Cardiac, Immune, Cancer, Endocrine, Sensory, Neuro Disorders Terms in this set (165) While caring for a client who has sustained a myocardial infarction, the nurse notes 8 premature ventricular contractions in 1 minute on the cardiac monitor. The

Cardiac, Immune, Cancer, Endocrine, Sensory, Neuro Disorders Terms in this set (165) While caring for a client who has sustained a myocardial infarction, the nurse notes 8 premature ventricular contractions in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water and oxygen at 2 L/min. The nurse's first course of action should be to: A. Increase the IV infusion rate B. Notify the physician promptly C. Increase the oxygen concentration D. Administer a prescribed analgesic B. PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post-MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability. Which of the following is an expected outcome for a client on the second day of hospitalization after an MI? the client: A. Continues to have severe chest pain B. Can identify risk factors for MI C. Participates in a cardiac rehabilitation walking program D. Can perform personal self-care activities without pain D. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehab program. Which of the following is the most appropriate diet for a client during the acute phase of an NSTEMI? A. Liquids as desired B. Small, easily digested meals C. Three regular meals a day D. Nothing by mouth B. Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only or restricted to NPO unless their condition is very unstable. During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when the palpation of the radial pulse reveals: A. Two regular beats followed by one irregular beat B. An irregular rhythm with pulse greater than 100 C. Pulse rate below 60 D. A weak, thread pulse B. Characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the physician. A weak, thread pulse is characteristic of a client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular contraction. When teaching a client about self-care following placement of a new permanent pacemaker to the upper left chest, the nurse should include which information? A. Take and record daily pulse rate B. Avoid air travel because of airport security alarms C. Immobilize the affected arm for 4 to 6 weeks D. Avoid using a microwave oven A. The nurse must teach the client how to take and record the pulse daily. The pacemaker metal casing does not set off airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required. Microwave ovens are safe to use and do not alter pacemaker function. A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first? A. Prepare for transcutaneous pacing B. Prepare to defibrillate the client at 200 J C. Administer an IV lidocaine infusion D. Schedule the operating room for insertion of a permanent pacemaker A. Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of third-degree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent pacemaker can be inserted. An older adult is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a permanent pacemaker is to: A. Maintain skin integrity B. Maintain cardiac conduction stability C. Decrease cardiac output D. Increase activity level B. Maintaining cardiac conduction stability to prevent arrhythmias is a priority immediately after artificial pacemaker implantation. The client should have continuous electrocardiographic monitoring until proper pacemaker functioning is verified. Skin integrity, while important, is not an immediate concern. The pacemaker is used to increase heart rate and cardiac output, not decrease it. The client should limit activity for the first 24 to 48 hours after pacemaker insertion. The client should also restrict movement of the affected extremity for 24 hours. When teaching the client about complications of atrial fibrillation, the nurse should instruct the client to avoid which of the following? A. Stasis of blood in the atria B. Increased cardiac output C. Decreased pulse rate D. Elevated blood pressure A. Atrial fibrillation occurs when the SA node no longer functions as the heart's pacemaker and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed, atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not associated with increased cardiac output, elevated BP, or decreased pulse rate. A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take first? A. Obtain the client's weight B. Assist the client into high-Fowler's position C. Auscultate lung sounds D. Check oxygen saturation with pulse oximeter B. Using the airway, breathing, circulation priority approach to client care, the first action the nurse should take is to assist the client into high-Fowler's position. This will decrease venous return to the heart (preload) and help relieve lung congestion. A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? A. "I sleep on three pillows each night." B. "My feet are bigger than normal." C. "My pants don't fit around my waist." D. "I don't have the same appetite I used to." A. Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure. A nurse is assessing a client with heart failure. What breath sound is commonly auscultated in clients with heart failure? A. tracheal. B. fine crackles. C. coarse crackles. D. friction rubs. B. Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are typically caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound? A. a first heart sound (S1). B. a third heart sound (S3). C. a fourth heart sound (S4). D. a murmur. B. An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves. Systemic Lupus Erythematosus Autoimmune, inflammatory disorder of the connective tissue Can cause major body organs and systems to fail Factors that trigger lupus Sunlight Stress Pregnancy Drugs Nursing Assessment for suspected lupus Joint pain and decreased mobility Fever - also heart rate Nephritis - urine output, gravity Pleural effusion - lung sounds Pericarditis - friction rub, pain, fever Abdominal pain - auscultate, palpate, BM Photosensitivity - wear shades, dim lights in room Plans and interventions for lupus Instruct client to avoid prolonged exposure to sunlight Instruct client to clean the skin with mild soap Monitor and instruct client in administration of steroids - look out for Cushing's or Addison's, glucose levels Oncologic emergencies Superior vena cava syndrome - partial occlusion of SVC, SOB, JVD, decreased perfusion Spinal cord compression - lead to permanent neuro impairment (secondary spinal injury), check reflexes and full neuro assessment Pericardial effusion & cardiac tamponade - need immediate drainage, prepare for pericardocentesis or drain Disseminated intravascular coagulation (DIC) - clotting and bleeding simultaneously Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Tumor lysis syndrome - may need emergent dialysis Leukemias characterized by an abnormal overproduction of immature forms of any of the leukocytes. There is an interference with normal blood production that results in decreased numbers of erythrocytes, platelets, and mature leukocytes. The lack of mature leukocytes leads to _________________________________ immunosuppression and higher risk of infection Diagnosis of leukemia is made by... biopsy, bone marrow aspiration, lumbar puncture, and frequent blood counts Leukemia is treated with... chemotherapy and bone marrow transplant Pathophysiology of polycythemia vera Abnormal clonal stem cells interfere with or suppress normal stem cell growth. Uncontrolled and rapid cellular reproduction and maturation cause proliferation or hyperplasia of all bone marrow cells. With polycythemia vera, increased RBC mass makes the blood abnormally viscous and __________ blood flow to the _. inhibits; microcirculation In polycythemia vera, diminished blood flow and set the stage for intravascular thrombosis. thrombocytosis Polycythemia vera complications Hemorrhage (GI, hematuria, intracranial) Vascular thromboses Secondary gout Uric acid calculi Myelofibrosis Stroke Acute leukemia Myocardial infarction Biggest complication in an immunocompromised patient is... infection In the immunocompromised patient, nursing care should focus on... preventing infection and education Rheumatoid Arthritis involves... Chronic, systemic, symmetrical autoimmune inflammatory disease Primarily attacks peripheral joints and surrounding muscles, tendons, ligaments, and blood vessels Extra-articular involvement of organs such as skin, heart, lungs, and eyes may occur Marked by spontaneous remissions and unpredictable exacerbations Clinical manifestations of RA... Fatigue, general malaise, anorexia/weight loss Persistent joint pain Characteristic morning stiffness lasting >1 hour Tenderness, swelling, restricted ROM of joints Joint deformities, nodules HIV/AIDS Renders patients susceptible to opportunistic infections, unusual cancers, and other abnormalities Marked by progressive failure of the immune system HIV transmission means contact with infected blood, secretions, or body fluids (semen, pre-seminal fluid, rectal or vaginal fluid, human milk) and associated with identifiable high-risk behaviors Assessment for suspected HIV History of one or more risk factors Infection Myalgia Headache Nausea, anorexia Dry cough Chronic diarrhea Involuntary weight loss HIV complications Opportunistic infections HIV wasting syndrome Neoplasms Premalignant diseases Organ-specific syndromes Immunodeficiency AIDS-associated dementia/encephalopathy Death Radiation Used to kill a tumor, reduce the tumor size, relieve obstruction Can destroy rapidly multiplying cancer cells as well as normal cells Can be