IV for severe • Volume expanding fluids are usually given to clients in shock. However, if the shock is cardiogenic, pulmonary edema may result. • Drugs of choice for shock - Digitalis preparations: Increase the contractility of the heart muscle - Vasoconstrictors (Levophed, Dopamine): Generalized vasonconstriction to provide more available blood to the heart to help maintain cardiac output. • A common volume-expanding substance is plasma and possibly whole blood. • You are caring for a woman who was in severe automobile accident several days ago. She has several fractures and internal injuries. The exploratory laparotomy was successful in controlling the bleeding. However, today you find that this client is bleeding from her incision, short of breath, has a weak thready pulse, has cold and clammy skin, and hematuria. - What do you think is wrong with the client, and what would you expect to do about it? - These are typical signs and symptoms of DIC crisis. Expect to administer IV heparin to block the formation of thrombin (Coumadin does not do this). However, the client described is already past the coagulation phase and into the hemorrhagic phase. Her management would be administration of clotting factors along with palliative treatment of the symptoms as they arise. (Her prognosis is poor). • NCLEX-RN questions on CPR often deal with prioritization of actions. Question: What actions are required for each of the following situations? - A 24-year old motorcycle accident vistim with a ruptured artery if the leg is pulseless and apneic. - A 36-year old first time pregnant woman who arrests during labor. - A 17-year old with no pulse or respirations who is trapped in an overturned car, which is starting to catch fire. - A 40-year old businessman who arrests two days after a cervical laminectomy. • WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS) - The American Heart Association recommends that those with known angina pectoris seek emergency medical care if chest pain is NOT relieved by three nitroglycerin tablets 5 minutes apart over a 150minute period. - A person with previously unrecognized coronary disease experiencing chest pain persisting for 2 minutes or longer should seek emergency medical treatment. • It is important for the nurse to stay current with the American Heart Association’s guidelines for Basic Life Support (BLS) by being certified every two years as required. • If one rescuer is performing CPR, 1 15:2 ratio of compression to ventilations is performed for 4 cycles, then reassess for breathing and pulse. If two rescuers are performing CPR, a 15:2 ratio is now recommended for compressions to ventilations. Perform for 15 cycles with a 100/min compression rate. When trading off, start with compressions. • Initiate CPR with BLS guidelines immediately, then move on to Advanced Cardiac Life Support (ACLS) guidelines. • When significant arterial acidosis is noted, try to reduce PCO2 by increasing ventilation, which will correct arterial, venous, and tissue acidosis. Bicarbonate may exacerbate acidosis b producing CO2. Thus, the ACLS guidelines have recommended bicarbonate NOT be used unless hyperkalemia and/or preexisting acidosis is documented. • Infants/prematures may have problems with the following that can predispose to arrest: Beware of the “H’s” – hypoxia, hypoglycemia, hypothermia, increased H+ (metabolic and/or respiratory acidosis), hypercoagulability (if polycythemia exists). • Changes is osmolarity cause shifts in fluid. The osmolarity of the extracellular fluid (ECF) is almost entriely due to sodium. The osmolarity of intracellular fluid (ICF) is related to many particles, with potassium being the primary electrolyte. The pressures in the ECF and the ICF are almost identical. If either ECF or ICF change in concentration, fluid shifts from the area of lesser concentration to the area of greater concentration. • Dextrose 10% is a hypertonic solution and should be administered IV. • Normal saline is an isotonic solution and is used for irrigations, such as bladder irrigations or IV flush lines with intermittent IV medication. • Use only isotonic (neutral) solutions in irrigations, infusions, etc., unless the specific aim is to shift fluid into intracellular or extracellular spaces. • Potassium imbalances are potentially life-threatening, must be corrected immediately. A low magnesium often accompanies a low K+, especially with the use of diuretics. • Fluid Volume Deficit: Dehydration - Elevated BUN: The BUN measures the amount of urea nitrogen in the blood. Urea is formed in the liver as the end product of protein metabolism. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidneys. - Creatinine, as with BUN, is excreted entirely by the kidneys and is therefore directly proportional to renal excretory function. However, unlike BUN, the creatinine level is affected very little by dehydration, malnutrition, or hepatic function. The daily production of creatinine depends on muscle mass, which fluctuates very little. Therefore, it is a better test of renal function than is the BUN. Creatinine is generally used in conjunction with the BUN test and they normally are in a 1:20 ratio. - Serum osmolality measures the concentration of particles in a solution. It refers to the fact that the same amount of solute is present, but the amount of solvent (fluid) is decreased. Therefore, the blood can be considered “more concentrated.” - Urine osmolality and specific gravity increase. • Check the IV tubing container to determine the drip factor because drip factors vary. The most common drip factors are 10, 12, 15, and 60 drops per milliliter. A microdrip is 60 drops per milliliter. • Flushing a saline lock requires approximately 1 ½ times the amount of fluid that the tubing will hold in order to efficiently flush the tubing. REMEMBER to use sterile technique to prevent complications such as infiltration, emboli and infection. • A pH of less than 6.8 or more than 7.8 is NOT COMPATIBLE WITH LIFE. • The acronym ROME can help you remember: Respiratory, Opposite, Metabolic, Equal. • Review the order of blood flow to the heart: - Unoxygenated blood flows from the superior and inferior vena cava into the right atrium, then to the right ventricle. It flows out of the heart through the pulmonary artery, to the lungs for oxygenation. The pulmonary vein delivers oxygenated blood back to the left atrium, then to the left ventricle (largest, strongest chamber) and out the aorta. - Review the three structures that control the one-way flow of blood through the heart: 1. Valves Atrioventricular valves  Tricuspid (right side)  Mitral (left side) Semilunar valves  Pulmonary (in pulmonary artery)  Aortic (in aorta) 2. Cordae Tendinae 3. Papillary muscles • Since the T waves represents repolarization of the ventricle, this is a critical time in the heartbeat. This action represents a resting and regrouping stage so that the next heartbeat can occur. If defibrillation occurs during this phase, the heart can be thrust into a life-threatening dysrhythmia. • Observe the client for tolerance of the current rhythm. This information is the most important data the nurse can collect on the client with an arrythmia. • REMEMBER to monitor the client as well as the machine! If the EKG monitor shows a severe dysrhythmia, but the client is sitting up quietly watching a TV without any sign of distress, assess to determine if the leads are attached properly. • Marking the operative site is required for procedures involving right/left distinctions, multiple structures (fingers, toes), or levels (spinal procedures). Site marking should be done with the involvement of the client. • Wound dehiscence is separation of the wound edges and is more likely to occur with vertical incisions. It usually occurs after the early postoperative period, when the client’s own granulation tissue is “taking over” the wound, after absorption of the sutures has begun. Evisceration of the wound is protrusion of intestinal contents (in an abdominal wound) and is more likely in clients who are older, diabetic, obese, or malnourished and have prolonged paralytic ileus. • NCLEX-RN items will focus on the nurse’s role in terms of the entire perioperative process. Sample: A 43-year old mother of 2 teenage daughters enters the hospital to have her gallbladder removed in a same-day surgery using a scope instead of an incision. What nursing needs will dominate each phase of her short hospital stay? - Preparation phase: Education about postoperative care, NPO, assist with meeting family needs. - Operative phase: Assessment, management of the operative suite. - Post-anesthesia phase: Pain management, post-anesthesia precautions. - Post-operative phase: Prevent and assess for complications, pain management, dietary restrictions, activity. • HIV clients with tuberculosis require respiratory isolation. Tuberculosis is the only real risk to non-pregnant caregivers that is not related to a break in universal precautions (i.e., needle sticks, etc.). • STANDARD PRECAUTIONS: - Wash hands, even if gloves have been worn to give care - Wear gloves (latex) for touching blood or body fluids, or any non-intact body surface. - Wear gowns during any procedure that might generate splashes (changing clients with diarrhea). - Use masks and eye protection during activity which might disperse droplets (suctioning). - Do not recap needles, dispose of in puncture-resistant containers. - Use mouth piece for resuscitation efforts. - Refrain from giving care if you have open skin lesions. • Caregivers