FINAL REVIEW

by LELIA DURAN-MORA

Isotonic fluids
Isotonic fluid- stays where I put it
Close to ECF
Cells dont shrink or swell
Crystalloid
NS, LR
D5W infuses as isotonic but disperses into a hypotonic
solution

Hypotonic fluids
Hypotonic fluids- moves OUT of the
vessel
Used to replace cellular fluid
Overuse can lead to intravascular
depletion, hypotension, cellular edema,
cell damage
NS

Hypertonic fluids
Hypertonic-Enters the vessel
Shifts from the intracellular to the
extracellular
Causes cells to shrink
If administered too quickly or in large
volumes can cause circulatory overload &
dehydration
Administer slowly & cautiously

Fluid Volume Deficit-Hypovolemia

Hypovolemia-abnormal fluid loss-water &
electrolyte loss proportional

Vomiting
Diarrhea
GI suctioning
Sweating
Decrease PO intake
Fluid Shifts

Acites
Burns
DI
Adrenal insufficiency
Osmotic diuresis
Hemorrhage
Coma

Fluid Volume Deficit

decreased

Signs &
Symptoms

rapid weight loss

temperature,
cool clammy skin
due to
vasoconstriction

decreased skin
turgor

thirst

oliguria

confusion

concentrated
urine

muscle weakness
cramps

Management of Fluid Volume

Deficit

Provide oral fluids

Oral care, non-irritating fluids

IV solutions-isotonic fluids

I&O, weight, VS, CVP, LOC,

Assess breath sounds

Monitor urine output 30ml/hr

Assess skin turgor & color

Assess urine concentration

Identify at risk patients

Assess nausea, diarrhea, or other cause & treat

Antiemetic

Antidiarrheal

Fluid Volume ExcessHypervolemia

Hypervolemia
Fluid overload or diminished homeostatic mechanisms
heart failure
renal failure
cirrhosis of liver

excessive dietary sodium or sodium-containing IV solutions

Diagnostic Findings
Decreased BUN & HCT (dilution)
CXR- pulmonary congestion

Signs & Symptoms

Edema
JVD

Increased CVP

Increased weight

Increased UOP

SOB

Adventitious breath sounds

Elevated HR & BP
Increased pulse pressure

Fluid Volume Excess - Nursing

Management
I&O and daily weight
Assess lung sounds, edema
monitor responses to
medications- diuretics
Promote adherence to fluid
restrictions
patient teaching related to
sodium and fluid restrictions

Monitor, avoid sources

of excessive sodium,
including medications
Promote rest
Semi-Fowlers position
for orthopnea
Skin care,
positioning/turning

Electrolyte Imbalances
Sodium: hyponatremia, hypernatremia
Potassium: hypokalemia, hyperkalemia
Calcium: hypocalcemia, hypercalcemia
Magnesium: hypomagnesemia, hypermagnesemia
Phosphorus: hypophosphatemia, hyperphosphatemia
Chloride: hypochloremia, hyperchloremia

Hyponatremia
Serum sodium less than 135 mEq/L
Causes:

adrenal insufficiency
water intoxication
SIADH
losses by vomiting, diarrhea,
sweating, diuretics

Signs & Symptoms

(Cont)

Neurological changes
Cerebral edema
Seizures, muscle twitching
Confusion

Medical management:
water restriction
sodium replacement

Signs & Symptoms:

poor skin turgor

dry mucosa
headache
decreased salivation
decreased BP
Nausea
abdominal cramping

Nursing management:
assessment and prevention
dietary sodium and fluid
intake
identify and monitor at-risk
patients
effects of medications
(diuretics, lithium)

Hypernatremia
Serum sodium greater than
145mEq/L
Causes:
Excess water loss
Excess sodium
administration
Diabetes Insipidus
Heat stroke

Note: thirst may be impaired

in elderly or the ill
Medical management:
hypotonic electrolyte
solution or D5W

Nursing management:
assessment and
Signs & Symptoms:
prevention
Thirst
assess for OTC sources of
Elevated temp, HR, & BP
sodium
Dry, swollen tongue
offer and encourage
Sticky mucosa
fluids to meet patient
Confusion/restlessness/irritab
needs
ility
provide sufficient water
Seizure activity
with tube feedings

Hypokalemia
Below-normal serum
potassium (<3.5 mEq/L)
Causes:

GI losses
Medications
Digoxin toxicity

Medical management:

increased dietary
potassium
potassium replacement

Nursing management:

Nutritional/Medication
education

Signs & Symptoms

Fatigue
Anorexia
Nausea & vomiting
Dysrhythmias
Muscle weakness & cramps
Paresthesias
Decreased muscle strength
ECG changes

Severe hypokalemia is
life-threatening
Monitor ECG
Nursing care related to IV
potassium administration

Hyperkalemia
Serum potassium greater than 5.0
mEq/L
Causes:
impaired renal function
Potassium conservative diuretics
Metabolic acidosis
Addissons disease
Crushing injuries
Burns

Manifestations:
Muscle weakness
Tachycardia-bradycardia
Disrhythmias
Flacis paralysis, paresthesias
Intestinal colic, cramps, abdominal
distention
Irritability, anxiety
ECG changes (elevated T waves,
prolonged PR interval absent P waves, ST
depression)

Medical management:
Monitor ECG,
Limitation of dietary potassium,
Cation-exchange resin (Kayexalate),
IV sodium bicarbonate ,
IV calcium gluconate,
Regular insulin and hypertonic dextrose IV,
-2 agonists,
Dialysis
Nursing management:
assessment of serum potassium levels
monitor medication affects
dietary potassium restriction/dietary teaching for
patients at risk
Hemolysis of blood specimen or drawing of blood
above IV site may result in false laboratory result
Salt substitutes, medications may contain potassium
Potassium-sparing diuretics may cause elevation of
potassium
Should not be used in patients with renal dysfunction

Hypocalcemia
Serum level less than 8.5 mg/dL
Causes:
Hypoparathyroidism
Malabsorption