internal or external Radiation side effects Fatigue Anorexia Immunosuppression Tissue damage Ulcerations GI effects Chemotherapy Involves the administration of cytotoxic medications and chemicals to promote tumor cell death Chemotherapy disrupts the cell cycle in various phases, interfering with cellular __________________ and _. metabolism, reproduction Side effects of chemotherapy Bone marrow suppression (immunosuppression, thrombocytopenia, anemia) GI effects (anorexia, N/V, diarrhea) Stomatitis, mucositis Alopecia (hair loss, leads to altered body image) Fatigue Xerostomia (dry mouth) Leading causes of death in patients with lupus kidney failure; heart failure tumor lysis syndrome Chemotherapy can cause massive destruction of cells leading the creation of uric acid which can be toxic to the kidneys leading to Acute Tubular Necrosis. You can try to prevent this with hydration and allopurinol. bone marrow transplant infusion of healthy bone marrow cells to a recipient with matching cells from a donor needs a neutropenic diet (nothing raw, no fresh fruit, etc.) polycythemia vera treatment relies primarily on phlebotomy to reduce hematocrit - bleed them/ drain them (usually 1 or so a week or monthly) - prevent DVT and PE deep vein thrombosis blood clot forms in a large vein, usually in a lower limb DVT nursing interventions bed rest, TPA, no pillow under knees or massaging of extremity, TPA within 5 days, heparin, analgesics, diuretics DVT diagnostic tests D Dimer ESR Venous Duplex Venogram Ultrasound MRI HIV/AIDS risk factors -exposure to infected blood, body fluids, or tissue -unprotected sex, multiple sex partners, intravenous drug use -can go undiagnosed in older adults due to similarity of symptoms common with other illness in this age group (data collection and comprehensive assessment extremely important) HIV diet bland, fruits/veggies, high protein, supplementation avoid dairy, spicy or acidic foods Hypertension formula BP = CO x PR increased cardiac output AND increased peripheral resistance Cardiac output equation CO = HR x SV (heart rate x stroke volume) P wave atrial depolarization QRS complex represents ventricular depolarization S-T segment entire ventricular myocardium depolarized T wave represents ventricular repolarization ECG Heart Rate calculation QRS complexes in 6 large blocks X 10 Left sided heart failure symptoms -Left = lungs (and heart) -Crackles, increased HR, SOB, palpitations, dizzy, lightheaded, confused, restless, cough, dyspnea Right sided heart failure symptoms -Pitting Edema -Ascites -Hepatic enlargement -JVD -Parasternal lift -Nausea -Decreased appetite -Cold extremities -Diaphoresis Zone of ischemia Tissue that is oxygen deprived; ECG shows T-wave inversion zone of injury ST elevation occurs in the area of injury next to infarct; tissue is viable as long as circulation is adequate zone of infarction Area of cell death and muscle necrosis; Q wave on ECG MI symptoms -Shortness of breath, indigestion, nausea, anxiety -Cool, pale and moist skin. -Symptoms cannot always be distinguished . Preload/Afterload Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart. Increased afterload causes decreased stroke volume; increased cardiac workload cor pulmonale, right ventricular failure enlargement of the right ventricle, resulting from chronic disease within the lungs, that causes congestion within the pulmonary circulation and resistance of blood flow to the lungs U.N.L.O.A.D. F.A.S.T. ...tx for HF... Upright position Nitrates Lasix Oxygen ACE inhibitors Digoxin Fluids (decrease) Afterload (decrease) Sodium restriction Test (Dig level, ABGs, potassium level) cardioversion synchronized elective restoration of a normal heart rhythm by electric shock; 50-100 joules defibrillation brief discharges of electricity are applied across the chest to stop dysrhythmias (ventricular fibrillation, V-tach); 120-200 joules ACE inhibitors "PRIL" Captopril, Enalapril, Afosiopril Antihypertensive. Blocks Angiotensin Converting Enzyme (ACE) in lungs from converting angiotensin I to angiotensin II (powerful vasoconstrictor). Increases cardiac output, rate, and contractility; Decreases BP, Decreased Aldosterone secretions, Sodium and fluid loss. Check BP before giving (hypotension) *Orthostatic Hypotension ACE inhibitors side effects dizziness, nonproductive cough, GI distress, orthostatic hypotension, headache, hyperkalemia alpha blockers (__zosin) adverse effects palpitations, orthostatic hypotension, tachycardia, edema, chest pain, dizziness, HA, anxiety, depression, weakness, numbness, fatigue, N&V, diarrhea, constipation, abdominal pain, incontinence, dry mouth and pharygitis, sexual dysfunction ARBs (__sartan) side effects -dizziness -lightheadedness -diarrhea -insomnia -confusion does not effect exercise response Antihypertensive