who are pregnant may choose not to care for a client with Cytomegalovirus (CMV). • Pediatric HIV is often evidenced by lymphoid interstitial pneumonitis. • The focus of NCLEX-RN questions is likely to be assessment of early signs of the disease and management of complications associated with HIV. • For narcotic induced respiratory depression, administer Naloxone 0.1mg to 0.4mg IV every 2-3 minutes as needed, until 1.0mg is achieved. • Use non-invasive methods for pain management when possible: - Relaxation techniques - Distraction - Imagery - Biofeedback - Interpersonal skills - Physical care: altering positions, touch, hot and cold applications. • Narcotic analgesics are prepared for pain relief because they bind to the various opiate receptor sites in the CNS. Morphine is often the preferred narcotic (REMEMBER: it causes respiratory depression). • Other agonists are meperidine and methadone. Narcotic antagonists block the attachment of narcotics to the receptors, such as Narcan (naloxone). Once Narcan has been given, additional narcotics cannot be given until the Narcan effects have passed. • Do not take away the coping style used in a crisis state… DENIAL. It is a useful and needed tool at the initial stage for some. Support, do not challenge, unless it hinders/blocks treatment – endangering the patient. MEDICAL –SURGICAL NURSING RESPIRATORY SYSTEM • Fever can cause dehydration from excessive fluid loss in diaphoresis. Increased temperature also increases metabolism and the demand for oxygen. • High risk for pneumonia: - Any person, who has altered level of consciousness, has depressed or absent gag reflex and cough reflexes, is susceptible to aspirating oropharyngeal secretions. (Alcoholics, anesthesized individuals, those with brain injury, drug overdose, or stroke victims). - When feeding, raise the head of the bed and position the client on side – not on back. • Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue. • Hydration – enables liquification of mucous trapped in the bronchioles and alveoli, facilitating expectoration. Essential for the client experiencing fever. Important because 300 to 400 ml of fluid are lost daily by the lungs through evaporation. • Irritability and restlessness are early signs of cerebral hypoxia – the client is not getting enough oxygen to the brain. • Pneumonia preventatives: - Elderly: flu shots; pneumonia immunizations; avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols); do not smoke. - Immunosuppressed and debilitated persons: infection avoidance, sensible nutrition, adequate intake, balance of rest and activity. - Comatose and immobile persons: elevate head of bed to feed; turn frequently. • Compensation occurs over time in clients with chronic lung disease, and arterial blood gases (ABGs) are altered. It is imperative that baseline data are obtained on the client. • Productive cough and comfort can be facilitated by Semi- Fowler’s or high Fowler’s positions, which lessen pressure on the diaphragm from abdominal organs. Gastric distention becomes a priority in these clients because it elevates the diaphragm and inhibits lung expansion. • Pink puffer: Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe, which causes the person to work harder to breathe, but the amount of O2 taken in in adequate to oxygenate the tissues. • Blue bloater: insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right- sided heart failure. • Cells of the body depend on oxygen to carry out their functions. Inadequate arterial oxygenation is manifested by cyanosis and slow capillary refill (<3 seconds). A chronic sign is clubbing of the fingernails, and a late sign is clubbing of the fingers. • Caution must be used in administering O2 to COPD client. The stimulus to breathe is hypoxia (hypoxic drive) not the usual hypercapnia, the stimulus to breathe for healthy persons. Therefore, if too much oxygen is given, the client may stop breathing! • Health Promotion: - Eating consumes energy needed for breathng. Offer mechanically soft diets, which do not require as much chewing and digestion. Assist with feeding if needed. - Prevent secondary infections – avoid crowds, contact with persons who have infectious diseases, and respiratory irritants (tobacco smoke). - Teach client to report any change in characteristics of sputum. - Encourage client to hydrate well and to obtain immunizations needed (flu and pneumonia). • When asked to prioritize nursing actions, use the ABC rule: - Airway first - Then breathing - Then circulation • Look and listen. If breath sounds are clear, but the client is cyanotic and lethargic, adequate oxygenation is not occurring. • The key to respiratory status assessment of breath sounds as well as visualization of the client. Breath sounds are better “described,” not named, e.g., sounds should be described as “crackles,” “wheeze,” “hihg-pitched whistling sound,” rather than “rales,” “rhonchi,” etc., which may not mean the same thing to each clinical professional. • Watch for NCLEX-RN questions that deal with oxygen delivery. In adults, O2 must bubble through some type of water solution so it can be humidified if given at >4 L/min or delivered directly to the trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx provide adequate humidification. • With cancer of the larynx, the tongue and mouth often appear white, gray, dark brown, or black, and may appear patchy. • Tracheostomy care involves cleaning the inner cannula, suctioning, and applying a clean dressing. • Air entering the lungs is humidified along the naso-bronchial tree. This natural humidifying pathway is gone for the client who has had a laryngectomy. If the air is not humidified before entering the lungs, secretions tend to thicken and become crusty. • A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks (first 24 hours). • Fear of choking is very real for laryngectomy clients. They cannot cough as before because the glottis is gone. Teach the “glottal stop” technique to remove secretions (take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube). • TB SKIN TEST: a positive TB skin test is exhibited by an induration 10mm or greater in diameter 48 hours after skin test. Anyone who has received a BCG vaccine will have a positive skin test and must be evaluated using a chest x-ray. • Teaching is very important with the TB client. Drug therapy is usually long term (9 months or longer). It is essential that the client take the medications as prescribed for the entire time. Skipping doses or prematurely terminating the drug therapy can result in a public health hazard. • TEACHING POINTS – - Rifampin: Reduces effectiveness of oral contaceptives; should use other birth control methods during treatment; gives body fluids orange tinge; stains soft contacts. - Isoniazid (INH): Increases Dilantin levels. - Ethambutal: Vision check before starting therapy and monthly; may have to take 1 to 2 years longer. - Teach rationale for combination drug therapy to increase compliance. Resistance develops more slowly if several anti-TB drugs given, instead of just one drug at a time. • Some tumors are so large that they fill entire lobes of the lung. When removed, large spaces are left. Chest tubes are not usually used with these clients because it is helpful if the mediastinal cavity, where the lung used to be, fills up with fluid. This fluid helps prevent a shift of the remaining chest organs to fill the empty space. • If the chest tube remains disconnected, do not clamp! Immediately place the end of the tube in a container of sterile saline or water until a new drainage system can be connected. • If the chest tube is accidentally removed from the client, the nurse should apply pressure immediately with an occlusive dressing and notify the healthcare provider. • Chest Tube NCLEX-RN content: Fluctuations (tidaling) in the fluid will occur if there is no external suction. These fluctuating movements are a good indicator that the system is intact and should move upward with each inspiration and downward with each expiration. If fluctuations cease, check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client’s position, since expanding lung tissue may be occluding the tube opening. Remember, when external suction is applied the fluctuations cease. Most hospitals DO NOT MILK chest tubes as a means of clearing or preventing clots – it is too easy to remove chest tubes. Mediastinal tubes may have orders to be stripped because of location, compared to larger thoracic cavity tubes. • Various pathophysiological conditions can be related to the nursing diagnosis “Ineffective Breathing Patterns.” 1. Inability of air sacs to fill and empty properly (emphysema, cystic fibrosis) 2. Obstruction of the air passages (carcinoma, asthma, chronic bronchitis) 3. Accumulation of fluid in the air sacs (pneumonia) 4. Respiratory muscle fatigue (COPD, pneumonia) RENAL SYSTEM • Normally, kidney excrete approximately 1ml of urine per kg of body weight per hour, which is about 1 to 2 liters in a 24-hour period. • Electrolytes are profoundly affected by kidney problems. There must be a balance between extracellular fluid and intracellular fluid to maintain homeostasis. A change in the number of ions or in the amount of fluid will cause a shift in one direction or the other. Sodium and chloride are the primary extracellular ions. Potassium and phosphate are the primary intracellular ions. • In some cases, persons in ARF may not experience the oliguric phase but may progress directly to diuretic phase during which the urine output may