Signs & Symptoms

Tetany
Circumoral numbness
Paresthesias

Pancreatitis

Hyperactive DTRs
Alkalosis
Massive transfusion of citrated blood

Trousseaus sign

Renal failure

Chvostek's sign

Medications

Seizures

SHOCKClassifications of Shock
Hypovolemic: shock state resulting from decreased intravascular volume
due to fluid loss
Cardiogenic: shock state resulting from impairment or failure of
myocardium
Septic: circulatory shock state resulting from overwhelming infection
causing relative hypovolemia
Neurogenic: shock state resulting from loss of sympathetic tone causing
relative hypovolemia
Anaphylactic: circulatory shock state resulting from severe allergic reaction
producing overwhelming systemic vasodilation, relative hypovolemia

Fluid Replacement
Crystalloids: 0.9% saline, lactated ringers,
hypertonic solutions (3% saline)
Colloids: albumin, dextran (dextran may
interfere with platelet aggregation)
Blood components for hypovolemic shock
Complications of fluid replacement include fluid
overload, pulmonary edema, & abdominal
compartment syndrome

Management
Treat underlying cause
Assess LOC, VS, urine output, skin, labs, change in
pulse pressure
Hemodynamics

Report a SBP < 90 mmHg or drop of 40 mmHg

from base line
ScvO2-Continuous central venous oximetry monitoring

Measures tissue hypoperfusion

Catheter in SVC
70% normal-during shock it is decreased
CVP (RA Pressure)- Measures fluid status in vascular
system

Normal 4-12 mm HG

Management
Decrease oxygen demands
Sedation-decrease metabolic demands
Pain control with IV opioids
Prevent shivering

Oxygen delivery
O2 & mechanical ventilation

Support BP & C.O

IVF
Meds
PRBC/blood products

Disseminated Intravascular
Coagulopathy (DIC)
Occurs in response to an underlying condition

Sepsis
Trauma
Cancer
Shock
Abruptio placentae
Toxins
Allergic reactions

Potentially life threatening

Normal anticoagulant pathways are altered D/T
inflammation from the underlying disease
process

Disseminated Intravascular
Coagulopathy (DIC)
Insult
leading to
inflammatio
n

Fibrinolyn
ic system
suppress
ed

Unable to
coagulate

Massive
number of
clots in
circulation

Organs fail
D/T clots
causing
ischemia

Platelets
&
clotting
factors
are
consume
d in clot
formatio
n
Excessive
bleeding

Fibrin
degradatio
n products
released

Elevated

Disseminated Intravascular
Coagulopathy (DIC)

Platelet
Fibrinogen

Decreased

PT
PTT
D-dimer
FDP

Medical management of DIC

Treat underlying cause
Correct tissue ischemia

Improving O2
Fluid replacement
Correct electrolyte imbalances
Vasopressive medications
Replace blood products
Platelets
Cryoprecipitate-replaces fibrinogen
FFP-replace coagulation factors

Heparin therapy (controversial)

Nursing management of DIC

Risk for deficient fluid volume R/T bleeding
Avoid activities that can increase ICP
Monitor VS , neuro checks, abdominal girth, urine
output
Avoid meds that interfere w/ platelet function
Avoid rectal probes & medications
Avoid IM injections
Monitor amount of external bleeding
Dressings, suction output, peripads, stools, avoid menses

Use low pressure w/ any suctioning

Careful oral hygiene
Avoid disturbing formed clots

Nursing management of DIC

Risk for impaired skin integrity R/T ischemia
or bleeding
Assess skin with attention to bony prominences
& skin folds
Reposition carefully
Perform skin care Q 2 hours
Use lambs wool between digits & around ears
Apply prolonged pressure after injections

Nursing management of DIC

Risk for imbalanced fluid volume R/T
excessive blood and/or blood product
replacement
Auscultate breath sounds every 2 hrs prn
Monitor edema
Monitor input-speak with MD about
concentrating drips if necessary
Administer diuretics as prescribed

Nursing management of DIC

Ineffective tissue perfusion R/T
micothrombi
Assess neuro, pulmonary, integumentary
systems
Monitor response to heparin therapy
Assess extend of bleeding
Monitor fibrinogen levels

Anxiety R/T uncertainty of possible

death
Identify coping mechanisms & encourage
use
Explain procedures & rationale in simple

Diabetic Ketoacidosis (DKA)

Caused by an absence of or inadequate
amount of insulin resulting in abnormal
metabolism of carbohydrate, protein, and
fat

Infection
Non-compliance with insulin
Errors in insulin dosage
Equipment errors

Clinical features
Hyperglycemia
Dehydration
Acidosis

Diabetic Ketoacidosis (DKA)

Manifestations include:
The 3 Ps: Polyuria(increased urine),
Polydipsia(increased thirst),
Polyphagia(increased hunger)
Blurred vision, weakness, headache
Anorexia, severe abdominal pain, nausea,
vomiting
Acetone breath (fruity odor to breath)
Hyperventilation with Kussmaul respirations
Mental status changes
Hypotension, tachycardia, EKG changes
Warm, flushed, dry mucous membranes

Assessment of DKA
Blood glucose levels vary from 300800 mg/dL
Severity of DKA is not related to blood glucose level
Ketoacidosis is reflected in low serum bicarbonate
and low pH(metabolic); low PCO 2 reflects
respiratory compensation
Ketone bodies in blood and urine
Electrolytes vary according to water loss and level
of hydration (hyperkalemia)

Treatment of DKA
Rehydration with IV fluid

Normal Saline 0.5-1L/hr for first few hours

NS 250-500ml/hr
NS for patients with hypertension, hypernatremia, & HF
D5W after blood glucose reaches 300 mg/dL

IV continuous infusion of regular insulin

Insulin reduction reverses acidosis
Accuchecks every hour

Reverse acidosis and restore electrolyte balance

Note: rehydration leads to increased plasma volume
and decreased K+, insulin enhances the movement of
K+ from extracellular fluid into the cells
Potassium replacement may be required

Treatment of DKA
Monitor
Blood glucose and renal function/UO
EKG and electrolyte levelsPotassium
VS, lung assessments, signs of fluid overload

Prevention
Sick day rules
Continue with insulin administration as glucose continues to rise during
stress
Small frequent portions of CHO
Check glucose & ketones q3-4 hours
Sick day kit

Assess for underlying causes

Physical & psycological

Diagnosis and proper management of diabetes

Hyperglycemic Hyperosmolar
Nonketotic Syndrome (HHNS)
Hyperosmolality and hyperglycemia occur due to lack of
effective insulin.
Ketosis is minimal or absent.

