Exam 2 study guide, Acid Base, IV, Pain, Cardio PDF

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Acid Base, IV, Pain, Cardio...

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Intro to Med Surg Exam #2 Pain         

Pain is subjective, the patient’s report of pain is the most valid information Consequences of untreated pain: un-necessary suffering, physical (issues with ADLs) and psychosocial dysfunction (depression and anxiety), immunosuppression, sleep disturbance Biopsychosocial model of pain: physiologic, affective, cognitive, behavioral, sociocultural Nociceptive pain can be somatic or visceral Somatic pain is superficial or deep, localized, arises from bone, joint, muscle, skin, or connective tissue Visceral Pain is from activation of nociceptors in the internal organs and lining of the body cavities, tumor involvement or obstruction Neuropathic pain: damage to peripheral nerve or CNS, numbing, hot-burning, shooting, stabbing, or electrical in nature, sudden, short lived, intense, lingering Nociceptive pain responds to opioid and non-opioid meds Nociception: the process that communicates pain to the CNS o Transduction: conversion of a stimulus into an action potential, NSAIDs work here, hinder release of inflammatory mediators o Transmission: process by which pain signals are relayed from the periphery to the spinal cord and then to the brain o Perception: pain is defined o Modulation:

Intravenous Therapy  ***calculate a drip rate gtt/min= (amount of solution in mL X drop factor)/(time in hoursx60 mins)  Document: gage, number of attempts, location, blood return/flush, dressing, method of stabilizing, type and rate of IV fluid, patient tolerance, patient education  Label the site with gage, date, time, and initials  Infiltration: injection of solution into tissues o Swelling, burning, tightness, pain, cool skin, slow IV flow rate  Phlebitis: inflammation of a vein o Redness, tenderness, puffy tissue over vein, elevated site temperature, palpable cord  Cellulitis and infection at site o Redness, warmth, swelling, patient might have fever  Extraversion: pass out of a vessel into the tissue o Symptoms: discomfort, swelling, burning, erythema, blanching, blistering, ulceration, necrosis o Medications that have a high risk of extraversion: phenytoin potassium chloride, vancomycin, calcium chloride, calcium gluconate, diazepam, metronidazole, nafcillin  Change tubing every 72 to 96 hours  Crystalloid solutions have things dissolved in them (hypertonic, hypotonic, isotonic)  Colloid solutions have things in them that are not dissolved such as albumin  Hypotonic: more water then electrolyte, water moves into cells, usually maintenance fluids o Ex: 0.45% NS  Isotonic: expands ECF, ideal to replace ECF fluid loss o EX: 5% dextrose, free water without electrolytes, treatment of hypernatremia OR 0.9%NS OR LR o Do not use LR with hyperkalemia or lactic acidosis  Hypertonic fluids: raises osmolality of ECF, requires frequent monitoring of BP, BS, and Na levels o EX: D5 1/2NS or D10W  Steps of IV push: identify patient, assess site, scrub the hub, check patency of line, flush with 5-10mL of NS, remember the medication rate of infusion and push the medication, flush again at the same rate as the medication, document dose given and how patient tolerated, remember to go back and evaluate patient Acid Base

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Respiratory center in medulla controls breathing The respiratory system begins to compensate within 1 to 3 minutes of an acid base imbalance Enemies of the respiratory system: COPD, pneumonia, Respiratory failure, PE, pulmonary edema, neuromuscular disease, electrolyte disturbance Renal system enemies: diabetes, hypertension, kidney disease, nephrotoxic drugs, congenital renal disease If all components are abnormal it is partially compensated It is fully compensated if pH is normal and CO2 and HCO3 are abnormal o If Ph is 7.35-7.39 then it was acidosis o If pH was 7.4 to 7.45 then it was alkalosis Metabolic acidosis o HCO3 loss or acid retention o Causes: DKA, diarrhea, renal failure, shock o Symptoms: Headache, decreased BP, Hyperkalemia, muscle twitching, warm, flushed skin, N/V/D, change in LOC, kussmal respirations o Treatment: correct underlying condition, respiratory compensation, I and O, Insulin for DKA, keep your eye on the K+, pump up the bicarb, monitor V/S, ECG, ABG, and electrolytes

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Metabolic Alkalosis o Loss of H+ or gain of bicarb, or both o Causes: vomiting, excessive GI suction, diuretics, hypochloremia o Symptoms: dizzy, seizure, lethargic, coma, confusion, weakness, cramps, hypertonic muscles, respiratory depression, N/V, hypokalemia o Treatment: get rid of HCO3, increase H+, stop loop diuretics, DC NG suction, antiemetic, Diamox, supplemental O2, seizure precautions, IV potassium, Monitor V/S, ECG, monitor ABG and electrolytes