be as much as 10 liters per day. • Body weight is a good indicator of fluid retention and renal status. Obtain accurate weights on all clients with renal failure – done on the same scale at the same time every day. • Fluid Volume Alterations Fluid • Excess symptoms: - Dyspnea - Tachycardia - Jugular vein distention - Peripheral edema - Pulmonary edema • Fluid deficit symptoms: - Decreased urine output - Reduction in body weight - Decreased body turgor - Dry mucous membranes - Hypotension - Tachycardia • Watch for signs of hyperkalemia: dizziness, weakness, cardiac irregularities, muscle cramps, diarrhea, and nausea. • Potassium has a critical safe range (3.5 to 5.0 mEg/L) because it affects the heart, and any imbalance must be corrected by medications or dietary modification. Limit high potassium foods (bananas, avocados, spinach, fish) and salt substitutes, which are high in potassium. • Clients with renal failure retain sodium. With water retention, the sodium becomes diluted and serum levels may appear near normal. With excessive water retention, the sodium levels appear decreased dilution). Limit fluid and sodium intake in ARF clients. • During oliguric phase, minimize protein intake. When the BUN and creatinine return to normal, aRF is determined to be resolved. • Accumulation of waste products from protein metabolism is the primary cause of uremia. Protein must be restricted in CRF clients. However, if protein intake is inadequate, a negative nitrogen balance occurs causing muscle wasting. The glomerular filtration rate (GFR) is most often used as an indicator of level of protein consumption. • DIALYSIS COVERED BY MEDICARE: - All persons in the United States are eligible for Medicare as of their first day of dialysis under special End Stage Renal Disease funding. - Medicare card will indicate ESRD. - Transplantation is covered by Medicare procedure; coverage terminates six months postoperative if dialysis is no longer required. • Protein intake is restricted until blood chemistry shows ability to handle protein catabolites: urea, creatinine. Ensure high calorie intake so protein is spared for its own work: give hard candy, jelly beans, flavored carbohydrate powders. • As kidneys fail, medications must often be adjusted. Of particular importance is digoxin toxicity since digitalis preparations are excreted by the kidneys. Signs of toxicity in adults include nausea, vomiting, anorexia, visual disturbances, restlessness, headache, cardiac arrythmias, and pulse <60 beats per minute (bradycardia). • The major difference between dailysate for hemodialysis and peritoneal dialysis is the amount of glucose. Peritoneal dialysis dialysate is much higher in glucose. For this reason, if the dialysate is left in the peritoneal cavity too long, hyperglycemia may occur. • The key to resolving UTI with most antibiotics is to keep the blood level of the antibiotic constant. It is important to tell the client to take the antibiotics round-the-clock and not skip doses so that a consistent blood level can be maintained for optimal effectiveness. • Location of the pain can help determine location of the stone. - Flank pain usually means the stone is in the kidney or upper ureter. If it radiates in the abdomen or scrotum, the stone is likely to be in the ureter or bladder. - Excruciating, spastic-type pain is called colic. - During kidney stone attacks, it is preferable to administer pain medications at regularly scheduled intervals rather than PRN to prevent spasm and optimize comfort. • Percutaneous nephrostomy: A needle/catheter is inserted through the skin into the calyx of the kidney. The stone may be dissolved by percutaneous irrigation with a liquid which will dissolve the stone, or ultrasonic sound waves (lithotripsy) can be directed through the needle/catheter to break up the stone which then can be eliminated through the urinary tract. • Bladder spasms frequently occur after TURP. Inform the client that the presence of the oversized balloon on the catheter (30 to 45 cc inflate) will cause a continuous feeling of needing to void. The client should not try to avoid around the catheter since this can precipitate bladder spasms. Medications to reduce or prevent spasms should be given. • Instillation of hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid. Use only sterile saline for bladder irrigation after TURP since the irrigation must be isotonic to prevent fluid and electrolyte imbalance. • Inform the client prior to discharge that some bleeding is expected after TURP. Large amounts of blood or frank bright bleeding should be reported. However, it is normal for the client to pass small amounts of blood during the healing process as well as small clots. He should rest quietly and continue drinking large amounts