Infection (pancreatitis, sepsis)

Medications (thiazides, steroids)
Tube feedings, TPN
Dialysis

Hyperglycemia causes osmotic diuresis with loss of water and

electrolytes; hypernatremia, and increased osmolality occur.

Hyperglycemic Hyperosmolar
Nonketotic
Syndrome
(HHNS)

Glucose levels 600-1200mg/dL

Blood tests
Electrolytes
BUN & creatinine
ABGs & serum osmolality

Manifestations include:

hypotension
profound dehydration
tachycardia
variable neurologic signs due to cerebral dehydration
Many symptoms same as with DKA

High mortality

Treatment of HHNS
Rehydration
Normal Saline 0.5-1L/hr
1/2NS in patients with hypertension, HF, or hypernatremia
D5W once blood glucose reaches 300mg/dL

Insulin administration
Monitor fluid volume and electrolyte status
Prevention
BGMs
Diagnosis and management of diabetes
Assess and promote self-care management skills

ACID BASEMetabolic Acidosis

Manifestations: headache, confusion, drowsiness,
increased respiratory rate and depth, decreased blood
pressure, decreased cardiac output, dysrhythmias,
shock
if decrease is slow, patient may be asymptomatic until
bicarbonate is 15 mEq/L or less
Correct underlying problem, correct imbalance
Bicarbonate may be administered

Metabolic Acidosis (contd)

With acidosis, hyperkalemia may occur as potassium shifts out of
cell
As acidosis is corrected, potassium shifts back into cell,
potassium levels decrease
Monitor potassium levels
Serum calcium levels may be low with chronic metabolic acidosis
Must be corrected before treating acidosis

Respiratory Acidosis
Low pH <7.35
PaCO2 >45 mm Hg
Always due to respiratory problem with inadequate
excretion of CO2-retention
With chronic respiratory acidosis, body may
compensate, may be asymptomatic
Symptoms may be suddenly increased pulse, respiratory rate
and BP, mental changes, feeling of fullness in head

Compensation
When acid-base imbalance, body attempts to
compensate
attempt to return the pH to the normal range.

**Can be uncompensated or compensated

Compensation
Uncompensated
pH outside normal range, either pCO2 or HCO3 is abnormal

***Fully compensated
pH returns to normal range
***pCO2 and HCO3 may both be abnormal

How this effects ABG

Look at the pH in a slightly different way
pH of <7.40 is now going to be considered acidosis
pH > 7.40 is now going to be considered alkalosis

Interpretation
pH 7.38, pCO2 56, HCO3 35
pH normal but <7.4
pCO2
HCO3
ROME: Respiratory Opposite
Respiratory Acidosis Compensated (pH WNL)

Question
All of the following might be a cause of respiratory
acidosis except:
A. Sedation
B. Head trauma
C. COPD
D. Hyperventilation
Answer: D - Hyperventilation causes respiratory
alkalosis

ACUTE RENAL FAILURE

Prerenal Etiology
Diminished blood flow:
Volume depletion
Vasodilation *(septic shock)
Decreased cardiac output
Vasoconstriction of renal vessels

Can progress to intrarenal damage

if prolonged hypoperfusion
MAP < 60-70 mmHg for longer than 30
minutes risk renal injury, particularly if
Accompanied by hypoxia
7/1/15

Prerenal Treatment

Best treatment is PREVENTION!

Avoiding circulatory crises
Careful use of nephrotoxic drug (give isotonic
fluids or sodium bicarb as prophylaxis)

Fluid/volume replacement
Caution in patients with underlying
cardiac disease

7/1/15

May require inotropes, antidysrhythmic agents,

preload/afterload reducers, intraaortic balloon
pump
May require hemodynamic monitoring to guide
. 47
treatment

Phases of ARF
Maintenance Phase (oliguria)
BUN and creatinine increase daily
Urine output at lowest amt

Oliguric > output < 400 ml/day

Fluid overload, electrolyte imbalances (elevated K+), acidosis

and infections
Length: 8 14 days, may last

1 11 months

7/1/15

Time = Potential Permanent Damage

48

Phases of ARF
Diuresis Phase
Gradual increase in urine
output

Recovery Phase

Renal tissue recovers & repairs

Gradual return of tubular function

BUN & creatinine normalize in 3 12

months

Potential residual
impairment of
GFR(1-3%)

Recovery of GRF
Laboratory values
stabilize and improve

7/1/15

Early dialysis may prevent the traditional

diuretic phase of ARF

Physical Findings of ARF

Neurological - confusion, lethargy, decreased
level of consciousness, stupor

Gastrointestinal - nausea, vomiting, anorexia,

distention, constipation, or diarrhea

Respiratory - crackles, pulmonary edema,

Kussmauls respirations

Cardiovascular - tachycardia, dysrhythmias,

rub, pericarditis, increased blood pressure

Integumentary - dry skin, pruritus, edema,

bruising, pallor, uremic frost
50
7/1/15

Laboratory for ARF (cont.)

Serum

Potassium ()
Phosphate ()
Calcium ( )

Urine

Urine electrolyte levels

Urine Specific Gravity
Urine osmolality
GFR

Blood gases

Assess for metabolic acidosis

51

7/1/15

Nursing Management
Reduce metabolic rate
Assess fluid and
electrolyte status
VS, monitor rhythm
I& O, daily weights

7/1/15

(bed rest, monitor

temp.)
Turn, C&DB, Incentive
spirometer

Lung sounds

Asepsis with invasive

line care (central lines,
urinary catheters)

Edema, skin turgor

Skin and mouth care

Nursing Diagnoses
Fluid Volume deficit
Excess fluid volume
Risk for infection
Imbalanced nutrition
Anxiety
Deficient knowledge
7/1/15

Question
What actions and treatments can reverse ARF at the
prerenal phase?
Answer

Maintain fluid volume, cardiac output,

and blood pressure. Prevention!!!

7/1/15

Question
How is Kayexalate given? What effects are expected?
Answer:
Given PO or Rectally(retention enema)
Expect to decrease potassium level
May cause diarrhea

7/1/15

ANGINA
Risk Factors

Modifiable

High cholesterol

Smoking

Hypertension

DM

Obesity

Inactivity

Non-modifiable

Family history

Age

Gender

Race

Chart 28-1 Page 758

Tobacco Cessation
Nicotine Patch
Nicotine CQ, Habitrol

Bupropion (Zyban)
Medications have same effects on
heart as smoking.
Should be used for short period of
time & at lowest doses.

Angina
Stable: Occurs with exertion & subsides with rest &/or
nitroglycerine
Unstable: Increase in frequency & severity- may not be
relieved with rest &/or nitroglycerine
Intractable or refractory: Severe & incapacitating
Variant: Pain at rest. Reversible ST segment elevations.
Possibly from spasms
Silent: No pain but obvious changes on EKG

Clinical Manifestations
The most common symptom of myocardial ischemia is
chest pain;
Diaphoresis, pale, nausea & vomiting

Classic symptoms

Often midsternal, crushing or heavy May be described as

tightness, choking, or a heavy sensation (elephant on chest)

Anxiety frequently accompanies the pain

May radiate to arm, jaw, or back
Atypical symptoms are more common in women and in
persons who are older, or who have a history of heart
failure or diabetes.
Dyspnea
Weakness

Nursing Management
Treatment of angina pain is a priority nursing
concern
Treatment goal: decrease myocardial oxygen
demand and increase oxygen supply while
maintaining cardiac output
Decrease demand
Stop all activities
Sit or rest

Increase O2 supply
Administer O2

12 Lead EKG-assess for ST elevations and T wave

abnormalities

Nursing Management
Relieving pain & signs of ischemia
Improve respiratory function
Promote adequate tissue perfusion
Reduce anxiety
Monitor & manage potential complications
Promoting home & community self care

Coronary Catheterization
Slide
#28
Invasive procedure used to measure the

pressures with in the chambers of the heart

(right) & visualize patency of the coronary
arteries (left)
Consent
Allergies
IV contrast or shellfish

Labs
BUN & creat

Pre & Post procedure education

Answer
D
A modifiable risk factor for coronary artery disease is cigarette
smoking. Race, gender, and family history are nonmodifiable risk
factors.

Question
Is the following statement True or False?
Nitroglycerin tablets should never be removed and stored in metal
or plastic pillboxes
True
Nitroglycerin tablets should never be removed and stored in metal
or plastic pillboxes.

Question
What is the purpose of an echocardiogram?
A. Evaluate arterial function of the heart
B. Evaluate ventricular function of the heart
C. Detect hyperkinetic wall motion
D. Identify ischemia changes

DYSRHYTHMIAS
Atrial Fibrillation

Uncoordinated electrical
impulses. Rapid &
disorganized

No discernible P wave

Irregular ventricular rate

(Irregularly, irregular)

Results in loss of atrial

kick=decrease C.O

High risk for pulmonary

or systemic emboli

Critical Thinking Challenge

The patient comes to the emergency
department complaining of headache,
numbness of his left arm and hand, and
slurred speech. His pulse is 120 and
irregular. His blood pressure is 136/88.
What is a probable cause for his
symptoms?
Atrial Fib
Possible stroke from emboli

Second-Degree Block: Mobitz

Type I Wenckebach
Steadily lengthening PR interval
Eventually leads to loss of a QRS

Nonconducted P wave
P-P interval regular ; R-R interval
irregular
QRS normal
Self-limiting; rarely progresses
May decrease cardiac output

Second-Degree Block: Mobitz

Type I Wenckebach (continued)

Question
True or False
Patients in atrial fibrillation are at increased risk for
stroke?
True
Patients with atrial fibrillation are not pumping blood
through the heart effectively and can develop clots that
may dislodge and move to the extremities, lungs, and
neurological system

VALVULAR DISORDERS
Infective Endocarditis Assessment
Symptoms:

Malaise
Anorexia/weight loss
Cough
Back & joint pain
May be mistaken for the flu

Elevated WBC, ESR, & C-reactive protein

High risk population

Blood cultures-aerobic &

anaerobic

In children

Tetralogy of Fallot
VSD
Coarctation of the Aorta

Diagnosis:
echocardiogram: Doppler
or TEE

Prosthetic heart valves

Hx of endocarditis
IV drug use
Body piercings

Treatment:

Antibiotics IV for 2-6

weeks
Rest
VS (temp)
72

Nursing Management
Monitor VS
Pt may have fever for weeks

Assess Heart Sounds-listen for new or worsening

murmur
Monitor for emboli
Home IV antibiotic therapy
Monitor lines

Rheumatic Endocarditis
Rheumatic fever

Rheumatic heart disease

Occurs most often in school-age children, after group A betahemolytic streptococcal pharyngitis.
Injury to heart tissue is caused by inflammatory or sensitivity
reaction to the streptococci.
Results in permanent changes in the valves.
Need to promptly recognize and treat strep throat to prevent
rheumatic fever.
Penicillin is most common antibiotic treatment

Mitral Regurgitation

Leaflets do not close because they have

thickened and fibrosed causes backflow
of blood from left ventricle to left atrium
during systole

MVP
Left ventricular ischemia
Rheumatic heart disease
Endocarditis
Collagen-vascular diseases
Cardiomyopathy

Mitral Regurgitation
Backflow causes left atrium to stretch and
hypertrophy
Leads to
blood flow from lungs
(pulmonary congestion)
Usually asymptomatic
CHF, dyspnea, cough
Fatigue, weakness
Systolic murmur (high-pitched, blowing sound
over apex of heart

Aortic Regurgitation

Backflow of blood into the left ventricle from

the aorta ventricle also receives blood from
the left atrium
Ventricle dilates in attempt to accommodate
increased blood volume
Hypertrophy occurs in effort to expel blood forcefully

Endocarditis
Congenital
Syphilis
Blunt chest trauma
May be unknown cause

Aortic Regurgitation
May be asymptomatic

Forceful heartbeat
Visible pulsation at carotid or temporal arteries
Diastolic murmur
Exertional dyspnea, orthopnea
Corrigans pulse (Water-hammer) quick, sharp
pulse then collapse
Widened pulse pressure

Diagnostics
Echo/TEE
MRI

Aortic Regurgitation
Management
Avoid physical exertion, competitive sports, & isometric
exercise
Treat dysrhythmias
Vasodilators
Calcium channel blockers: nifedipine
ACE inhibitors;-pril

Valvuoplasty or replacement before LV failure occurs

Also with LV hypertrophy despite symptoms

ALTERED CEREBRAL TISSUE

PERFUSION:Stroke
The brain ages
3.6 years for
each hour that
a stroke goes
untreated

Nursing Care
Ischemic & Hemorrhagic CVA
Impaired skin integrity

Frequent assessment
Repositioning & minimizing shear & friction
Keep skin clean & dry, message of healthy skin
Nutrition

Interrupted family coping

Support systems
Encourage patient to be independent

Sexual dysfunction
Medical and psychological reasons

Medications
Antifibrinolyti
c

Anticoagulant Platelet
Inhibiting
Heparin

Amicar
Tpa

Coumadin
Aspirin

Ticlid
Aggrenox
Plavix

Detecting complications
(also check picture of brain)

Early signs of increased ICP

Restlessness

Increased respiratory effort

Late signs of increased ICP

Erratic pulse & respiratory rate

Purposeless movement

Pupillary changes

Unilateral weakness
Constant headache

Decrease LOC

Widening pulse pressure

Projectile vomiting

Hemiplegia, decorticate, or
decerebrate posturing

Loss of reflexes

HEART FALURE
Right-sided failure
Clinical Manifestations
RV cannot eject sufficient amounts of blood and blood backs up in the
venous system.
Peripheral edema
Hepatomegaly
Ascites
Anorexia
Nausea
Weakness
Weight gain.

Left-sided Hert failure

Clinical Manifestations

LV cannot pump blood effectively to the systemic circulation

Pulmonary venous pressures increase
Pulmonary congestion
Dyspnea
Cough
Crackles
Impaired oxygen exchange.

General

CV

Respiratory

Neuro

Renal

GI

Fatigue

S3

Dyspnea on
Exertion (DOE)

Confusion

Oliguria
decreased
frequency
during
day

Anorexia
nausea

Decreased
activity
intolerance

PMI
displaced

Crackles

AMS

nocturia

Enlarged liver

Dependent
edema

Pallor &
cyanosis

Orthopnea
PND

lighthead
edness

Weight
gain

JVD

Cough on
exertion/supine

Assessment

Acites

Hepatojugular
reflex

Fluid collecting in the tissues, note the dent where somebody has
pressed on top of the hand- a sign of heart failure.

Medications
Diuretics
Loop (furosemide)
Thiazide (metolazone)
Aldosterone Antagonist (spironolactone)

Digitalis (lanoxin, digoxin)

Calcium Channel Blockers (contraindicated in systolic HF)
Norvasc, Plendil

Nursing Assessment
Health history
Sleep and activity
Knowledge and coping
Physical exam

Mental status
Lung sounds: crackles and wheezes
Heart sounds: S3
Fluid status/signs of fluid overload
Daily weight and I&O

Assess responses to medications

Nursing Diagnoses
Activity intolerance and fatigue R/T decreased CO
Excess fluid volume R/T HF syndrome
Anxiety R/T breathlessness from inadequate
oxygenation
Powerlessness R/T chronic illness & hospitalizations
Ineffective therapeutic regimen management R/T
lack of knowledge

NursingPlanning
Goals:
promoting activity and reducing fatigue
relieving fluid overload symptoms
decreasing anxiety or increasing ability to manage anxiety
teaching the patient about the self-care program.

Activity Intolerance
Bed rest for acute exacerbations-leads to deconditioning,
bedsores, DVT- should be discouraged
Encourage regular physical activity; 3045 minutes daily
Walking
Start slow & increase duration/frequency

Pacing of activities
Avoid having 2 energy consuming activities on same day or
concurrent days

Small frequent meals

Cardiac Rehab

 Wait 2 hours after eating for physical activity

Avoid activities in extreme hot, cold, or humid
weather
Modify activities to conserve energy
Positioning
elevation of the HOB to facilitate breathing and rest
support of arms

Problems/Complications
Hypokalemia R/T excessive diuresis
Hyperkalemia R/T ACE inhibitors, ARBs, potassium
sparing diuretics
Hyponatremia R/T excessive diuresis
Volume depletion R/T excessive fluid loss
Increased serum creatinine & hyperuricemia (gout)

Pediatric Population
Most commonly acquired heart disease in
children
Result of congenital defect or disease
Rheumatic heart disease
Kawasaki disease
Infectious endocarditis

Commonly occurs in children under the age

of 1yr
Heart compensates like an adult
(hypertrophy) but very limited in infants d/t
size

Pediatric Population
Assessment
Tachycardia
Tachypnea

Right-sided failure
Hepatomegaly
Irritability & restlessness from abdominal pain from
distention

Extremity edema is late sign in children

Left-sided failure
Symptoms same as adult

Pediatric Population
Signs & symptoms very subtle in infants
Breathless, tires easily, difficulty feeding
Diaphoretic from feeding
Generalized edema instead of dependent
May be periorbital

Abrupt weight gain may be first indication

Enlarged liver/acites
Apical heartbeat displaced d/t enlargement
If width of heart is > the width of the chest the
heart is considered enlarged