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Respiratory Acidosis o Caused by hypoventilation, carbonic acid buildup (CO2 combines with H20 to form carbonic acid, carbonic acid stays in blood and separates into HCO3 and H+ resulting in decreased pH) o Hypoventilation is the main cause (head injury, narcotics, spine injury, pneumonia, PE)

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Symptoms: lethargy, headache, restless, confusion, coma, tachycardia, dysrhythmia, hypotension, dyspnea, respiratory distress **Nursing management: improve ventilation and lower PaCO2, improve gas exchange or ventilation (correct underlying condition, bronchodilators and medications, supplemental O2, chest PT), monitoring, treat hyperkalemia

Respiratory Alkalosis o Hyperventilation is the main cause due to fear, pain, medications, or drugs that are respiratory stimulants, CNS lesions o Mechanical ventilation can cause o Symptoms: anxiety, light headed, paresthesia (numbness), confusion, blurred vision, palpitations, dysrhythmias, diaphoresis, dry mouth, tetany (twitching) of arms and legs, rapid, deep respirations (kussmaul), respiratory failure due to fatigue o **Nursing Management: correct underlying disorders, supplemental O2, reduce fever, eliminate source of sepsis, reduce anxiety, protect from injury, paper bag, monitor V/S, monitor ABG and electrolytes

Pulmonary  Focused respiratory assessment is very important- ABC priority  Edema is part of the Circulation  Ventilation- movement of air into lungs  Respiration/oxygenation- gas exchange  Upper airway (non-sterile)- nasal passages, pharynx, larynx, upper trachea, nasal cavities, sinuses, warm and filter air, get out particles (goblet cells produce mucus to trap particles), cilia move trapped particles out of airway (cough reflex)  Lower airway (sterile)- bronchi, bronchioles, alveoli, lots of blood vessels for gas exchange, smooth muscle for constriction  **Airway assessment- altered RR and O2, labored breathing, accessory muscle use, cyanosis or pallor, clubbing, chest diameter and appearance of fingernails, cough or sputum, breath sounds, weight, LOC and energy

 Assess lung sounds before and after interventions Influenza- upper respiratory infection that can progress to pneumonia  Transmitted via droplets  Rapid onset of symptoms: Fever, Aches, Chills, Tiredness  Need viral culture or rapid flu test, viral culture more accurate  Treatment: supportive, rest, hydration, analgesics, antipyretics  Vaccinate! Pneumonia- caused by bacteria, virus, fungi, chemicals and aspiration leading to inflammation and impaired gas exchange  Can be community acquired or hospital acquired  CAP- cannot have been in a hospital in 14 days, empiric antibiotic treatment  Productive cough, fever, chills, dyspnea, chest pain, crackles, accessory muscle use, increased WBC, decreased o2 stat and AMS (late signs)  Complications: sepsis, empyema, respiratory failure  Nursing Diagnosis: impaired gas exchange, activity intolerance, altered airway clearance, acute pain (chest)  Treatment: O2, antibiotic, chest psychotherapy (vibration), postural drainage, monitoring of respiratory status, adequate hydration, high calorie meals COPD  Includes chronic bronchitis and emphysema, and sometimes asthma  Patient have a hard time eliminating CO2, high risk for acidosis  Decreased force vital capacity over 1 second (FEV)  Air trapping and hyperinflation  Bronchitis: inflammation and increased sputum  Emphysema: alveolar destruction and bleb formation  Increased risk for respiratory infections  Biggest risk factor is smoking, age and genetics play a role (more likely to get if you have alpha antitrypsin deficiency)  Manifestations: increased AP, SOB, chronic productive cough, increased CO2 level, increased WBC  Exacerbation can lead to respiratory failure  Weight loss and malnutrition are signs of advancing disease Cardiovascular Care of the Older Adult  Functions of the Cardiovascular system: deliver O2 and glucose to cells, remove waste, transport of hormones, redistribution of body heat, participation in immunity  Preload- volume that comes into the right atrium and right ventricle, end diastolic pressure  Afterload: the pressure the heart is pumping against to get blood to the body  Aging o Increased collagen, decreased elasticity o Heart valves are thick and rigid o Electrical issues o Increased BP o Altered med absorption, polypharmacy  Hypertension is the most common medical diagnosis in the US o Systolic pressure of over 130 OR o Diastolic pressure over 80  Direct relationship with hypertension and cardiovascular disease  Know the BP categories  Blood pressure= CO X Peripheral Resistance (combine function of heart and blood vessels  CO= HR X Stroke Volume  CO- blood pumped out of heart in 1 minute  SV- blood pumped out of heart with each contraction