drugs used to lower blood pressure (see pic) Beta Blockers (__olol) decrease heart rate and dilate arteries by blocking beta receptors Beta blocker side effects Bradycardia, HF, contra with asthma, reflex tach, GI disturbance Calcium Channel Blockers decrease contractility, heart rate and conduction and they also cause vasodilation; used to control hypertension, angina, and dysrhythmias; do not administer medication if pulse is <50; does not treat acute attacks of angina; end in "dipine" or "pamiPr HCTZ (hydrochlorothiazide) Diuretic Statins Cholesterol drugs -sartans ARBs Cancer CAUTION C - change in bowel/bladder A - sore won't heal U - unusual bleeding T - thickening/lump I - indigestion O - obvious change wart/mole N - nagging cough/hoarseness Unexplained weight loss, fatigue, night pain Radiation Safety Time, distance, shielding Addison's disease occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone Blood sugar mnemonic Hot and dry = sugar high Cold and clammy = need some candy Cushing's syndrome caused by prolonged exposure to high levels of cortisol diabetes insipidus (DI) antidiuretic hormone (ADH) is not secreted, or there is a resistance of the kidney to ADH diabetes mellitus (DM) insulin is not secreted adequately or tissues are resistant to its effects type 1 diabetes symptoms - Thirst - Extreme hunger - Frequent urination - N&V - Acetone Breath - Fatigue - Rapid weight loss - Unconsciousness DKA Nursing Interventions - Assess: airway, LOC, hydration status, electrolytes, blood glucose level, temperature, urine output, mental status q1h, VS q 15 mins until stable, hourly blood glucose - Treat underlying cause - Monitor fluid status during aggressive replacement (1-2 L 0.9% NS over first 30 mins - 1 hour, 0.45% saline infused slower) - If BS = 250mg/dL add dextrose!! - Regular insulin IV (0.1 unit/kg bolus, 01 unit/kg/hr continuous drip) - Replace serum K - Infuse bicarb if severe acidosis occurs Hyperthyroidism symptoms Nervousness, weight loss despite increased appetite, excessive sweating and heat intolerance, palpitations, frequent bowel movements, muscular weakness of the proximal type and tremor Hypothyroidism symptoms Fatigue, lethargy. Modest weight gain with anorexia. Dry, coarse skin and cold intolerance. Swelling of face, hands, and legs. Constipation. Weakness, muscle cramps, arthralgias, paresthesias, impaired memory and hearing. type 2 diabetes Diabetes of a form that develops especially in adults and most often obese individuals and that is characterized by high blood glucose resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production. immune response The body's defensive reaction to invasion by bacteria, viral agents, or other foreign substances. Abnormal posturing decorticate and decerebrate Autonomic Dysreflexia (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) Left CVA aphasia, apraxia, slow and cautious Right CVA lack of insight, left side neglect, impulsive, short attention span, Intracranial Pressure (ICP) the amount of pressure inside the skull ICP nursing interventions Elevate HOB 35-45 deg Neck in neutral pos. Avoid flexion of hips Avoid isometric or resistive exercises Restrict fluid intake Avoid valsalva maneuvers Foley O2 Control body temp Cushing's triad r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure) Multiple Sclerosis Symptoms -Weakness, numbness, tingling in a limb -Optic neuritis (amaoursis fugax) -Double vision -Loss of balance -Urinary frequency/urgency -Ataxia (lack of voluntary movements) -Hyper-reflexia -Fatigue -Hoffman sign (flicking middle finger causes thumb flexion) -Lhermittes sign (shock sensation down spine on neck flexion) tonic-clonic seizure generalized seizure in which the patient loses consciousness and has jerking movements of paired muscle groups Stroke management Use of Tissue Plasminogen Activator (tPA) within the first 3 hours -> thrombolysis -> reopen occluded arteries -> reperfusion of ischemic penumbra (Side effect: increased risk of hemorrhage, reperfusion injury). Following stroke -> cerebral autoregulation of perfusion is lost -> perfusion depended on (perfusion pressure)/(vascular resistance) -> Increase in vascular resistance after stroke therefore increased pressure is necessary to perfuse tissue adequately. DO NOT LOWER BLOOD PRESSURE FOLLOWING STROKE unless it reaches dangerous levels. Investigations: CT of head on admission -> exclude hemorrhage, tumor, subdural hematoma. Establish extent of infarct and presence of previous infact. CT Angiography -> demonstrate cerebral arterial stenosis or occlusion. Carotid and vertebral artery duplex U/S -> stenosis or occlusion. Echocardiogram -> where cardiac source is likely. CXR, ECG, FBC, Glucose, Coagulation. MRI -> sensitive in detecting and localizing acute ischemic brain lesions.