S3

Thoracentesis to
drain fluid-CT may be
inserted

Atelectasis
Collapse of alveoli
Causes:
bronchial obstruction by secretions due to
impaired cough mechanism
conditions that restrict normal lung expansion on
inspiration
Hypoventilation-shallow breathing
Compression-lung cancer

Postoperative patients at high risk

Atelectasis
Symptoms:
Cough
Sputum production
Low-grade fever

Respiratory distress, anxiety, symptoms of

hypoxia occur if large areas of lung are
affected

Nursing Management
Prevention
Frequent turning, early mobilization
Strategies to improve ventilation:
deep breathing exercises at least every 2 hours
incentive spirometer

Strategies to remove secretions:

coughing exercises, suctioning, aerosol therapy,
chest physiotherapy

Types of Pneumonia (Table 23-1, pg

556)

Community Acquired Pneumonia

CAP
Onset in community or within first 48
hours of hospitalization
Viruses most common cause in infants
& children
(Nosocomial) Hospital Acquired
Pneumonia
Occurring 48 hrs after hospitalization
with patients without symptoms at
time of admission

Clinical Symptoms
Chills-sudden onset
Fever (101-105 degrees) rapidly rising
Pleuritic chest pain aggravated by deep
breathing & coughing
May be tachypneic use of accessory
muscles
URI
Purulent sputum
Orthopnea
Poor appetite

Diagnosis
Physical Exam
H&P

ABGs

CBC

Sputum cultures
CXR

Blood cultures

Collecting a Sputum Culture

1. Have patient rinse mouth with water
2. Instruct patient to take several deep breaths
3. Cough deeply
4. Expectorate into sterile specimen cup
5. Label, date, & time per hospital policy

Nursing Diagnoses
Ineffective airway clearance r/t secretions
Activity intolerance r/t impaired respiratory
function
Risk for fluid volume deficient r/t fever &
increased RR
Imbalanced nutrition: less than body
requirements
Deficient knowledge about treatment &
preventative health measures

Goals
Improve airway clearance
Maintenance of proper fluid volume, adequate
nutrition
Patient understanding of treatment,
prevention
Absence of complications
Conservation of energy

Treatment

Fluids

IV due to fever and tachypnea

Encourage po fluids unless
contraindicated

Antimicrobials (within 4
hours)

Depends on gram stain results

and specific pathogens
Specific pathogens (Table 23-1,
pg558)
Not effective for viral

Antipyretics

Analgesics

Antitussive

Warm, moist inhalation

Antihistamines

Nasal decongestants

Treatment

Rest -Positioning to promote rest, breathing

(Semi-Fowlers)

C&DB, chest physiotherapy

O2 prn

Prevent spread of infection

Maintaining nutrition
Provide nutritionally enriched foods, fluids
Patient teaching

The following is the standard of care

for administration of the first dose of
antibiotics in a patient suspected with
CAP pneumonia
A. 8 hours
B. 2 hours
C. 4 hours
D. Within 24 hours
Answer: C
Prompt administration of antibiotics (within 4
hours where CAP is suspected

True or False
Patients with pneumonia are at increased risk of
dehydration
Answer: True
Patients with pneumonia are at increased risk for
dehydration due to insensible volume loss from elevated
temperature & tachypnea.

Pediatric Oxygenation
Problems
NUR 2731

Croup
Inflammation of the trachea, larynx and major bronchi
Most common in children 3 months to 6 years
Most common in Fall and Winter months
(Oct. March)

Usually a viral infection

Croup

Onset is gradual-mild symptoms at bedtime

Afebrile or mildly elevated
Most commonly viral in nature
Other causes
Bacterial
Allergy induced
Acid reflux
Measles
RSV
Inhaled environmental irritants

Signs and Symptoms

Awaken in sudden respiratory distress
Seal like, barking cough, inspiratory stridor, retractions
Symptoms last several hours then resolve by morning
Danger of glottal obstruction from inflammation

Treatment
Will need to be hospitalized if:

Enlarged, reddened epiglottis

Respiratory distress
Peripheral cyanosis
Dehydration

ER treatment
Corticosteroids
Racemic epinephrine via nebulizer
IVF if dehydrated

RSV
Respiratory Syncytial Virus

Most common cause of bronchiolitis

(inflammation of the small airways in the lung)
and pneumonia in children under 1 year of age

RSV
Results from a cold

spread when droplets containing the virus are

sneezed or coughed into the air
direct and indirect contact with nasal or oral
secretions from infected persons

RSV
Who is affected:
Infants < 6 weeks old
Premature infants
children less than 2 years of age with congenital heart or
chronic lung disease
children with compromised immune systems

Signs and Symptoms

Runny nose
Coughing and sneezing
Fever (low grade)
Malaise
Poor appetite/dehydration

Signs and Symptoms

Child can develop respiratory distress

Wheezing
Retractions
Grunting
Rales, rhonchi
apnea

Treatment
Testing for RSV
Bulb syringe method
Place 1-2ml NS into nostril and aspirate with bulb
syringe.
Place contents from bulb syringe in sterile specimen
container

Dacron swab method

Place 1-2ml NS into each nostril
Place dacron swab into nostril until you feel resistance
and rotate in nostril several times. Take swab out of
nostril and place in other nostril and repeat procedure.
After, place swab in sterile specimen container

Treatment
Contact precautions
Treat symptoms

Antipyretics
Rest
Fluids
Nutrition
Cool mist humidifier or humidified oxygen
Saline nasal drops

Prevention
Universal precautions- hand hygiene
Wash and disinfect toys
Avoid second hand smoke or smoking in the home.
**Children who get RSV have a 33-50% chance of
developing asthma later in life

Nursing Diagnoses
Impaired gas exchange
Impaired airway clearance
Ineffective breathing pattern
Activity intolerance
Pain, acute
Deficient knowledge

CHEST TRAUMAFlail Chest

Three or more adjacent ribs fractured in more
than one location OR ribs, cartilage & sternum
Flail segment floats freely
Paradoxical chest movement
Contracts inward with inhalation - expands outward
with exhalation
Creates dead space & alveoli destruction=impaired gas
exchange

Treat with intubation, mechanical ventilation,

pulmonary care, and pain management

Pneumothorax
Air (pneumo) in pleural space
(thoracic cavity)- prevents lung from
expanding-lung collapses

Simple (spontaneous)
Traumatic
Tension

Etiology
Spontaneous
Rupture of blebs
Bronchopleural fistula

Traumatic Pneumothorax
Laceration/trauma/surgery
May be associated with blood
(hemopneumothorax)
Chest tube insertion needed
Open pneumo-sucking chest wound
Heart & great vessels swing from side to side
(mediastinal swing)
Three-side occlusive dressing
Allow small amount of air to escape from
occlusive dressing

Hemothorax

Chylothorax

Blood in pleural space

Lymphatic fluid in pleural space

Tension Pneumothorax

Mediastinum shifts in opposite

direction when air fills pleural space

Compression of great vessels

Deviation of trachea

Hemothorax
Blood (hemo) in pleural space
Chest tube insertion needed

Hemothorax

(continued)

Signs and Symptoms

or absent lung sounds (unilateral usually)

Dullness to percussion
Hypotension
Respiratory distress

Slide 148

Tension Pneumothorax
Life-threatening
Increased intrapleural and intrathoracic
pressures cause compression of heart and
great vessels
Cardiovascular collapse

Tension Pneumothorax
Emergent treatment with needle
thoracostomy
14 gauge needle, 2nd intercostal space,
midclavicular line

Chest tube inserted after needle

decompression

Tension Pneumothorax

Elsevier items and derived items 2009, 2005, 2001 by Saunders, an

imprint of Elsevier Inc.

Slide 152

Tension Pneumothorax

(continued)

Signs and Symptoms

severe respiratory distress
or absent lung sounds (unilateral usually)
resistance to manual ventilation
Cardiovascular collapse (shock)
asymmetric chest expansion
anxiety, restlessness or cyanosis (late)
JVD or tracheal deviation (late)

Pneumothorax Treatment
Plug the hole-petroleum gauze
Have the patient inhale & strain
Chest tube
Abx
O2

Chest Tube
Inserted into the pleural space
to re-establish negative intrapleural pressure
remove air, fluid or blood.

Chest drain
Chest tube management

Nursing management

Maintain sterile occlusive gauze over insertion site.

Keep all tubing straight

Keep all connections tight

Keep chambers at appropriate water

levels

Mark fluid level and time each shift

Maintain suction as ordered (20cmH2O)

Observe for air leak

Assess the patient !!

Vital signs

Auscultate lung sounds/Assess respirations

O2

Drainage- notify MD if > 100-200ml/hr

Turn & reposition Q2h

Encourage C&DB

D/C Chest tube

Pre-medicate patient with analgesic

Prepare Vaseline gauze to cover insertion
site when healthcare provider removes
tube ??? why Vaseline
Have patient take a deep breath &
perform Valsalva maneuver
Follow-up CXR

DrowningFactors that contribute

Age of Child

> 12 months
Most infants drown in bathtubs
1-4 year olds drown in pools
Older children & adults drown in large bodies of water

Gender
Males 5X more likely to drown than females
Take dares
Swim under the influence

Drowning that occurs outside of the home mostly

occur in summer months

Interventions
Education to prevent drowning
Toilet locks
Supervision in pool or tub
Pool door locks
Pool alarm
Life jackets while boating
CPR class
Help parents cope
If child dies allow private time for parents to be with child
Support the parents
Communication

Anemia
Reduction of circulating RBCs or hemoglobin
-Increased RBC loss
- Decreased production
- Defective production
- Combination of these

***Anemia is a reflection of other problems

Signs and Symptoms

Pallor
Tachycardia
Angina
Heart failure
SOB, fatigue
Headache, dizziness
GI disturbance

Iron Deficiency Anemia

Poor dietary intake

Vegetarians without adequate supplements

children

alcoholics

Iron Replacement

Ferrous sulfate
Feosol, Fer-In-Sol po

Ferrous fumarate
Feostat, FEM iron IM, po

Ferrous gluconate
Fergon, Ferralet po

Iron Dextran
InFeD IV, IM

Nutrition
Organ meats, poultry, red meat
Legumes
Dried fruit, nuts,
Iron fortified breads & flour
Leafy green vegetables

Patient Teaching

eggs, milk, cheese, antacids Fe absorption

IS POISONOUS IN CHILDREN

Store in a safe place

Take 2-3 months after Hgb is normal

( Fe stores)

Utilize Z-track with IM

Megablastic Anemia
Large RBC (immature)
Deficiency of vit B12
Folic acid deficiency
parasites--tapeworm--infected fresh H2O fish
**worm competes with host for vit B12
B12 and Folic acid deficiencies may coexist

Signs and Symptoms

Smooth, red tongue (sore)
Diarrhea (mild)
Pale mucous membranes
Numbness to extremities (B12)
Gait, proprioception, use of assistive devices, altered sensation
At risk for safety issues

Weakness, fatigue

Vitamin B-12 (Cobalamin) Deficiency

Dietary deficiency (rare)
Lack of the INTRINSIC FACTOR (pernicious

anemia)-binds in gastric mucosa with B12 &

carried to small bowel

Gastrectomy
Small bowel resection

Small intestine disorders

Crohns disease

Long-term H2 blocker use

Diagnostics
Intrinsic Factor Antibody test
Positive test =pernicious anemia

Schilling test (radioactive B12)

24 hour urine
All urine needs to be collected

Management

Nutrition:
B 12 in IM form

organ meats
Legumes & nuts
whole grains
wheat germ
fish
Milk
Green veggies

Management
Determine cause & correct
Replacement of Folic Acid

Nutrition
o
Decrease ETOH intake
o
green leafy vegetables
o
whole grains
o
meat
o
fish
Folate 1mg QD

Nursing Process: Planning

Major goals include:
decreased fatigue
attainment or maintenance of adequate nutrition
maintenance of adequate tissue perfusion
compliance with prescribed therapy
absence of complications

Interventions
Balance physical activity, exercise, and rest
Maintain adequate nutrition
Patient education to promote compliance with
medications and nutrition
Monitor VS and pulse oximetry, provide supplemental
oxygen as needed
Monitor for potential complications

CANCER-Primary/Secondary
Prevention

Primary prevention-Reducing riskspromotion strategies

Avoid carcinogens.
Lifestyle & dietary changes
Public & patient education

Secondary prevention-screening & early

detection
Cancer screening
Self-breast/testicular exam
Screening colonoscopy & Pap test

Leukemia
NUR 2731

Leukemia
Leukocytosis

increased level of leukocytes in circulation

Significant cause is hematologic malignancy

Leukemia is neoplastic proliferation of one particular cell

type
Cells are immature

CLL- mature cells

Originates in stem cells

Myeloid or lymphoid

leukemia

Leaves little room for normal cell production

Can occur in liver & spleen

May infiltrate other organs & tissues

Meninges, lymph nodes, gums, & skin

Genetics, viral pathogens, bone marrow damage from

radiation exposure

Acute or Chronic

Myeloid or Lymphoid

Common symptoms

Enlarged liver & spleen with abdominal pain

Bone pain due to expansion of marrow

Anemia

Thrombocytopenia

Weakness & fatigue

Diagnosed via CBC, Bone marrow analysis

Treated with chemotherapy, BMT, or both

AML
Acute Myeloid Leukemia
Neutropenia & thrombocytopenia

Fever, infection, bleeding, petechiae

Complications

Bleeding- GI, pulmonary, intracranial

Tumor Lysis Syndrome

ALL
Acute Lymphocytic Leukemia
Occurs mostly in children

Boys > girls

Peak age 4 yrs old
98% remission rate in kids

Symptoms common with other leukemias including

meningeal involvement

Headache
Vomiting

CML
Chronic Myeloid Leukemia
Uncommon in people < 20 yrs old
Symptoms

SOB, confusion due to decrease capillary perfusion

Malaise
Anorexia
Weight loss

CLL
Chronic Lymphocytic Leukemia
Older adults-average age 72 yrs old
Most common form of leukemia
Leukemic cells are mature-malignant clone of B
lymphocytes
Symptoms

Lymphadenopathy
ITP
B symptoms
Fevers
Night sweats
Weight loss
Life threatening infections

Complications
Infection
Bleeding/DIC
Renal dysfunction
Tumor lysis syndrome
Nutritional depletion
Mucositis
Depression & anxiety

Nursing diagnoses
Risk for infection & bleeding
Neutropenic & bleeding precautions
Monitor lab results

H&H
Platelets
PT/PTT
WBC/ANC

Nursing diagnoses
Imbalanced nutrition; less than body requirements
Goal-improved nutritional status

Oral care before & after meals including an oral anesthetic

Antiemetic therapy
Small frequent meals that are soft and moderate temperature
Nutritional supplements
Daily weight
Calorie counts
TPN

Nursing diagnoses
Acute pain
Goal-ease of pain & discomfort

Acetaminophen
Cool water for temperatures & diaphoresis
Change bed clothes frequently
PCA
Massage
Active listening
Provide for uninterrupted sleep

Nursing diagnoses
Self care deficit
Goal-improved self care
Encourage patient to perform as much self care as they can to prevent deconditioning
Assist patient when needed

Risk for fluid volume deficit

Goal-maintain fluid & electrolyte balance

I&O
Daily weight
Physical assessment
Monitor appropriate labs
Replacement of fluids
Administer antiemetic or antidiarrheal

 CANCER: NURSING MANAGEMENTN

Stomatitis
Irritation of oral cavity cause from certain types of
chemo/radiation. Usually develops 5-14 days post
treatment
Oral cavity red, swollen, ulcerated, painful, bleeding,
secondary infection
Affects speech, eating, desire to complete oral hygiene
May result in delay of treatment d/t decrease in chemo
dose or increase in hospital stay
Assess oral cavity-ensure dentures fit properly
Instruct patient to notify RN of any pain, bleeding or
ulcerations

Care
Mild stomatitis

Use NS rinse q 2 while awake & q 6 at night

Remove dentures except at meals

Encourage oral hygiene after meals & prn. Soft toothbrush w/

nonabrasive toothpaste. Flossing unless painful or PLT count
< 40,ooo

Avoid mouthwash, tobacco, ETOH

Severe stomatitis

Oral cultures if indicated

Administer prescribed oral rinses/anesthetics

Provide for liquid or pureed diet

Monitor for dehydration

Administer pain medications

Superior Vena Cava Syndrome

Compression of SVC by tumor, enlarged lymph nodes,
or clot
Obstructs venous drainage of head, neck, arms, &
thorax
Occurs mostly in lung Cancer
SOB, hoarseness, chest pain
Edema
Engorged veins
Increased ICP

Superior Vena Cava Syndrome

(continued)

DX: clinical findings, CXR, Chest CT

Medical Treatment

Radiation
Anticoagulant or thrombolytic therapy for clot
Stents
Surgery
Oxygen, corticosteroids, diuretics

Superior
Vena
Cava
Syndrome
Nursing Treatment
(continued)

Identify high risk patients

Monitor & report symptoms
Avoid upper extremity blood draws & BP
Position patient to facilitate breathing & comfort
Promote energy conservation
Monitor fluid volume status
Provide post op care if appropriate

DIC
Blood clots form but clotting cascade destroys clotting
factors faster than they can be replaced
Hematologic cancers, prostate, GI, & lungs
Chemotherapy
DX:
Prolonged PTT, PT, INR
Decreased PLT, Fibrinogen, clotting factors, H&H
Elevated D-Dimer

DIC
Medical Treatment:
Treat underlying cancer
Anticoagulants
Transfusion of FFP, cryoprecipitates, PRBC

Nursing Care:
Monitor VS
I&O
Assess for changes in physical assessment
Review labs
Safety/bleeding precautions
TC&DB