Hypertension  Primary Hypertension: no identifiable cause (most of population) (idiopathic)  Secondary Hypertension: know cause, treat the cause, treat the HTN  Biggest issue with HTN is end organ damage o Heart: increased workload plus decreased blood to coronary arteries leads to LV hypertrophy, MI, heart failure o Kidney: Glomular damage o Brain: increased risk for hemorrhagic stroke o Retinas: retinal hemorrhage leading to blindness o Aorta and other vessels: more likely to rupture  *** HTN risk factors: advancing age, being male, being African American, family history, heavy alcohol use, tobacco use, high salt intake, obesity, glucose intolerance, physical inactivity, stress, hyperlipidemia  Hypertension is usually asymptomatic, but patient may have headache, palpations, fatigue, SOB  HTN requires BP monitoring and other tests including renal function, routine eye exam, blood cholesterol testing, DM screening  Treatment includes: o Lifestyle modifications: loose weight, sodium restriction, decreased alcohol intake, exercise, relaxation therapy, smoking cessation, DASH diet (decreased cholesterol and saturated fat, increased fruits and veggies) o Medications: diuretics, B-blockers, calcium channel blockers, ACE inhibitors, other vasodilators

Congestive Heart failure (CHF) OR Heart Failure (HF)  Impaired cardiac function where the heart is unable to maintain CO to meet metabolic needs (failure of forward flow, congestion of backward flow)  65% will die within 5 years  New York heart association class- how bad is the heart failure and what can this patient do? Class 1 is no limitations, class 5 is the most severe  Classified as left sided or right sided AND/OR systolic vs. diastolic o Left sided heart failure leads to the most organ damage because the organs aren’t getting enough blood o Diastolic HF- heart can’t relax normally for filling, less blood in ventricles o Systolic HF- weakened muscle, can’t squeeze as well

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 The body tries to compensate, but it increases workload and fluid overload, worsening the HF, a treatment goal is to inhibit these mechanisms o Body activates sympathetic NS leading to increased HR and vasoconstriction o Hormonal activation stimulates the RAAS system o Hypertrophy of heart muscle, increasing the size of the muscle and decreasing CO o Increases myocardial O2 requirements Manifestations: fatigue, DOE, PND, wheezing, cough, weight gain, ankle swelling, oliguria, noctuiria, cyanosis, pallor, orthopnea, change in LOC, arrhythmias Study Right sided Vs. Left

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Frequently acute HF presents as pulmonary edema- lung alveoli and pulmonary interstitial space becomes filled with fluid and compromise O2 and CO2 exchange Nursing priorities for pulm edema: oxygenation, mobilize mucus Diagnosis for CHF: ECG, chest X-ray, thyroid panel, ANP or BNP, echo High BNP indicates fluid volume overload, heart is stretched out, monitor this in acute exacerbations Echo looks at Ejection Fraction, the lower the percent the worse the heart failure, best measures systolic Cardiomegaly: enlarged heart **Medication Therapy aimed at optimizing CO o Reduce Preload- Na and H2o restriction, diuretics, venous vasodilators (nitrates) o Reduce afterload- ACE inhibitors, IV nitroprusside or nesiritide (Natrector) (vasodilators) o Improving contractility- cardiac glycosides such as digoxin, dopamine or dopubatimne (low dose beta blockers)

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**Treatment for HF: control underlying disease, DASH diet, fluid and sodium restrictions, O2 therapy, Daily weight, exercise as tolerated, I/Os, Educated on meds, body and mental changes, energy conservation, efficiency

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Potential complications: pulmonary edema, pleural effusion, dysrhythmias, LV thrombus, hepatomegaly, renal failure, electrolyte and acid base issues

Teacher Review  Process for starting IV  IV push  IV infusion, primary or secondary lines  Calculation question, drip rate  ABG interpretation  Nursing care for pneumonia, COPD, influenza  3 or more pounds in 24 hours  5 or more pounds in a week o change diet and fluid intake to help avoid exacerbation  interventions: life threatening, safety  pain: assessment tools, non-verbal patients, treatment, consequences of untreated pain...