of fluid. CARDIOVASCULAR SYSTEM • What is the relationship of the kidneys to the cardiovascular system? - The kidneys filter about a liter of blood per minute - If cardiac output is decreased, the amount of blood going through the kidneys is decreased; urinary output is decreased. Therefore, a decreased urinary output may be a sign of cardiac problems. - When the kidneys produce and excrete 0.5 ml of urine per kg of body weight or average 30 ml/hr output, the blood supply is considered to be minimally adequate to perfuse the vital organs. • Angina is caused by myocardial ischemia. Which cardiac medications would be appropriate for acute angina? - Digoxin – Not appropriate – Increases the strength and contractility of the heart muscle; the problem in angina is that the muscle is not receiving enough oxygen. Digoxin will not help. - Nitroglycerin – Appropriate – Causes dilation of the coronary arteries, allowing more oxygen to get to the heart muscle. - Atropine – Not appropriate – Increases heart rate by blocking vagal stimulation, which suppresses the heart rate. Does not address the lack of O2 to the heart muscle. - Propanolol (Inderal) – Not appropriate – for acute angina attack; however, is appropriate for long-term management of stable angina because it acts as a beta-blocker to control vasoconstriction. • Blood pressure is created by the difference in the pressure of the blood as it leaves the heart and the resistance it meets flowing out to the tissues. Therefore, any factor that alters cardiac output or peripheral vascular resistance will alter blood pressure. Diet and exercise, smoking cessation, weight control, and stress management can control many factors that influence the resistance blood meets as it flows from the heart. • Remember the risk factors for hypertension: heredity, race, age, alcohol abuse, increased salt intake, obesity, and use of oral contraceptives. • The number one cause of CVA with hypertensive clients is non-compliance with medication regime. Hypertension is often symptomless, and antihypertensive medications are expensive and have side effects. Studies have shown that the more clients know about their antihypertensive medications, the more likely they are to take them – teaching is important. • Decreased blood flow results in diminished sensation in the lower extremities. Any heat source can cause severe burns before the client actually realizes the damage is being done. • A client is admitted with severe chest pain and states that he feels a terrible, tearing sensation in his chest. He is diagnosed with a dissecting aortic aneurysm. What assessment should the nurse obtain in the first few hours? - Vital signs q1 hour - Neurological vital signs - Respiratory status - Urinary output - Peripheral pulses • During aortic aneurysm repair, the large arteries are clamped for a period of time and kidney damage can result. Monitor daily BUN and creatinine levels. Normal BUN is 10 to 20 mg/dl and normal creatinine is 20:1. When this ratio increases or decreases, suspect renal problems. • A positive Homen’s sign is considered an early indication of thrombophlebitis. However, it may also indicate muscle inflammation. If a deep vein thrombosis has been confirmed, a Homan’s sign should not be elicited because of the increased risk of embolization. • Heparin prevents conversion of fibrinogen to fibrin and prothrombin to thrombin, thereby inhibiting clot formation. Since the clotting mechanism is prolonged, do not cause tissue trauma which may lead to bleeding when giving heparin subcutaneously. Do not massage area or aspirate; give in the abdomen between the pelvic bones; 2 inches from umbilicus; rotate sites. • HEPARIN: - Antagonist: Protamine Sulfate - LAB: PTT or APTT determines efficacy - Keep 1.5 to 2.5 times normal control • COUMADIN: - Antagonist: Vitamin K - LAB: PT determines efficacy - Keep 1.5 to 2.5 times normal control • INR: Desirable therapeutic level usually 2 to 3 seconds (reflects how long it takes a blood sample to clot). • A holter monitor offers continuous observation of the client’s heart rate. To make assessment of the rhythm strips, most meaningful, teach the client to keep a record of: - Medication times and doses - Chest pain episodes – type and duration - Valsalva maneuver (straining at stool, sneezing, coughing) - Sexual activity - Exercise • Cardioversion is the delivery of synchornized electrical shock to the myocardium. • Differentiate in synchronous and asynchronous pacemakers: - Synchronous or demand pacemaker fires only when the client’s heart rate falls below a rate set on the generator. - Asynchronous or fixed pacemaker fires at a constant rate. • Restricting sodium reduces salt and water retention, thereby reducing vascular volume and preload. • DIGITALIS: